Every finding on record at North Capitol Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to ensure adequate assistance and supervision was provided for a resident during incontinent care, resulting in a fall from bed and resident being hospitalized for a left hip fracture for 1 of 1 resident reviewed for falls (Resident B). Findings include: The clinical record for Resident B was reviewed on 8/12/26 at 12:56 p.m. The resident's diagnosis included, but were not limited to, cerebral palsy (lifelong neurological disorder that permanently affects movement, muscle control, and posture) and fracture of greater trochanter of left femur (broken left hip). A Quarterly Minimum Data Set (MDS) Assessment, completed 4/1/26, indicated the resident was cognitively intact. The resident required maximum assistance of staff for bed mobility and total assistance of staff for toileting hygiene. The resident was always incontinent of bowel and bladder. A care plan, last reviewed 4/1/26, indicated Resident 12 was at high risk for falls due to history of falls, incontinence, impaired mobility due to Cerebral palsy, muscular dystrophy, debility, cramps and spasms, and bilateral upper extremity contractures. The goal was for the resident's fall risk factors will be reduced in an attempt to avoid significant fall related injury. The approaches included, but were not limited to, two-person assistance with all Activities of Daily Living (ADL) care. A nursing progress note, dated 6/27/26 at 6:05 a.m., indicated the Certified Nursing Aide (CNA) was providing a.m. care. The CNA had stated to the writer that the resident was rolled onto his side in bed. The CNA stepped a few feet away to get a brief from the bedside table. The CNA heard the resident scream and saw the resident sliding. The CNA ran to stop the resident from sliding off the bed. The resident landed on his buttocks on the floor. The nursing progress note did not indicated there were two staff members providing a.m. care for the resident. A progress note, dated 6/27/26 at 10:37 a.m., indicated the CNA reported the resident was in pain during ADL care. Resident B requested to go to the hospital. Resident B was admitted to the hospital on [DATE]. An Interdisciplinary Team (IDT) progress note, dated 6/29/26 at 10:08a.m., indicated Resident B had a fall on 6/27/26. The description of incident was that a CNA was providing a.m. care and rolled resident to the side of bed, went to grab brief, and during the situation resident rolled onto the floor and landed on his buttock. The immediate/short term interventions put in place at time of the fall was the CNA was instructed to have all materials prior to starting care. The root cause of fall was the CNA was not properly prepared for care.The hospital discharge instructions, dated [DATE], indicated Resident B had been seen by the Orthopedic Trauma Team. The resident had sustained the following injuries, left femur fracture. During an observation and interview on 8/12/26 at 12:56 p.m., Resident B was lying in his bed. Resident B indicated he had fallen from bed and broke his hip and back. Resident B had been in bed, and a CNA was changing his brief. The CNA had left him on the edge of the bed and he had fallen. The CNA was alone when providing his care. There were supposed to be two CNAs when he received care, but that did not always happen. The CNA went to get the brief from the drawer and Resident B had fallen out of the bed. During an interview on 8/13/26 at 11:29 a.m., CNA 4 indicated she was caring for Resident B at the time of the fall on 6/27/26. CNA 4 had stepped away from Resident B and was heading out of the room when CNA 4 heard Resident B scream out. CNA 4 turned around and saw Resident B fall out of bed. Resident B was contracted (a stiff condition where muscles, tendons, ligaments, or skin tightens and shortens) and CNA 4 could not figure out how he fell. CNA 4 had positioned Resident B in the middle of the bed before stepping away. On 8/13/26 at 12:38 p.m., the Director of Nursing Services (DNS) provided the Fall Management Policy, last revised 8/2022, that read .It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls This citation was related to Intake 3071046410 IAC (Indiana Administrative Code) 16.3.1-24(a)(2)(b)

Based on observation, interview, and record review, the facility failed to irrigate (flush) a urinary catheter, as ordered by the physician, for 1 of 3 residents reviewed for urinary catheters (Resident D).Findings include: The clinical record for Resident D was reviewed on 5/7/26 at 10:10 a.m. The resident's diagnosis included, but was not limited to, obstructive and reflux uropathy (urine cannot drain through the urinary tract). A care plan, last reviewed 3/11/26, indicated Resident D required an indwelling urinary catheter related to obstructive uropathy. The goal was that catheter care would be managed appropriately. The interventions included avoid obstruction in the drainage of the catheter and provide assistance for catheter care.A Quarterly Minimum Data Set (MDS) Assessment, completed 3/18/26, indicated the resident was cognitively intact and had an indwelling urinary catheter. A physician's order, dated 4/24/2026, indicated Resident D was to receive Clorpactin WCS-90 (antimicrobial solution) 60 milliliter (ml) instilled into the bladder through the indwelling catheter. The Clorpactin was to stay in the bladder for 15 to 30 minutes and then be drained. This was to be done every three days. The April and May 2026 Medication Administration Records indicated the Clorpactin WCS-90 was unavailable from pharmacy on 4/27/26, and marked as completed on 4/30, 5/3, and 5/6/26.During an interview on 5/7/26 at 11:01 a.m., Resident D indicated his urinary catheter kept getting clogged and the staff did not assist him with doing catheter care. His urinary catheter had not been irrigated at the facility. The urine in the resident's urinary catheter tubing was observed to be cloudy and contained sediment (particles). During an interview on 5/7/26 at 1:38 p.m., Licensed Practical Nurse (LPN) 2 indicated there was no Clorpactin WCS-90 in the unit treatment cart or the unit medication room. The pharmacy had never sent the Clorpactin WCS-90 to the facility. During an interview on 5/7/26 at 2:49 p.m., the Director of Nursing (DON) indicated the Clorpactin WCS-90 had not been in the building. The nurses may have irrigated the resident's urinary catheter with normal saline. Resident D's urinary catheter should have been irrigated with Clorpactin WCS-90, as ordered by the physician. On 5/8/26 at 11:00 a.m., the Executive Director provided the Medication Administration Procedure, last revised April 2025, that read .Withheld or Refused medications documented in the EMAR [Electronic Medication Administration Record] . Medication administration will be recorded on the EMAR after given .This citation relates to Intake 2992630.410 IAC (Indiana Administrative Code) 16.3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure residents' right to be free from misappropriation of their narcotic medication for 4 of 4 residents reviewed for misappropriation. (Residents C, D, E, and F)Findings include:1.An interview was conducted with the Director of Nursing Services (DNS) on 1/28/26 at 10:59 a.m. The DNS indicated there were about thirty fentanyl patches unaccounted for. At 3:30 p.m., the DNS indicated the Fentanyl/Duragesic Controlled Substance Record logs should have been completed by the nurse who removed the old fentanyl patch and applied the new fentanyl patch every 72 hours. It should have been the same nurse for removal as for new application, and a different nurse for the witnessed entries. The logs didn't make any sense, because Licensed Practical Nurse (LPN) 4 documented as the witness to Register Nurse (RN) 2's application, but they didn't even work the same shift. Once each log was completed, it was supposed to be filed and uploaded into the residents' electronic clinical record. There were multiple logs that were missing. An interview was conducted with the DNS on 1/29/25 at 10:53 a.m., when she provided the July, 2025 and one undated Shift Change Verification of Controlled Substances (12 hour) forms. She indicated the undated form was either for August, 2025 or September, 2025. She was unsure which, and the form for the other month was missing. The DNS indicated no one at the facility routinely reviewed residents' narcotic logs for accuracy and to assure that all narcotic medication was accounted for. She only reviewed the narcotic logs, if staff alerted her to a discrepancy. She thought Pharmacist 6 reviewed narcotic logs monthly during pharmacy medication reviews, but she was unsure. She discussed the missing fentanyl patches with Pharmacist 6, and he provided the delivery information for her during the investigation. She discussed with Pharmacist 6 as to why the pharmacy would send more fentanyl patches, after they just sent a month's worth. Since this occurred, she reviewed the narcotic logs more often. Their nurse practitioner discussed the issue with her coworkers as well, in regard to notifying her if they received requests for narcotic prescriptions on the weekends. They discovered most narcotic prescription requests from RN 2 and LPN 4 occurred on the weekend, when there was an on-call nurse practitioner working. The facility's investigation proved there were unaccounted for fentanyl patches, based on the amount delivered minus what was ordered to be administered and the amount of fentanyl patches remining. She and the ADNS interviewed RN 2 and LPN 4 about the fentanyl patches that were unaccounted for. An interview was conducted with the Clinical Director of Resident F's hospice company on 1/29/26 at 12:49 p.m. She indicated she was the supervisor of the hospice nurse who first discovered the fentanyl patch issue at the end of September, 2025 at the facility. Resident F had just been admitted to hospice. Resident F was due for her fentanyl patch to be changed, and the hospice nurse asked the facility staff to apply one, but there were no fentanyl patches available for application. It didn't make sense, because Resident F just had a batch of patches delivered. a. Resident F's physician's order indicated staff were to apply a 72-hour fentanyl (25 mcg/hr [hour]) patch every three days. The July, August, and September, 2025 medication administration records (MAR) indicated the above referenced fentanyl patch was applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/124/25, 7/27/25, 7/30/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 8/29/25, 9/1/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN (Registered Nurse) 2 and LPN (Licensed Practical Nurse) 4, except on 8/17/25. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 in Resident F's clinical record. The corresponding 8/14/25 to 9/29/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/29/25, 8/31/25, 9/4/25, 9/7/25 at 6:00 a.m., 9/7/25 at 6:00 p.m., 9/10/25 at 6:00 a.m., 9/10/25 at 6:00 p.m., 9/12/25, 9/13/25, 9/14/25, 9/15/25, 9/16/25, 9/18/25, 9/20/25, 9/26/25, 9/27/25, 9/28/25, and 9/29/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, and 8/23/25. The logs indicated there was no fentanyl patch removal on 8/25/25, when the new patch was applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 9/7/25, 9/10/25, 9/12/25, 9/13/25, 9/14/25, 9/16/25, 9/18/25, 9/20/25, 9/26/25, 9/28/29, and 9/29/29. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident F was delivered 49 fentanyl patches, and 13 of them were unaccounted for. b. Resident C's physician's order indicated staff were to apply a 72-hour fentanyl patch (75 mcg/hr) every three days. The July, August, and September, 2025 MARs indicated the above referenced fentanyl patch was applied every three days, as ordered, except on 8/20/25, because the medication was unavailable. They indicated fentanyl patches were applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/124/25, 7/27/25, 7/30/25, 8/2/25, 8/5/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/23/25, 8/26/25, 8/29/25, 9/1/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN 2 and LPN 4. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 in Resident C's clinical record. The corresponding 8/14/25 to 9/28/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/25/25, 8/28/25, 9/1/25, 9/4/25, 9/7/25, 9/9/25, 9/10/25, 9/12/25, 9/14/25, 9/19/25, 9/21/25, 9/24/25, 9/26/25, and 9/28/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 9/1/25, and 9/28/25. The logs indicated there was no fentanyl patch removal on 8/25/25 and 9/28/25, when the new patches were applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 9/7/25, 9/10/25, 9/12/25, 9/14/25, 9/19/25, 9/21/25, 9/24/25, and 9/26/25. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident C's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident C was delivered 31 fentanyl patches, and 4 of them were unaccounted for. An interview was conducted with the DNS on 1/29/25 at 10:53 a.m., when she provided the July, 2025 and one undated Shift Change Verification of Controlled Substances (12 hour) forms. She indicated the undated form was either for August, 2025 or September, 2025. She was unsure which, and there was no form for the other month. c. Resident E's physician's order indicated staff were to apply a 72-hour fentanyl (25 mcg/hr) patch every three days. The July, August, and September, 2025 MARs indicated the above referenced fentanyl patch was applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/24/25, 7/27/25, 7/30/25, 8/2/25, 8/5/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 8/29/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN 2 and LPN 4, except on 8/17/25. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 in Resident E's clinical record. The corresponding 8/14/25 to 9/29/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 9/4/25, 9/7/25, 9/10/25, twice on 9/12/25 at 6:00 a.m., 9/13/25, 9/14/25, 9/15/25, 9/18/25, 9/25/25, 9/27/25, 9/28/25, and 9/29/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 9/25/25, 9/27/25, 9/28/25, and 9/29/25. The logs indicated there was no fentanyl patch removal on 9/25/25, 9/27/25, 9/28/25, and 9/29/25 when the new patch was applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 9/7/25, 9/10/25, twice on 9/12/25, 9/13/25, 9/14/25, 9/15/25, and 9/18/25. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident E's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident E was delivered 40 fentanyl patches, and 14 of them were unaccounted for. d. Resident D's physician's order indicated staff were to apply a 72-hour fentanyl (50 mcg/hr) patch every three days. The staff were to verify placement of the fentanyl patch, every shift. The July, August, and September, 2025 MARs indicated the above referenced fentanyl patch was applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/24/25, 7/27/25, 7/30/25, 8/2/25, 8/5/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 8/29/25, 9/1/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN (Registered Nurse) 2 and LPN (Licensed Practical Nurse) 4, except on 8/17/25. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 or from 9/11/25 to 9/28/25 in Resident D's clinical record. The corresponding 8/14/25 to 9/29/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/24/25, 8/26/25, 8/28/25, 8/29/25, 9/1/25, 9/2/25, twice on 9/4/25, 9/7/25, 9/8/25, and 9/10/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/24/25, and 8/26/25. The logs indicated there was no fentanyl patch removal on 8/26/25, when the new patch was applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 8/28/25, 8/29/25, 9/1/25, 9/2/25, twice on 9/4/25, 9/7/25, 9/8/25, and 9/10/25. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident D's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident D was administered 40 fentanyl patches and 19 of them were unaccounted for. The documented interview, dated 9/30/25, with RN 2, conducted by the ADNS and DNS, documented by the ADNS, and included in the investigative file into Resident C's, D's, E's, and F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, On Tuesday September 30th 2025 the DON [Director of Nursing, also known as DNS] spoke with [name of title of RN 2] regarding Fentanyl patches narcotic count error flowsheet, [name of RN 2] stated that she puts the Fentanyl patches on due to [name and title of LPN 4] is allergic to Fentanyl. DON explained to [name of RN 2] that she needed to take a urine drug test, [Name of RN 2] complied [sic] drug test negative, [name of RN 2] stated that yes she did apply patches but only because the other nurse said that she was allergic to Fentanyl. DON explained to nurse that she is suspended during investigation. [Name of RN 2] then exited the building. RN 2's Employee Communication form, dated 10/16/25, indicated there was an incident on 9/30/25 regarding policy/procedure violation of controlled substances, code of ethics, and gross carelessness. It indicated, Employee failed on multiple occasions to follow [name of facility's] Controlled substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction) policy. Continued policy violations include.Gross Carelessness and Code of ethics. She was terminated on 10/16/25. The documented interview, dated 9/30/25, with LPN 4, conducted by the ADNS and DNS, documented by the ADNS, and included in the investigative file into Resident C's D's E's and F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, On Tuesday September 30, 2025 the DON spoke with [name and title of LPN 4] regarding Fentanyl patches narcotic count errors on flowsheet, [name of LPN 4] stated that she is allergic to Fentanyl and that [name and title of RN 2] puts the patches on the resident, DNS explained to nurse [name of LPN 4] that she needs to take s [sic] drug test [name of LPN 4] stated that she took a Percocet earlier that morning due to back pain. Urine Drug test was given and was positive for opiods [sic.] DON explained to nurse that she was suspended during investigation [name of LPN 4] then left the building. LPN 4's Employee Communication form, dated 10/16/25, indicated there was an incident on 9/30/25 regarding policy/procedure violation of Drug and Alcohol, Controlled substance, Investigation, and code of ethics. It indicated, Employee failed on multiple occasions to follow [name of facility's] Controlled substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction) policy. Employee failed to participate in an active investigation and failed to pass a drug screen during that investigation. Continued violations include.Gross Carelessness and Code of ethics. She was terminated on 10/16/25. During the survey process RN 2, LPN 4, and Pharmacist 6 were unavailable for interviews. The Controlled Substances: Storage, Documentation, Inventory and Destruction policy was provided by the DNS on 1/29/26 at 11:30 a.m. It indicated, Purpose of Policy: To prevent diversion, improper use and accidents related to controlled substances. Policy: It is the policy of this facility that all controlled substances will be stored, recorded, accounted for, and destroyed by state regulation.Documentation 1. When a controlled substance is administered to a resident, it must be recorded in the resident's Medication Administration (MAR) as well as in the resident's Controlled Substances Inventory Record at the time of administration.Inventory of Controlled Substances (Shift to Shift Count.) 6. The Shift Change Verification of Controlled Substances form and addition/removal logs will be maintained in the facility for 24 months. 7. The resident's Controlled Substance Record will be scanned into resident documents. The Abuse Prohibition, Reporting, and Investigation policy was provided by the ED (Executive Director) on 1/23/26 at 4:31 p.m. It indicated, It is the policy of [name of facility] to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation.Misappropriation of Resident Funds or Property -Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident' property or money without the resident's consent. Cross Reference F697-The facility failed to verify placement of residents' fentanyl patches, as ordered. Cross Reverence F755-The facility failed to implement pharmaceutical procedures that assured the accurate acquiring, receiving, dispensing, and administering of narcotic medication. This Citation relates to Intake 2632048. 3.1-28(a)

F697Based on interview and record review, the facility failed to provide residents' pain medication, as ordered, and to verify placement of residents' fentanyl patches, as ordered, for 4 of 4 residents reviewed for pain management. (Residents C, D, E, and F)Findings include:1. The clinical record for Resident C was reviewed on 1/28/26 at 2:33 p.m. The resident's diagnosis included, but was not limited to: chronic pain. The at risk for pain care plan, revised 1/19/26, indicated the resident was non-verbal and staff must anticipate her needs. Staff were to assess for non-verbal indicators of pain and provide intervention, as ordered. An approach was to administer her medications, as ordered, starting 3/17/22. The physician's orders indicated to apply a 72-hour fentanyl patch (75 mcg/hour) every three days, starting 6/8/24 and ending 9/29/25. The August, 2025 medication administration record (MAR) indicated the fentanyl patch was not applied on 8/20/25, because the medication was unavailable. The current physician's order, starting 2/19/23, indicated to verify placement of the fentanyl patch, every shift. The July, August, and September, 2025 MARs indicated the placement of Resident C's fentanyl patch was not verified on the following dates and shifts: second shift on 7/11/25, first shift on 7/13/25, first shift on 8/12/25, first shift on 9/12/25, and first shift on 9/27/25. 2. The clinical record for Resident F was reviewed on 1/28/26 at 1:56 p.m. The resident's diagnosis included, but was not limited to: chronic pain. The pain assessment, dated 9/23/25, indicated a pain assessment interview was not conducted, because Resident F was rarely/never understood. The staff assessment for pain indicated she had non-verbal sounds (crying, whining, gasping, moaning, or groaning) in the last five days as indicators of pain or possible pain. The resident's indicators of pain or possible pain were observed daily in the last five days. The at risk for pain care plan, starting 6/14/23 and revised 10/6/25, indicated an approach was to administer her medications, as ordered. The physician's orders indicated to apply a 72-hour fentanyl (25 mcg/hour) patch every three days, starting 4/7/25 and ending 8/1/25; starting 8/1/25 and ending 8/5/25, and starting 8/8/25 and ending 9/29/25.The July and August, 2025 MAR indicated a fentanyl patch was applied on 7/30/25, but the next one was not applied until 8/8/25, (missing two ordered applications). The August, 2025 MAR indicated the fentanyl patch was not applied on 8/4/25, because the medication was unavailable. The physician's order, from 8/12/25 to 12/14/25, indicated staff were to verify placement of the fentanyl patch, every shift. The September, 2025 MAR indicated the placement of Resident F's fentanyl patch was not verified on first shift on 9/12/25 and first shift on 9/17/25. 3. The clinical record for Resident E was reviewed on 1/29/26 at 11:53 a.m. The resident's diagnosis included, but was not limited to: chronic pain. The at risk for pain care plan, starting 7/13/23 and revised 11/12/25, indicated an approach was to administer medications, as ordered. The physician's order, starting 6/29/24 and ending on 9/29/25, indicated staff were to apply a 72-hour fentanyl (25 mcg/hour) patch every three days. The September, 2025 MAR indicated the fentanyl patch was not applied on 9/1/25, because a new prescription was needed. The physician's order, from 5/19/25 to 1/16/26, indicated to verify placement of the fentanyl patch, every shift. The July, 2025 MAR indicated the placement of Resident E's fentanyl patch was not verified on first shift on 7/13/25 and first shift on 7/22/25. 4. The clinical record for Resident D was reviewed on 1/29/26 at 12:16 p.m. The resident's diagnosis included, but was not limited to: neuralgia (sharp, severe nerve pain). The at risk for pain care plan, starting 9/3/15 and revised 12/15/25, indicated an approach was to administer medications, as ordered. The physician's order, starting 2/21/25 and ending 7/15/25; 7/15/25 to 9/21/25; 9/21/25 to 90/22/25; and 9/22/25 to 9/29/25, indicated staff were to apply a 72-hour fentanyl (50 mcg/hour) patch every three days. Starting 1/2/19, the staff were to verify placement of the fentanyl patch on every shift. The September, 2025 MAR indicated the placement of Resident D's fentanyl patch was not verified on first shift on 9/12/25. An interview was conducted with the Director of Nursing Services (DNS) on 1/28/26 at 10:59 a.m. The DNS indicated there were issues, involving two nurses and fentanyl patch diversion, on the unit where Resident C, Resident D, Resident E, and Resident F resided. The Pain Management policy was provided by the DNS on 1/29/26 at 11:30 a.m. It indicated, It is the policy of [name of facility] to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management.Physician orders for pain medication will be prescribed based upon the resident's intensity of pain.A plan of care will be written with the initiation of pain medication and individualized to the resident. This citation relates to Intake 2632048.3.1-37(a)

Based on interview and record review, the facility failed to implement pharmaceutical procedures that assured the accurate acquiring, receiving, dispensing, and administering of narcotic medication; to ensure medication records were in order; and ensure that an account of all controlled medications was maintained and periodically reconciled for 4 of 4 residents reviewed for pain management. (Residents C, D, E, and F)Findings include:1. The clinical record for Resident F was reviewed on 1/28/26 at 1:56 p.m. The resident's diagnosis included, but was not limited to: chronic pain. An interview was conducted with the Clinical Director of Resident F's hospice company on 1/29/26 at 12:49 p.m. She indicated she was the supervisor of the hospice nurse who first discovered the fentanyl patch issue at the end of September, 2025 at the facility. Resident F had just been admitted to hospice. Resident F was due for her fentanyl patch to be changed, and the hospice nurse asked the facility staff to apply one, but there were no fentanyl patches available for application. It didn't make sense, because Resident F just had a batch of patches delivered. The pain assessment, dated 9/23/25, indicated a pain assessment interview was not conducted, because Resident F was rarely/never understood. The staff assessment for pain indicated she had non-verbal sounds (crying, whining, gasping, moaning, or groaning) in the last five days as indicators of pain or possible pain. Her indicators of pain or possible pain were observed daily in the last five days. The physician's orders indicated to apply a 72-hour fentanyl (25 mcg/hr [hour]) patch every three days, starting 4/7/25 and ending 8/1/25; starting 8/1/25 and ending 8/5/25, and starting 8/8/25 and ending 9/29/25. The July, August, and September, 2025 MARs indicated the above referenced fentanyl patch was applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/124/25, 7/27/25, 7/30/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 8/29/25, 9/1/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN 2 and LPN (Licensed Practical Nurse) 4, except on 8/17/25. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 in Resident F's clinical record. The corresponding 8/14/25 to 9/29/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/29/25, 8/31/25, 9/4/25, 9/7/25 at 6:00 a.m., 9/7/25 at 6:00 p.m., 9/10/25 at 6:00 a.m., 9/10/25 at 6:00 p.m., 9/12/25, 9/13/25, 9/14/25, 9/15/25, 9/16/25, 9/18/25, 9/20/25, 9/26/25, 9/27/25, 9/28/25, and 9/29/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, and 8/23/25. The logs indicated there was no fentanyl patch removal on 8/25/25, when the new patch was applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 9/7/25, 9/10/25, 9/12/25, 9/13/25, 9/14/25, 9/16/25, 9/18/25, 9/20/25, 9/26/25, 9/28/29, and 9/29/29. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident F was delivered 49 fentanyl patches, and 13 of them were unaccounted for. RN 2, LPN 4, and Pharmacist 6 were unavailable for interviews. 2. The clinical record for Resident C was reviewed on 1/28/26 at 2:33 p.m. The resident's diagnosis included, but was not limited to: chronic pain. The pain assessment, dated 7/17/25, indicated a pain assessment interview was not conducted, because Resident C was rarely/never understood. The staff assessment for pain indicated she had facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) in the last five days as indicators of pain or possible pain. Her indicators of pain or possible pain were observed daily in the last five days. The physician's order, starting 6/8/24 and ending on 9/29/25, indicated staff were to apply a 72-hour fentanyl (75 mcg/hr) patch every three days. The July, August, and September, 2025 MARs indicated the above referenced fentanyl patch was applied every three days, as ordered, except on 8/20/25, because the medication was unavailable. They indicated fentanyl patches were applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/124/25, 7/27/25, 7/30/25, 8/2/25, 8/5/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/23/25, 8/26/25, 8/29/25, 9/1/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN 2 and LPN 4. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 in Resident C's clinical record. The corresponding 8/14/25 to 9/28/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/25/25, 8/28/25, 9/1/25, 9/4/25, 9/7/25, 9/9/25, 9/10/25, 9/12/25, 9/14/25, 9/19/25, 9/21/25, 9/24/25, 9/26/25, and 9/28/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 9/1/25, and 9/28/25. The logs indicated there was no fentanyl patch removal on 8/25/25 and 9/28/25, when the new patches were applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 9/7/25, 9/10/25, 9/12/25, 9/14/25, 9/19/25, 9/21/25, 9/24/25, and 9/26/25. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident C's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident C was delivered 31 fentanyl patches, and 4 of them were unaccounted for. An interview was conducted with the DNS on 1/29/25 at 10:53 a.m., when she provided the July, 2025 and one undated Shift Change Verification of Controlled Substances (12 hour) forms. She indicated the undated form was either for August, 2025 or September, 2025. She was unsure which, and there was no form for the other month. RN 2, LPN 4, and Pharmacist 6 were unavailable for interviews. 3. The clinical record for Resident E was reviewed on 1/29/26 at 11:53 a.m. The resident's diagnosis included, but was not limited to: chronic pain. The physician's orders indicated to apply a 72-hour 25 mcg/hr (hour) fentanyl patch every three days, starting 6/29/24 and ending 9/29/25. The July, August, and September, 2025 MARs indicated the above referenced fentanyl patch was applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/24/25, 7/27/25, 7/30/25, 8/2/25, 8/5/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 8/29/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN 2 and LPN 4, except on 8/17/25. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 in Resident E's clinical record. The corresponding 8/14/25 to 9/29/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 9/4/25, 9/7/25, 9/10/25, twice on 9/12/25 at 6:00 a.m., 9/13/25, 9/14/25, 9/15/25, 9/18/25, 9/25/25, 9/27/25, 9/28/25, and 9/29/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 9/25/25, 9/27/25, 9/28/25, and 9/29/25. The logs indicated there was no fentanyl patch removal on 9/25/25, 9/27/25, 9/28/25, and 9/29/25 when the new patch was applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 9/7/25, 9/10/25, twice on 9/12/25, 9/13/25, 9/14/25, 9/15/25, and 9/18/25. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident E's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident E was delivered 40 fentanyl patches, and 14 of them were unaccounted for. RN 2, LPN 4, and Pharmacist 6 were unavailable for interviews. 4. The clinical record for Resident D was reviewed on 1/29/26 at 12:16 p.m. The resident's diagnosis included, but was not limited to: neuralgia (sharp, severe nerve pain). The physician's order, starting 2/21/25 and ending 7/15/25; 7/15/25 to 9/21/25; 9/21/25 to 90/22/25; and 9/22/25 to 9/29/25, indicated staff were to apply a 72-hour fentanyl (50 mcg/hr) patch every three days. The staff were to verify placement of the fentanyl patch, every shift, starting 1/2/19. The July, August, and September, 2025 MARs indicated the above referenced fentanyl patch was applied on the following dates: 7/3/25, 7/6/25, 7/9/25, 7/12/25, 7/15/25, 7/18/25, 7/21/25, 7/24/25, 7/27/25, 7/30/25, 8/2/25, 8/5/25, 8/8/25, 8/11/25, 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/26/25, 8/29/25, 9/1/25, 9/4/25, 9/7/25, 9/10/25, 9/13/25, 9/16/25, 9/19/25, 9/22/25, 9/25/25, and 9/28/25. The only staff to apply these fentanyl patches were RN 2 and LPN 4, except on 8/17/25. There were no corresponding Fentanyl/Duragesic Controlled Substance Record logs for the applications of fentanyl patches from 7/1/25 to 8/13/25 or from 9/11/25 to 9/28/25 in Resident D's clinical record. The corresponding 8/14/25 to 9/29/25 Fentanyl/Duragesic Controlled Substance Record logs contradicted the August and September, 2025 MARs. The logs indicated fentanyl patches were applied on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/24/25, 8/26/25, 8/28/25, 8/29/25, 9/1/25, 9/2/25, twice on 9/4/25, 9/7/25, 9/8/25, and 9/10/25. The logs indicated there were no witnesses for the fentanyl patch removals on the following dates: 8/14/25, 8/17/25, 8/20/25, 8/23/25, 8/24/25, and 8/26/25. The logs indicated there was no fentanyl patch removal on 8/26/25, when the new patch was applied. The logs indicated RN 2 was her own witness to patch removal on the following dates: 8/28/25, 8/29/25, 9/1/25, 9/2/25, twice on 9/4/25, 9/7/25, 9/8/25, and 9/10/25. The nurse who signed off on the MARs as having applied the fentanyl patch did not always match the nurse who signed off on the logs as having applied the fentanyl patch. The pharmacy documentation, included in the investigative file into Resident D's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, between 7/5/25 and 9/28/25, Resident D was administered 40 fentanyl patches and 19 of them were unaccounted for. An interview was conducted with the DNS on 1/28/26 at 3:20 p.m. She indicated the Fentanyl/Duragesic Controlled Substance Record logs should have been completed by the nurse who removed the old fentanyl patch and applied the new fentanyl patch every 72 hours. It should have been the same nurse for removal as for new application, and a different nurse for the witnessed entries. The logs didn't make any sense, because LPN 4 documented as the witness to RN 2's application, but they didn't even work the same shift. Once each log was completed, it was supposed to be filed and uploaded into the residents' electronic clinical record. There were multiple logs that were missing. Resident D's missing logs were most disturbing to her, because the logs were missing for fentanyl patch deliveries made only a week earlier. An interview was conducted with the DNS on 1/29/25 at 10:53 a.m., when she provided the July, 2025 and one undated Shift Change Verification of Controlled Substances (12 hour) forms. She indicated the undated form was either for August, 2025 or September, 2025. She was unsure which, and the form for the other month was missing. No one at the facility routinely reviewed residents' narcotic logs for accuracy and to assure that all narcotic medication was accounted for. She only reviewed the narcotic logs, if staff alerted her to a discrepancy. She thought Pharmacist 6 reviewed narcotic logs monthly during pharmacy medication reviews, but she was unsure. She discussed the missing fentanyl patches with Pharmacist 6, and he provided the delivery information for her during the investigation. She discussed with Pharmacist 6 as to why the pharmacy would send more fentanyl patches, after they just sent a month's worth. Since this occurred, she reviewed the narcotic logs more often. Their nurse practitioner discussed the issue with her coworkers as well, in regard to notifying her if they received requests for narcotic prescriptions on the weekends. They discovered most narcotic prescription requests from RN 2 and LPN 4 occurred on the weekend, when there was an on-call nurse practitioner working. The facility's investigation proved there were unaccounted for fentanyl patches, based on the amount delivered minus what was ordered to be administered and the amount of fentanyl patches remining for each resident. She and the ADNS interviewed RN 2 and LPN 4 about the fentanyl patches that were unaccounted for. The documented interview, dated 9/30/25, with RN 2, conducted by the ADNS and DNS, documented by the ADNS, and included in the investigative file into Resident C's, D's, E's, and F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, On Tuesday September 30th 2025 the DON [Director of Nursing, also known as DNS] spoke with [name of title of RN 2] regarding Fentanyl patches narcotic count error flowsheet, [name of RN 2] stated that she puts the Fentanyl patches on due to [name and title of LPN 4] is allergic to Fentanyl. DON explained to [name of RN 2] that she needed to take a urine drug test, [Name of RN 2] complied [sic] drug test negative, [name of RN 2] stated that yes she did apply patches but only because the other nurse said that she was allergic to Fentanyl. DON explained to nurse that she is suspended during investigation. [Name of RN 2] then exited the building. The 9/30/25 documented interview with LPN 4, conducted by the ADNS and DNS, documented by the ADNS, and included in the investigative file into Resident C's D's E's and F's fentanyl patch diversion, was provided by the DNS on 1/28/26 at 10:45 a.m. It indicated, On Tuesday September 30, 2025 the DON spoke with [name and title of LPN 4] regarding Fentanyl patches narcotic count errors on flowsheet, [name of LPN 4] stated that she is allergic to Fentanyl and that [name and title of RN 2] puts the patches on the resident, DNS explained to nurse [name of LPN 4] that she needs to take s [sic] drug test [name of LPN 4] stated that she took a Percocet earlier that morning due to back pain. Urine Drug test was given and was positive for opiods [sic.] DON explained to nurse that she was suspended during investigation [name of LPN 4] then left the building. RN 2, LPN 4, and Pharmacist 6 were unavailable for interviews. The Controlled Substances: Storage, Documentation, Inventory and Destruction policy was provided by the DNS on 1/29/26 at 11:30 a.m. It indicated, Purpose of Policy: To prevent diversion, improper use and accidents related to controlled substances. Policy: It is the policy of this facility that all controlled substances will be stored, recorded, accounted for, and destroyed by state regulation.Documentation 1. When a controlled substance is administered to a resident, it must be recorded in the resident's Medication Administration (MAR) as well as in the resident's Controlled Substances Inventory Record at the time of administration.Inventory of Controlled Substances (Shift to Shift Count.) 6. The Shift Change Verification of Controlled Substances form and addition/removal logs will be maintained in the facility for 24 months. 7. The resident's Controlled Substance Record will be scanned into resident documents. This Citation relates to Intake 2632048. 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure a staff member did not initiate chest compressions to a hospice resident that had an advanced directive in place Do Not Resuscitate (DNR) code status. (Resident B)Findings include:The clinical record for Resident B was reviewed on [DATE] at 9:45 a.m. The diagnosis included, but was not limited to: Alzheimer's disease. An Indiana Physician Orders Scope of Treatment (POST), dated [DATE], indicated Resident B had a Do Not Resuscitate (DNR) advanced directive. A care plan, dated [DATE], indicated Resident B had an advanced directive in place, DNR. A care plan, dated [DATE], indicated Resident B has difficulty making self understood not able to communicate. A care plan, dated [DATE], indicated Resident B received hospice services related to Alzheimer's disease. A physician's order, dated [DATE], indicated Resident B's code status was DNR. An event, dated [DATE], indicated Resident B had an unwitnessed fall. The resident was found having seizure activity with a laceration to the back of her head. She was sent to the emergency room (ER) for evaluation. A nursing progress note for Resident B, dated [DATE] at 7:34 a.m., indicated Called to unit from can [Certified Nursing Assistant] .resident had a fall .noted resident on floor near dining room having a seizure with blood noted coming from the back of her head .resident continues in seizure with snoring sounds and respirations at 10 resident seizure lasted 4 minutes, ems [Emergency Medical Services] and fire department arrived. Resident transported to [hospital] ER [medical provider] notified .Resident vs [vital signs] 159/81[blood pressure] 109 [heart rate] 24 [respirations]. A nursing progress note for Resident B, dated [DATE] at 10:30 p.m., indicated Resident returned from ER visit at 930pm. No new orders received,.Area to back of head intact without any s/s [signs/symptoms] of bleeding noted. resident shows no s/s of headache, pain or discomfort noted at this time. resident resting in her room at this time. staff will continue to monitor resident. An observation was made of Resident B on [DATE] at 10:29 a.m. The resident was observed in bed with eyes closed. The television was on in the resident's room. An observation was made of Resident B on [DATE] at 2:23 p.m. The resident was observed sitting on the side of the bed. The resident was clothed and the television was on. An interview was conducted with Hospice Staff Nurse 1 on [DATE] at 10:38 a.m. She indicated she was notified Resident B had fallen and started to shake. The facility nurse thought the resident was seizing and provided Cardiopulmonary Resuscitation (CPR) to the resident when she had a heartbeat and had not stopped breathing. Resident B's Representative was very upset about the facility staff initiating CPR. The facility staff had informed Hospice Staff Nurse 1, they would not call hospice prior to sending a resident out to the hospital that had fallen and was bleeding from a head wound. An interview was conducted with the Assistant Director of Nursing Services (ADNS) on [DATE] at 11:26 a.m. She indicated on the morning of [DATE], she called to the memory care unit due to Resident B had fallen. After entering the unit, she had observed the resident on the floor bleeding from the back of her head. License Practical Nurse (LPN) 2 was on the floor and on her cell phone with a 911 dispatcher. At that time, Resident B was seizing and snoring breath sounds. LPN 2 was pushing on the resident's chest area, but she was trying to rouse the resident. She had suggested to turn the resident on her side, but they decided not to move her due to not knowing the extent of the resident's injuries to her head. EMS arrived and transferred the resident to the hospital emergency room. After, she notified Resident B's Representative and hospice personnel. An interview was conducted with LPN 2 on [DATE] at 11:41 a.m. She indicated she was notified Resident B had fallen. She ran into the memory care unit and checked Resident B's code status. She observed the resident on floor and having a seizure. The resident's back of head was bleeding a lot and her breathing sounded like a snore. She contacted 911 and was instructed by the dispatcher to initiate CPR. LPN 2 performed light chest compressions to the resident. The resident came out of the seizure and breathing returned to normal. She then turned the resident on her side. EMS arrived and wrapped the resident's head, placed a neck brace on and oxygen. The resident was awake and breathing normal when she was transferred to the hospital. The resident was returned later that day. During the incident, she was in the heat of the moment. It was the first time she had experienced a resident in that condition. ADNS had handled the paperwork and notified the medical provider, family and hospice. Education was provide to her after the incident. She was educated about moving in correct order which means understand the situation and code status. An interview was conducted with Qualified Medication Aide (QMA) 3 on [DATE] at 12:25 p.m. She indicated on the morning of [DATE], she had walked on the memory care unit and had observed Resident B on the floor with nursing staff around making sure she was okay. LPN 2 was performing CPR on the resident. EMS arrived and transferred the resident to the hospital. An interview was conducted with Resident B's Representative on [DATE] at 1:49 p.m. She indicated she was notified by the facility the resident had an unwitnessed fall and had a seizure. She had sustained a head injury to the back of her head and was transferred to the hospital. She was in the hospital for approximately 8 hours and returned to the facility the same day. The facility staff had initiated CPR on Resident B and that was upsetting. The resident was a DNR and all the advanced directive paperwork was in her chart. The nursing staff had acted in a panic mode. An Advanced Directives policy was provided by the Executive Director on [DATE] at 3:30 p.m. It indicated, .It is the policy of this facility to provide information to resident/resident representative his/her rights to formulate advanced directives. The facility will not discriminate against any individual based on whether or not they have implemented an advanced directive. If a resident has a valid Advanced Directive, the facility's care will reflect the resident's wishes as expressed in the Directive, in accordance with state law. This citation relates to Intake 2640525.

Based on observation, interview, and record review, the facility failed to perform hand hygiene during medication administration and failed to ensure that indwelling catheter tubing and drainage bag were kept off a fall mat and the floor for 6 of 8 residents reviewed for medication administration and 1 of 1 resident reviewed for urinary catheter. (Residents' 5, 12, 26, 34, 40, 50, and 72) Findings include: 1a. The clinical record for Resident 26 was reviewed on 7/24/25 at 9:30 a.m. The diagnoses included, but were not limited to, paranoid schizophrenia. An observation was conducted of a medication administration for Resident 26 with Licensed Practical Nurse (LPN) 2 on 7/29/25 at 8:31 a.m. LPN 2 was observed obtaining the resident's blood pressure by utilizing a Dinamap (an electronic device for blood pressure monitoring). She then went to the medication cart and prepped for the resident's medication for administration. During that time, she was observed touching her hair, eye glasses, the computer mouse, keys, medication cards, medication cups, water pitcher and drinking cups. After, she returned back to the resident and administered the medications in the medication cup. There was no observation of LPN 2 utilizing hand hygiene before or after the medication administration to the resident. 1b. The clinical record for Resident 50 was reviewed on 7/24/25 at 9:45 a.m. The diagnoses included, but was not limited to, stroke. An observation was conducted of a medication administration for Resident 50 with LPN 2 on 7/29/25 at 8:42 a.m. LPN 2 was observed at the medication cart preparing the resident's medications. She had pulled the medication cards out of the medication cart and popped the pill medications in the medication cup. During the preparation, LPN 2 had a black hair tie on her right wrist with long black strands of hair hanging from the hair tie. She was observed touching her hair, the computer mouse, keys, medication cards, medication cups, water pitcher and drinking cups. After, she knocked onto the resident's door and administered the medications to the resident. There was no observation of LPN 2 utilizing hand hygiene before the medication administration. 1c. The clinical record for Resident 40 was reviewed on 7/24/25 at 10:45 a.m. The diagnoses included, but was not limited to, stroke. An observation was conducted of a medication administration with LPN 2 for Resident 40 on 7/29/25 at 8:50 a.m. LPN 2 was observed obtaining the resident's blood pressure utilizing a hand held blood pressure monitoring device. She then went to the medication cart and pulled the resident's medications. LPN 2 pulled the medication cards and popped the pill medications into a medication cup. During that time, she touched the computer mouse, medication cards, medication cups, water pitcher and drinking cups. After, LPN 2 went into the resident's room and administered the medication to the resident. There was no observation of LPN 2 utilizing hand hygiene prior to the administration of medications to the resident. 1d. The clinical record for Resident 12 was reviewed on 7/24/25 at 11:45 a.m. The diagnoses included, but was not limited to, Parkinson's disease. An observation was conducted of a medication administration with LPN 2 for Resident 12 on 7/29/25 at 9:08 a.m. LPN 2 was observed preparing the resident's medications at the medication cart. She pulled the medications, removed a pair of gloves from a box, and then poured water from the water pitcher into a cup. After, she entered the resident's room, donned on her gloves. She then touched the bedside table with her gloved hands. She then administered the resident's nasal spray. After, she doffed the gloves and administered the pill medications. During that time, the resident had requested removing her straw from her Styrofoam cup and place the straw into her new cup. LPN 2 was observed donning on one glove; removing the straw and placing it in the new cup. After, she doffed her glove and left the resident's room. There was no observation of LPN 2 utilizing hand hygiene before or after donning gloves nor prior to administration of medications to the resident. 1e. The clinical record for Resident 34 was reviewed on 7/24/25 at 1:00 p.m. The diagnoses included, but was not limited to, hypertension. During an observation of a medication administration with LPN 2 for Resident 34 on 7/29/25 at 9:24 a.m., LPN 2 was observed preparing the resident's medication from the medication cart. First, the resident's blood pressure was obtained by utilizing a Dinamap. She then pulled the resident's medications from the medication cart. After, she crushed the medications. During that time, LPN 2 was observed touching the medication cards, keys, Ensure supplement, pill crusher, plastic sleeves, medication cups and drinking cups. She then administered the medication to the resident. There was no observation of LPN 2 utilizing hand hygiene prior to the medication administration to the resident. An interview was conducted with the Director of Nursing (DON) on 7/29/25 at 3:02 p.m. She indicated LPN 2 should have utilized hand hygiene prior to administration of the medications to the residents. 2. The clinical record for Resident 72 was reviewed on 7/29/25 at 11:00 a.m. The diagnoses included, but were not limited to, gastrostomy tube. An observation of medication administration was conducted, on 7/29/25 at 11:15 a.m., with Registered Nurse (RN) 3. RN 3 performed hand hygiene prior to arriving at the medication cart, she then used a laptop on the medication cart to view and verify the resident's orders. RN 3 prepared Resident 72's medication by crushing one tablet and placed it into a medication cup, and poured 10 milliliters of a liquid sucralfate into another medication cup. RN 3 then entered Resident 72's room and donned personal protective equipment (PPE), a gown and gloves. Hand hygiene was not performed prior to donning PPE. RN 3 verified placement of the gastrostomy tube before administering the resident's medications. RN 3 then doffed her PPE and performed hand hygiene before leaving the resident's room. During an interview with RN 3 on 7/29/25 at 11:35 a.m., she indicated she normally used hand hygiene before donning PPE and administering medication, but must have forgotten during the observation. 3. The clinical record for Resident 5 was reviewed on 7/25/25 at 10:17 a.m. The diagnoses included, but were not limited to, epilepsy and gastrostomy (g-tube) status. A care plan, last reviewed 7/9/25, indicated Resident 5 required an indwelling urinary catheter related to neurogenic bladder. The goal was for her to be free from complications related to the indwelling catheter. The interventions included, but were not limited to, do not allow catheter tubing or any part of the drainage system to touch the floor and to position drainage bag below the bladder. During an observation on 7/25/25 at 10:08 a.m., Resident 5 was observed lying in bed in her room. The urinary catheter tubing was laying on a fall mat at her bedside. The urine in the tubing was dark yellow in color. During an observation on 7/28/25 at 1:51 p.m., Resident 5 was observed lying in her bed. The bed was in the low position. The catheter tubing was laying on the fall mat beside her bed and the urinary drainage bag was laying behind the fall mat, touching the floor. During an interview on 7/28/25 at 1:52 p.m., RN 3 indicated the catheter tubing should not be laying on the fall mat and the urinary drainage bag should not be touching the floor. A Standard and Transmission-Based Precautions (Isolation) Policy, last revised 2/2025, was provided by the Executive Director on 7/30/25 at 3:40 p.m. It indicated .Hand Hygiene . Perform hand hygiene: Before and after having direct contact with a resident . Use of Personal Protective Equipment - Gown and Gloves: Applies to anyone entering the room who may touch the resident or objects in the room should wear PPE. Perform Hand Hygiene prior to entering the room and before leaving the room .Gloves: Perform hand hygiene prior to donning and after doffing gloves . An Infection Control Prevention and Control Program policy was provided by the DON on 7/29/25 at 3:07 p.m. It indicated, .Prevention of spread of infections is accomplished by the core principles of infection control including, but not limited to hand hygiene. 3.1-18(b)(1) 3.1-18(l)

Based on observation and interview, the facility failed to ensure a call light system and ceilings and walls in residents' rooms were in good repair for 7 of 7 residents reviewed for environment, and to provide a home-like environment in the memory care unit common area with the potential to effect 19 of 19 residents. (Residents 1, 2, 15, 31, 34, 35, and E)Findings include: 1. On 7/24/25 at 11:02 a.m., the walls in Resident E's room were observed to have scrapes with paint missing, as well as chipping in the baseboards. 2. On 7/24/25 at 11:32 a.m. a random observation was conducted of exposed wiring from a call light cord coming out of the wall in Resident 31's room.3. On 7/24/25 at 1:36 p.m. an observation was conducted of gouges in the walls and baseboards of Resident 35's room. During this observation, Resident 35 indicated the walls had been like that for a year and he would like it to be fixed. 4. On 7/24/25 at 1:42 p.m. a random observation was conducted of gouges on a wall and a missing baseboard in Resident 34's room.5. On 7/25/25 at 10:27 a.m., the walls in Resident 2's room were observed to have gouges and missing baseboards. 6. On 7/28/25 at 10:52 a.m., a wall in Resident 15's room was observed to have gouges and cracks adjacent to the window. Splatter of unknown origin were also observed on the ceiling. 7. On 7/28/25 at 10:56 a.m., a random observation revealed splatter from an unknown origin on the ceiling in Resident 1's room as well as a hole in the wall adjacent to the window.An environmental tour of the facility was conducted, on 7/28/25 at 2:00 p.m., with the Executive Director (ED) and the Maintenance Director. Observations of Resident E and Resident 35's room revealed gouges and missing paint towards the bottoms of the wall just above the baseboards. The baseboards were also noted to have missing, broken off pieces. The Maintenance Director indicated the damage occurred from the residents' wheelchairs and that the wall had been previously repaired. The ED indicated it was more cost effective to paint and repair the walls instead of placing a barrier to prevent damage to the walls Resident 1 and 15's rooms were observed with splatter on the ceiling and gouges in the walls. The ED indicated facility staff from various departments conduct companion rounds during which the environment can be observed to address potential issues. He indicated these issues must have been missed during those rounds. Resident 31's room was observed alongside the ED and Maintenance Director, revealing the exposed wiring from the resident's call light with the cover detached from the wall. The ED indicated it was common for the coverings to come off of the wall and they have to reapply adhesive to reattach it. The memory care unit common area on the third floor was observed to have multiple tables pushed to the center of the room and plain walls with no decorations or personalization. The ED indicated the common area did appear plain and could use more personalization to provide a more home-like environment. On 7/30/25 at 3:00 p.m., the ED indicated the facility did not have a policy related to home-like environment standards.3.1-19(f)(5)

Based on interview and record review, the facility failed to timely coordinate care with hospice for scheduled pain medication and failed to administer medication as ordered for 1 of 1 resident reviewed for hospice and 1 of 5 residents reviewed for unnecessary medications. (Resident 11 and Resident D) Findings include: 1. The clinical record for Resident 11 was reviewed on 7/23/25 at 2:14 p.m. The diagnoses included, but were not limited to, senile degeneration of the brain and generalized arthritis. A care plan, initiated 4/8/25, indicated Resident 11 required hospice services related to his diagnosis of senile degeneration of the brain. The goal was for him to experience death with dignity and physical comfort. The interventions included, but were not limited to, administer pain medications as ordered and notify physician and hospice of unrelieved or worsening pain and for the hospice licensed nurse to visit two times weekly to obtain vital signs and provide medication management. A Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report, dated 5/22/25, indicated Resident 11 was to have tramadol (pain medication) 25 milligram (mg) twice daily for pain. The Electronic Health Record (E.H.R.) for Resident 11 did not contain a physician's order for tramadol 25 mg to be administered twice daily for pain. A Quarterly Minimum Data Set (MDS) assessment, completed 7/7/25, indicated Resident 11 had short-term and long-term memory problems. During an interview on 7/30/25 at 12:21 p.m., Hospice Nurse (HN) 4 indicated she had given the order to start tramadol 25 mg twice daily on 5/22/25. She could not recall which of the facility nurses she had given the order to. She had intended for Resident 11 to receive tramadol 25 mg twice daily for pain and was unaware that he had not been receiving the medication twice daily. During an interview on 7/30/25 at 2:21 p.m., the Director of Nursing (DON) indicated the facility did not have an order for Resident 11 to receive tramadol 25 mg twice daily. She was unsure why the order had not been placed in the electronic health record. During an interview on 7/30/25 at 4:38 p.m., the Nurse Consultant (NC) indicated the HN should ask for a copy of the current electronic medication administration record (EMAR) when they were visiting the hospice resident and reconcile the EMAR with their orders to ensure the facility, and the hospice company had coordinated care. 2. The clinical record for Resident D was reviewed on 7/24/25 at 10:45 a.m. The diagnoses included, but were not limited to, stroke. A physician's order, dated 3/4/22, indicated the resident was to receive 100 milligrams of metoprolol once a day. The July 2025 Medication Administration Record (MAR) indicated the following days the 100 milligrams of metoprolol was not administered as ordered: 7/13/25 – documented as not administered due to low blood pressure; blood pressure reading was 108/74, 7/14/25 – no documentation why the medication was not administered, 7/16/25 – no documentation why the medication was not administered, and 7/25/25 – documented as not administered due to low blood pressure; blood pressure reading was 94/68. Resident D's medical record did not indicate the medical provider was notified to hold and/or not administer the 100 milligrams of metoprolol. An interview was conducted with the Director of Nursing on 7/29/25 at 3:02 p.m. She indicated Resident D's 100 milligrams of metoprolol order should have had parameters when the medication should be held and the order did not. The staff should have called the provider to receive an order to hold the medication. On 7/30/25 at 4:14 p.m., the DON provided the Hospice Policy, last reviewed September 2024, which indicated .It is the policy of this facility that when a resident elects the hospice benefit, the contracted hospice company and the facility will coordinate to establish both a person centered plan of care reflecting the physical, spiritual, mental and psychosocial needs of the resident as well as a pattern of communication between the hospice company, healthcare professionals, facility staff and resident/ representative. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to administer gastric tube feeding as ordered by the physician for 1 of 1 resident reviewed for gastric tube feeding (Resident 5). Findings include: The clinical record for Resident 5 was reviewed on 7/25/25 at 10:17 a.m. The diagnoses included, but were not limited to, epilepsy and gastrostomy (g-tube) status. A physician's order, dated 4/21/25, indicated she was to receive Glucerna 1.5 (type of nutritional formula) at 50 milliliters (mLs) an hour with 45 mLs of water flushes per hour. A care plan, last edited 7/3/25, indicated Resident 5 was at nutritional risk related to dependency on enteral nutrition (nutrition via gastric tube) for nutritional needs. The goal was for her to maintain her weight without significant weight changes. The interventions included, but were not limited to, provided enteral feedings as ordered by the physician. On 7/25/25 at 10:17 a.m., Resident 5 was observed lying in her bed. Her gastric tube (g-tube) feeding pump was running at 55 mLs per hour. On 7/28/25 at 2:37 p.m., Resident 5 was observed with Registered Nurse (RN) 3. Resident 5 was lying in her bed with her g-tube feeding running. RN 3 indicated the feeding was running at 55 mLs an hour with 40 mLs of water flushes each hour. RN 3 checked the physician's orders and indicated the g-tube feeding should be running at 50 mLs an hour and the water flushes should be 45 mLs per hour. RN 3 would adjust the rate to reflect the physician's order. On 7/29/25 at 9:46 a.m., the Executive Director provided the Enteral Therapy Policy, last reviewed January 2016, which indicated .A licensed nurse will take, note, and implement physician orders for enteral therapy. 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a resident with intrusive wandering, document new behavior events in the clinical record, and timely update the plan of care with new interventions for behaviors for 2 of 3 residents reviewed for dementia care (Resident K and Resident 61). Findings include: 1a. The clinical record for Resident K was reviewed on 7/23/25 at 11:15 a.m. The diagnoses included, but were not limited to, dementia with behavioral disturbances, anxiety, and traumatic brain injury. He was readmitted to the facility, on 7/16/25, following an extended hospital stay. A Quarterly Minimum Data Set (MDS) assessment, completed 6/6/25, indicated he rarely/never made himself understood and sometimes understood what was said to him. He had short-term and long-term memory problems and severely impaired decision-making skills. He had displayed inattention. He displayed physical behaviors, such as hitting, kicking, scratching or pushing one to three times in the seven day look back period. He had displayed wandering behaviors daily in the seven day look back period. He was able to walk 150 feet with supervision. A care plan, last reviewed on 7/16/25, indicated Resident K would wander into rooms on the secured unit. The goal was for him to not experience lasting distress, to not cause distress to others, and to not cause harm to himself or others. The interventions included, but were not limited to, address any immediate needs such as hunger, thirst, pain, boredom, loneliness, or tiredness, encourage him to engage in activities, ensure his safety, when redirecting the resident to call him by name and then approach, provide a calm, unhurried, and supportive approach, and remove him from the immediate area to further evaluate needs. 1b. The clinical record for Resident 61 was reviewed on 7/23/25 at 11:10 a.m. The diagnoses included, but were not limited to, dementia with psychotic disturbance. A Quarterly MDS assessment, completed 5/16/25, indicated she had short-term and long- term memory problems and was able to recall the location of her own room. She had experienced delusions. She could walk 150 feet independently. A care plan, with a start date of 1/16/25 and last revised 7/30/25, indicated she had an altercation with a peer. The goal was for her not to have distress related to the incident. The interventions included, but were not limited to, separate resident for safety and observe for signs and symptoms of distress, initiated on 1/16/25.On 7/23/25 at 11:15 a.m., Resident K was observed attempting to walk into Resident 61's room and was redirected by the Memory Care Coordinator (MCC). Resident K's clinical record contained a Nursing Progress Note, dated 7/26/25 at 6:00 a.m., that indicated a nursing assistant reported Resident K was bleeding. The nurse saw a scratch on Resident K's arm and wiped the scratch with normal saline.An Incident Report submitted to the Indiana Department of Health, dated 7/26/25 at 5:01 a.m., was provided by the Executive Director (ED) on 7/28/25 at 10:45 a.m. The Incident Report indicated that Resident K and Resident 61 had a resident-to-resident incident. The type of injury was a small scratch on Resident K's hand. The immediate action taken was both residents were separated, and the families and physicians were notified.The clinical record for Resident K did not include a Behavior Communication Note or documentation about the reportable incident between Resident K and Resident 61. Resident K's clinical record contained a Nursing Progress Note, dated 7/26/25 at 11:31 a.m., that indicated Resident K had been pacing up and down the hallway going from room to room. Resident K was redirected multiple times and unable to be redirected. Resident K was following other residents down the halls. Resident K was administered lorazepam (anti-anxiety medication) for restlessness and some agitation. Resident K's clinical record contained a Nursing Progress Note, dated 7/27/25 at 9:51 a.m., that indicated Resident K had wandered into another resident's room. The resident had pushed Resident K out of his room. There were no injuries noted and no signs or symptoms of pain or discomfort. Resident K was placed on 15-minute checks. The Executive Director, Director of Nursing Services, Assistant Director of Nursing Services, Nurse Practitioner and Resident K's wife were made aware. Resident K's clinical record contained a Nursing Progress Note, dated 7/28/25 at 3:09 a.m., indicated there were no apparent injuries from the earlier incident. Resident K remained on 15-minute checks. Resident K was ambulating with steady gait quickly in the hallway and attempting to wander in and out of rooms. Redirection was offered to Resident K using a kind soft voice, food, toileting, and support. As needed lorazepam was administered due to Resident K becoming aggravated when redirection was attempted. A progress note, dated 7/28/25 at 8:41 a.m., indicated Resident K had been involved in two separate altercations over the weekend related to wandering in and out of other residents' rooms. Resident K resided in the cottage (dementia care) unit and often wandered without purpose. Resident K was placed on 15-minute checks related to other residents becoming agitated with resident K's wandering. It was reported that Resident 61 had scratched Resident K during their altercation, but upon further assessment the scratches were noted to be in healing stage. One of the scabs on the scratches became dislodged following the altercation. Resident K does not remember either incident when questioned. Resident K's clinical record did not contain an Interdisciplinary Team (IDT) review of the incident, on 7/26/25, or the intrusive wandering. A care plan, initiated 7/28/25, indicated Resident K had an episode of intrusive wandering. The goal was for the staff to redirect him during increased wandering. The approach was for increased supervision, offer snacks, walk with resident, and redirect resident back to his room. Resident 61's clinical record did not contain documentation of the incident between Resident 61 and Resident K, a New Behavior Event, or a Behavior Communication Note of the incident between Resident 61 and Resident K on 7/26/25. Resident 61's care plan had not been updated. Resident K's clinical record contained the following progress notes: A Memory Care Social Services Progress Note, dated 7/28/25 at 4:19 p.m., indicated Resident K had displayed the behavior of intrusive wandering. The immediate interventions done were to walk with Resident K, offer snacks, and redirect him back to his room. A Nursing Progress Note, dated 7/28/25 at 10:10 p.m., indicated Resident K continued on 15- minute checks. Resident K was continuously wandering from room to room and up and down the hall. When redirection was attempted multiple times, Resident K would walk faster. He was redirected to his room unsuccessfully and continued to wander. As needed medication was given. A Nursing Progress Note, dated 7/29/25 at 2:26 a.m., indicated Resident K remained on 15-minute checks. He was pacing up and down the hallway in a quick manner, opening closed doors, and entering rooms. Staff immediately redirected him. Resident K was unaware of personal space nor intrusive behavior. Toileting was offered and as needed pain medication was given due to him rubbing his knee and back. He consumed a snack and fluid before returning to his room. A Memory Care Social Services Progress Note, dated 7/29/25 at 1:39 p.m., indicated Resident K was up for breakfast and lunch in the dining room with staff walking up and down the hallway with him. He remained on 15-minute checks. He was resting in bed at that time with no signs or symptoms of distress.During an interview on 7/29/25 at 2:30 p.m., the Memory Care Coordinator (MCC) and Activity Aide (AA) 5 indicated that Resident 61 was not normally aggressive with other residents. Resident 61 normally told other residents to go on if they came into her room. Resident K had always wandered into other residents rooms and this was not a new behavior for him. The staff redirected him with snacks or by walking with him.Resident K's clinical record included a Nursing Progress Note, dated 7/30/25 at 5:17 a.m., that indicated Resident K was ambulating and following Resident 61 up the hallway. Resident 61 turned around and shoved Resident K, causing him to fall against elevator wall and slide down to his coccyx (bottom). Resident K did not hit his head and there were no apparent injuries. Resident 61's clinical record contained a Nursing Progress Note, dated 7/30/25 at 5:22 a.m., that indicated Resident 61 had been ambulating and was being followed by Resident K. Resident 61 began screaming and yelling for Resident K to quit following them. Resident 61 then turned around and shoved Resident K, causing him to fall against the elevator wall and slide down to his coccyx (bottom). Resident 61 then went to her room and slammed the door. Resident K's clinical record contained a Nursing Progress Note, dated 7/30/25 at 5:26 a.m., that indicated Resident K continued to attempt to enter other rooms and follow people closely while walking in the hallway. During an interview on 7/30/25 at 9:21 a.m., the Director of Nursing (DON) indicated Resident K had one-on-one care started after the incident. Resident K had been on 15- minute checks up until the time of the incident. Resident behaviors were documented in the nursing notes. During an interview on 7/30/25 at 2:22 p.m., the DON indicated the incident, on 7/26/25 at 5:00 a.m., between Resident K and Resident 61 had not been witnessed. The Certified Nurse Aide (CNA) had found Resident K and Resident 61 standing close together with Resident K's hand bleeding. The CNA was unable to definitively say Resident 61 scratched Resident K. Resident K had 15-minute checks initiated on 7/26/25. The memory care unit was staffed with one CNA on the night shift and the Nurse of the attached ventilator unit covered the dementia unit as well. On 7/29/25 at 3:34 p.m., the Executive Director provided the Behavior Management Policy, last revised August 2022, which indicated .It is the policy of American Senior Communities to provide behavior interventions for residents with problematic or distressing behaviors . Interventions provided by both individualized and non pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavioral expression.1. Care plans should be initiated for any behavioral expression that is problematic or distressing to the resident, other resident or caregivers. Care plan interventions should be individualized and non pharmacological interventions which address both proactive and responsive interventions.4. If the behavioral expression is new, worsening, or high risk the nurse will record the behavior using the New/Worsening Behavior Event. New or worsening behaviors are reviewed by the IDT for assessment and preventative actions. New/Worsening Behaviors include: a. Behaviors that are new for the resident b. Behaviors that are directed at another resident.c. Behaviors that are increasing in either frequency or severity d. Behaviors that have potential for risk to others including sexual advances, intrusive wandering.The IDT review is a discussion with the team as to the behavioral expression, and evaluation of interventions, presentation of new interventions if applicable, and an assessment of any underlying causes of the behavior [i.e. pain, environmental stressor, medical illnesses, etc.]. The root cause and preventative interventions will be included in the resident's plan of care. 5. If the behavioral expression is not new, worsening or high risk; the nurse will record the behavior in the progress notes using the Behavior Communication Note. The IDT will review progress notes the next business day to determine if immediate follow up action is required for the Behavior Communication. If the behavior requires an interdisciplinary response as described above, the IDT will complete the IDT Behavior Review. If not, the plan of care will be reviewed and updated in needed to include a description of the behavior and effective interventions.3.1-37(a)

Based on interview and record review, the facility failed to timely identify and obtain physician's orders for a surgical wound that was present upon admission to the facility for 1 of 4 residents reviewed for wounds (Resident B). Findings include: The clinical record for resident B was reviewed on 2/6/25 at 11:30 a.m. The diagnoses included, but were not limited to, anal abscess (swollen area within body tissue, containing an accumulation of pus) and colostomy (colon was diverted to an artificial opening in the abdominal wall). She was admitted to the facility on [DATE]. An admission assessment, dated 1/13/25 at 8:04 p.m., indicated she had a wound on her right buttock which was 28 centimeters (cm) in length and 13 cm in width. The depth of the wound was eight cm. There were no other wounds identified on the admission assessment. A Nursing Progress Note, dated 1/13/25 at 9:54 p.m., indicated .This writer notified [name of hospital that discharged resident] . regarding treatment orders for resident .unable to find treatment orders but will reach out day shift and wound care regarding orders and have the orders faxed to facility [sic]. A Nursing Progress Note, dated 1/13/25 at 12:36 a.m., indicated the right buttock wound dressing was done with minimal drainage observed. An ostomy (surgically created opening) dressing was done. A care plan, initiated 1/14/25, indicated she was at risk for skin breakdown or further skin breakdown due to current skin impairment and impaired mobility. The goal was for her to be free from further skin breakdown. The interventions included, but were not limited to, preventive treatments as ordered, supplements as ordered, turn and reposition at least every two hours, and provide assistance as needed. A physician's order, dated 1/14/25, indicated to change colostomy bag daily. A physician's order, dated 1/14/25, indicated to provide ostomy care every shift and as needed. Assess the stoma (opening in the abdomen which is used to remove body waste, such as feces and urine, into a collection bag) site every shift for redness, drainage, swelling, warmth and skin integrity. A Nursing Progress Note, dated 1/14/25 at 2:57 p.m., indicated Resident B had an ostomy with a dehisced (separation or opening of a previously closed wound) wound on her abdomen. The clinical record did not contain a treatment order for the right buttock wound or the dehisced abdominal wound on Resident B's abdomen upon admission to the facility. A physician's order, dated 1/15/25, indicated to cleanse the buttock wound, pat dry, and lightly pack the wound with a quarter (1/4) strength Dakin's (antiseptic solution) soaked rolled gauze, cover with ABD (type of dressing), and secure with tape twice daily. A Nursing Progress Note, dated 1/15/25 at 11:02 p.m., indicated the abdominal assessment of an ileostomy (small intestine was diverted to an artificial opening in the abdominal wall) and colostomy. She had two ostomy bags. There was no redness or swelling observed in the area. An Interdisciplinary Team (IDT) Note, dated 1/16/25 at 1:45 p.m., indicated Resident B had a skin injury wound on her right buttock and right thigh. She was admitted to the facility with a diagnosis of anal abscess and type 2 diabetes and had surgical debridement (removal of damaged tissue). The treatment used for the wound was Dakin's solution. A Nursing Progress Note, dated 1/18/25 at 6:22 a.m., indicated the abdominal assessment of an ileostomy and colostomy. The stoma was pink. A Nursing Progress Note, dated 1/19/25 at 10:20 a.m., indicated Resident B's vital signs were within normal limits. She had no complaints about pain or discomfort. The Assistant Director of Nursing had contacted the facility to follow up on Resident B's surgical site related to possible worsened dehiscing due to surgery. Missing staples were observed at the mid abdominal area. Colostomy care was done, and colostomy bag was changed. A dressing was applied to the abdominal area, which was red and painful during treatment. The Nurse Practitioner was notified, and Resident B was sent to hospital. The Hospital- ER (emergency room ) transfer form, dated 1/19/25, indicated the condition requiring an ER visit was a dehisced incision. The skin condition described at the time of transfer was missing staples. An Acute Care Hospital Colon Rectal Surgery Consult note, dated 1/20/25, indicated Resident B presented with a midline wound separation as well as newly diagnosed pneumonia. She had been having drainage into her wound and separation of the midline wound with surrounding redness and pain. The physical exam showed the abdomen as soft, with dehiscence of the inferior aspect of midline wound. The superior staples were intact. The colostomy was functioning and has surrounding erythema (redness). Resident B was readmitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment, completed 1/29/25, indicated Resident B was cognitively intact and dependent on toileting. During an interview on 2/6/25 at 2:15 p.m., Resident B indicated she had staples on her stomach when she first came to the facility. She had noticed some drainage from the staples before she went back to the hospital. She had told one of the nurses about the drainage. She was unsure how or when the staples were removed, she thought they just fell out. During an interview on 2/7/25 at 1:20 p.m., the Corporate Nurse Consultant (CNC) indicated when Resident B was admitted to the facility, on 1/13/25, there were two ostomy bags present on her abdomen. The discharge hospital had not sent any treatment orders with the discharge packet. Initially, the admitting nurse thought she had two ostomies. The Assistant Director of Nursing Services (ADNS) reached out to the discharging hospital, on 1/13/25, to obtain treatment orders for her wounds. A treatment order for her right buttock and thigh was obtained on 1/15/25. Treatment orders for Resident B's wounds should have been obtained upon admission. There was no physician's order present for the use of two ostomy bags. During an interview on 2/7/25 at 1:40 p.m., Licensed Practical Nurse (LPN) 2 indicated she had changed Resident B's colostomy bag. There were two ostomy bags present on Resident B's abdomen; one was covering her colostomy, and one bag was over the open, dehisced wound. LPN 2 had notified the former Director of Nursing. During an interview on 2/7/25 at 1:58 p.m., the ADNS indicated when Resident B was admitted to the facility, on 1/13/25, the nurses had assumed that the colostomy and wound adjacent to it were all part of the same area. Resident B had been sent to the facility with two ostomy bags present on the abdomen and both bags had stool in them. The staples on Resident B's abdomen had been covered with the adhesive wafer of the ostomy bag. On 1/19/25, the ADNS was contacted by the nurse on duty around 4:00 a.m. or 5:00 a.m. The nurse on duty was concerned Resident B's surgical wound was coming open. The ADNS was unsure why the nurse on duty had called her instead of the physician when she noticed a change in the wound. The ADNS had called the facility later in the morning, on 1/19/25, and had the staff check the wound. The physician had been notified of the change in appearance of the wound and Resident B had been sent to the acute care hospital for an evaluation. On 2/7/25 at 1:20 p.m., the CNC provided the Nursing Admission/Return Admission Policy and Procedure, last reviewed July 2024, which read . to provide baseline and accurate documentation of the mental and physical condition of each resident admitted or readmitted to the facility . Admission procedures will be followed for all new admissions including respite care .Initial nursing assessment: Admission Observation .5. A thorough head to toe assessment [including skin] must be done at admission. Any alterations in skin integrity must be identified on nursing assessment. The physician must be notified for specific treatment orders . On 2/7/25 at 1:20 p.m., the CNC provided the Skin Management Program, last reviewed May 2022, which read .Procedure For Alteration In Skin Integrity- Pressure and Non-Pressure .1. Alterations in skin integrity will be reported to the MD/NP [sic], the resident and/or resident representative as well as to the direct care staff. 2. Treatment order will be obtained from the MD/NP [sic] . This citation relates to Complaint IN00452731. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident who required follow-up care with an Ears, Nose, and Throat (ENT) physician was provided transportation to those appointments 1 of 3 residents reviewed for quality of care. (Resident C) Findings include: The clinical record for Resident C was reviewed on 9/24/24 at 1:23 p.m. The diagnoses included, but were not limited to, malignant neoplasm of oropharynx (a type of head and neck cancer that starts in the middle part of the throat), tongue cancer, laryngectomy (removal of part or all the voice box), glossectomy (removal of part or all the tongue) and hydrocephalus (a buildup of extra fluid within the brain). A list of Resident C's appointments for the last six months was provided by Executive Director (ED) on 9/24/24 at 11:09 a.m. The list indicated in the last six months the resident had appointments on 4/5/24, 4/16/24, and 6/27/24. The resident required transportation to appointments and to be accompanied by a Respiratory Therapist (RT). The resident had a [NAME]-tube (a laryngectomy tube used for breathing and placed in a hole in the neck) and resided on the ventilator (Vent) unit. Resident C's clinical record indicated, under the orders section, he had an appointment scheduled for 4/5/24 at 8:00 a.m. at a local hospital for a PET scan (positron emission tomography, an imaging test that can create three dimensional [3D] pictures of the body's organs and tissues). A hospital discharge summary, dated 3/25/24, indicated Resident C's discharge diagnoses included, but were not limited to, oropharynx cancer (dated 3/21/24). The hospital performed a chest CT (computed tomography, imaging used to obtain detailed internal images) on 3/21/24, which indicated a similar 7 mm (millimeter) pulmonary nodule and a similar 2.2 cm (centimeter) nodule along the left front thyroid lobe. The scheduled follow-up appointments were: - An ENT physician on 3/28/24 at 2:35 p.m., - A CT of the head on 4/22/24 at 2:20 p.m., and - A neurosurgical follow-up with testing on 4/22/24 at 2:30 p.m. A nursing note, dated 3/28/24 at 2:23 p.m., indicated Resident C went to the ENT physician's appointment that day. A nursing note, dated 3/29/24 at 7:11 a.m., indicated Resident C returned to facility and two additional appointments were noted for the resident to see ENT physician and the facility was to provide transportation. The clinical record did not indicate the dates of the two additional appointments, nor did it indicate when/if transportation had been set up for those appointments. A nursing note, dated 4/5/24 at 10:28 a.m., indicated no one showed up to transport resident (sic, Resident C) to his appointment. Writer will call to reschedule for another day. The clinical record did not indicate when/if transportation had been set up for the appointment. Resident C's clinical record did not indicate he had gone to the neurosurgical follow-up appointment, on 4/22/24, nor the head CT scheduled on 4/22/24. The clinical record did indicate an appointment was scheduled for Dr. (sic, doctor) (left blank) CT Scan following on the 5th floor suite 5100 on 4/22/24 at 1:30 p.m. Under special instructions it indicated an appointment, on April 22, 2024, at 355 [NAME] 16th street at 1:30 p.m. Another appointment listed in the orders section of the clinical record, indicated he was scheduled with the ENT physician, on 6/27/24 at 9:35 a.m., but the method of transportation was left blank. The clinical record did not indicate when/if transportation was scheduled. A nursing note, dated 6/7/24 at 2:17 p.m., indicated they were directed by the Respiratory Therapist (RT) manager, at the time, that Resident C's appointment with the on 6/13/24, needed to be rescheduled due because there was not an available RT to attend the appointment with the resident. The appointment was rescheduled for 6/27/24 at 9:35 a.m. The clinical record did not indicate when/if transport had been scheduled for the 6/27/24 appointment. A nursing note, dated 6/27/24 at 11:41, indicated, Resident C missed his appointment with the ENT physician related to transportation never showed up and the ENT physician's office called to reschedule the appointment. The appointment was rescheduled for 7/1/24 at 11:45 a.m. The clinical record did not indicate when/if transportation was set up for the appointment. Resident C's clinical record did not indicate he had made the, 7/1/24, appointment with the ENT physician. An interview with the ENT physician's office scheduler conducted on 9/24/24 at 2:59 p.m., indicated Resident C had no showed for the following appointments: 4/25/24, 6/27/24, 7/1/24, and 8/28/24. An interview with the ED was conducted on 9/25/24 at 10:51 a.m. He indicated the facility primarily used one provider for all transportation to/from the facility for appointments that cannot go by the facility's bus. He indicated, the facility did have another contract with another transportation provider, but that provider had not provided good service. Another interview with ED on the same day at 11:37 a.m., indicated the person who was responsible for ensuring a vent resident was supplied with an RT for transport to/from outside appointments was the facility's pervious RT manager. The ED indicated the previous RT manager failed to ensure that coordination of care and appointments were missed. An interview with the Director of Nursing (DON) was conducted on 9/25/24 at 12:15 p.m. She indicated, regarding Resident C's missed appointments for neurosurgical follow-up and the CT of the head, both on 4/22/24, it was the responsibility of the admitting nurse to review the discharge summary to ensure proper follow-up appointments are placed on the facility's schedule. She indicated not only should the admitting nurse review the discharge summary, but it should have been reviewed a second time. She indicated she had no idea how the appointments weren't placed on his schedule not once but twice. She indicated when an appointment was scheduled for a resident, a note should have been placed in the clinical record indicating the setup of transportation with who and what time and date. She indicated she was unaware of the ENT physician's appointment, on 4/25/24, but acknowledged the nursing note written, on 3/29/24, indicating two additional appointments were to occur. She stated it was reasonable to correlate the 4/25/24 appointment and the 6/13/24 appointment were the two additional appointments, but the agency nurse failed to ensure those appointments were communicated nor had transportation been set up. She indicated she was aware of the 7/1/24 appointment because of the missed transportation on 6/27/24. She stated she was unaware of why the resident did not make it to the appointment on 7/1/24. She did indicate it would be reasonable to ascertain the 8/28/24 appointment could have been a rescheduled appointment from the missed 7/1/24 appointment but was unsure who might have confirmed the appointment, on 8/28/24, as there were no notes regarding this appointment in his clinical record. An interview with the owner of the transportation service, contracted by the facility, conducted on 9/26/24 at 10:12 a.m., indicated, according to his records, the facility had not made any attempts for transportation services for Resident C for the appointments on 4/25/24, 6/13/24, 6/27/24, 7/1/24, and 8/28/24. A Scheduled Appointment Policy was provided, on 9/26/24 at 2:59 p.m., from the DON. The policy indicated, It is the policy of this facility that continuity of care and safety during resident's scheduled appointments outside the facility will be maintained .Upon receiving notification of a scheduled appointment, an order shall be written and entered into the orders section of the EMR [sic, electronic medical record] to communicate the pending appointment via the 'appointment flowsheet' in EMAR [sic electronic medication administration record] to the clinical staff. 2. The IDT [sic, interdisciplinary team] will review scheduled appointments for the day during the administrative meeting for transportation and follow-up .6. The licensed nurse will document resident status upon leave from the facility and upon return from leave, and any other pertinent information . This citation relates to Complaint IN00443023. 3.1-37(a) 3.1-37(b)

Based on observation, interview, and record review, the facility failed to ensure a resident's safety when using a mechanical sling lift by a staff member not securing the sling clip to the peg on the mechanical lift and causing a resident to fall to the floor for 1 of 3 residents reviewed for falls. (Resident K) Findings include: The clinical record for Resident K was reviewed on 9/26/24 at 10:21 a.m. His diagnoses included, but were not limited to, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), and contractures (a permanent or temporary shortening of muscles, tendons, skin, and other soft tissues that causes joints to stiffen and limit movement). A Physical Therapy Evaluation, dated 5/20/24, indicated Resident K required a mechanical lift for transfers. A nursing note, dated 9/23/24 at 9:49 a.m., indicated the nurse was alerted by a certified nursing assistant (CNA) that Resident K fell . The resident was lying on the floor in the entry to his room on his back. The CNA reported the strap clip on the sling had come undone and he fell to the floor. The resident reported, at time of the fall, he had pain in his head, neck and back. A small amount of blood was noted on the floor from behind his head. The resident was transferred to the local emergency room . He was admitted for unrelated issues. A demonstration of the facility's Maxi-lift (mechanical sling lift) operation was observed on 9/26/24 at 11:00 a.m. by the Director of Nursing and the Regional Nurse Consultant. They indicated two CNAs had placed Resident K into the Maxi-lift sling and while one of the CNAs was up by the resident's head with the unit's controller, the other CNA was by his feet. They indicated one of the clip straps came off the peg because the clip strap was not locked in place at the time but was rather placed on the peg without pulling the clip in a downward direction to lock it on the peg and the resident subsequently fell to the ground. When asked if this mechanical lift was new to the facility, they indicated it was not. The DON indicated until this event happened, she did not fully understand how that piece of equipment had fully operated. An interview with CNA 4 was conducted on 9/26/24 at 1:04 p.m. She indicated she had assisted Resident K with taking a shower and placed him into the mechanical sling lift to get him back to bed when one of the things fell off and the resident fell on to the floor hitting his head. When asked if the thing was one of the clip straps she indicted yes, it was. She indicated the clip did not break, but that it just came undone from the left post/peg. She indicated the clip strap would not lock onto the peg/post. She indicated she had experienced difficulties with some of the pad clips not locking prior to this event and thought it was just a bad pad. She indicated, she was trained previously on the operation of that lift and was retrained after the incident, but indicated even during the retraining, she had an issue with getting the clip to lock on the peg/post. She indicated prior to the incident Resident K was agitated and complained of pain and the staff was trying to get him back into bed. An instructional video for how to attach a clip sling like the ones used at the facility was accessed on 9/27/24 at 5:15 p.m., at https://vimeo.com/243747880 and indicated: 1. Place the clip from the sling onto the knob on the cradle ensuring to place the peg into the largest opening on the clip. 2. Pull down on the strap directly below the clip so the clip locks onto the peg. The clip will lock onto the peg when it is in the upper, smallest opening on the clip. 3. Gravity will allow the clip to stay secured on the top portion of the clip. 4. Always check and make sure each clip is securely attached prior to lifting the patient. This citation relates to Complaint IN00443958. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to properly store foods in the kitchen. This affected of 60 residents in the facility who eat food from the kitchen. Findings include: An initial tour of the kitchen was conducted on [DATE] at 10:11 a.m. with Registered Dietician (RD). During the initial tour the following was observed: In the walk-in fridge: - On a shelf in the fridge was a metal pan which contained a package of meat. RD indicated, at the time of the observation, the meat in the pan was thawing and should have been labeled with the kind of meat it was and a date indicating when it was taken out of the freezer to ensure its use within 72 hours of thawing. - Two unopened half gallons of lactose free milk where found to be expired. The expiration dates on the containers of lactose free milk were [DATE] and [DATE] respectively. - Sitting on the floor of the fridge in a milk crate were two unopened gallon jugs of milk. According to the RD at the time of the observation, no food items should be stored on the floor of the fridge. - On a multi-shelf rack within the fridge, a tray contained 2 glasses of pre-poured milk and 3 glasses of orange juice. The tray was labeled with a use by date of ,d+[DATE] and the glasses of milk and juice were not labeled. During the initial tour, it was observed that the Dietary Manager's (DM) mustache was not covered by a hair net and his mustache was more than a ,d+[DATE] inch long. DM indicated at the time of the observation, he was unaware of the need to also cover his mustache when wearing a beard net. During the initial tour, it was observed that a large trash can that was not in current use did not have a lid on it. A Food Storage policy received on [DATE] at 4 p.m. from RD indicated, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored at an appropriate temperature and by methods designed to prevent contamination .6. Food is stored a minimum of 6 inches above the floor .on clean racks or other clean surfaces and protected from contamination .The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicated the date by which the food shall be consumed or discarded .Refrigerated, ready-to-eat, potentially hazardous food purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded. This opened food can be held at 41 degrees Fahrenheit or less for no more than 7 days and the date marked may not exceed the manufacturer's use-by-date .11. Refrigeration .f. All foods shall be covered or wrapped tightly, labeled, and dated .12 .d. Items that have been frozen and thawed should be used with 72 hours of being thawed, unless otherwise specified by the manufacturer. The Retail Food Establishment Sanitation Requirements Refuse, Recyclables and Returnables Section 392 indicated, (a) Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (1) inside the retail food establishment if the receptacles and units: (A) contain food residue and are not in continuous use . 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment related to splintered chair rails behind beds; scrapped walls with exposed drywall; phone [NAME] with exposed wires; not ensuring wheel chairs were clean; not assuring feeding pump poles were clean; bed linens, towels, and washcloths with stains; bedroom furniture on the vent unit with missing and scratched veneer; and floors with loose and missing tiles for 10 of 15 residents reviewed for environment (Resident D, 21, 24, 27, 28, 30, 36, 44, 53 and 55). Findings include: 1. On 5/28/24 at 10:28 a.m., Resident 44's room was observed. The chair rail behind his bed was splintered and broken. 2. On 5/28/24 at 10:21 a.m., Resident 36's room was observed. The wall by the sink was chipped and drywall was exposed. The chair rail behind his bed was broken and splintered. The telephone jack was pulled from the wall with wires exposed. 3. On 5/28/24 at 10:36 a.m., Resident 27's room was observed. The telephone jack was pulled from the wall with wires exposed. 4. On 5/28/24 at 11:10 a.m., Resident 28's room was observed. The chair rail behind the bed was broken and the paint on the wall at the back of the bed was scraped. 5. On 5/28/24 at 10:32 a.m., Resident 21 was observed sitting in her wheelchair at an activity in the common area. Her wheelchair had a dried orange substance splattered all over the wheels of the wheelchair. 6. On 5/29/24 at 10:04 a.m., Resident 53 was observed laying in his bed in his room. There was a brown stain present on his pillow case. There was an IV pole with a gastric feeding pump attached to it at his bedside. The base of the pole had brown stains and dried gastric tube feeding formula present on it. There were brown spots on the floor by the pole. 7. On 5/29/24 at 9:56 a.m., Resident D's room was observed. The floor of the room was missing pieces of flooring. The bedside table was worn, scratched, and missing pieces of the black veneer. 8. On 5/28/24 at 12:15 p.m., Resident 30 and Resident 42's room was observed. There were stains present on Resident 30's sheets. The floor had pieces of laminate flooring that did not match the rest of the floor. Resident 30 indicated that housekeeping rarely swept or mopped, and the clean sheets and towels were often stained. The flooring had come up and it was replaced with flooring that did not match. 9. On 5/28/24 at 11:56 a.m., Resident 55's room was observed. The foot board of the bed was crooked and not attached on one side. 10. On 5/28/24 at 11:53 a.m., Resident 24's room was observed. The flooring at the foot of the bed was loose and pulling up from the floor. The built in bedside storage table was worn, with scratches and missing pieces of black veneer. On 5/31/24 at 11:30 a.m., the clean linen cart on the vent unit was observed with RN (Registered Nurse) 2. There were wash cloths and towels on the clean linen care that had brown stains present on them. RN 2 indicated there had been a lot of complaints from the residents and families about the stained linen. RN 2 had noticed that the sheets, towels, washcloths and blankets were often stained and had made the laundry aware of the issue. On 5/31/24 at 2:00 p.m., RN 2 indicated that housekeeping on the vent unit had been a problem. The housekeepers seem to only sweep and go over the floors with a swifter looking device. The items in the rooms are not getting wiped down. The unit appeared dirty. She had brought up the lack of housekeeping and had been told there were staffing issues with housekeeping. On 6/3/24 at 11:13 a.m., an environmental tour was completed with the ED (Executive Director). Resident 44's room was observed and the chair rail behind the bed was broken and splintered. The ED indicated it should be fixed and that it was an ongoing problem in many of the rooms. Resident 36's room was observed and the chair rail behind the bed continued to be broken and splintered. The wall by the sink had chipped and exposed drywall. and the phone jack continued to have exposed wires. The ED indicated the area on the wall had been an ongoing problem and that the phone jack could be fixed. Resident 27's room was observed, and the phone jack had exposed wires. Resident 53's room was observed and the IV pole by the bed had brown spots and an old piece of plastic wrapped around the bottom of the pole. The ED indicated that the pole should be cleaned. Resident D's room was observed to be missing a 2-inch x 4-inch piece of flooring by the head of the bed. The furniture in the room was worn, scratched, and missing black veneer. The ED was unsure of when the furniture on the vent unit had last been replaced. Resident 30's room was observed to have mismatched flooring. The ED indicated that some of the flooring had become loose and had been replaced with the flooring that was available. Resident 55's room was observed, and the foot board was crooked on the end of the bed and the low air loss mattress pump was laying on the floor under the foot of the bed. The ED indicated he would have someone look at the bed and fix the foot board. Resident 24's room was observed to have flooring boards that were loose and pulling up from the floor. The built-in bedside table was worn, with scratches and missing pieces of black veneer. The ED indicated that the flooring should have been repaired. Deep cleaning of rooms was scheduled monthly. Resident 21 was observed in the common area of the dementia care unit sitting in her wheelchair. The wheelchair was observed to have dried, caked on food and an orange substance splattered on the wheels of her wheel chair. The ED indicated the wheelchair needed to be cleaned. During an interview on 6/3/24 at 3:03 p.m., Family Member 24 indicated that the bed linens were not always clean and had stains. The furniture on the vent unit was old and worn looking and could be replaced. On 6/3/24 at 1:25 p.m., the ED provide the schedule for deep cleaning of the resident rooms for March, April, and May 2024. The ED indicated that there were no logs available to track when deep cleaning of the resident rooms had been completed. On 6/3/24 at 1:25 p.m., the ED provided the Deep Cleaning Practices policy, last revised December 2021, which read Deep cleaning calendars should list rooms and area for each housekeeping assignment area. New calendars should be made out each month, and past months retained for at least 1 year. Each housekeeper when completing a deep clean shall fill out a quality control deep cleaning checklist signed and dated and provide it to the housekeeping supervisor upon completion of the deep clean. The deep cleaning checklist should be used for supervisor to utilize as an inspection tool to ensure the room has been cleaned within standards . 3.1-19(f)(5) 3.1-19(g)(4)

Based on observation, interview and record review, the facility failed to have the Interdisciplinary team (IDT) determine and document a self medication assessment was clinically appropriate for 1 of 1 residents randomly observed with medications by their side in a common area. (Resident 18) Findings include: A random observation of Resident 18 was made on 5/28/24 at 11:12 a.m. Resident 18 was sitting in the common area/lounge on the second floor and on a table beside her was a medication cup with pills in it. The cup had several unidentified medication tablets in it. Resident 18 indicated, she questioned the number of medications in the cup and did not want to take medications without knowing what she was given. An interview with Licensed Practical Nurse (LPN 22) conducted on 5/28/24 at 11:17 a.m. indicated, she had given Resident 22 her morning medications and believed she had placed them in her mouth prior to leaving the resident. LPN 22 indicated, Resident 18 must have spit them out back into the cup after she left the resident. An interview with Resident 18 conducted on 5/28/24 at 11:19 a.m. indicated, she had not spit her medications out into the cup. She indicated, she had not attempted to take the medications as she was concerned with what medications they were. Resident 18's clinical record was reviewed on 5/29/24 at 1:21 p.m. Resident 18's diagnoses included, but not limited to, paranoid schizophrenia, anxiety disorder, and major depressive disorder. The clinical record for Resident 18 did not contain a Self-Administration of Medication assessment. A Quarterly Minimum Data Set, dated dated dated [DATE] indicated, Resident 18 had a moderate cognitive deficit. Resident 18's care plan reviewed at the same time as her clinical record did not contain a care plan regarding her being able to self-administer any medications. A Self-Administration of Medication policy received on 5/29/24 at 1:06 p.m. from Nurse Consultant indicated, Procedure: Alert residents will be informed of their right to self-administer medications upon admission. If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the 'Self-Administration of Medication Assessment' observation. A physician order will be obtained specifying the resident's ability to self-administer medications and, if necessary, listing which medication will be included in the self-administration plan .The resident will be assessed for continued self-administration of medications quarterly and with any significant change of condition. The resident's care plan will be updated to include self-administration. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to provide dependent residents with oral care, complete bed bath, hair care, and emptying of a bedside commode for 3 of 6 residents reviewed for activities of daily living (ADLs). (Resident D, Resident E, and Resident F) Findings include: 1. The clinical record for Resident D was reviewed on 5/31/24 at 3:05 p.m. The diagnoses included, but were not limited to, hypertension, congestive heart failure, diabetes mellitus, and muscle weakness. A care plan for skin integrity, dated 5/21/24, indicated Resident D had impaired skin integrity. He was on bedrest, limited in his ability to change positions, and a problem for shear and friction related to required maximum assistance with bed mobility. A physician order, dated 5/17/24, indicated to perform oral care three times a day. An observation conducted of Resident D, on 5/29/24 at 9:56 a.m., of a white coated substance to his tongue. An observation conducted of Resident D, on 5/29/24 at 10:43 a.m., of a white coated substance to his tongue. An observation conducted of Resident D, on 5/30/24 at 11:45 a.m., of a white coated substance to his tongue along with foam on the inside of his mouth. A skills competency form, review date of 03/2023, was provided by the Director of Nursing (DON) on 5/31/24 at 2:30 p.m. The form indicated to check teeth, mouth, tongue, and lips for odor, cracking, sores, bleeding, and discoloration. 2. The clinical record for Resident E was reviewed on 5/31/24 at 10:31 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, tracheostomy status, dependence on ventilator, muscle weakness, morbid obesity, and diabetes mellitus. An ADL care plan, dated 8/4/22, indicated Resident E required assistance with ADLs including bed mobility, transfers, and toileting related to chronic respiratory failure, anxiety disorder, depression, and debility. An approach was listed to assist with toileting and/or incontinence care as needed. A quarterly minimum data set (MDS) assessment, dated 4/4/24, indicated Resident E was cognitively intact, needed substantial/maximal assistance with toileting hygiene and personal hygiene, and supervision/touching assistance with toilet transfer. An observation conducted of Resident E, on 5/28/24 at 12:15 p.m., of a yellow liquid present in the bedside commode in Resident E's room. Upon interviewing Resident E, she indicated she got up around 6:00 a.m. on 5/28/24 to utilize the bedside commode and it was not emptied at that time. An observation conducted of Resident E, on 5/28/24 at 2:25 p.m., of a yellow liquid still present in the bedside commode of Resident E's room. 3. The clinical record for Resident F was reviewed on 5/31/24 at 10:03 a.m. The diagnoses included, but were not limited to, respiratory failure, diabetes mellitus, obesity, tracheostomy status, gastrostomy status, and dependence on ventilator. An admission MDS assessment, dated 4/1/24, indicated Resident F was dependent for ADLs, totally incontinent of bowel, and an indwelling catheter. An ADL care plan, dated 3/28/24, indicated Resident F required assistance with ADLs including bed mobility, transfers, eating, and toileting related to mobility deficits, respiratory failure, obesity, ventilator status, and muscle weakness. The approach listed to assist with bathing as needed, assist with bed mobility as needed, and assist with toileting and/or incontinent care as needed. An observation conducted of Resident F, on 5/28/24 at 11:23 a.m., of a bed bath being provided by Certified Nursing Aide (CNA) 6. CNA 6 obtained a basin containing soapy water. She started utilizing a washcloth to Resident F's arms, abdomen, and frontal perineal area. CNA 6 obtained a basin of more water to continue to provide a bed bath to Resident F. CNA 6 positioned Resident F to the right side and proceeded to utilize the washcloth to the back, buttocks, and posterior thighs. CNA 6 indicated she completed the bed bath after placing a gown on Resident F and covering her up with a blanket. CNA 6 did not wash Resident F's face, hair, or both legs below the knees, and feet. Resident F's hair appeared greasy and unkept. CNA 6 indicated she attempted to provide all residents on the unit with a bed bath daily, but Tuesdays were Resident F's bathing days. An observation conducted of Resident F, on 5/29/24 at 10:38 a.m., noted her hair appeared greasy. An observation conducted of Resident F, on 5/31/24 at 2:00 p.m., noted her hair appeared greasy. Documents titled shower report were reviewed and indicated the last time a staff member checked to indicate Resident F had shampoo to their hair was 5/10/24. A skills competency form, dated 03/2023, was provided by the DON on 5/31/24 at 2:30 p.m. The form indicated to wash, rinse, and pat dry the face, neck, ears, behind ears, shoulder, underarm, arm, hand, fingers, abdomen, leg, foot, toes, neck, back, buttocks, and anal area. This citation relates to Complaint IN00433435. 3.1-38(a)(2)(A) 3.1-38(a)(2)(C) 3.1-38(a)(3)(A) 3.1-38(a)(3)(B) 3.1-38(a)(3)(C)

Based on observation, interview, and record review, the facility failed to ensure a low air loss mattress was functioning for 2 of 2 residents reviewed for pressure ulcers. (Resident D and Resident 45) Findings include: 1. The clinical record for Resident D was reviewed on 5/31/24 at 3:05 p.m. The diagnoses included, but were not limited to, hypertension, congestive heart failure, diabetes mellitus, and muscle weakness. A care plan for skin integrity, dated 5/21/24, indicated Resident D had impaired skin integrity. He was on bedrest, limited in his ability to change positions, and a problem for shear and friction related to required maximum assistance with bed mobility. An approach was listed to utilize a pressure reducing/redistribution mattress on the bed/low air loss (LAL) mattress. An observation conducted of Resident D, on 5/29/24 at 9:56 a.m., laying on a mattress with a pump to the foot board. There were no lights on the pump to indicate it was on and functioning. An observation conducted of Resident D, on 5/29/24 at 10:43 a.m., laying in bed with the LAL mattress pump to the foot board not having lights on to indicate it was on and functioning. An observation conducted of Resident D, on 5/30/24 at 9:35 a.m., laying in bed with the LAL mattress pump remained without lights on to indicate it was on and functioning. An observation conducted of Resident D, on 5/30/24 at 11:45 a.m., laying in bed with the LAL mattress pump remained without lights on to indicate it was on and functioning. An interview conducted with Respiratory Therapist (RT) 5, on 5/30/24 at 12:10 p.m., indicated there are times where the lights would [NAME] and indicate the generator was activated. When that occurs, he would check resident rooms to ensure all items were working. RT 5 went to the outlet that the LAL mattress was plugged into, but it appeared that it wasn't plugged in entirely into the outlet. RT 5 placed the plug entirely into the outlet and the lights came on for Resident D's LAL mattress. The mattress was observed to be rising when the LAL mattress pump had lights on to indicate it was operational. 2. The clinical record for Resident 45 was reviewed on 5/31/24 at 10:09 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, congestive heart failure, tracheostomy status, gastrostomy status, reduced mobility, muscle weakness, and epilepsy. A significant change minimum data set (MDS) assessment, dated 2/22/24, indicated Resident 45 was dependent on staff for activities of daily living care. A physician order, dated 3/27/24, indicated the utilization of a LAL mattress to Resident 45's bed. A care plan for skin integrity, revised 5/28/24, indicated Resident 45 had a history of impaired skin integrity/pressure injury to their left hip that had healed previously and a history of multiple pressure ulcers. A pressure reducing mattress/LAL mattress was listed as an approach. An observation conducted of Resident 45, on 5/29/24 at 10:33 a.m., with the LAL mattress pump, located on the foot board to the bed, was without lights to indicate it was on and functioning. An interview with RT 5, on 5/29/24 at 10:35 a.m., indicated that the plug came undone that connected to the pump of the LAL mattress. RT 5 plugged the cord into the pump and the lights came on to indicate the pump was on. Resident 45's mattress proceeded to raise after the cord was plugged back into the pump. A policy titled Skin Management Program, dated 5/22, was provided by the Director of Nursing (DON) on 5/31/24 at 2:30 p.m. The policy indicated the following, .PROCEDURE FOR WOUND PREVENTION .3. Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk factors to include but not limited to the following .All residents will have a pressure redistribution mattress .If resident prefers to utilize a mattress or cushion not provided by the facility this will be addressed in the residents care plan 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure flooring was in good condition to prevent accident hazards for a resident that had tripped on loose flooring and had fallen for 1 of 2 residents reviewed for accidents. (Resident E) Findings include: The clinical record for Resident E was reviewed on 5/31/24 at 10:31 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, tracheostomy status, dependence on ventilator, muscle weakness, morbid obesity, and diabetes mellitus. An ADL care plan, dated 8/4/22, indicated Resident E required assistance with ADLs including bed mobility, transfers, and toileting related to chronic respiratory failure, anxiety disorder, depression, and debility. An approach was listed to assist with toileting and/or incontinence care as needed. A quarterly minimum data set (MDS) assessment, dated 4/4/24, indicated Resident E was cognitively intact, needed substantial/maximal assistance with toileting hygiene and personal hygiene, and supervision/touching assistance with toilet transfer. An interview conducted with Resident E, on 5/28/24 at 12:15 p.m., indicated there was a piece of flooring that was not level. She tripped due to her shoe being caught on the floor due to a piece of flooring that was missing. She went to sit on the bed, that was not locked at that time, and she twisted and fell on to her bottom. She was able to see the subfloor due to the missing flooring. An observation conducted during the interview, noted a piece of wood flooring that was present underneath Resident E's wheels to the foot of her bed that were mismatched. Resident E indicated they put that newer flooring down after she fell . A fall event, dated 3/26/24, indicated Resident E had fallen onto the floor while transferring from wheelchair to bed. Resident E stated she tripped on a piece of impaired floorboard and the floorboard was loose. Maintenance was made aware of loose flooring, and they immediately fixed that floorboard. An interdisciplinary team (IDT) note, dated 3/27/24, indicated the root cause of Resident E falling was loose flooring. An interview conducted with Registered Nurse 2, on 5/30/24 at 11:40 a.m., indicated the flooring had been coming up throughout the unit. It started on the 4th floor and now it's on the unit that Resident E resided on. For some reason the floorboard came up and Resident E tripped on it causing her to fall. A policy titled Fall Management, revised 8/2022, was provided by the Executive Director on 5/31/24 at 8:52 a.m. The policy indicated the following, .It is the policy of [name of company/corporation] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls 3.1-45(a)(1) 40287

Based on interview and record review, the facility failed to ensure a dependent resident did not experience a fall from their bed that later resulted in a hospitalization with a nasal fracture, lip hematoma (solid swelling of clotted blood within the tissues), and a clavicle contusion (bruise) for 1 of 1 resident reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/3/23 at 11:46 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, Alzheimer's disease with late onset, attention to tracheostomy, hemiplegia and hemiparesis, muscle weakness, contracture to left and right ankle, and malnutrition. A quarterly minimum data set (MDS) assessment, dated 10/5/22, indicated the inability to perform a mental status assessment, the need for total assistance of 2 staff person for bed mobility, transfers, toileting, and bathing. Also, the need for total assistance of one staff for dressing and personal hygiene. A fall event, dated 12/3/22 at 2:03 p.m., indicated a witnessed fall occurred. The document indicated Resident B had a witnessed fall to where they hit their head. There was a laceration and swelling along with pain. Resident B was nonverbal and unable to voice their needs and wants. Prior to the fall Resident B was lying in bed and after the fall the resident was positioned on the floor lying on their stomach. The summary on how the fall occurred indicated the following, she was providing incontinence care and had resident on her right side. when residents upper body began to slide out. She attempted to grab her, but she was too slippery [sic]. A progress note, dated 12/3/22 at 1:30 p.m., indicated the following, .Writer was notified by staff that the resident had fallen out of bed during check and change. The resident was visualized lying prone on the ground between the bed and window. She was dressed in only a gown and was disconnected from her vent. Writer rolled the resident over and unhooked her from the Gtube [gastrostomy tube] feeding. RT [Respiratory Therapist] stepped in and began to Ambu resident. Upon assessment, the resident sustained a laceration to her lip and hematoma to her forehead. At baseline resident is non verbal, unable to articulate orientation or follow commands An interview conducted with Certified Nursing Assistant (CNA) 2, on 1/3/23 at 12:18 p.m., indicated Resident B just slid off the mattress when she was providing care. Resident B had 2 padded things on both sides of her bed. She conducted care with the padded items on the bed because the resident doesn't have side rails. Resident B slid off towards the head of the bed. She was laying on her right side. She required total assistance with care and was not able to move. When she turned, the machine she was on had her coughing and it jerked her. When she jerked her whole body moved while she was on her side. She went headfirst when she fell . The bed was positioned flat. Resident B proceeded to be on her right side, coughed, and then slid while on her side. Resident B was on a special mattress for her skin, but her daughter put lotions and oils her up with Vaseline and stuff. The daughter does that often. Resident B's whole body was covered. CNA 2 wasn't sure if the daughter came in on 12/3/22. An interview conducted with Corporate Nurse 3 on 1/3/23 at 3:50 p.m. indicated Resident B was on a specialty mattress that had bolsters, but the bolsters were a part of the mattress and did not disconnect from the mattress. The mattress was described as having individual pockets that fill up with air and that didn't require the need to have any specialty instructions for any type of linen to place on the mattress. With the mattress the nursing staff would be able to place a fitted sheet to have linen underneath the resident. An interview conducted with Family Member (FM) 5, on 1/4/23 at 9:46 a.m., indicated she did not receive a phone call from the nursing facility in regards to Resident B falling from her bed. She received a phone call from the emergency room physician around 6:20 p.m. and was asked questions about Resident B. This was when she was made aware of Resident B being in the hospital. Resident B had been in the hospital at 4 hours at that point. FM 5 indicated Resident B flipped over the bolsters and hit the nightstand with the side of her face. The bed bolsters were not there to secure her while changing her. She was a 2-person assist with transfers and care. There was only 1 person caring for her. She was 183 pounds. The CNA rested Resident B's body against the bolsters and when the CNA pushed Resident B over, she landed over them and onto the floor. There was another CNA on the Ventilator unit that should have been in the room but they were not. Resident B had been at the facility since March of 2013. She ended up having a fractured nose, hematoma to her face, bilateral black eyes, and was unstable in the intensive care unit for days. Resident B was on a standard mattress while at the facility. The bed bolsters were just added protection. There were separate from the mattress and they attached to the bed frame. The bolsters were not meant for support. Resident B couldn't lift her legs nor her body. Her right side was contracted. Resident B had Aquafor but she was out of Aquafor. The last time she was there visiting Resident B was the day prior to the incident on 12/3/22. FM 5 doesn't recall what condition her skin was like at the hospital besides the swelling and bruising to her face. A hospital document, dated 12/3/22, indicated the following, .History and Physical .What was described to me is that while repositioning and turning her in the bed, the top half of her body got over the rail and she ultimately fell to the floor face first. After the event her vital signs were similar .Assessment/Plan .1. Trauma .has nasal fracture .lip hematoma, right periclavicular contusion A Skills Validation document titled OCCUPIED BED, dated 02/2010, was provided by the Executive Director on 1/3/23 at 2:27 p.m. The document indicated the following, .8. Lower head of bed .9. Drape resident .10. Turn resident on side, away from staff .11. Loosen bottom sheet and roll sheet toward resident tucking it snugly against the resident's back .12. Unfold clean bottom sheet on center of bed and fit corners over mattress .14. Slowly turn resident onto back then to other side over roll of linen .27. Document and report any unexpected findings This Federal tag relates to Complaints IN00397558 and IN00397604. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide a resident with adequate assistance of 2 staff members for bed mobility. This resulted in a fall with a [CONDITION(S)] for 1 of 3 residents reviewed for accidents (Resident B). Findings include: The clinical record for resident B was reviewed on 5/10/22 at 9:42 a.m. The Resident's diagnosis included, but were not limited to, fractured right hip and [CONDITION(S)] (inability to move one side of the body). A Physical Therapy Progress and Discharge Summary, dated 12/22/21, indicated he required total assistance rolling side to side in bed. He was dependent of the helper to do all the effort of turning. Assistance of 2 or more helpers was required for him to complete the activity. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/3/22, indicated he required total assistance of 2 staff members for bed mobility and toileting. An Occupational Therapy Discharge Summary, dated 3/20/22, indicated his self-care function score was 0 (Score 0-12; 12 being the highest function). His mobility function score was 0 (Score ranges from 0-12; 12 being the highest function). He required 70 to 75 % assist to safety roll from side to side. A care plan, with a start date of 12/3/21, indicated he was at risk for falls due to immobility, requiring assistance with ADL (Acts of Daily Living) care, lack of understanding, altered awareness and various medications. The goal was for his fall risk to be reduced in an attempt to avoid significant fall related injury. The approaches included, but were not limited to, nonskid footwear, initiated 12/3/21, call light in reach, initiated 3/24/22, personal items in reach, initiated 3/24/22. A Fall Event Report, dated 3/25/22, indicated he had fallen from bed while staff were providing care. He had rolled onto the floor and was in a sitting position by the bed. The interventions that was put into place was for 2 staff to assist with ADL care. An IDT (Interdisciplinary Team) progress note, dated 3/28/22 at 1:32 p.m., indicated the root cause was determined to be that staff was performing adl care and he had rolled out of bed. The intervention to be put in place to address the root cause was for 2 staff members to assist with all adl care. The care plan was updated with the new intervention. A Significant Change of Status MDS (Minimum Data Set) Assessment, completed 3/29/22, indicated he required extensive assistance of 2 staff members for bed mobility and toileting. A progress noted, dated 4/19/22 at 11:11 p.m. read Resident receiving care. Staff member pulled resident toward him. Resident backside facing CNA [Certified Nursing Assistant]. Resident the [sic] rolled off LT [sic] side of bed. Landing on RT [sic] side. Struck dresser with Lt[sic] side of head and his back. This nurse entered room. Resident against dresser and awake . Assisted to bed .Call placed to MD [sic]. Sent to ER [sic] to Tx[sic] and eval[sic] 911 called to transport . A CT (Computerized Tomography) Scan was performed on 4/20/22 at 4:11 a.m. at the acute care hospital. The findings indicated there was a minimally displaced proximal right femoral neck (hip) fracture. A Provider Consult Note, dated 4/20/22, indicated that the CT scan and x-rays were reviewed. Resident B was in some pain but was otherwise comfortable. His POA (Power of Attorney) was with him. They did not want to proceed to surgery. The POA was concerned that he would not make it through the surgery. The plan was to treat the fracture non operatively. An IDT progress note, dated 4/21/22 at 10:08 a.m., indicated the root cause of the fall was that resident slid off the bed. The intervention to be put in place to address the root cause of the fall was to order a 42-inch low air loss mattress with bolsters. The care plan was updated with the new intervention. On 5/10/22 at 12:37 p.m., the DON (Director of Nursing) provided the investigation file for the fall on 4/19/22. It contained a statement from LPN (Licensed Practical Nurse) 12, who was on duty at the time of the fall. It indicated that the CNA had asked for her assistance in providing care and he was at the bed as the nurse entered the room to assist. She had witnessed Resident B slide off of the mattress. During an interview on 5/10/22 at 2:05 p.m., Physical Therapist 2 indicated she had not seen him since he was discharged from Physical Therapy in December 2021. He had needed 2 people to assist with bed mobility at the time he was discharged . He had not been referred back to therapy due to any changes in his bed mobility. He required 2 staff members to safely provide bed mobility. During an interview on 5/10/22 at 2:21 p.m., the Therapy Manager indicated he had recently been seen by occupational therapy to establish a range of motion and splinting program. He would need 2 people to assist him with bed mobility. During an interview on 5/10/22 at 3:35 p.m., CNA (Certified Nursing Assistant) 15 indicated she was not present when he fell out of bed either time. She always used 2 people to provide bed mobility and turn him because he was a big guy. During an interview on 5/11/22 at 9:24 a.m., CNA 16 indicated he had been providing care for him on 4/19/22 when he slipped off of the bed. He had asked the nurse to help him change Resident B. She had gone to get something and was coming to assist me. I slid him toward the left side of the bed, getting ready to change his brief. I looked over and tried to grab the brief off of the dresser. He just slipped off the bed. Confidential interviews were conducted during the course of the survey. They indicated that he had fallen twice during his stay at the facility, both times there had been only one person assisting him when he fell . After the second fall on 4/20/22 he had been sent to the emergency room and the fracture was found. He can not move his right side at all. He is really only able to move his left hand and arm. The facility had recently gotten him a new mattress. The old mattress had been slippery, which may have contributed to the falls. On 5/11/22 at 8:31 a.m., the DON provided the Fall Management Program Policy, revised 11/2017, which read .It is the policy of . to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .5. Residents who are categorized as moderate to high risk should had fall interventions implemented based on resident specific factors .Post fall .6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls . This Federal Tag relates to complaint IN 872. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a treatment was initiated for an identified alteration of skin integrity for a resident with a history of skin impairment to where 2 unstageable pressure ulcers were identified for 1 of 3 residents reviewed for skin impairment. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/29/20 at 6:30 p.m. The [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 10/13/20, indicated extensive assistance with personal hygiene, toileting, dressing, bed mobility and transfers for Resident B. He was marked at risk for developing pressure ulcers. A care plan for skin integrity, dated 5/1/19, indicated the following, .Resident is at risk for skin breakdown or further skin breakdown due to: walks occasionally, decreased sensation to extremities, mobility slightly limited, potential friction and shearing problem, incontinent episodes; Dx (diagnosis) of DM (diabetes mellitus) type 2 with [MEDICAL CONDITION] .Approach .Assess and document skin condition weekly and as needed .Encourage resident to turn and reposition at least every 2 hours; provide assistance as needed A care plan for impaired skin integrity, dated 10/21/20, indicated the following, .Resident has impaired skin integrity: Right heel diabetic non-pressure ulcer related to decreased sensation to extremities .Approach .Treatment as ordered .Turn and reposition every 2 hours .Wound Location: Right heel A physician order, dated 11/3/20, indicated [MEDICATION NAME] was used as treatment for [REDACTED]. A Weekly Summary, dated 12/7/20, indicated Resident B had an open area to his right heel. A Weekly Wound Review document, dated 12/9/20, was completed for Resident B. The document indicated a stage 4 Diabetic Non-Pressure Ulcer was present to the right heel. There were no other skin impairments noted for Resident B. A document titled Wound Management, dated 12/9/20, indicated a stage 3 ulcer to Resident B's right heel measuring 4 centimeters in length by 6 centimeters in width with 0.3 centimeters in depth. The area was covered by 25% slough tissue. Upon review of the progress notes, Resident B was found to test positive for COVID-19 via rapid test on 12/11/20. He was moved to the COVID unit on 12/14/20. A document titled New Skin Event, dated 12/18/20, indicated an open area was identified to Resident B's sacrum measuring 11 centimeters in length by 15 centimeters in width with 0.1 centimeters in depth. There was yellow slough to the wound bed with an abdominal pad and secure with tape noted under preventative measures. There were no treatment orders to the identified area to Resident B's sacrum, on 12/18/20, noted under physician orders [REDACTED]. A Weekly Summary, dated 12/23/20, indicated an area was identified to Resident B's left buttock and right heel. A Wound Management document, dated 12/23/20, indicated an unstageable ulcer was identified on Resident B's left hip. The area measured 10 centimeters in length by 9 centimeters in width with no depth measured. The wound was covered with 50% slough tissue. Another Wound Management document, dated 12/23/20, indicated an unstageable ulcer was identified on Resident B's sacrum. The area measured 11 centimeters in length by 16.5 centimeters in width with no depth measured. The wound was covered with 100% slough tissue. Another Wound Management document, dated 12/23/20, indicated the wound to Resident B's right heel was declining. The area measured 7 centimeters in length by 9 centimeters in width with 0.2 centimeters in depth noted. The area was covered by 80% of eschar tissue. A care plan for impaired skin integrity, dated 12/23/20, indicated the following, .Resident has impaired skin integrity: Pressure wounds to sacrum and left hip r/t (related to) recent COVID 19 (sic) infection with decreased activity and mobility A physician order, dated 12/24/20, indicated the following, .Santyl .cleanse sacral wound and left hip wound with normal saline. Pat dry. Apply thin layer of Santyl to wound bed and cover with ABD dressing; secure with tape .Once A Day There were no previous treatment orders for Resident B's identified skin impairment to the sacrum and left hip prior to 12/24/20. The progress notes indicated Resident B was found unresponsive and sent to the hospital on [DATE]. Hospital records, dated 12/24/20, indicated the following, .He has been unresponsive since admission to the ER (emergency room ) .Assessment/Plan .1. Pneumonia due to COVID-19 virus .2.[MEDICAL CONDITION] Hospital records titled Wound Care Note, dated 12/28/20, indicated Resident B had an unstageable ulcer to his right heel that measured 4.6 centimeters in length by 6 centimeters in width with 0.2 centimeters in depth. The depth was obscured by necrosis and 75% to 100% of the wound was covered with soft, black eschar. There was an unstageable pressure ulcer to the left ischium measuring 15 centimeters in length by 7.6 centimeters in width with 0.1 centimeters in depth. The depth was obscured by necrosis possible osteo[DIAGNOSES REDACTED] and consisted of 75% to 100% of soft, black eschar. There was an unstageable pressure ulcer to the sacrum measuring 20 centimeters in length by 7 centimeters in width with 5 centimeters in depth. There was full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. There were recommendations for a nutritional consult, surgery consult, and a workup for osteo[DIAGNOSES REDACTED]. An interview conducted with the Executive Director (ED), on 12/29/20 at 5:30 p.m., indicated the wound nurse quit this past Sunday and the Director of Nursing (DON) was covering but she is out sick right now. That left the Assistant Director of Nursing (ADON) to cover the wound rounds but she was new to the position and still training. The Certified Nursing Assistants (CNAs) should be doing their rounds and if they find any skin alteration, they are to notify the charge nurse who then notified the DON and/or wound nurse to follow-up with the skin alteration. A policy titled SKIN MANAGEMENT PROGRAM, dated 7/2020, was provided by the ED on 12/29/20 at 6:07 p.m. The policy indicated the following, .Wound Nurse: The facility will designate license nurse responsible oversight and coordination of the skin management program. The wound nurse and/or IDT (interdisciplinary team) will review, assess and document on any new skin alterations in skin integrity the following business day to determine root cause and implement wound/skin integrity healing interventions and then on a weekly basis .4. Residents identified at risk for pressure ulcer/injury and those with pressure ulcer/injury will have an individualized care plan developed with specific risk factors and contributing factors including preventative measures .6. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes .PROCEDURE FOR ALTERATIONS IN SKIN INTEGRITY - PRESSURE AND NON-PRESSURE .5. The wound nurse/designee will be notified of alterations in skin integrity .a) The wound nurse/designee is responsible for communicating to IDT on a weekly basis by utilizing the Composite Report .i) Wound Management for ulcers (arterial, diabetic, pressure or venous) will be updated weekly until resolved .7. IDT will review residents with alterations in skin integrity weekly following the IDT Weekly Wound Round Policy This Federal tag related to Complaint IN 231. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident with a signed DNR (Do Not Resuscitate) did not receive CPR (cardiopulmonary resuscitation) when breathing had ceased for 1 of 33 residents with a signed DNR directive causing the resident to be revived, transported to the hospital and placed on ventilator support (Resident B, LPN #1) in a sample of 4. Findings include: The record for Resident B was reviewed on [DATE] at 10:15 a.m. [DIAGNOSES REDACTED]. Resident B's record included an "Out of Hospital Do Not Resuscitate Declaration and Order," signed on [DATE] by Resident B's responsible party. A Care Plan, dated [DATE], indicated Resident B was a no code, DNR. The goal indicated "Resident will not receive CPR." Interventions included, but were not limited to, "Facility to honor resident choice." A Nursing Progress Note, dated [DATE] at 1:30 p.m. indicated during a routine dressing change, the resident was found to be non-responsive. The RT (Respiratory Therapist) was called to the room and began suctioning the resident who remained unresponsive. The nurse called 911, CPR had been initiated and the EMTs (Emergency Medical Technicians) arrived and took over Resident B's care, transporting her to the hospital. During an interview with the HFA (Health Facility Administrator) on [DATE] at 9:50 a.m., she indicated Resident B had stopped breathing, the nurse panicked and got the RT who initiated CPR. The HFA also indicated during this interview Resident B was a DNR, and facility protocol was not followed, it "never should have happened." The HFA indicated she had called the resident's responsible party and apologized and explained to him what had happened. During an interview with LPN #1 on [DATE] at 4:30 p.m., she indicated she "froze", she was "nervous, had never been in a code before." LPN #1 also indicated if she had it to do over again, she would have checked her daily report sheet, containing each resident's name and code status before anything else was initiated. A current facility policy, dated ,[DATE] and last revised ,[DATE], titled "Do Not Resuscitate" was provided by the HFA on [DATE] at 10:30 a.m. The policy indicated: "Policy: It is the policy of this facility that all residents/responsible parties will be given the right to formulate an advanced directive for 'DO NOT RESUSCITATE' at admission/readmission.... ...15. The signed and dated OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION AND ORDER yellow form will be placed in the resident's chart under the advanced directive section.... ...17. The DNR order will also be indicated on the resident's Medication Administration Record...." This federal tag relates to Complaint IN 178. 3XXX,[DATE](a)

1a. Based on interview and record review, the facility failed to ensure a resident with [MEDICAL CONDITION], a Foley catheter, and on antibiotics for a urinary tract infection was adequately assessed/monitored for changes in health status; and 1b. The facility failed to ensure a resident on an antibiotic for aspiration pneumonia was adequately assessed/monitored for changes in health status resulting in hospitalization for a critical illness for 1 of 8 residents reviewed for hospitalization (Resident #56). 2. Based on observation, interview, and record review, the facility failed to effectively manage a resident's pain by failing to administer pain medication as ordered and failing to subjectively assess for efficacy following administration of pain medication for 1 of 2 residents reviewed for pain control (Resident #86). Findings include: 1a. Resident #56's record was reviewed on 11/4/2013 at 9:11 A.M. Resident #56 was admitted to the facility on [DATE], and had current [DIAGNOSES REDACTED].). Admission vitals recorded on 8/29/2013 at 10:02 P.M., indicated Resident 56's oxygen saturation (O2 sat) was 98% on room air, blood pressure (b/p) 108/68, respirations (R) 18 per minute, and his pulse was 99 beats per minute. An admission nursing assessment note dated 8/30/2013 at 12:45 A.M., indicated Resident #56 was alert and oriented to person and place, incontinent of urine, and had clear breath sounds without respiratory distress. A social service note dated 9/4/2013 at 2:30 P.M., indicated Resident #56 was cognitively intact with a BIMs (Brief Interview Mental Status assessment) score of 13 and was a full code. A nurse's note dated 9/5/2013 at 2:57 P.M., indicated Resident #56 had to be catherized via an in and out catheter due to [MEDICAL CONDITION] with eight hundred ml (milliliters) of dark, amber, cloudy, urine noted. An untimed telephone physician's orders [REDACTED]. A nurse's note dated 9/5/2013 at 6:30 P.M., indicated Resident #56 was catherized due to [MEDICAL CONDITION]. The nurse performed I/O (In and out catheter) and noted "1200 mls" of "very dark reddish-black urine with very bad odor." A nurse's note dated 9/6/2013 at 8:56 A.M., indicated the facility notified the physician regarding Resident #56's [MEDICAL CONDITION]. The physician gave orders to anchor a Foley catheter, start IV fluids, and ordered a BMP (basic metabolic panel) to be drawn on 9/7/2013. The record lacked documentation the BMP lab was obtained. The record lacked documentation which indicated staff assessed Resident #56's urine and/or monitored his urine output on the following dates: 9/6/2013, 9/7/2013, 9/10/2013, 9/14/2013, and 9/16/2013. During an interview on 11/5/2013 at 10:13 A.M., the DON indicated the facility did not have documentation which indicated the lab company had attempted to obtain the ordered lab prior to 9/11/2013. The DON indicated the lab informed her they attempted to obtain the lab on 9/11/2013 however Resident #56 refused three times so they did not attempt again. The facility did not notify the doctor the lab had not been drawn the day it was ordered. The DON indicated on 9/12/2013, when the facility realized the lab had not been drawn, the physician was notified and he reordered the BMP to be drawn on 9/13/2013. A lab report record dated 9/13/2013 at 3:01 P.M., indicated a BMP lab was obtained from Resident #56. This document indicated a creatinine level of 0.5 low (normal ranges of 0.6 to 1.3) and a BUN/CREAT RATIO of 48 high (normal ranges 6-25). A comparison result drawn on 9/5/2013, indicated a creatinine level of 0.6 and a BUN/CREAT RATIO of 37. This report indicated a decline in Resident #56's status. During an interview with the Director of Nursing (DON) and the Executive Director (ED) on 11/4/13 at 1:34 P.M., the DON indicated if a resident had a Foley catheter urine needed to be measured. During an interview on 11/5/2013 at 2:00 P.M., the DON indicated after Resident #56 had a Foley catheter inserted due to [MEDICAL CONDITION] and antibiotics for a urinary tract infection, staff did not consistently monitor urine output and/or assess Resident #56's urine. A document titled "American Senior Communities Medicare Documentation Guideline" dated 10/09, provided by the DON on 11/4/2013 at 1:41 P.M., indicated, ".... recommended documentation to support daily skilled services.... Urinary/Urinary Tract Infection: Hydration status, description of urine-color, odor, consistency, S/S (signs/symptoms)-chills, nausea, vomiting, flank/abdominal pain, fever, malaise, frequency, urgency, dysuria, mental status change, administration of antibiotics, resident response, side effects, presence of catheter-insertion, irrigation, replacement...." 1b. A nurse's note documented on 9/17/2013 at 3:39 A.M. for events that occurred on 9/16/2013, indicated, "...writer came on shift at 2 pm at that time resident continued with ABT(antibiotic), but showed no S/S of any distress. At 3 pm (sic) aide had writer help transfer resident to shower chair. While in shower resident experienced resp. (respiratory) distress. Writer helped aide return resident to his bed. At that time V/S (vitals) were (temperature) 96.8 (degrees Fahrenheit) (blood pressure) 108/68 (pulse) 124 (oxygen) 02 sat (saturation) 82% and resp. rapid and labored at 24. Writer obtained O2 and was able to increase O2 sat to 88 % on 4 liters. resident (sic) was also suctioned at this time, writer obtained a large amount of very thick white mucus with particles of food imbedded in it. Writer called the MD and received new orders to change the current antibiotic to..., Stat (immediately) Chest X-ray, for possible asperation (sic).... Through out the night resident has shown a steady decline, but has remained responsive. V/S (vitals) at this time (temperature) 96.6, (blood pressure b/p) 112/64 (pulse) 110 (oxygen saturation) 88% on 4 liters O2, (respirations) rep. rapid and shallow at 26, blood sugar 86. Will continue to monitor." A physician's telephone order dated 9/16/2013 at 6:00 P.M., indicated orders which included a stat chest x-ray and for O2 (oxygen) as needed to keep Resident 56's oxygen saturations above 90%. The chest x-ray results, received on 9/17/13, indicated an early infiltrate in the right upper lung field. The record lacked documentation to indicate lungs sounds/respiratory status were assessed following identification of the infiltrate. The record lacked documentation to indicate oxygen saturation was monitored and interventions implemented to ensure Resident 56's oxygen saturation was maintained above 90% per the physician's orders [REDACTED]." An ED (Emergency Department) Progress Note, dated 9/17/13 at 1:05 p.m., indicated, "...from ECF (Extended Care Facility) per EMS (Emergency Medical Services) for difficulty breathing...breathing slowly and hypoxic...with GCS (Glasco Coma Scale) of 4. Gross hematuria...SBP (systolic blood pressure) 70...lack of responsiveness...In the ED foley catheter changed over and urine appears frankly purulent...acute [MEDICAL CONDITION], metabolic acidosis, [MEDICAL CONDITION]." An emergency room physician's report dated September 17, 2013 at 1:13 P.M., indicated, "...At facility was being treated for [REDACTED]. Facility y staff noted patient to be less responsive than baseline this am, and called EMS. He was noted to have a [MEDICATION NAME] on, ems removed and administered 0.4 [MEDICATION NAME]. On arrival patient is breathing slowly w/a (with a) GCS (Glasco Coma Scale) of 4. SBP (systolic blood pressure) of 117. Intubated for... inability to protect airway....Respiratory Rate 24 br/min (beats per minute) Hi...Severe distress, ill-appearing... Respirations: Respiratory distress moderate, labored...glasgow coma scale (GCS): Total score 4...." This report indicated Resident 56's arterial blood gas results indicated his oxygen saturation was low at 84%. A late entry nurse's note documented after Resident #56 was sent to the emergency room dated 9/17/2013 at 2:38 P.M., indicated, "Res was not given his scheduled morning narc (narcotic) due to him being transferred to the ER. Res had noted blood in his urine; no abdomonal (sic) distension noted at the time. Res skin has continued to be clammy and sweaty since this mornings rounds. Treatment to non pressure wounds were completed as oedered (sic). Res was sent out to the ER around noon due to low stats (sic)..." An acute care hospital critical staff progress note dated September 17, 2013 at 3:17 P.M., indicated Resident 56 had been admitted from the emergency room for, "...urosepsis secondary to obstruction at prostatic site admitted from ER for ams (altered mental status)/SHOCK/aCUTE RENnal (sic) failure, [MEDICAL CONDITION]. Dependent [MEDICAL CONDITION] opacities may represent aspiration or infection...impression and plan... Neuro/Psych...Likely a combo of Infection/Sepsis/[MEDICAL CONDITION] multiple sedative pain meds on [MEDICAL TREATMENT]...Borderline BP with Lactic acidemia, WEBC (sic) count---Possible source PICC/URINE/?/Pneumonia.... [MEDICAL CONDITION] Intubated for airway protection, being hyperventilated for maintaining PH... Bibailar atelectasis/Aspiration+Pneumonia....Infectious [MEDICAL CONDITION] secondary to Line infection vs Urine vs Pneumonia... Significant leucocytosis-Sepssi (sic) most likely dehydration is a possibility... altered mental status... [MEDICAL CONDITION] pneumonitis...Hypoxemia..., [MEDICAL CONDITION] insufficiency... Acidosis..., [MEDICAL CONDITIONS] systemic [MEDICAL CONDITION] response syndrome (SIRS)... Urinary tract infection...critically ill patient....." A nurse's note dated 9/17/2013 at 4:24 P.M., indicated, "writer notified by ER nurse res was admitted with urosepsis and acute [MEDICAL CONDITION]" During an interview regarding facility expectations for nursing care related to aspiration, on 11/4/2013 at 10:05 A.M., the Infection Control Nurse stated, "...I would absolutely expect lung assessments. I will see what policy we have but it is standard nursing for residents with aspiration." The Infection Control Nurse indicated Resident #56 was sent to the emergency room due to a low blood pressure and low O2 saturation. During this interview documentation of all lung assessments and vitals completed for Resident 56 were requested. During an interview with the Director of Nursing (DON) and the Executive Director (ED) on 11/4/13 at 1:34 P.M., the DON indicated the facility did not have a specific policy which indicated a nurse should do a lung assessment for residents being treated for [REDACTED]. The DON indicated if a resident had orders to have their O2 sats maintained at a certain level oxygen saturation monitoring should have been done, at a minimum, of each shift. She indicated she would check but did not think the facility had a specific policy. A document titled "American Senior Communities Medicare Documentation Guideline" dated 10/09, provided by the DON on 11/4/2013 at 1:41 P.M., indicated recommended documentation to support daily skilled services. "...Pulmonary disease/Pneumonia/respiratory: Lung sounds, ability to cough and deep breathe, description amount of sputum, presence and type of cough, oxygen (liters/delivery)-tolerance, activity tolerance/endurance, episodes of dyspnea/apnea, changes in mental status, physician notification/order changed, [MEDICAL CONDITION]-location, amount, interventions...." During an interview on 11/4/2013 at 1:41 P.M., the Executive Director indicated the American Senior Communities Medicare Documentation Guideline was not a facility policy. She further indicated it was a guide line recommended for skilled assessments and documentation for residents on Medicare. The ED indicated Resident #56 was not on Medicare but was on Medicaid therefore the skilled services and documentation were not required in his case. During an interview on 11/5/2013 at 2:00 P.M., the DON indicated after Resident #56 had aspirated and was started on antibiotics to treat aspiration pneumonia, documentation was not available which indicated his respiratory status was consistently assessed per standards of nursing care. During the exit conference on 11/5/2013 at 3:00 P.M., the DON and ED were asked if they had any further information or documentation. Both the DON and ED indicated they did not have further documentation or information regarding Resident #56. 2. Resident #86's record was reviewed on 11/2/2013 at 10:30 A.M. Resident #86 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Assessment Tool ((MDS) dated [DATE], indicated Resident #86 was cognitively intact with a BIMs (Brief Interview Mental Status) score of 15 out of 15. Physician orders [REDACTED]." During observations on 10/29/2013 at 9:43 A.M., Resident #86 was observed to repeatedly moan and rub his left leg. During an interview at this time, Resident #86 stated, "I've been trying to get medicine since 9:00." Resident was observed to point at the clock in his room. Resident #86 stated, "I have put on the light about a hundred times. My pain is a 10. The last time I had pain meds (medications) it was five A.M. It is in my left leg and foot." Resident #86 indicated the pain was so bad he couldn't stand for anyone to touch his leg even for bathing. At this time (10:00 A.M.), Licensed Practical Nurse (LPN) #8 entered Resident #86's room. LPN #8 stated, 'I will see if you have PRN (as needed) [MEDICATION NAME]. Things change. I was off." Resident #86 stated, "I've been trying to get pain medicine for an hour." LPN #8 stated, "You had pain med at 6:00." Resident #86 stated, "It wasn't 6:00 it was 5:00." LPN #8 stated, "With him I go by how he acts. If he is up and around in his wheel chair then I know medicine is working. I don't go by what he says. I go by visual." During an interview on 10/29/2013 at 10:28 P.M., Unit Manager #9 indicated the facility utilized the 1:10 pain scale unless a resident was non-verbal." Unit Manger #9 indicated it wasn't for her to determine if they are not in pain. If the resident is verbal they use the pain scale. During an interview with the Director of Nursing (DON) and the Executive Director (ED) on 11/4/13 at 1:34 P.M., the DON indicated the pain scale used by the facility was in the policy and pain should be assessed before and after pain medication is given. Pain is what the patient says it is. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 10/20/13 at 2 A.M. for complaints of severe pain. The record lacked documentation of the effectiveness of the pain medication. 10/21/2013 at 10:00 P.M. for complaints of severe pain. A nurse's note dated 10/21/2013 at 10:02 A.M. indicated, "...pain meds given x 1 and was effective..." A nurse's note dated 10/21/2013 at 11:35 A.M., indicated, "resident continues to be very aggressive. resident was requesting for pain medication every hour." 10/22/2013 at 2:00 A.M. "c/o generalized severe pain-effective." A nurse's note dated 10/22/2013 at 2:36 A.M. indicated, "res resting at this time. voiced c/o generalized pain and severe pain in bil (bilateral) feet d/t (due to gout. prn (as needed) given and effective...." 10/22/2013 at 4:00 P.M. for "generalized pain." At 5:00 P.M. documentation indicated, "effective." 10/23/2013 at 10:33 (AM or PM not specified)- for complaints of pain "7-feet and elbow." 11:33 effective "better." 10/24/2013 at 10:40 P.M. complaints of "severe pain effective." 10:24/2013 at 2:40 A.M. complaints "pain effective." 10/26/2013 at 2:00 A.M. complaints of "pain in feet effective." A nurse's note dated 10/26/2013 at 2:47 A.M., indicated, "Resident compaines (sic) about nausea and pain in left lower part of leg. Resident was given [MEDICATION NAME]-PRN. [DEVICE] worked propertly (sic). Resident most of night spent on the wheelchair." A nurse's note dated 10/26/2013 at 11:52 A.M., indicated, "resident c/o pain and nausea. res was given prn [MEDICATION NAME] and [MEDICATION NAME]. resident continued asking for more pain medicine. resident was redirected calmly and the (sic) he fell asleep." The MAR indicated [REDACTED].M. (9 hours and 52 minutes earlier). The record lacked documentation PRN pain medication was given as ordered. 10/26/2013 at 6:00 P.M. 1"10/10-severe foot pain-effective." A nurse's noted dated 10/26/2013 at 9:12 P.M., "res c/o (complaints of) pain severe pain to BLE (bilateral lower extremity) r/t (related to) gout x 1 this shift relieved by prn pain..." A nurse's note dated 1027/2013 at 5:02 P.M., indicated a nurse called the nurse practitioner (NP) with "concerns" about Resident #86's "prn pain med, dose, and frequency of need for med." The NP gave a new order for "an increase in Tylenol 650 mg q (every) 6 hr (hours)." This note indicated, "...that MD will need to eval res for change in meds and communication will happen on Monday morning 10/28/2013." The record lacked documentation the the Tylenol was administered. 10/28/2013 at 2:00 A.M. complaints of "left foot pain-8 out of 10." "Effective-2:30 A.M." 10/28/2013 at 6:00 A.M. complaints of "left foot pain-8 out of 10." "6:35 effective." 10/29/2013 at 1:00 P.M. "severe pain-effective." A nurse's note dated 10/29/2013 at 3:26 P.M., indicated, "resident complained of pain several times during the shift, resident was seen by NP and new orders were given...." 10/29/2013 at 5:00 P.M. "severe pain-effective." 10/29/2013 at 2:00 A.M. "complaints of leg pain - 8 out of 10-effective 3AM." 10/29/2013 at 6:00 A.M. "c/o (complaints) leg pain 8 out of 10." "Effective at 7 am." 10/30/2013 at 10:00 A.M. "c/o leg pain - 8 out of 10-effective at 11 am." 10/30/2013 (time not legible) "c/o severe pain" "Effective," 10/31/2013 at 2:00 P.M. "co pain." "Effective." 10/31/2013 at 6:00 P.M. "c/o leg pain-effective at 6:30 P.M." 10/31/2013 at 10:00 P.M. "c/o leg pain -8 out of 10-effective at 10:30 P.M." A nurse's note dated 10/31/2013 at 8:07 P.M., indicated, "...Resident has requested pain medication q 4 hours...." 11/1/2013 at 2:30 A.M. "Pain-effective 5:30 A.M." 11/1/2013 at 2:00 P.M. "leg pain 8 out of 10-helpful-2:20 P.M." 11/1/2013 at 6:00 P.M. "leg pain 8 out of 10-helpful-6:30 P.M." 11/1/2013 at 10:00 P.M. "leg pain 8 out of 10-helpful-10:30 P.M." A nurse's note dated 11/2013 at 11:38 P.M., indicated, "...Prn [MEDICATION NAME] gaven (sic) at 2;00 (sic) pm, 6:00 pm and 10:00 pm, for C/O leg pain...." 11/2/2013 at 2:30 A.M. "leg pain effective 3:30" A nurse's note dated 11/2/2013 at 7:23 A.M., indicted "resident complain of pain. PRN medication given as ordered with effect...." 11/2/2013 at 11:00 P.M. "leg pain effective 12:02." 11/2/2013 at 3:00 A.M. "leg pain effective 4a." 11/2/2013 at 10:00 A.M. "pain in legs-up mobile wheel chair." The record lacked documentation of the effectiveness of the pain medication. 11/2/2013 at 3:00 P.M. " pain in legs-up w/c mobile." The record lacked documentation of the effectiveness of the pain medication. 11/2/2013 at 8:00 (A.M. or P.M. not indicated) "pain in feet-up mobile." The record lacked documentation of the effectiveness of the pain medication. 11/3/2013 at (time not legible) "up w/c c/o foot pain-up mobile." The record lacked documentation of the effectiveness of the pain medication. 11/3/2013 at 3:00 P.M. "...legs-up mobile." The record lacked documentation of the effectiveness of the pain medication. Resident #86's care plan dated 10/28/2013, indicated Resident 86 had a problem with pain and was at risk for pain related to Gout. A goal listed indicated Resident 86 would have pain relief within 30 minutes of intervention. Approaches listed to meet this goal included: Administer meds as ordered, document effectiveness of PRN medication, notify MD if pain is unrelieved and/or worsening, observe for non verbal signs of pain, offer non pharmacological interventions such as quiet environment, rest, shower, back rub, and/or reposition. The record lacked documentation which indicated the facility consistently documented Resident #86's level of pain, location of pain, the efficacy of the PRN pain medication, used a measurable method to determine the efficacy of the PRN medication, consistently administered PRN pain medication when indicated as ordered, and/or administered scheduled pain medication (Tylenol) as ordered. A facility policy dated 1/3/2013 and identified as current by the ED on 11/4/2013 at 11:05 A.M., indicated, "It is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, including pain management. it is the responsibility of the facility to ensure each resident is assessed for pain, and the efficacy of pain medication, while keeping the resident as comfortable and pain free as possible.... The following guidelines will be used when assessing pain. INTERVIEWABLE RESIDENT The pain management program will be determined based upon the resident's verbal response to the questions on the pain assessment/interviewable resident. Pain medications will be prescribed and given based upon the intensity of the pain as follows: MILD, MODERATE, SEVERE, VERY SEVER, HORRIBLE...The physician will be notified of changes in the resident's verbal and/or non verbal expressions of pain. Physician orders [REDACTED]. Residents receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass. Documentation of administration of ordered PRN pain medication will be initialed on the front of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A plan of care will be written with the initiation of pain medication and individualized to the resident, addressing potential side effects, limitations due to pain, behavioral symptoms, and alternative pain relief techniques. The licensed nurse will monitor the efficacy of the [MEDICATION NAME] and keep the physician informed of any indicators of drug or dosage change as it relates to the resident's pain management...." During the exit conference on 11/5/2013 at 3:00 P.M., the DON and ED were asked if they had any further information or documentation. Both the DON and ED indicated they did not have further documentation or information regarding Resident #86. This Federal tag relates to complaint IN 825. 3.1-37(a)

1a. Based on interview and record review, the facility failed to ensure a resident with [MEDICAL CONDITION], a Foley catheter, and on antibiotics for a urinary tract infection was adequately assessed/monitored for changes in health status; and 1b. The facility failed to ensure a resident on an antibiotic for aspiration pneumonia was adequately assessed/monitored for changes in health status resulting in hospitalization for a critical illness for 1 of 8 residents reviewed for hospitalization (Resident #56). 2. Based on observation, interview, and record review, the facility failed to effectively manage a resident's pain by failing to administer pain medication as ordered and failing to subjectively assess for efficacy following administration of pain medication for 1 of 2 residents reviewed for pain control (Resident #86). Findings include: 1a. Resident #56's record was reviewed on 11/4/2013 at 9:11 A.M. Resident #56 was admitted to the facility on [DATE], and had current [DIAGNOSES REDACTED].). Admission vitals recorded on 8/29/2013 at 10:02 P.M., indicated Resident 56's oxygen saturation (O2 sat) was 98% on room air, blood pressure (b/p) 108/68, respirations (R) 18 per minute, and his pulse was 99 beats per minute. An admission nursing assessment note dated 8/30/2013 at 12:45 A.M., indicated Resident #56 was alert and oriented to person and place, incontinent of urine, and had clear breath sounds without respiratory distress. A social service note dated 9/4/2013 at 2:30 P.M., indicated Resident #56 was cognitively intact with a BIMs (Brief Interview Mental Status assessment) score of 13 and was a full code. A nurse's note dated 9/5/2013 at 2:57 P.M., indicated Resident #56 had to be catherized via an in and out catheter due to [MEDICAL CONDITION] with eight hundred ml (milliliters) of dark, amber, cloudy, urine noted. An untimed telephone physician's orders [REDACTED]. A nurse's note dated 9/5/2013 at 6:30 P.M., indicated Resident #56 was catherized due to [MEDICAL CONDITION]. The nurse performed I/O (In and out catheter) and noted "1200 mls" of "very dark reddish-black urine with very bad odor." A nurse's note dated 9/6/2013 at 8:56 A.M., indicated the facility notified the physician regarding Resident #56's [MEDICAL CONDITION]. The physician gave orders to anchor a Foley catheter, start IV fluids, and ordered a BMP (basic metabolic panel) to be drawn on 9/7/2013. The record lacked documentation the BMP lab was obtained. The record lacked documentation which indicated staff assessed Resident #56's urine and/or monitored his urine output on the following dates: 9/6/2013, 9/7/2013, 9/10/2013, 9/14/2013, and 9/16/2013. During an interview on 11/5/2013 at 10:13 A.M., the DON indicated the facility did not have documentation which indicated the lab company had attempted to obtain the ordered lab prior to 9/11/2013. The DON indicated the lab informed her they attempted to obtain the lab on 9/11/2013 however Resident #56 refused three times so they did not attempt again. The facility did not notify the doctor the lab had not been drawn the day it was ordered. The DON indicated on 9/12/2013, when the facility realized the lab had not been drawn, the physician was notified and he reordered the BMP to be drawn on 9/13/2013. A lab report record dated 9/13/2013 at 3:01 P.M., indicated a BMP lab was obtained from Resident #56. This document indicated a creatinine level of 0.5 low (normal ranges of 0.6 to 1.3) and a BUN/CREAT RATIO of 48 high (normal ranges 6-25). A comparison result drawn on 9/5/2013, indicated a creatinine level of 0.6 and a BUN/CREAT RATIO of 37. This report indicated a decline in Resident #56's status. During an interview with the Director of Nursing (DON) and the Executive Director (ED) on 11/4/13 at 1:34 P.M., the DON indicated if a resident had a Foley catheter urine needed to be measured. During an interview on 11/5/2013 at 2:00 P.M., the DON indicated after Resident #56 had a Foley catheter inserted due to [MEDICAL CONDITION] and antibiotics for a urinary tract infection, staff did not consistently monitor urine output and/or assess Resident #56's urine. A document titled "American Senior Communities Medicare Documentation Guideline" dated 10/09, provided by the DON on 11/4/2013 at 1:41 P.M., indicated, ".... recommended documentation to support daily skilled services.... Urinary/Urinary Tract Infection: Hydration status, description of urine-color, odor, consistency, S/S (signs/symptoms)-chills, nausea, vomiting, flank/abdominal pain, fever, malaise, frequency, urgency, dysuria, mental status change, administration of antibiotics, resident response, side effects, presence of catheter-insertion, irrigation, replacement...." 1b. A nurse's note documented on 9/17/2013 at 3:39 A.M. for events that occurred on 9/16/2013, indicated, "...writer came on shift at 2 pm at that time resident continued with ABT(antibiotic), but showed no S/S of any distress. At 3 pm (sic) aide had writer help transfer resident to shower chair. While in shower resident experienced resp. (respiratory) distress. Writer helped aide return resident to his bed. At that time V/S (vitals) were (temperature) 96.8 (degrees Fahrenheit) (blood pressure) 108/68 (pulse) 124 (oxygen) 02 sat (saturation) 82% and resp. rapid and labored at 24. Writer obtained O2 and was able to increase O2 sat to 88 % on 4 liters. resident (sic) was also suctioned at this time, writer obtained a large amount of very thick white mucus with particles of food imbedded in it. Writer called the MD and received new orders to change the current antibiotic to..., Stat (immediately) Chest X-ray, for possible asperation (sic).... Through out the night resident has shown a steady decline, but has remained responsive. V/S (vitals) at this time (temperature) 96.6, (blood pressure b/p) 112/64 (pulse) 110 (oxygen saturation) 88% on 4 liters O2, (respirations) rep. rapid and shallow at 26, blood sugar 86. Will continue to monitor." A physician's telephone order dated 9/16/2013 at 6:00 P.M., indicated orders which included a stat chest x-ray and for O2 (oxygen) as needed to keep Resident 56's oxygen saturations above 90%. The chest x-ray results, received on 9/17/13, indicated an early infiltrate in the right upper lung field. The record lacked documentation to indicate lungs sounds/respiratory status were assessed following identification of the infiltrate. The record lacked documentation to indicate oxygen saturation was monitored and interventions implemented to ensure Resident 56's oxygen saturation was maintained above 90% per the physician's orders [REDACTED]." An ED (Emergency Department) Progress Note, dated 9/17/13 at 1:05 p.m., indicated, "...from ECF (Extended Care Facility) per EMS (Emergency Medical Services) for difficulty breathing...breathing slowly and hypoxic...with GCS (Glasco Coma Scale) of 4. Gross hematuria...SBP (systolic blood pressure) 70...lack of responsiveness...In the ED foley catheter changed over and urine appears frankly purulent...acute [MEDICAL CONDITION], metabolic acidosis, [MEDICAL CONDITION]." An emergency room physician's report dated September 17, 2013 at 1:13 P.M., indicated, "...At facility was being treated for [REDACTED]. Facility y staff noted patient to be less responsive than baseline this am, and called EMS. He was noted to have a [MEDICATION NAME] on, ems removed and administered 0.4 [MEDICATION NAME]. On arrival patient is breathing slowly w/a (with a) GCS (Glasco Coma Scale) of 4. SBP (systolic blood pressure) of 117. Intubated for... inability to protect airway....Respiratory Rate 24 br/min (beats per minute) Hi...Severe distress, ill-appearing... Respirations: Respiratory distress moderate, labored...glasgow coma scale (GCS): Total score 4...." This report indicated Resident 56's arterial blood gas results indicated his oxygen saturation was low at 84%. A late entry nurse's note documented after Resident #56 was sent to the emergency room dated 9/17/2013 at 2:38 P.M., indicated, "Res was not given his scheduled morning narc (narcotic) due to him being transferred to the ER. Res had noted blood in his urine; no abdomonal (sic) distension noted at the time. Res skin has continued to be clammy and sweaty since this mornings rounds. Treatment to non pressure wounds were completed as oedered (sic). Res was sent out to the ER around noon due to low stats (sic)..." An acute care hospital critical staff progress note dated September 17, 2013 at 3:17 P.M., indicated Resident 56 had been admitted from the emergency room for, "...urosepsis secondary to obstruction at prostatic site admitted from ER for ams (altered mental status)/SHOCK/aCUTE RENnal (sic) failure, [MEDICAL CONDITION]. Dependent [MEDICAL CONDITION] opacities may represent aspiration or infection...impression and plan... Neuro/Psych...Likely a combo of Infection/Sepsis/[MEDICAL CONDITION] multiple sedative pain meds on [MEDICAL TREATMENT]...Borderline BP with Lactic acidemia, WEBC (sic) count---Possible source PICC/URINE/?/Pneumonia.... [MEDICAL CONDITION] Intubated for airway protection, being hyperventilated for maintaining PH... Bibailar atelectasis/Aspiration+Pneumonia....Infectious [MEDICAL CONDITION] secondary to Line infection vs Urine vs Pneumonia... Significant leucocytosis-Sepssi (sic) most likely dehydration is a possibility... altered mental status... [MEDICAL CONDITION] pneumonitis...Hypoxemia..., [MEDICAL CONDITION] insufficiency... Acidosis..., [MEDICAL CONDITIONS] systemic [MEDICAL CONDITION] response syndrome (SIRS)... Urinary tract infection...critically ill patient....." A nurse's note dated 9/17/2013 at 4:24 P.M., indicated, "writer notified by ER nurse res was admitted with urosepsis and acute [MEDICAL CONDITION]" During an interview regarding facility expectations for nursing care related to aspiration, on 11/4/2013 at 10:05 A.M., the Infection Control Nurse stated, "...I would absolutely expect lung assessments. I will see what policy we have but it is standard nursing for residents with aspiration." The Infection Control Nurse indicated Resident #56 was sent to the emergency room due to a low blood pressure and low O2 saturation. During this interview documentation of all lung assessments and vitals completed for Resident 56 were requested. During an interview with the Director of Nursing (DON) and the Executive Director (ED) on 11/4/13 at 1:34 P.M., the DON indicated the facility did not have a specific policy which indicated a nurse should do a lung assessment for residents being treated for [REDACTED]. The DON indicated if a resident had orders to have their O2 sats maintained at a certain level oxygen saturation monitoring should have been done, at a minimum, of each shift. She indicated she would check but did not think the facility had a specific policy. A document titled "American Senior Communities Medicare Documentation Guideline" dated 10/09, provided by the DON on 11/4/2013 at 1:41 P.M., indicated recommended documentation to support daily skilled services. "...Pulmonary disease/Pneumonia/respiratory: Lung sounds, ability to cough and deep breathe, description amount of sputum, presence and type of cough, oxygen (liters/delivery)-tolerance, activity tolerance/endurance, episodes of dyspnea/apnea, changes in mental status, physician notification/order changed, [MEDICAL CONDITION]-location, amount, interventions...." During an interview on 11/4/2013 at 1:41 P.M., the Executive Director indicated the American Senior Communities Medicare Documentation Guideline was not a facility policy. She further indicated it was a guide line recommended for skilled assessments and documentation for residents on Medicare. The ED indicated Resident #56 was not on Medicare but was on Medicaid therefore the skilled services and documentation were not required in his case. During an interview on 11/5/2013 at 2:00 P.M., the DON indicated after Resident #56 had aspirated and was started on antibiotics to treat aspiration pneumonia, documentation was not available which indicated his respiratory status was consistently assessed per standards of nursing care. During the exit conference on 11/5/2013 at 3:00 P.M., the DON and ED were asked if they had any further information or documentation. Both the DON and ED indicated they did not have further documentation or information regarding Resident #56. 2. Resident #86's record was reviewed on 11/2/2013 at 10:30 A.M. Resident #86 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Assessment Tool ((MDS) dated [DATE], indicated Resident #86 was cognitively intact with a BIMs (Brief Interview Mental Status) score of 15 out of 15. Physician orders [REDACTED]." During observations on 10/29/2013 at 9:43 A.M., Resident #86 was observed to repeatedly moan and rub his left leg. During an interview at this time, Resident #86 stated, "I've been trying to get medicine since 9:00." Resident was observed to point at the clock in his room. Resident #86 stated, "I have put on the light about a hundred times. My pain is a 10. The last time I had pain meds (medications) it was five A.M. It is in my left leg and foot." Resident #86 indicated the pain was so bad he couldn't stand for anyone to touch his leg even for bathing. At this time (10:00 A.M.), Licensed Practical Nurse (LPN) #8 entered Resident #86's room. LPN #8 stated, 'I will see if you have PRN (as needed) [MEDICATION NAME]. Things change. I was off." Resident #86 stated, "I've been trying to get pain medicine for an hour." LPN #8 stated, "You had pain med at 6:00." Resident #86 stated, "It wasn't 6:00 it was 5:00." LPN #8 stated, "With him I go by how he acts. If he is up and around in his wheel chair then I know medicine is working. I don't go by what he says. I go by visual." During an interview on 10/29/2013 at 10:28 P.M., Unit Manager #9 indicated the facility utilized the 1:10 pain scale unless a resident was non-verbal." Unit Manger #9 indicated it wasn't for her to determine if they are not in pain. If the resident is verbal they use the pain scale. During an interview with the Director of Nursing (DON) and the Executive Director (ED) on 11/4/13 at 1:34 P.M., the DON indicated the pain scale used by the facility was in the policy and pain should be assessed before and after pain medication is given. Pain is what the patient says it is. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 10/20/13 at 2 A.M. for complaints of severe pain. The record lacked documentation of the effectiveness of the pain medication. 10/21/2013 at 10:00 P.M. for complaints of severe pain. A nurse's note dated 10/21/2013 at 10:02 A.M. indicated, "...pain meds given x 1 and was effective..." A nurse's note dated 10/21/2013 at 11:35 A.M., indicated, "resident continues to be very aggressive. resident was requesting for pain medication every hour." 10/22/2013 at 2:00 A.M. "c/o generalized severe pain-effective." A nurse's note dated 10/22/2013 at 2:36 A.M. indicated, "res resting at this time. voiced c/o generalized pain and severe pain in bil (bilateral) feet d/t (due to gout. prn (as needed) given and effective...." 10/22/2013 at 4:00 P.M. for "generalized pain." At 5:00 P.M. documentation indicated, "effective." 10/23/2013 at 10:33 (AM or PM not specified)- for complaints of pain "7-feet and elbow." 11:33 effective "better." 10/24/2013 at 10:40 P.M. complaints of "severe pain effective." 10:24/2013 at 2:40 A.M. complaints "pain effective." 10/26/2013 at 2:00 A.M. complaints of "pain in feet effective." A nurse's note dated 10/26/2013 at 2:47 A.M., indicated, "Resident compaines (sic) about nausea and pain in left lower part of leg. Resident was given [MEDICATION NAME]-PRN. [DEVICE] worked propertly (sic). Resident most of night spent on the wheelchair." A nurse's note dated 10/26/2013 at 11:52 A.M., indicated, "resident c/o pain and nausea. res was given prn [MEDICATION NAME] and [MEDICATION NAME]. resident continued asking for more pain medicine. resident was redirected calmly and the (sic) he fell asleep." The MAR indicated [REDACTED].M. (9 hours and 52 minutes earlier). The record lacked documentation PRN pain medication was given as ordered. 10/26/2013 at 6:00 P.M. 1"10/10-severe foot pain-effective." A nurse's noted dated 10/26/2013 at 9:12 P.M., "res c/o (complaints of) pain severe pain to BLE (bilateral lower extremity) r/t (related to) gout x 1 this shift relieved by prn pain..." A nurse's note dated 1027/2013 at 5:02 P.M., indicated a nurse called the nurse practitioner (NP) with "concerns" about Resident #86's "prn pain med, dose, and frequency of need for med." The NP gave a new order for "an increase in Tylenol 650 mg q (every) 6 hr (hours)." This note indicated, "...that MD will need to eval res for change in meds and communication will happen on Monday morning 10/28/2013." The record lacked documentation the the Tylenol was administered. 10/28/2013 at 2:00 A.M. complaints of "left foot pain-8 out of 10." "Effective-2:30 A.M." 10/28/2013 at 6:00 A.M. complaints of "left foot pain-8 out of 10." "6:35 effective." 10/29/2013 at 1:00 P.M. "severe pain-effective." A nurse's note dated 10/29/2013 at 3:26 P.M., indicated, "resident complained of pain several times during the shift, resident was seen by NP and new orders were given...." 10/29/2013 at 5:00 P.M. "severe pain-effective." 10/29/2013 at 2:00 A.M. "complaints of leg pain - 8 out of 10-effective 3AM." 10/29/2013 at 6:00 A.M. "c/o (complaints) leg pain 8 out of 10." "Effective at 7 am." 10/30/2013 at 10:00 A.M. "c/o leg pain - 8 out of 10-effective at 11 am." 10/30/2013 (time not legible) "c/o severe pain" "Effective," 10/31/2013 at 2:00 P.M. "co pain." "Effective." 10/31/2013 at 6:00 P.M. "c/o leg pain-effective at 6:30 P.M." 10/31/2013 at 10:00 P.M. "c/o leg pain -8 out of 10-effective at 10:30 P.M." A nurse's note dated 10/31/2013 at 8:07 P.M., indicated, "...Resident has requested pain medication q 4 hours...." 11/1/2013 at 2:30 A.M. "Pain-effective 5:30 A.M." 11/1/2013 at 2:00 P.M. "leg pain 8 out of 10-helpful-2:20 P.M." 11/1/2013 at 6:00 P.M. "leg pain 8 out of 10-helpful-6:30 P.M." 11/1/2013 at 10:00 P.M. "leg pain 8 out of 10-helpful-10:30 P.M." A nurse's note dated 11/2013 at 11:38 P.M., indicated, "...Prn [MEDICATION NAME] gaven (sic) at 2;00 (sic) pm, 6:00 pm and 10:00 pm, for C/O leg pain...." 11/2/2013 at 2:30 A.M. "leg pain effective 3:30" A nurse's note dated 11/2/2013 at 7:23 A.M., indicted "resident complain of pain. PRN medication given as ordered with effect...." 11/2/2013 at 11:00 P.M. "leg pain effective 12:02." 11/2/2013 at 3:00 A.M. "leg pain effective 4a." 11/2/2013 at 10:00 A.M. "pain in legs-up mobile wheel chair." The record lacked documentation of the effectiveness of the pain medication. 11/2/2013 at 3:00 P.M. " pain in legs-up w/c mobile." The record lacked documentation of the effectiveness of the pain medication. 11/2/2013 at 8:00 (A.M. or P.M. not indicated) "pain in feet-up mobile." The record lacked documentation of the effectiveness of the pain medication. 11/3/2013 at (time not legible) "up w/c c/o foot pain-up mobile." The record lacked documentation of the effectiveness of the pain medication. 11/3/2013 at 3:00 P.M. "...legs-up mobile." The record lacked documentation of the effectiveness of the pain medication. Resident #86's care plan dated 10/28/2013, indicated Resident 86 had a problem with pain and was at risk for pain related to Gout. A goal listed indicated Resident 86 would have pain relief within 30 minutes of intervention. Approaches listed to meet this goal included: Administer meds as ordered, document effectiveness of PRN medication, notify MD if pain is unrelieved and/or worsening, observe for non verbal signs of pain, offer non pharmacological interventions such as quiet environment, rest, shower, back rub, and/or reposition. The record lacked documentation which indicated the facility consistently documented Resident #86's level of pain, location of pain, the efficacy of the PRN pain medication, used a measurable method to determine the efficacy of the PRN medication, consistently administered PRN pain medication when indicated as ordered, and/or administered scheduled pain medication (Tylenol) as ordered. A facility policy dated 1/3/2013 and identified as current by the ED on 11/4/2013 at 11:05 A.M., indicated, "It is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, including pain management. it is the responsibility of the facility to ensure each resident is assessed for pain, and the efficacy of pain medication, while keeping the resident as comfortable and pain free as possible.... The following guidelines will be used when assessing pain. INTERVIEWABLE RESIDENT The pain management program will be determined based upon the resident's verbal response to the questions on the pain assessment/interviewable resident. Pain medications will be prescribed and given based upon the intensity of the pain as follows: MILD, MODERATE, SEVERE, VERY SEVER, HORRIBLE...The physician will be notified of changes in the resident's verbal and/or non verbal expressions of pain. Physician orders [REDACTED]. Residents receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass. Documentation of administration of ordered PRN pain medication will be initialed on the front of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A plan of care will be written with the initiation of pain medication and individualized to the resident, addressing potential side effects, limitations due to pain, behavioral symptoms, and alternative pain relief techniques. The licensed nurse will monitor the efficacy of the [MEDICATION NAME] and keep the physician informed of any indicators of drug or dosage change as it relates to the resident's pain management...." During the exit conference on 11/5/2013 at 3:00 P.M., the DON and ED were asked if they had any further information or documentation. Both the DON and ED indicated they did not have further documentation or information regarding Resident #86. 3.1-37(a)

Based on interview and record review, the facility failed to provide the necessary care and services for a resident with a know [MEDICAL CONDITION] with severe pain for 1 of 5 residents reviewed for quality care and services provided (Resident #F). Findings: Resident #F's record was reviewed on 11/19/2012 at 9:40 A.M. Resident #F was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #F had current [DIAGNOSES REDACTED]. Resident #F had a current care plan concern originally dated 2/1/12 which indicated he had a short term memory problem. He had another current care plan concern originally dated 2/1/2012 which indicated he had difficulty making himself understood due to [MEDICAL CONDITION]. Goals for this concern included Resident #F would have adequate two way communication with staff on a daily basis. Approaches to meet this goal included being observed for changes in condition. A nurse's note dated 11/9/12 indicated Resident #F fell out of bed at 11:15 P.M. on 11/8/2012. An assessment was completed, no injuries were noted, and he denied pain at that time. The doctor was notified of this information. A current physician's orders [REDACTED]. A nurse's note dated 11/9/12 at 8:32 P.M. indicated a Certified Nursing Assistant (CNA) notified the nurse Resident #F could not bear weight on his left leg which was unusual for him. PRN (as needed) Tylenol was given. NP #3 (Nurse Practitioner) was notified and a STAT x-ray of his left hip was ordered for a suspected fracture following the fall on 11/8/2012. His left hip had minor bruising. Documentation was lacking of a pain assessment according to the facility's policy for Resident #F's pain. The Medication Administration Record indicated Resident #F received [MEDICATION NAME] (Tylenol) on 11/9/12 at 7 A.M. The MAR lacked documentation Resident #F received PRN pain medicine as indicated in the above nursing note. Documentation on the back of the MAR on 11/9/2012 at 7:00 A.M., Resident #F was administered [MEDICATION NAME] (Tylenol) for "pain in leg" and results effective. An un-timed entry for 11/9/12 indicated he was administered Tylenol for complaints of hip pain and results were effective. The Tylenol order was ordered for mild pain. Documentation was lacking of a pain assessment per the facility's policy. A nurse's note dated 11/10/ at 12:09 A.M.(third shift) indicated Resident #F denied pain at present time. His left hip was x-rayed earlier and staff would continue to monitor. The next nursing note was dated 11/10/2012 at 4:47 P.M.. This note indicated, "Resident with new order: [MEDICATION NAME]/acetamin 5/325 mg ([MEDICATION NAME]) 1 tab every 4 hours by mouth as needed. May get first dosage from EDK (emergency drug kit). New orders noted and State Guardian aware. This note was entered by LPN (Licensed Practical Nurse) #4. From 11/10/2012 at 12:09 A.M. to 11/20/2012 at 4:47 P.M. (16 hours and 38 minutes) documentation was lacking of Resident #F being assessed for pain per the facility's policy. During an interview on 11/20/2012 at 2:10 P.M., LPN #4 stated, "He was not hurting that bad. I got the order for [MEDICATION NAME] just in case but he did not need it at the time." A nurse's note dated 11/10/2012 at 9:00 P.M. indicated Resident #F was given PRN Tylenol for pain and he would continue to be observed. Documentation was lacking of a pain assessment per the facility's policy. A nurse's note dated 11/10/2012 at 10:22 P.M. indicated ,"Resident hip x-ray back with results, left subcapital hip FX (fracture). (Physician named) office notified and (NP #3 named) aware, and with new orders. Resident to see orthopedics on Monday. Please manage pain with PRN medication and put heat and ICE alternate and send if change in condition to ER (emergency room .) NP did not want resident sent to ER, because they send him back. (NP #3 named) said that she would talk to MD (medical doctor). On coming nurse aware, will continue to observe." The next nurse's note dated 11/11/2012 at 6:19 A.M. (7 hours and 57 minutes after the last dose of pain medicine was administered), indicated, "Resident x ray showed up fracture and pain medication PRN given treatment applied as ordered . . .resident was not in kind of distress through out night. f/u will continue." This nurse's note was entered by Registered Nurse (RN) #5. Documentation was lacking of a pain assessment per the facility's policy.. The MAR indicated RN #5 administered Tylenol on 11/10/1012 at 11:00 P.M. for "pain" and it was effective. During an interview on 11/20/2012 at 2:15 P.M., RN #5 stated, "He was in pain but [MEDICATION NAME] ([MEDICATION NAME]) was not available so I gave him Tylenol. I don't think [MEDICATION NAME] in EDK (emergency drug kit)." When asked how he knew Resident #F was in pain he replied, "He cant talk .facial expressions, grimacing, hurt during care. Once we settled him-ok . Moving him hurt him." He indicated when the pharmacy arrive he administered it to him." The MAR indicated RN #5 administered [MEDICATION NAME] on 11/11/2012 at 4:00 A.M. (5 hours after Resident #F was assessed by an RN to need the stronger pain medication) for pain and it was effective. The next nurse's note dated 11/11/2012 at 1:02 P.M. indicated, ". . .res (resident) kept in bed this shift d/t (related to) L (left) [MEDICAL CONDITION], writer will make appt (appointment) with Ortho Indy first thing in am. res given PRN pain medication x 2. will continue to monitor." This nurse's note was signed by LPN #7. Documentation was lacking of a pain assessment per the facility's policy. The MAR indicated RN #7 administered two doses of [MEDICATION NAME] on 11/11/2012. The MAR lacked documentation of the time the [MEDICATION NAME] was administered, a reason for the administration of the [MEDICATION NAME], or the efficacy of the pain medication. The Narcotic sign out sheet for the [MEDICATION NAME] indicated on 11/11/2012 LPN #7 removed [MEDICATION NAME] at 9:00 A.M. and 2:30 P.M. LPN #7 was not available for an interview. The next nurse's note dated 11/11/2012 at 7:33 P.M. indicated the resident continued on an antibiotic for a urinary tract infection with no adverse effects. He would continue to be monitored. Documentation was lacking of an assessment of Resident #F's pain. The MAR and the Narcotic sign out sheet lacked documentation Resident #F received pain medicine since 11/11/2012 at 2:30 P.M. This nurse's note was signed by LPN #4. The next nurse's note dated 11/11/2012 at 9:06 P.M. indicated, "Resident resting in bed comfortable, took all medication without difficulty, and pain pill PRN give for left hip pain with effect. Resident needs extensive assistance with ADL's (activities of daily living), two to change . . Will continue to observe." This nurse's note was signed by LPN #4 and lacked documentation of a pain assessment per the facility's policy. The MAR and Narcotic Sign Out indicated the last dose of pain medication administered was from LPN #7 at 2:30 P.M. The next nurse's note dated 11/12/2012 at 8:32 A.M. indicated, "Writer contacted Ortho Indy for appt with orthopedist. Physician stated to send res to ER d/t no appts available today. PCP notified, State Guardian and DNS notified. Ambulance called for transport." This note was signed by LPN #7. The MAR and the Narcotic Sign Out sheet indicated LPN #7 removed and administered [MEDICATION NAME] to Resident #F at 6:00 A.M. Documentation was lacking of a pain assessment and efficacy of the pain medication administered. During an interview on 11/19/2012 at 11:19 A.M., The ED indicated at the time they did not question the NP's order not to send him out. In retrospect they should have called the medical director but nurses were trained to follow doctor's orders and they relied on them. She said not to send him out. If ordered to do something they felt was not standard practice they should have called the medical director. The medical director was very receptive to their calls and she felt she could call him any time. The DON (who was not employed by the facility at the time of this incident) indicated at this time her past experience would lead her to believe the resident would have been sent back to wait for surgery and the staff were immobilizing his fracture. During an interview on 11/19/2012 at 2:45 P.M., The ADON (Assistant Director of Nursing) stated, "The nurse called me because the Xray machine was broken. The company kept calling and reporting it was broken. It was a stat order. I would have expected it done within 4-6 hours. The nurse called me and I told him if they couldn't get it done within another hour to hour and half we would have to send him out. When we got the results the nurse told me the NP didn't want him sent out. I was shocked. This was a [MEDICAL CONDITION]. I asked him if he was sure this is what she said and he said he went back and forth with her and she wanted to wait until Monday to make an appointment with Ortho Indy. We worried all weekend. If his condition would have changed, increase in pain, swelling, anything we would have sent him out." During an interview on 11/19/2012 at 2:20 P.M.., The Personal Service Coordinator for the orthopedic surgeon who performed Resident #F's hip surgery stated, "He should have been sent to the hospital from the beginning. I spoke with (Surgeon named) who was on call and another surgeon and they both said he should have been sent to ER immediately. Even if he would have came here on Monday we would have sent him to the ER. At minimum even if the ER would have sent him back they would have applied a brace stabilizer. He would not have been neglected at the ER." During an interview with the facility's Medical Director who was also the physician NP #3 worked under indicated, NP #3 was a very detailed practitioner. He had not talked to her so he did not know her thought process in the decision to not send him. He however was going to talk to her and would call me back. He stated, "General practice-I think he should- at least my gut sense of that was he should have been seen in the ER." During an interview on 11/20/2012 at 8:50 A.M., The Executive Director was asked to provide the plan of care that was in place so the staff would know how to care for a resident with a [MEDICAL CONDITION]. The DON indicated at this time staff were immobilizing Resident #F's hip while he waited for his appointment on Monday. The DON and ADON were asked what the procedure was for the immobilization of a hip and/or what immobilization of a fx hip meant to them. The ADON indicated it was protecting the area and keeping him in bed. During an interview on 11/20/2012 at 9:00 A.M., When asked if she cared for Resident #F the weekend before he was sent to the hospital CNA (Certified Nursing Assistant) #1 replied, "I took care of him that weekend. Two of us had to turn him. I wouldn't touch him without help. It was horrifying. He was in terrible pain until the ambulance came and got him. The aide gave me report when I came on and she said she tried to turn him by herself and he was screaming in pain. Me and (CNA #2 named) turned him using a sheet. They were just giving him Tylenol. I asked if they would give him [MEDICATION NAME]." When asked how she positioned him when he ate she replied, "I just sat him up like normal." During an observation on 11/20/2012 at 9:00 A.M., Resident #F was observed sitting in a wheel chair in his room. CNA #1 was present. Resident #F was asked if he remembered the weekend before he went to the hospital. He attempted to verbalize an answer but was unable. He just shook his head. I asked him if he had been in pain. He shook his head yes. During an interview on 11/20/2012 at 9:15 A.M., CNA #2 stated, "No nurse told me how to turn him. We just did it that way because he hurt so bad." When asked if she sat him up to eat she indicated yes but he just nibbled but he didn't eat because he hurt to much. During an interview on 11/20/2012 at 2:15 P.M., The ED stated, CNAs are not qualified to assess pain. Pain is relative. I don't know if they told the nurse he was in severe pain." When reminded the resident had a change in status because according to their nurses and their documentation Resident #F started out on Tylenol which was ordered for mild pain then required stronger narcotic pain medicine ([MEDICATION NAME]) which according to their policy was to be given for severe pain she did not have a response. At this time the ADON, DON, and ED were asked if they had any further documentation regarding pain assessments, medication administration, care planning regarding the [MEDICAL CONDITION], policies regarding fracture care, communication with the doctor about the increased pain and they indicated they had nothing else. During an interview on 11/20/2012 at 1:41 P.M., the Medical Director indicated he spoke with NP #3 and she indicated to him her thinking was he was stable, pain was controlled, and she felt because of this the ER would have sent him back to the facility. When she talked with the nursing staff she was not aware he was in a lot of pain. An Orthopedic Initial Consult report dated 11/12/2012 indicated Resident #F presented at the ER after sustaining injury to his left hip 3 days prior after a fall at the nursing facility. Pt is noted to have the following injuries: Left femoral neck fracture, 100% displaced. Recommended treatment: Hemiarthoplasty. Surgery planned for tomorrow. Orders included admit to hospital, plan on surgery tomorrow,with hemiarthroplasty if cleared, left lower extremity non-weight baring, Bucks traction, pre-op work up and nothing by mouth after mid-night. Resident #F had left hip surgery, recovered in the hospital, and was returned to the facility. A current policy titled 'Pain Management' provided by the ADON (Assistant Director of Nursing ) on 1/20/2012 at 1:10 P.M. indicated, "It is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, including pain management. It is the responsibility of the facility to ensure that each resident is assessed for pain, and the efficacy of pain medication, while keeping the resident as comfortable and pain free as possible. Procedure: 1. Residents are assessed for pain upon admission, quarterly, and with a significant change in the resident's condition and/or new onset of pain. 2. The following guidelines will be used when assessing pain, using the specific pain assessment. INTERVIEWABLE RESIDENT-The pain management program will be determined based upon the resident's verbal response to the questions on the pain assessment/interviewable resident. Pain medications will be prescribed and given based upon the intensity of the pain as follows: MILD, MODERATE, SEVER, VERY SEVERE, HORRIBLE. NON-INTERVIEWABLE RESIDENT-The pain management program will be determined based upon staff observation of non-verbal signs of pain as follows: NON-VERBAL SOUNDS (crying, whining, gasping, moaning, or groaning). VOCAL COMPLAINTS OF PAIN (that hurts, ouch, stop). FACIAL EXPRESSIONS (grimaces, wines, wrinkled forehead, furrowed brow, clenched teeth). PROTECTIVE BODY MOVEMENTS OR POSTURES (bracing, guarding, rubbing or massaging a body part, clutching or holding a body part during movement). 3. The physician will be notified of the resident's verbal and/or nonverbal expression of pain. 4. Physician orders [REDACTED]. 5. Resident's receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass. 6. Documentation of administration of ordered PRN pain medication will be initialed on the front of the Medication Administration Record (MAR). 7. Additional information including, but not limited to reasons for administration, interventions, and effectiveness of pain medication will be documented on the back of the MAR, or on the facility specific pain management flow sheet. 8. A plan of care will be written with the initiation of pain medication and individualized to the resident, addressing potential side effects, limitations due to pain, behavioral symptoms, and alternative pain relief techniques. 9. The licensed nurse will monitor the efficacy of the [MEDICATION NAME] and keep the physician informed of any indicators of drug or dosage change as it related to the resident's pain management. . . This Federal tag relates to Complaint IN 493 3.1-37(a)