Every finding on record at Rehabilitation Center at Hartsfield Village

Based on observation, record review, and interview, the facility failed to ensure personal care signs were not posted in a resident's room and meals were served timely to each resident's table for 4 of 4 residents reviewed for dignity. (Residents 14, 21, 9, and 107)Findings include:1. During a random observation on 8/13/25 at 9:00 a.m., a sheet of paper listing Resident 14's swallowing guidelines was posted on the wall next to the doorway of the resident's bathroom. On 8/14/25 at 9:20 a.m., the sign remained in the resident's room. The record for Resident 9 was reviewed on 8/14/25 at 9:32 a.m. Diagnoses included, but were not limited to, Alzheimer's and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 6/7/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. The resident was dependent with eating and received a mechanically altered diet. The resident did not have a Care Plan related to posting personal care signs in her room. During an interview on 8/18/25 at 3:20 p.m., the Director of Nursing indicated the sign had been removed. 2. During a random observation on 8/13/25 at 10:08 a.m., a sheet of paper listing Resident 21's swallowing guidelines was posted on the wall above her bed. On 8/14/25 at 1:30 p.m., the information related to the swallowing guidelines remained on the resident's wall. The record for Resident 21 was reviewed on 8/13/25 at 2:20 p.m. Diagnoses included, but were not limited to, Parkinson's disease and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS) assessment, dated 7/20/25, indicated the resident was cognitively impaired for daily decision making. The resident would hold food in her mouth or cheeks or would have residual food in her mouth after meals. The resident received a mechanically altered diet. The resident did not have a Care Plan related to posting personal care signs in her room. During an interview on 8/18/25 at 3:20 p.m., the Director of Nursing indicated the sign had been removed. 3. During a random observation on 8/12/25 at 12:46 p.m., Resident 9 was in his room in bed eating his lunch. A sheet of paper listing the resident's swallowing guidelines was posted above his bed. On 8/13/25 at 9:42 a.m., 8/14/25 at 9:23 a.m., 8/15/25 at 8:40 a.m. and 12:05 p.m., and on 8/18/25 at 8:47 a.m., the swallowing guidelines continued to be posted above the resident's bed. The record for Resident 9 was reviewed on 8/15/25 at 11:39 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 6/23/25, indicated the resident was cognitively impaired for daily decision making. The resident required set up or clean up assistance with eating. The resident also received a mechanically altered therapeutic diet. The resident did not have a Care Plan related to posting personal care signs in his room. During an interview on 8/18/25 at 3:20 p.m., the Director of Nursing indicated the sign had been removed. 4. During an observation of the noon meal on 8/12/25 at 12:12 p.m., Resident 107 was seated at a table in his high back wheelchair. There was another resident seated at the table with him and other residents seated at a table in front of him. There were a total of 13 residents in the dining room. At 12:29 p.m., the resident was resting his head on the table. He had not received his tray yet and his table mate ate in front of him as well as the residents at the other table. Resident 107 was the last resident to receive his tray at 12:33 p.m. At that time, a CNA sat down next to him and proceeded to feed him.The record for Resident 107 was reviewed on 8/14/25 at 10:13 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS) assessment, dated 8/6/25, indicated the resident was cognitively impaired for daily decision making and he required substantial/maximum assistance with eating. He held food in his mouth and/or cheeks or had residual food in his mouth after meals. He received a mechanically altered therapeutic diet. During an interview on 8/18/25 at 10:35 a.m., the Director of Nursing was informed the resident received his tray last while the other residents were eating around him. No additional information was provided. 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure proper medication storage related to insulin pens and multi-dose vials not labeled when opened or expired for 3 of 5 medication carts and 1 of 1 medication rooms reviewed. (D Wing 1st Floor Cart, A Wing 1st Floor Cart, D Wing 2nd Floor Cart, 1st Floor Medication Room)Findings include:1. The 1st Floor Medication Room was observed with RN 2 on [DATE] at 11:01 a.m. Inside the refrigerator was an opened multi-dose vial of Tuberculin (a medication used for tuberculosis testing). The vial was dated as opened [DATE]. The label on the vial indicated to discard after 30 days. 2. The 1st Floor D Wing medication cart was observed with LPN 1 on [DATE] at 11:11 a.m. There was an insulin lispro pen with no open date and an insulin glargine pen with no open date. 3. The 1st Floor A Wing medication cart was observed with LPN 1 on [DATE] at 11:13 a.m. There was a Novolog insulin pen with no open date, a Lantus insulin pen with no open date, and an insulin lispro pen with no open date which was only labeled with a room number. 4. The 2nd Floor D Wing medication cart was observed with RN 3 on [DATE] at 11:21 a.m. There was a Lantus insulin pen with an open date of [DATE] and an insulin lispro pen with an open date of [DATE].During an interview on [DATE] at 10:00 a.m., the Director of Nursing (DON) was made aware of the medication labeling and storage concerns and any applicable policies were requested.The current and undated Vials and Ampules of Injectable Medications policy, provided by the DON on [DATE] at 10:15 a.m., indicated the date opened, and the initials of the first person to use the vial must be recorded on the multidose vials either on the vial label itself or an accessory label affixed for that purpose. Once opened guidelines recommend discarding multidose vials (other than some insulins) 28 days after use.The current and undated Medication Labels policy, provided by the DON indicated all prescription medication labels should include the following: for injectables and liquids the strength, amount and time to be given, prescriber's name, and patient's name and room number.The Lantus (insulin glargine) medication instructions insert indicated, an opened Lantus Kwik Pen should be used within 28 days of first use. Once opened, the pen should be stored at room temperature (below 86 F) and used within 28 days.The Novolog (insulin aspart) medication instructions insert indicated, Novolog insulin, both in vials and pens, expires 28 days after it has been opened, even if it has been refrigerated.The Humalog (insulin lispro) medication instructions insert indicated, throw away the Humalog pen you are using after 28 days, even if it still has insulin left in it.3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure a Physician's Order was in place for a resident with a back brace and skin discolorations were assessed and monitored for 1 of 1 resident reviewed for positioning and range of motion and 2 of 3 residents reviewed for non-pressure skin conditions. (Residents 2, 19 and 135)Findings include:1. On 8/12/25 at 11:24 a.m., Resident 2 was observed seated in her wheelchair in her room. There was a black vest-like back brace in place over her chest and back. She indicated she was supposed to wear it for two fractures in her back. On 8/14/25 at 11:35 a.m., Resident 2 was observed seated in her wheelchair in her room watching television. She had a black vest-like back brace in place over her chest and back. On 8/14/25 at 2:44 p.m., Resident 2 was observed seated in her wheelchair in her room speaking with a visitor. She had a black vest-like back brace in place over her chest and back. Record review for Resident 2 was completed on 8/13/25 at 3:05 p.m. Diagnoses included, but were not limited to, wedge compression fracture of third thoracic vertebra and wedge compression fracture of second thoracic vertebra. The admission Minimum Data Set (MDS) assessment, dated 5/29/25, indicated the resident was cognitively intact and dependent on staff for assistance with ADLs (activities of daily living). A Care Plan, dated 7/19/25, indicated the resident had healing fractures to T2 and T3. There were no interventions related to the back brace. A Care Plan, dated 7/19/25, indicated the resident was non-compliant with the back brace. There were no interventions related to when the resident was supposed to wear the back brace. The hospital After Visit Summary, dated 6/11/25, indicated the resident was to wear a TLSO (thoracic lumbar sacral orthosis) back brace when out of bed. The Physician's Order Summary, dated 8/2025, lacked any orders for a back brace, guidance on when the resident should wear it, or monitoring to the skin under the brace. During an interview on 8/15/25 at 9:44 a.m., the Director of Nursing was made aware of the lack of a Physician's Order for the back brace. No further information was provided. 2. During a random observation on 8/12/25 at 10:28 a.m., Resident 19 was resting in bed. There was a dressing on his right knee and a large purple bruise next to the dressing. On 8/14/25 at 3:14 p.m., the resident's knee was observed with LPN 2. At that time, LPN 2 indicated she did not know if the bruise was from surgery or a fall, or how long the bruise had been present. The record for Resident 19 was reviewed on 8/13/25 at 2:24 p.m. Diagnoses included, but were not limited to, diabetes, sepsis, and lymphoma. The 8/7/25 admission Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and was dependent in activities of daily living (ADLs) and transfers. A Care Plan, dated 8/1/25, indicated the resident was at risk for complications associated with anticoagulant (blood thinner) therapy. Approaches included observing the skin with each encounter for bruising. The record lacked monitoring of the resident's bruise. During an interview on 8/14/25 at 3:50 p.m., Assistant Director of Nursing (ADON) 1 indicated bruising should be monitored and documented in the resident's record. During an interview on 8/18/25 at 3:24 p.m., the Director of Nursing (DON) was informed of the findings and offered no additional information. 3. During random observations on 8/12/25 at 11:29 a.m., 8/14/25 at 9:48 a.m., and 8/15/25 at 10:58 a.m., bruises were observed to Resident 135's left cheek, right hand, and right arm. During an interview on 8/12/25 at 11:29 a.m, the resident indicated the bruises were from the motor vehicle accident and subsequent hospitalization that led to her admission to the facility. The record for Resident 135 was reviewed on 8/15/25 at 10:05 a.m. Diagnoses included, but were not limited to, fractures of the left wrist and osteoarthritis. A Physician's hospital note, dated 8/4/25, indicated the resident was in a car accident and had an open fracture of her left wrist and a bruise on her left cheek. The 8/8/25 Nurse's admission Assessment indicated the resident was cognitively intact for daily decision making. The assessment did not include documentation of the resident's bruises. An 8/11/25 Physician's Order indicated complete head to toe assessment and document. Measure any bruises or skin tears noted. The record lacked monitoring of the resident's bruises. During an interview on 8/18/25 at 3:24 p.m., the Director of Nursing (DON) was informed of the findings and offered no additional information. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a urinary catheter collection bag was kept below the level of the bladder, and the tubing was kept free from constriction or pulling for 1 of 1 resident reviewed for urinary catheters. (Resident 119)Finding includes: During a random observation on 8/12/25 at 2:56 p.m., Resident 119 was observed resting in bed. The urine collection bag for his Foley catheter (a tube inserted through the urethra to drain the bladder) was on the bed, under a blanket. During a random observation on 8/14/25 at 10:38 a.m., the resident was in his room, seated in his wheelchair. The Foley bag was lying under the wheelchair. The resident was stepping on the tubing with hard-soled shoes.During a random observation on 8/15/25 at 9:50 a.m., the resident was observed resting in bed. The tubing to the urine collection bag for his Foley catheter was pulled taut. The bag was hooked under the wheelchair next to the bed. At that time, RN 1 was in the room, talking with the other resident who resided there.During a random observation on 8/15/25 at 2:15 p.m., the resident was observed resting in bed. The urine collection bag was hooked on the bed frame. The catheter tubing was coming out of the bottom of the resident's narrow pant leg, and under his foot. At that time, CNA 1 was in the room checking on the resident. The record for Resident 119 was reviewed on 8/15/25 at 11:54 a.m. Diagnoses included, but were not limited to, left femur (thigh bone) fracture, urinary retention, and dementia.The 6/29/25 admission Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, required substantial assistance in chair-to-bed transfers, and required an indwelling catheter for urination. A Care Plan, dated 7/7/25, indicated the resident required an indwelling urinary catheter. The short term goal indicated the resident would have their catheter managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. Approaches included positioning the bag below the level of the bladder.The record lacked documentation of monitoring the tubing and urine collection bag.During an interview on 8/18/25 at 9:23 a.m., the Administrator and Director of Nursing (DON) indicated they would re-educate staff and the resident on monitoring and maintaining the safety of the Foley catheter tubing and bags. A policy titled, Standards of Care for the Resident with an Indwelling Urinary Catheter, received as current from the DON on 8/18/25 at 1:00 p.m. indicated, . Hang the collection bag below the level of the bladder to prevent urine reflux to the bladder . When transporting or ambulating a resident, take care to avoid traction on the catheter and maintain the collection bag below the level of the bladder. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 7 residents observed during medication pass. Four errors were observed during 25 opportunities for errors during medication administration. This resulted in a medication error rate of 16%. (Residents 28 and 116)Findings include:1. On 8/13/25 at 8:24 a.m., RN 4 was observed preparing Resident 28's medications. The resident was going to receive one puff of a Breo Ellipta inhaler 200-25 microgram (mcg), the resident's mouth was to be rinsed after use. The resident was also supposed to receive Miralax (a laxative) 17 grams. The RN added 5 cubic centimeters (cc) of Miralax to a plastic cup and added 4 ounces of water. The RN proceeded to the resident's room. The RN handed the inhaler to the resident, she inhaled it herself and shut the lid and handed it back to the RN. The resident did not rinse her mouth afterwards nor was she instructed by the RN to rinse her mouth. The RN wiped down the inhaler and put it back in the box. She then went to the medication cart and obtained the Miralax mixture and left it on the resident's over bed table to drink. The resident drank all of the Miralax. At 8:47 a.m., the RN was asked to remove the bottle of Miralax from the medication cart. After reading the label, the RN indicated 17 grams was one tablespoon and she only gave the resident 5 cc's which wasn't enough. During an interview on 8/13/25 at 8:47 a.m., RN 4 indicated the marking inside the manufacture lid was not there anymore, so she just gave the 5 cc's and was not aware of how much 17 grams equaled to. Assistant Director of Nursing 1 was at the cart and indicated she should have figured out what the 17 grams equaled to prior to administering the medication. 2. On 8/13/25 at 7:54 a.m., LPN 3 was observed preparing medications for Resident 116. The resident was to receive 10 units of Lantus insulin by the way of an insulin pen. The resident was also going to receive Novolog insulin 5 units by the way of an insulin pen. The LPN dialed up both pens to their respective doses, however, the LPN did not prime the insulin pens prior to administration. During an interview on 8/13/25 at 8:13 a.m., LPN 3 indicated she was aware she needed to prime the insulin pens prior to administration. During an interview on 8/13/25 at 2:45 p.m., the Director of Nursing had no additional information to provide. The Lantus Insulin insert indicated to perform a safety test prior to administration. Dial a test dose of 2 Units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This would help you get the most accurate dose. Press the injection button all the way in and check to see that insulin came out of the needle. The dial would automatically go back to zero after you perform the test. If no insulin came out, repeat the test 2 more times. If there was still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. The Novolog insert indicated when using a Novolog Flex Pen for injecting insulin, it was crucial to prime the pen before each injection. Priming ensured that air bubbles were removed from the needle and the cartridge, pen, and needle were working correctly, allowing you to administer the full dose of insulin. 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure residents had a physician's order and an assessment indicating they were able to self-administer their own medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 136)Finding includes:During a random observation on 8/12/25 at 11:05 a.m., one pill was observed in a medicine cup on Resident 136's overbed table. At that time, the resident indicated it was an AREDS (an eye vitamin) tablet. She indicated the nurse gave her two, but she was saving one to take in the evening like she did at home. She indicated she informed the staff that she took the pills at separate times, but they kept bringing both in the morning. During an observation on 8/15/25 at 8:50 a.m., the resident unwrapped an AREDS tablet from a tissue that was in the drawer of her overbed table. At that time, the resident indicated she again saved it from the morning pills the nurse gave her so she could take it in the afternoon. The record for Resident 136 was reviewed on 8/13/25 at 3:41 p.m. Diagnoses included, but were not limited to, congestive heart failure and acute respiratory failure.The 8/9/25 Nurse's admission Assessment indicated the resident was cognitively intact for daily decision making, and required moderate assistance with activities of daily living (ADLs).A Physician's Order, dated 8/9/25, indicated PreserVision AREDS-2, 2 tablets once each morning. There was no order for self-administration.The 8/9/25 Self-Administration Assessment indicated it was not appropriate for the resident to self-administer any medications.During an interview on 8/18/25 at 3:24 p.m., the Director of Nursing (DON) was informed of the findings and offered no additional information.A policy titled, Self-Administration of Medication, received as current from the DON on 8/18/25 at 1:00 p.m. indicated, . Residents are permitted to [self-administer medications] if the facility's interdisciplinary team determines that the practice is safe for the resident and for other residents of the facility and there is a prescriber's order to self-administer.3.1-11(a)

Based on observation, record review, and interview, the facility failed to provide adequate supervision and implement planned interventions related to following swallowing guidelines for 2 of 2 residents reviewed for accidents/ hazards. (Residents 9 and 21)Findings include: 1. On 8/12/25 at 12:46 p.m., Resident 9 was observed in his room in bed eating his lunch. There were straws placed in the resident's beverages. A sign posted above the resident's bed indicated the following swallowing guidelines that were dated 6/23/25:-up for all meals-small sips/bites (cup or spoon)-slow rate-no strawsOn 8/15/25 at 8:40 a.m., the resident was in his room in bed eating his breakfast. At 12:33 p.m., the resident was in his room in bed eating his lunch. On 8/18/25 at 8:47 a.m., the resident was slouched down in his bed eating his breakfast. A straw was observed in his cup of juice that was almost empty. The record for Resident 9 was reviewed on 8/15/25 at 11:39 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 6/23/25, indicated the resident was cognitively impaired for daily decision making. The resident required set up or clean up assistance with eating. The resident also received a mechanically altered therapeutic diet. A Care Plan, dated 6/18/25, indicated the resident received a mechanically altered diet with no added salt and thickened liquids. Interventions included, but were not limited to, speech therapy to evaluate for diet upgrade as warranted and provide assist with intake as needed. A Physician's Order, dated 8/8/25, indicated the resident was to receive a no added salt mechanical soft diet with nectar thick liquids and high protein gelatin with lunch and dinner. During an interview on 8/18/25 at 10:35 a.m., the Director of Nursing was informed the swallowing guidelines were not followed. No additional information was provided. 2. During a random observation on 8/13/25 at 10:08 a.m., a sheet of paper listing Resident 21's swallowing guidelines was posted above the resident's bed. The swallowing guidelines, dated 7/15/25, indicated the resident was not to use straws. On 8/14/25 at 1:30 p.m., the resident was seated in her wheelchair in her room with her husband. The resident's lunch tray was on her over bed table. Straws were observed in the resident's juice, water, and a beverage that had been brought in from the outside. On 8/15/25 at 8:43 a.m., the resident was seated in her wheelchair in the Second Floor dining room eating her breakfast. There were straws in her Ensure and juice. On 8/18/25 at 8:43 a.m., the resident was seated in her wheelchair in the Second Floor dining room eating her breakfast. There were straws in her Ensure and juice. The record for Resident 21 was reviewed on 8/13/25 at 2:20 p.m. Diagnoses included, but were not limited to, Parkinson's disease and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS) assessment, dated 7/20/25, indicated the resident was cognitively impaired for daily decision making. The resident would hold food in her mouth or cheeks or would have residual food in her mouth after meals. The resident received a mechanically altered diet. A Care Plan, dated 7/23/25, indicated the resident could feed herself at meals with set up assistance related to the aging process status post hospitalization and right displaced proximal humerus fracture. Interventions included, but were not limited to, staff would provide hands on assistance as needed to ensure adequate intake. The August 2025 Physician's Order Summary (POS) indicated the resident received a regular diet with Ensure at breakfast and dinner. During an interview on 8/18/25 at 10:35 a.m., the Director of Nursing was informed the swallowing guidelines were not followed. No additional information was provided. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident was assessed to self administer medications for a random observation of a medication left at the bedside. (Resident D) Finding includes: On 9/9/24 at 1:53 p.m., Resident D was observed lying in her bed. There was pill in a medication cup on her overbed table. She indicated it was Imodium and the nurse had given it to her. The resident's record was reviewed on 9/9/24 at 1:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to endocarditis, Diabetes Mellitus and anemia. The Brief Interview for Mental Status assessment, dated 8/31/24, indicated the resident was cognitively intact. There was not an assessment to self administer medications or a Physician's order to self administer medications. During an interview on 9/9/24 at 1:58 p.m., the Assistant Director of Nursing (ADON) indicated the resident did not have a self medication assessment and should not have any pills in her room. She entered the room and asked the resident about the medication. The resident indicated it was Imodium and the nurse had given it to her. The ADON removed the medication to verify what it was. She indicated it was an agency nurse on duty and she would speak with her. The current Pharmaceutical Services Policy indicated, .Residents who have orders for self-administration of medication will have drug delivered by a licensed nurse/QMA

Based on observation, record review and interview, the facility failed to ensure a resident's PICC (peripheral inserted central catheter, a device used to administer medications intravenously) dressing was changed as ordered for 1 of 2 residents reviewed for intravenous care. (Resident B) Finding includes: On 9/9/24 at 9:30 a.m., Resident B was observed lying in bed. There was a PICC inserted in his left upper arm. During an interview at that time, QMA 1 indicated the PICC dressing was dated 8/26/24. The resident's record was reviewed on 9/9/24 at 9:50 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, osteomyelitis (bone infection) of the vertebrae, Parkinson's disease, anemia and weakness. The Admission Minimum Data Set assessment, dated 9/3/24, indicated the resident had significant cognitive impairment and was dependent on staff assistance for toileting and transfers. A Physician's Order, dated 9/2/24, indicated to change the PICC line dressing every seven days with a transparent dressing. The September 2024 Treatment Administration Record lacked documentation the PICC dressing had been changed on 9/2/24. A Progress Note, dated 8/28/24, indicated the resident had been admitted to the facility that day. There was a left upper arm PICC with a dressing dated 8/26/24. During an interview on 9/9/24 at 9:35 a.m., LPN 1 indicated the dressing was to be changed every seven days, and it was due to be changed that day. The dressing had not been changed since admission. The document, Care and Maintenance Chart, indicated a PICC dressing should be changed, .On admission, 24 hours after insertion, weekly and PRN (as needed) This citation relates to Complaint IN00442394.

Based on observation, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to staff (LPN 1) not donning the appropriate PPE (personal protective equipment) during a dressing change for 1 of 2 residents reviewed for intravenous care. (Resident B) Finding includes: On 9/9/24 at 10:41 a.m., LPN 1 was observed changing the PICC (peripheral inserted central catheter) dressing to Resident B's left upper arm. LPN 1 was wearing a face mask and gloves. He did not have a gown on. There was a sign posted on the resident's door which indicated the resident was on Enhanced Barrier Precautions. All persons entering the room had to sanitize their hands and staff performing direct care were to wear gloves and a gown. There was a PPE bin outside the resident's door with gowns and masks. During an interview with LPN 1 at the time of the observation, he indicated he thought the sign was for the resident's roommate. LPN 1 then indicated he should have a gown on and donned one at that time. The resident's record was reviewed on 9/9/24 at 9:50 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, osteomyelitis (bone infection) of the vertebrae, Parkinson's disease, anemia and weakness. The Admission Minimum Data Set assessment, dated 9/3/24, indicated the resident had significant cognitive impairment and was dependent on staff assistance for toileting and transfers. A Physician's Order, dated 9/2/24, indicated to change the PICC line dressing every seven days with a transparent dressing. The current policy, Prevention and Management of Multi-Drug Resistant Organisms, indicated, .Enhanced Barrier Precautions .high contact resident care activities: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator . and, .Gloves and gown prior to the high contact care activity This citation relates to Complaint IN00442394.

Based on observation, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside, for 4 of 4 random observations. (Residents 6, 73, 88, and 82) Findings include: 1. During random observations on 5/28/24 at 3:50 p.m., 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., and on 5/30/24 at 9:32 a.m., Resident 6 was observed in her room. At those times there was a Breo hand held inhaler, antibiotic ointment cream, and healing ointment cream observed on the window sill. The record for Resident 6 was reviewed on 5/29/24 at 1:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes, COPD, heart disease, high blood pressure, anxiety and depression. The 4/26/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. There was no self-administration of medication assessment located in the clinical record. The Physician Order Summary for the month of 5/2024 indicated there were no orders for the Breo inhaler or the antibiotic creams. There were no orders for the resident to self-administer her own medication or the healing cream. During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated there were no residents on the unit who were able to self-administer their own medications. 2. During random observations on 5/28/24 at 10:30 a.m., 11:47 a.m., 2:52 p.m., and 4:10 p.m., there was a bottle of Nystatin powder observed on Resident 73's night stand. The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI). The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. There was no self-administration of medication assessment located in the clinical record. Physician's Orders, dated 4/19/24, indicated Nystatin powder 100,000 unit/gram 1 application topical to scrotum for yeast twice a day upon rising and before bed. There was no Physician's Order to self-administer his own medications or to leave the medication at the bedside. During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated there were no residents on the unit who were able to self-administer their own medications. The Nystatin powder was not supposed to be left in the resident's room. 3. During random observations on 5/28/24 at 10:36 a.m., 11:47 a.m., 2:55 p.m., and 4:10 p.m., 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., and 5/30/24 at 9:35 a.m., there was bottle of Nystatin powder on Resident 88's dresser. The record for Resident 88 was reviewed on 5/30/24 at 9:40 a.m. Diagnoses included, but were not limited to, heart failure, high blood pressure, and anxiety disorder. The 3/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. There was no self-administration of medication assessment located in the clinical record. Physician's Orders, dated 5/13/24, indicated Nystatin powder 100,000 unit/gram apply to abdominal folds twice a day. There was no Physician's Order to self-administer her own medications or to leave the medication at the bedside. During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated there were no residents on the unit who were able to self-administer their own medications. The Nystatin powder was not supposed to be left in the resident's room. 48383 4. On 5/28/24 at 10:45 a.m., there were 3 containers of glucose tablets on the resident's night stand next to the bed. The resident indicated she would take them at night if her blood sugar dropped. On 5/28/24 at 11:50 a.m., glucose tablets were observed in the same place on the resident's nightstand. On 5/29/24 at 1:00 p.m. and 3:00 p.m., the resident was observed in her room, glucose tablets remained on the nightstand. On 5/29/24 at 1:37 p.m., the resident was not in her room, the 3 containers of glucose tablets were on the resident's nightstand. On 5/31/24 at 8:30 a.m., the resident's systane eye drops were not available in the medication cart. The resident indicated the eye drops were in her room but she couldn't give them to herself. The bottle of eye drops was observed on the window ledge. There was no medication label on the bottle and there was no box for the medication in the room. LPN 2 removed the eye drops from the resident's room and indicated she would order a new bottle from the pharmacy The record for Resident 82 was reviewed on 5/29/24 at 1:00 p.m. The diagnoses included, but were not limited to, diabetes, depression, weakness, Alzheimer's disease, thyroid disorder, and anemia. The Admission Minimum Data Set (MDS) assessment, dated 4/20/24, indicated the resident was cognitively intact for daily decision making. The resident received insulin 7 of 7 days for the last look back period. A Care Plan, dated 4/14/24, indicated the resident had the potential for hypo/hyperglycemia due to diabetes. A Physician's Order, dated 4/13/23, indicated to administer a 4-gram glucose chewable tablet as needed for a blood sugar less than 60 with symptoms of hypoglycemia. A Physician's Order, dated 4/13/23, indicated to administer Systane eye drops once a day in both eyes. There was no self-medication administration assessment. There was no Physician order to self-administer medications. During an interview on 5/30/24 at 1:15 p.m., ADON 1 indicated there were no residents on the unit who were able to self-administer their own medications. There was no additional information provided. 3.1-11

Based on observation, record review, and interview, the facility failed to ensure areas of bruising and skin tears were assessed and monitored for 4 of 6 residents reviewed for skin conditions non-pressure related. (Residents 26, 60, 168, and 6) Findings include: 1. On 5/29/24 at 9:45 a.m., Resident 26 was observed in her room in bed. An area of reddish purple discoloration was observed on top of the resident's right hand and in between her ring and middle finger. During an interview at that time, the resident indicated she hit her hand on the door frame. The record for Resident 26 was reviewed on 5/29/24 at 3:56 p.m. Diagnoses included, but were not limited to, Guillain-Barre syndrome and history of falling. The Admission Minimum Data Set (MDS) assessment, dated 5/8/24, indicated the resident had short and long term memory problems and was dependent on staff for transfers. The 5/2024 Physician's Order Summary (POS) indicated there was no order to monitor the bruising. The resident was to have weekly skin assessments on Wednesday. There was no documentation in the nursing progress notes nor on the 5/2024 Medication Administration Record (MAR) related to the discoloration. The weekly skin assessment was signed out as being completed on 5/8, 5/15, 5/22, and 5/29/24 on the 5/2024 MAR. There were special instructions to complete a head to toe assessment and document and measure any bruises or skin tears noted. There was no documentation related to the bruising. During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated bruises should have been documented when they were observed. A Physician's Order, dated 5/31/24, indicated to monitor the bruise to the right and left third metacarpophalangeal joint until resolved every shift. 2. On 5/29/24 at 9:43 a.m., Resident 60 was observed in her room seated in her chair. A light purple discoloration was observed on the top of her right hand. The record for Resident 60 was reviewed on 5/29/24 at 1:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation (irregular heartbeat) and hypertensive heart disease with heart failure. The Admission Minimum Data Set (MDS) assessment, dated 5/10/24, indicated the resident was cognitively intact. She needed partial to moderate assistance for transfers. The 5/2024 Physician's Order Summary (POS) indicated there was no order to monitor the bruising. There was no documentation in the nursing progress notes nor on the 5/2024 Medication Administration Record (MAR) related to the discoloration. During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated bruises should have been documented when they were observed. A Physician's Order, dated 5/30/24, indicated to monitor the bruise to the right hand until resolved every shift Nurses' Notes, dated 5/31/24 at 8:37 a.m., indicated the resident had bruising to the right hand, light purple in color and no pain was noted with tactile stimulation. The resident's family stated the bruise was from a previous IV insertion. 3. On 5/29/24 at 9:36 a.m., Resident 168 was observed in his room seated in a high back wheelchair. The resident was observed with multiple areas of reddish/purple discoloration to his bilateral arms and a dressing was in place to his left upper arm. The record for Resident 168 was reviewed on 5/29/24 at 2:18 p.m. Diagnoses included, but were not limited to, Parkinson's disease, atrial fibrillation (irregular heartbeat), and anemia. The 5 day Minimum Data Set (MDS) assessment, dated 5/21/24, indicated the resident was cognitively intact and required partial to moderate assistance with transfers. A Care Plan, dated 5/14/24, indicated the resident was at risk for complications associated with aspirin and antiplatelet therapy. Interventions included, but were not limited to, observe skin with each encounter for bruising and skin tears. The Admission assessment dated , 5/14/24, indicated the resident had bruises to the left upper arm, left antecubital, left lower arm, left wrist, left hand, right upper arm, right antecubital, front of neck, right side of neck, right elbow, right wrist, and right hand A Physician's Order, dated 5/20/24, indicated the resident was to have weekly skin assessments on Mondays. The 5/2024 Physician's Order Summary (POS), indicated there was no order to monitor the bruising and there was no order for the dressing to the left upper arm. There was no documentation in the nursing progress notes nor on the 5/2024 Medication Administration Record (MAR) related to the discoloration. During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated bruises should have been documented when they were observed. A Physician's Order, dated 5/30/24, indicated the resident's left arm was to be cleansed with normal saline, pat dry, and apply foam dressing every Monday, Wednesday, and Friday and as needed (PRN). A Physician's Order, dated 5/30/24, indicated to monitor the bruises to the resident's left forearm every shift until resolved. A Physician's Order, dated 5/31/24, indicated to monitor the scattered bruising to the resident's right forearm every shift until resolved. 10770 4. During random observations on 5/28/24 at 4:00 p.m. and on 5/29/24 at 8:20 a.m., Resident 6 was observed in bed. At those times a bandaid was noted to her left forearm with no date on it. Dried blood could be seen underneath the bandage. On 5/29/24 at 1:00 p.m. and 3:00 p.m., the resident was sitting up in her wheelchair beside the bed in her room. The bandaid was no longer there and a skin tear was observed to the left arm. The skin was rolled back and was bloody. On 5/30/24 at 9:32 a.m., the resident was observed sitting up in the wheelchair in her room. At that time, a clean bandaid was observed over the skin tear. The record for Resident 6 was reviewed on 5/29/24 at 1:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes, COPD, heart disease, high blood pressure, anxiety and depression. The 4/26/24 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 4/7/24, indicated the resident was at risk for skin breakdown. The approaches were to notify the nurse and physician of any skin changes and observe the skin with a.m. and p.m. care. There was no documentation in the nursing progress notes regarding any skin tear to the left forearm. During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated she was unaware the resident had a skin tear on her left arm. There should have been an assessment of the area and physician's orders to treat and monitor the area. During an interview on 5/30/24 at 2:00 p.m., the Hospice Nurse indicated the resident had a scab on that arm when she was first admitted , she told the staff to leave it open to air. She was unaware the area had reopened. Nursing Progress Notes, dated 5/30/24 at 2:11 p.m., indicated a new skin tear was noted on the left forearm that measured 2 centimeters (cm) by 1.6 cm. Nursing Progress Notes, dated 5/30/24 at 2:34 p.m., indicated the Nurse Practitioner was notified of the new skin tear and orders to cleanse with normal saline and apply an adaptive bandage was ordered. During an interview on 5/30/24 at 3:00 p.m., RN 1 indicated she had been taking care of the resident today and was unaware she had a skin tear to the left arm. She was not given any information when she came on shift from the night nurse. She measured the skin tear, notified the doctor, family and received an order to treat. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to uncovered foley (urinary) catheter bags with urine being seen from the hallway for 1 of 1 residents reviewed for dignity. (Resident 73) Finding includes: During random observations on 5/28/24 at 2:52 p.m. and 4:10 p.m., Resident 73 was observed in bed. At those times, his indwelling foley catheter bag was uncovered and hanging on the side of the bed. The urine in the bag could be seen from the hallway. On 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., the resident's foley catheter bag was uncovered and the urine in the bag could be seen from the hallway. On 5/30/24 at 9:34 a.m., and 3:00 p.m., the resident's foley catheter bag was uncovered and the urine in the bag could be seen from the hallway. The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI). The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling foley catheter. A Care Plan, dated 12/17/23, indicated the resident had potential complications related to an urinary indwelling catheter. Physician's Orders, dated 2/12/24, indicated foley catheter 16 French for urinary retention. During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing (ADON) 1 indicated the foley catheter bag should have been covered in a dignity bag. The current 1/1/24 Standards of Care for the Resident with an Indwelling Urinary Catheter policy provided by the Administrator on 5/31/24 at 2:25 p.m., indicated the drainage bag was to be covered with a dignity bag. 3.1-3(t)

Based on record review and interview, the facility failed to thoroughly investigate and resolve grievances in writing from a resident's family member for 1 of 1 resident reviewed for grievances. (Resident B) Finding includes: During an interview with Resident B and her husband on 5/28/24 at 2:57 p.m., they indicated he had a care plan meeting with staff to ensure the staff got his wife dressed and out of bed daily. He indicated the staff left the resident in her room and in the bed several times. Resident B's husband had filed a grievance with the administrator and had not received anything from the staff regarding his complaint. The husband indicated he had requested grievance information and had requested meeting several times to talk about his concerns. The resident's husband also indicated he felt the administrator had avoided responding to him regarding his concerns for his wife's care. The record for Resident B was reviewed on 5/28/24 at 10:00 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, weakness, dysphagia, oral phase, other lack of coordination, other speech and language deficits following cerebral infarction, unspecified protein-calorie malnutrition, dysphagia following other cerebrovascular disease, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus without complications, hypothyroidism, unspecified, depression, unspecified. The Admission Minimum Data Set (MDS) assessment, dated 4/29/24, indicated the resident was cognitively intact. Informal notes for resident B, received from the Administrator on 5/31/24 when asked for grievances, indicated the following: 5/6/24: Resident B's husband complained that his wife was in her wheelchair for one hour and spent 23 hours in the bed. He also complained that his wife did not attend the activities because she was in the bed. He stated the CNA told him that she could not transfer his wife unless she was agreeable to the care or transfer. The resident indicated he felt his wife was being kept in bed to make her too tired to attend activities. He also felt the staff did not communicate between shifts. There was no documentation of an investigation, summary, decision of confirmed or not confirmed, corrective action, or date a written decision was issued. 5/8/24: the resident's husband believed the staff continually changed the plan for the resident. Resident B's husband indicated that he wanted more showers for his wife instead of bed baths. The Director of Rehab discussed the involvement of therapy in shower sessions and continually communicated changes to nursing. 5/15/24: a care plan meeting was conducted. Resident B's husband was pleased with the therapy involvement in showers. 5/17/24: Resident B's husband was visibly upset and indicated the CNA's knew nothing about the orders for his wife. The staff attempted to calm Resident B's husband down and were unsuccessful. 5/20/24: Resident B's husband was visibly upset and waiting in the lobby for staff. Resident B's husband indicated the CNA's told him his wife was not scheduled for a shower for that day. Staff confirmed that Resident B's shower days were Monday and Thursday. The staff followed up with Resident B and her husband, and Resident B received her shower for 5/20/24. 5/24/24: Resident B's husband was waiting in the lobby for staff to arrive. Resident B's husband told staff he felt the staff was not listening to him. He began being disruptive and using aggressive language. Security asked Resident B's husband to leave the building until he felt calm enough to visit. 5/27/24: Resident B's husband informed the staff of a concern from Resident B, which related to a dining area attendant. Staff indicated they spoke to Resident B, and Resident B was not familiar with the concern. Staff reassured the resident that they were available if Resident B had any concerns. 5/28/24: the ADON told the Administrator that Resident B expressed to her that she might like to limit visits from her husband. Facility staff offered to help facilitate a conversation with Resident B and her husband. Resident B declined and indicated she would talk to her husband. The administrator reached out to the ombudsman for further support. A message was left and follow up plans were indicated. 5/30/24: the administrator checked in with Resident B and she indicated she was comfortable and had no concerns at this time. The staff indicated that they would continue to monitor the resident. There was no documentation to indicate written follow up from the facility was provided to Resident B and/or Resident B's representative regarding the concerns and/or grievances filed. During an interview on 5/31/24 at 4:10 p.m. with the Administrator, she indicated she allowed the staff to have full autonomy when it came to handling the concerns of their residents. She did not keep a grievance log and did not track grievances, she allowed the staff to handle the resolutions for the residents. During an interview on 6/3/24 at 4:20 p.m. with the Administrator, she indicated Resident B's husband did tell her his concerns, he also emailed his concerns to her, and expressed his desire to schedule a meeting to discuss his concerns. A Policy titled, Grievance Policy, provided by the Administrator on 6/3/234 at 3:30 p.m., indicated . The facility has named the Administrator or his/her designee as the Grievance Official. The Grievance Official shall oversee the grievance process, receiving, and tracking grievances through to their conclusions. In addition, the Grievance Official shall: Provide written outcomes to the resident/residents representative if requested . This Federal tag relates to Complaint IN00434235. 3.1-7(a)(2) 3.1-7(a)(3)(b)

Based on observation, record review, and interview, the facility failed to ensure foley (urinary) catheter bags and tubing were kept off the floor, for 2 of 2 residents reviewed for catheters. (Residents 73 and 93) Findings include: 1. During random observations on 5/28/24 at 10:30 a.m. and 11:47 a.m., Resident 73 was observed sitting in a wheelchair. At those times, his indwelling foley catheter bag was observed on the floor under the wheelchair. The catheter tubing was above his waist. On 5/29/24 at 3:00 p.m., and on 5/30/24 at 3:00 p.m., the resident was observed in bed. At those times, the foley catheter bag was touching the floor. On 6/3/24 8:50 a.m., the resident was observed sitting in the wheelchair in his room eating breakfast. At that time, the foley catheter bag was in a dignity bag under the wheelchair, however, the tubing was dragging on the floor. The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI). The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling foley catheter. A Care Plan, dated 12/17/23, indicated the resident had potential complications related to an urinary indwelling catheter. The approaches were to maintain the catheter bag and tubing below the bladder level. Physician's Orders, dated 2/12/24, indicated foley catheter 16 French for urinary retention. Physician's Orders, dated 4/16/24, indicated give Macrobid (an antibiotic) 100 milligrams (mg) daily for chronic UTI. During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing (ADON) 1 the foley catheter bag and/or tubing should not have been on the floor. 48383 2. On 5/28/24 at 1:30 p.m., Resident 93 was sitting in his wheelchair in front of the nurse's station. The resident had a Foley catheter and the tubing was observed on the floor. On 5/28/24 at 2:29 p.m., Resident 93 was observed in the same place. He was watching television by the nurse's station. The Foley catheter tubing remained on the floor. On 5/28/24 at 3:00 p.m., Resident 93 was observed sitting in his wheelchair in front of the television in the common area. The catheter tubing was observed on the floor. The record for Resident 93 was reviewed on 5/29/24 at 3:47 p.m. The diagnoses included, but were not limited to, anemia, hypertension (high blood pressure), urinary retention, arthritis, dementia, anxiety, and depression. The resident was dependent with toileting hygiene. The resident had an indwelling catheter. The Admission Minimum Data Set (MDS) Assessment, dated 4/12/24, indicated the resident was not cognitively intact for daily decision making. A Care Plan, dated 5/15/24, indicated the resident had a potential for complications related to a urinary indwelling catheter. A Physician's Order, dated 5/15/24, had indicated to insert a Foley catheter related to urinary retention. During an interview on 5/31/24 at 10:50 a.m., ADON 2 indicated the indwelling foley catheter tubing should not have been on the floor. A policy titled, Standards of Care for the Resident with an Indwelling Catheter, was provided as current by the Administrator on 5/31/24 at 2:25 p.m. The policy indicated, .Secure the catheter to the patients thigh using a securement device. Hang the collection bag below the level of the bladder to prevent urine reflux to the bladder. To maintain free urinary flow the catheter drainage tube is to be free of kinks . 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen. (Resident 60) Finding includes: On 5/28/24 at 1:58 p.m. and 4:05 p.m., Resident 60 was observed in her room. She had oxygen per nasal cannula in use. The resident's oxygen concentrator was set at 3 1/2 liters. On 5/29/24 at 9:42 a.m. and 1:21 p.m., the resident was again observed in her room with oxygen by the way of a nasal cannula in use. The resident's oxygen concentrator was set at 3 1/2 liters. On 5/30/24 at 9:40 a.m., the resident was observed in her room. Oxygen per nasal cannula was in use and the oxygen concentrator was set at 3 1/2 liters. The record for Resident 60 was reviewed on 5/29/24 at 1:34 p.m. Diagnoses included, but were not limited to, pneumonia, emphysema, and congestive heart failure. The Admission Minimum Data Set (MDS) assessment, dated 5/10/24, indicated the resident was cognitively intact and received oxygen therapy. A Care Plan, dated 5/3/24, indicated the resident required the use of oxygen therapy due to emphysema, congestive heart failure, chronic obstructive pulmonary disease, respiratory failure, pneumonia, and asthma. Interventions included, but were not limited to, oxygen as ordered. A Physician's Order, dated 5/3/24, indicated the resident was to receive oxygen at 4 liters per minute per nasal cannula continuously every shift. During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated she would check the resident's oxygen concentrator. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure blood pressure medication was not administered outside of the physician-ordered parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 88) Finding includes: The record for Resident 88 was reviewed on 5/30/24 at 9:40 a.m. Diagnoses included, but were not limited to, heart failure, high blood pressure, and anxiety disorder. The 3/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. Physician's Orders, dated 4/1/24, indicated Verapamil (a medication used to treat chest pain and lower the blood pressure) 120 milligrams (mg) give 60 mg twice a day and hold if the systolic blood pressure (top number) was under 140. The 4/2024 Medication Administration Record (MAR) indicated the Verapamil 60 mg was administered on the following dates with a blood pressure outside of the ordered parameters: 4/4 at 9:00 p.m. blood pressure of 139/79 4/6 at 9:00 p.m. blood pressure of 122/73 4/7 at 9:00 a.m. blood pressure of 133/74 4/8 at 9:00 a.m. blood pressure of 136/84 4/8 at 9:00 p.m. blood pressure of 130/80 4/9 at 9:00 p.m. blood pressure of 127/89 4/10 at 9:00 a.m. blood pressure of 126/70 4/10 at 9:00 p.m. blood pressure of 122/80 4/11 at 9:00 a.m. blood pressure of 135/81 4/11 at 9:00 p.m. blood pressure of 133/71 4/12 at 9:00 a.m. blood pressure of 122/82 4/12 at 9:00 p.m. blood pressure of 131/79 4/16 at 9:00 p.m. blood pressure of 132/72 4/17 at 9:00 a.m. blood pressure of 130/72 4/20 at 9:00 p.m. blood pressure of 138/83 4/22 at 9:00 p.m. blood pressure of 137/89 4/25 at 9:00 p.m. blood pressure of 131/71 4/26 at 9:00 p.m. blood pressure of 124/79 4/27 at 9:00 a.m. blood pressure of 122/79 4/29 at 9:00 p.m. blood pressure of 133/81 4/30 at 9:00 p.m. blood pressure of 114/83 The 5/2024 MAR indicated the Verapamil 60 mg was administered on the following dates with a blood pressure outside of the ordered parameters: 5/2 at 9:00 p.m. blood pressure of 127/80 5/3 at 9:00 a.m. blood pressure of 128/79 5/5 at 9:00 p.m. blood pressure of 120/70 5/15 at 9:00 p.m. blood pressure of 129/79 5/17 at 9:00 p.m. blood pressure of 113/71 5/20 at 9:00 p.m. blood pressure of 130/77 5/24 at 9:00 a.m. blood pressure of 130/78 During an interview on 5/31/24 at 10:32 a.m., Assistant Director of Nursing 1 indicated nursing staff should have followed the physician's orders for the administration of the Verapamil. 3.1-48(a)(3)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to dialysis day, dialysis chair time, and dialysis pick up time, for 1 of 1 resident reviewed for dialysis. (Resident 268) Finding include: 1. The record for Resident 268 was reviewed on 5/28/24 at 1:15 p.m. Diagnoses included, but were not limited to, fracture of nasal bones, subsequent encounter for fracture with routine healing, end stage renal disease, retention of urine, unspecified, dependence on renal dialysis, benign prostatic hyperplasia with lower urinary tract symptoms. The Admission Minimum Data Set (MDS) assessment, dated 5/22/24, was incomplete and in process. The resident was admitted on [DATE]. A Physician's Order, dated 5/22/24, indicated the resident was to receive hemodialysis at [name of] Dialysis Center, on Monday, Wednesday, and Friday. The resident's dialysis pick up time was ordered for 3:00 p.m. The resident's dialysis chair time was ordered for 4:00 p.m. A Progress Note, dated 5/29/24, indicated the resident received dialysis services on Tuesday, Thursday, and Saturday. The progress notes and the resident's dialysis communication book indicated the resident's dialysis pick up time was signed out at 12:00 p.m., and the resident's dialysis chair time was signed out at 1:00 p.m. During an interview on 5/31/24 at 2:31 p.m. with Assistant Director of Nursing (ADON) 1, she indicated the resident's dialysis order has not been updated and she would correct the order. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place related to staff failing to sanitize hands in between glove changes for 1 of 1 glucometer use observed and staff failing to donn personal protective equipment (PPE) for a resident in contact precautions during a random infection control observation. (Residents 53 and 73) Findings include: 1. On 5/29/24 at 4:34 p.m., LPN 1 was preparing to complete a blood sugar check via glucometer for Resident 53. The LPN donned gloves and did not hand sanitize nor wash her hands prior. After obtaining the resident's blood sugar result, the LPN removed her gloves and donned a new pair of gloves, she did not hand sanitize in between glove changes. She proceeded to cleanse the glucometer with a germicidal wipe and she removed her gloves. Again, she did not use hand sanitizer. The LPN prepared the resident's medications and administered them. She sanitized her hands prior to leaving the resident's room. During an interview on 6/3/24 at 9:47 a.m., Assistant Director of Nursing (ADON) 2, indicated the LPN should have hand sanitized prior to donning her gloves and in between glove changes. The facility Hand Hygiene policy was provided by the Administrator on 6/3/24 at 10:03 a.m. The policy indicated to decontaminate hands after glove removal and before medication administration. 10770 2. During a random observation on 5/31/24 at 7:45 a.m., the Wound Nurse was observed standing over Resident 73 finishing a skin treatment. At that time, the Wound Nurse was wearing gloves on both hands. She did not have on an isolation gown. A sign posted on the wall outside of the resident's room indicated enteric/contact isolation: all staff must wash their hands with soap and water and don an isolation gown and gloves prior to entering the room. Another sign posted on the wall indicated enhanced barrier precautions (EBP): if contact was made, a gown and gloves was required prior to touching the resident. A 3 tiered container full of isolation gowns, gloves, and face masks was located right by the resident's room door. During an interview on 5/31/24 at 7:52 a.m., the Wound Nurse indicated she was aware she needed to wear an isolation gown when performing the wound treatment, however, she was in a hurry this morning. The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI). The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling foley catheter. Physician's Orders, dated 2/12/24, indicated foley catheter 16 French for urinary retention. Physician's Orders, dated 5/22/24, indicated to cleanse the head of the penis with soap and water and apply triad wound paste every shift. Nursing Progress Notes, dated 5/24/24 at 2:34 p.m., indicated the resident had 3 foul smelling and mucus filled stool. A new order was obtained to collect a stool specimen. Nursing Progress Notes, dated 5/26/24 at 1:30 p.m., indicated the doctor was notified the resident tested positive for C-Difficile toxin. Physician's Orders, dated 5/26/24, indicated contact/enteric isolation. During an interview on 5/31/25 at 10:50 a.m., Assistant Director of Nursing 1 indicated the Wound Nurse should have donned an isolation gown prior to completing the resident's treatment to his penis area. The current 1/1/23 Prevention and Management of Multi-Drug Resistant Organisms policy, provided by the Director of Nursing on 6/3/24 at 1:30 p.m., indicated enhanced barrier precautions applied to residents with urinary catheters and gowns and gloves were required for high contact care activity. Contact Precautions applied to residents with infected Multi Drug Resistant Organisms and presence of acute diarrhea. 3.1-18(b)

Based on record review and interview, the facility failed to ensure the resident's family was notified of a change in condition, for 1 of 3 residents reviewed for notification of change. (Resident H) Finding includes: The record for Resident H was reviewed on 3/19/24 at 4:25 p.m. Diagnoses included, but were not limited to, sepsis, chronic respiratory failure, atrial fibrillation, anemia, heart failure, cirrhosis of the liver, alcohol abuse, and chronic kidney disease. A Nurse's Note, dated 2/26/24 at 9:31 a.m., indicated the Nurse Practitioner (NP) was notified due to the resident not being easily aroused, and only able to verbalize some words but was very lethargic. The NP indicated she would be in to assess the patient. A Nurse Practitioner (NP) Progress Note, dated 2/16/24 at 11:03 a.m., indicated the patient was being evaluated for increased lethargy and dyspnea (shortness of breath). Nursing staff indicated the patient refused oral intake this morning, and his breathing appeared labored. Labs were repeated this morning and results were pending. The patient was noted to awaken to verbal stimuli, however he had increased confusion, and respirations were tachypneic (rapid shallow breathing), but did not appear to be in distress. A Nurse's Note, dated 2/26/24 at 11:59 a.m., indicated the NP was made aware of the resident's hemoglobin of 6.9. A new order was obtained to check his Hemoglobin and Hematocrit stat (immediately). A Nurse's Note, dated 2/26/24 at 2:51 p.m., indicated the resident was being sent to the emergency room for altered mental status and acute kidney injury. A Nurses' Note, dated 2/27/24 at 12:43 a.m., indicated the resident was admitted to the hospital with the diagnoses of altered mental status, acute kidney injury, anemia, pneumonia, and hypotension. The Hospital Transfer Form, dated 2/26/24, indicated the time of transfer was 2:30 p.m., due to altered mental status. There was no documentation the resident's family was notified of the change of condition and the transfer to the hospital on 2/26/24. During an interview, on 3/20/24 at 9:15 a.m., the Assistant Director of Nursing indicated nursing staff were supposed to notify the resident's family at the time of the change in status. During an interview, on 3/20/24 at 12:00 p.m., the Director of Nursing indicated the resident's family was not notified of his change of condition and transfer to the hospital. This citation relates to Complaint IN00429419. 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure each resident was free from accidents related to a transfer with the Hoyer lift with only one assist which resulted in 19 sutures as well as a fractured tibia for 1 of 4 residents reviewed for accidents of the 7 residents who met the criteria for accidents. (Resident #77) Findings include: On 6/26/14 at 2:20 p.m., Resident #77 was observed lying in bed. The resident's bed was in a low position with bolsters noted to both sides. The resident was observed with a leg cast to his left leg. The resident's daughter was seated in a chair next to the bed. The record for Resident #77 was reviewed on 6/26/14 at 2:33 p.m. The resident was admitted to the facility on [DATE] and his latest return to the facility after a hospitalization was on 4/23/14. The resident's [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 9. The resident had no behaviors. He needed extensive assist with two person physical assist with bed mobility and transfers and he used a wheelchair. Review of the care plan dated 5/28/14 indicated the resident may be at risk for falls related to had a history of [REDACTED]. The Nursing approach regarding the mechanical lift was dated 7/24/13. Review of Physician order [REDACTED]. Review of Nursing Progress Notes dated 5/26/14 at 4:00 p.m., indicated resident up in Hoyer lift being transferred to geri chair. "CNA stated I looked down and noticed blood coming from leg." Resident noted with large skin tear to left lower leg. Small amount of bleeding, skin edges not well approximated, white fleshy skin noted. Searched room environment for any evidence of blood on equipment, bedside table, bed and floor and none was found. Instructed CNA to place resident back in bed. MD (Medical Doctor) telephoned order received to send resident to ER (emergency room ) for evaluation and treatment of [REDACTED]. Continued review of Nursing Progress Notes dated 5/26/14, at 9:15 p.m., indicated the resident returned to facility via ambulance. Telephoned the hospital nurse and report received. Resident noted with a soft cast to left leg and received 19 sutures to skin tear. Review of the left Tibia and Fibula x-ray report dated 5/26/14 indicated "Impression: Oblique fracture through the distal tibial diaphysis is not displaced. Vascular calcifications with soft tissue swelling." Review of the 5/26/14 incident and accident investigation of unknown origin provided by the facility on 6/26/14 at 3:00 p.m., indicated the resident did not know what happened. The injury was a skin tear to the left leg. Review of CNA #1's first statement dated 5/26/14 indicated "On May 26, 2014 I was working evenings. At 4 p.m., I was in room (Resident #77"s room number) transferring (Resident #77's room number) into chair for dinner. I asked resident to lift leg up when resident started to lift his left leg I noticed blood on leg. I got him into chair reported to nurse then I put pressure on wound after we placed resident back in bed." Review of CNA #1's second statement dated 5/27/14 indicated "I was in room (Resident #77's). Resident had his legs over the side of the bed. He was yelling 'I'm tied down, get me up, I'm tied down.' So I placed his legs back into the bed and proceed (sic) to get him dressed to get him up for dinner. I got resident up into hoyer pulled him from over the bed over to the geri chair. At that time resident left foot was bumping leg rest. I ask him to please lift up his leg. When he did I noticed his leg was bleeding. I lowered him into chair yelled for nurse grab a wash cloth and applied pressure. (sic) Nurse came in advised me there was a bathroom light going off. I went and answered light. When I came back she told me and the other aide to get him back in bed he was going to the hospital. So we placed him back in the bed by the hoyer." Continued review of the incident and accident form indicated there was an interview with the nurse who was on duty that day, taking care of Resident #77. Review of LPN #3's interview indicated CNA #1 did not ask the nurse for help with Resident #77. Review of the current and undated Hoyer Lift Policy provided by the Director of Nursing indicated "The purpose was to transfer residents from bed to wheelchair who are obese, large framed, or unable to assist themselves. The procedure was to explain to resident and bring hoyer lift to bedside and request a second or third attendant to assist as needed." Interview with the Director of Nursing on 6/27/14 at 9:15 a.m., indicated the facility's policy regarding Hoyer lifts was for two people to be present at all times while the lift was in use. She further indicated the CNA had been inserviced on the policy before and was aware of it. Interview with the Staff Development Nurse on 6/27/14 at 11:30 a.m., indicated it was the facility's policy to use two staff members when using the Hoyer lift to transfer a resident. 3.1-45(a)(1)