Every finding on record at Restoracy of Goshen, The

Based on record review and interview, the facility failed to follow physician orders for the administration of blood pressure medication and failed to follow the orders regarding medication parameters for blood pressure medication for 3 of 6 residents reviewed for quality of care. (Residents C, D & F)Findings include:1.A record review for Resident C was completed on 8/27/2025 at 9:40 A.M. Diagnoses included, but were not limited to: congestive heart failure, chronic kidney disease and hypertension.An admission Minimum Data Set (MDS) assessment, dated 5/24/2025, indicated Resident C had moderate cognitive impairment.A Physician's Order, dated 5/28/2025, indicated the resident was to receive carvedilol oral tablet 6.25 milligrams, one tablet orally two times a day for hypertension. The carvedilol medication had orders to have been held for the physician prescribed parameters of a systolic blood pressure less than 110 mmHg (millimeters of mercury) or a heart rate of less than 60 beats per minute. Review of the May 2025 Medication Administration Record (MAR) indicated a blood pressure and pulse had been obtained prior to the administration of the carvedilol from the 5/17/2025 evening dose through the 5/28/2025 morning dose. The MAR indicated from the 5/28/2025 evening dose through the 5/31/2025 evening dose, a blood pressure and pulse had not been obtained prior to administration of the carvedilol.The MAR for June 2025 and July 2025 had no documentation of a blood pressure or a pulse having been taken prior to the administration of the carvedilol.A Care Plan, initiated on 5/17/2025, indicated Resident C was at risk for an altered cardiovascular status with interventions including, but not limited to: monitor vital signs every shift and as needed. On 8/27/2025 at 1:52 P.M., the Director of Nursing (DON) indicated the blood pressure and pulse should have been obtained prior tot he administration of the carvedilol medication.2. A record review for Resident D was completed on 8/26/2025 at 11:02 A.M. Diagnoses included, but were not limited to: congestive heart failure, hyperlipidemia and hypertension.A Annual MDS assessment, dated 6/22/2025, indicated Resident D was rarely understood.A Physician's Order, dated 5/9/2025, indicated the resident was to receive carvedilol oral tablet 12.5 milligrams, one tablet by mouth, two times a day for hypertension. The following administration parameters were ordered: hold for a systolic blood pressure less than 110 mmHg (millimeters of mercury) or a heart rate of less than 60 beats per minute. The July 2025 and August 2025 MAR indicated a blood pressure and a pulse had not been obtained prior to the administration of the carvedilol medication for the evening doses.A Care Plan, initiated Resident D was at risk for cardiovascular complications related to multiple cardiovascular diseases. Interventions included, but were not limited to: administer medication per the physician's order, vital signs as ordered and notify the physician of any abnormal readings as needed.During an interview, on 5/27/2025 at 2:05 P.M., the DON indicated the blood pressure and pulse should have been obtained prior to the administration of the carvedilol medication.3. A record review for Resident F was completed on 8/26/2025 at 2:19 P.M. Diagnoses included, but were not limited to: hypertension, adult failure to thrive and cerebral infarction (stroke).A Quarterly MDS assessment, dated 6/15/2025, indicated Resident F had moderate cognitive impairment.A Physician's Order, dated 12/4/2024, indicated the resident was to receive losartan 100 milligrams orally daily. There were no administration parameters ordered for the administration of the losartan.The following blood pressures were obtained, the losartan given and the physician was not notified of the abnormal blood pressure readings.-7/1/2025 8:40 A.M. 113/55 mmHg-7/31/2025 9:45 A.M. 110/41 mmHg-8/11/2025 9:48 A.M. 123/41 mmHg-8/23/2025 9:10 P.M. 122/49 mmHgA Care Plan, initiated 11/9/2020 and revised on 5/21/2024, indicated Resident F had hypertension. Interventions included, but were not limited to: give antihypertensive medications as ordered and monitor for side effects of orthostatic hypotension.During an interview, on 8/27/2025 at 2:09 P.M., the DON indicated based on nursing judgement, she would have held the administration of the losartan for a systolic blood pressure less than 130 mmHg and a diastolic blood pressure less than 90 mmHg. She indicated every nurse was different regarding their nursing judgement. During an interview, on 8/27/2025 at 2:42 P.M., Resident F's nurse practitioner indicated she would not be cool with the losartan being given with the diastolic blood pressures in the 40's and 30's and was not aware the medication had been given with those blood pressure readings.A policy was requested for administration of antihypertensive medications, on 5/27/2025 at 3:00 P.M. The Executive Director indicated a policy was not available for administration of antihypertensive, but the staff should have followed the physician's orders. This citation relates to intakes 2562332 and 2579643.3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure 1 of 5 staff observed administering medication met professional standards regarding ensuring a resident consumed medication for 1 of 8 residents observed during medications pass. (Resident 26) Finding includes: During a medication administration observation, on 5/30/2025 at 7:15 A.M., QMA 5 obtained Resident 26's medications from the medication cart and placed the pills in a souffle' cup. Next, QMA 5 entered the resident's room and questioned Resident 26 about her pain. Resident 26 indicated she wanted a pain pill. QMA 5 placed the souffle cup with medications on the bed side table, exited Resident 26's room and obtained a pain pill from the narcotic locked box. QMA 5 returned to Resident 26's room and placed the soufflé cup with the pain pill next to the previously placed soufflé cup, which was still full of medication, on the bed side table and left the room without observing Resident 26 consume the medications. During an interview, on 5/30/2025 at 7:18 A.M., QMA 5 indicated she should have watched Resident 26 take the medications and should not have left the medications at the bed side On 5/30/2025 at 9:10 A.M., the Administrator provided the policy titled, Administering Oral Medications, undated, and indicated the policy was the one currently used by the facility. The policy indicated . 20. Remain with the resident until all medications have been taken 3.1-35(g)(1)

Based on observation, record review and interview, the facility failed to to notify the physician and obtain treatment orders timely for an unstageable pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 19) Finding includes: During an observation, on 5/28/2025 at 2:12 P.M., Resident 19 was observed to have a low air loss mattress on her bed. A record review for Resident 19 was completed on 5/29/2025 at 10:04 A.M. Diagnoses included, but were not limited to: dementia, seizures and palliative care. A Significant Change Minimum Data Set (MDS) assessment, dated 1/19/2025, indicated Resident 19 had severe cognitive impairment, had an unstageable pressure ulcer that was not present on admission, required substantial/maximal assistance for bed mobility and received hospice care. A Nursing Progress Note, dated 10/26/2024 at 1:26 A.M., indicated Resident 19 was observed to have a four centimeter by three centimeter pressure ulcer to her right hip. The pressure ulcer was described as open with adipose tissue exposed, drainage and slough (a collection of yellow or tan devitalized tissue that impedes healing). The pressure ulcer was cleansed and a bandage was applied. A Nursing Progress Note, dated 11/6/2024 at 12:29 P.M., indicated Resident 19 had an open area on the right hip. The physician, power of attorney and the Director of Nursing (DON) were notified. There was no documentation the physician had been notified of Resident 19's pressure ulcer until 11/6/2024, 11 days after the area had been identified. A Nursing Progress Note, dated 11/6/2024 at 12:30 P.M., indicated the physician had been informed that the pressure ulcer had been cleansed with normal saline, Betadine applied, and the area was covered with a bordered gauze dressing. The physician indicated to continue the same treatment daily. The order was written and the power of attorney was notified of the new treatment order. There was no documentation a treatment order had been obtained prior to 11/7/2024 for Resident 19's pressure area. During an interview, on 6/2/2025 at 10:35 A.M., the DON indicated an order for a treatment should have been obtained when the pressure ulcer was identified. She indicated a treatment order for the pressure ulcer could not be found in the medical record until 11/7/2024. A current policy was provided, on 6/2/2025 at 3:11 P.M., by the Executive Director. The policy titled, Pressure Ulcers/Skin Breakdown, indicated, .The physician of wound specialist will order pertinent wound treatments, including reduction surfaces, wound cleansing and debridement approaches, dressings [occlusive, absorptive, etc.], and application of topical agents 3.1-40(a)(2)

Based on record review and interview, the facility failed to follow physician orders by not obtaining ordered laboratory tests for 1 of 5 residents reviewed for unnecessary medications. (Resident 6) Finding includes: A record review for Resident 6 was completed on 5/29/2025 at 8:56 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, chronic kidney disease, chronic obstructive pulmonary disease (COPD and Parkinson's disease. A Medicare 5-day Minimum Data Set (MDS) assessment, dated 5/8/2025, indicated resident 6 received insulin injections and a diuretic. A Physician's Order, dated 9/17/2024, indicated to obtain a prealbumin (a protein in the blood to measure nutritional status) laboratory test for wound healing. This laboratory test could not be found on the laboratory portal or in the resident's medical record. A Physician's Order, dated 11/13/2024, indicated to obtain a hemoglobin A1C (measure of blood sugar for past 2-3 months) laboratory test on 12/17/2024. This laboratory test could not be found on the laboratory portal or in the resident's medical record. A Physician's Order, dated 1/23/2025, indicated to obtain a basic metabolic panel (fluid and electrolyte levels, kidney function and blood sugar levels) and a hemoglobin A1C every six months starting on the 20th of the each month. This laboratory test should have been obtained on 2/20/2025. This laboratory test could not be found on the laboratory portal or in the resident's medical record. A Physician's Order, dated 5/20/2025, indicated to obtain a basic metabolic panel and a hemoglobin A1C every six months starting on the 22nd of each month. This laboratory test should have been obtained on 5/22/2025. This laboratory test could not be found on the laboratory portal or in the resident's medical record. During an interview, on 6/2/2025 at 10:08 A.M., the Director of Nursing (DON) indicated the laboratory tests could not be found in the medical record or the laboratory portal. During an interview, on 6/2/2025 at 10:28 A.M., the DON indicated she had contacted the nurse practitioner who had placed the laboratory orders and he indicated he ordered the laboratory tests orders by accident. The DON indicated the facility had been under a prior management company and was she was unable to clarify why the lab orders had not been completed when they had been ordered. A current policy was provided, on 6/2/2025 at 3:11 P.M., by the Executive Director. The policy titled, Lab and Diagnostic Test Results, indicated, .Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs 3.1-49(a)

Based on interview and record review, the facility failed to ensure lab results were obtained in a timely manner and antibiotic treatment for a UTI was initiated in a timely manner for 1 of 1 residents reviewed for UTI (Resident 12). Finding includes: During an interview, on 5/28/2025 at 11:13 A.M. a family member of Resident 12 indicated she had been complaining about vaginal pain and had a history of UTI's (urinary tract infections). A record review was completed for Resident 12 on 5/29/2025 at 8:37 A.M. Diagnoses included, but were not limited to: dementia and type 2 diabetes. A Quarterly MDS (Minimum Data Set) assessment, dated 4/18/2025 indicated Resident 12's cognition was severely impaired, she was occasionally incontinent of bowel and bladder and required partial to moderate assistance with toileting and bathing. A Nursing Progress Note, dated 5/13/2025 at 10:45 A.M. indicated the resident had been seen by the Gynecologist. A Nursing Progress Note, dated 5/14/2025 at 2:56 P.M. indicated a call was placed to the OB/GYN (Obstetrics and Gynecology). The note indicated the facility had obtained the records from Resident 12's visit on 5/13/2025 and the note indicated a vaginal swab and urine test was completed to check for an infection. The note indicated for the facility staff to call back on 5/16/2025 for the results of the swab and urine test. A Nursing Progress Note, dated 5/16/2025 at 2:28 P.M. indicated the facility had attempted to contact the OB/GYN office without success. A Nursing Progress Note, dated 5/23/2025 at 1:40 P.M. indicated the facility had spoken with a nurse at the OB/GYN office regarding Resident 12's vaginal swab and urine results. The urinalysis test results indicated the resident was positive for E.Coli (Escherichia coli- a bacterial infection).The note indicated they had received a new order for the resident to begin fosfomycin tromethamine (an antibiotic) 3g (grams) every three days for a total of three doses. The medication was to be delivered to the facility on 5/23/2025 by (pharmacy name). The record lacked documentation that additional calls had been placed to the OB/GYN office between 5/16/2025 and 5/23/2025 in an attempt to obtain the results of Resident 12's vaginal swab and urine test. A Physician's Order, dated 5/24/2025 indicated for Resident 12 to begin fosfomycin tromethamine 3g by mouth one time a day for three days for a total of three administrations on 5/25/2025. The (pharmacy name) packing slip was reviewed and indicated the fosfomycin tromethamine 3g was delivered to the facility on 5/25/2025 at 3:07 A.M. A Nursing Progress Note, dated 5/25/2025 at 6:27 P.M. indicated Resident 12 received her first dose of fosfomycin tromethamine 3g. During an interview, on 5/30/2205 at 1:19 P.M., the DON indicated she was unsure as to why Resident 12's medication was not delivered in a timely manner but it should have been. She also indicated there should have been documentation between 5/16/2025 and 5/23/2025 of attempts made to contact the Residents OB/GYN for test results. On 6/2/2025 at 8:18 A.M., the DON provided the policy titled, Culture Tests Policy, dated 3/2/25 and indicated it was the policy currently being used by the facility. The policy indicated 8. Completed culture reports shall be reviewed by Charge Nurse and/or the Infection Preventionist and orders obtained, as soon as possible 3.1-41

Based on observation, record review and interview, the facility failed to follow enhanced barrier precautions for a resident with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 19) Finding includes: During an observation, on 5/28/2025 at 2:12 P.M., Resident 19 was observed to have an enhanced barrier precaution sticker on the door frame of her room. A record review For Resident 19 was completed on 5/29/2025 at 10:04 A.M. Diagnoses included, but were not limited to: dementia, seizures and palliative care. A Significant Change Minimum Data Set (MDS) assessment, dated 1/19/2025, indicated Resident 19 had severe cognitive impairment, had an unstageable pressure ulcer that was not present on admission, received hospice care, required substantial/maximal assistance for bed mobility and was dependent on toileting. A Physician's Order, dated 10/3/2024, indicated Resident 19 was ordered enhanced barrier precautions (infection control intervention to reduce the transmission of multi-drug-resistant organisms). During an observation, on 6/2/2025 at 11:45 A.M., Resident 19 was observed in bed and CNA 7 was observed providing incontinent care. CNA 7 only had gloves on for personal protective equipment. During an interview, on 6/2/2025 at 11:46 A.M., CNA 7 indicated she was not aware of any precautions she should have followed while caring for Resident 19. She indicated if Resident 19 was on any precautions, the facility should have informed her. During an observation, on 6/2/2025 at 11:48 A.M., LPN 6 was observed providing incontinence assistance with CNA 7 and changing a dressing to the resident's right hip unstageable pressure ulcer. LPN 6 and CNA 7 were only wearing gloves for personal protective equipment. During an interview, on 6/2/2025 at 1:31 P.M., LPN 6 indicated Resident 19 was on enhanced barrier precautions. She indicated CNA 7 and herself should have worn a gown and gloves while care was provided for incontinence and wound care. A current policy was provided, on 6/2/2025 at 3:11 P.M., by the Executive Director. The policy titled, Enhanced Barrier Precautions, indicated, .The [facility name] utilizes Enhanced Barrier Precautions [EBP] to reduce transmission of multidrug resistant organisms [MDRO], while maintaining a homelike environment and personal centered care .Enhanced Barrier Precautions indications: 2. Residents with chronic wounds and/or indwelling medical device, even without a known MDRO infection or colonization. a. Chronic wounds include, but are not limited to, pressure ulcers .4. Enhanced Barrier Precautions will be utilized only during prolonged high-contact resident care activities. Examples include, but not limited to: f. Changing brief or assistance with toileting .h. Wound care of chronic wounds 3.1-18(a)

Based on record review and interview, the facility failed to ensure a resident's family member/Power of Attorney (POA) was notified when a medication was discontinued for 1 of 3 resident's reviewed for medication changes. (Resident B) Finding includes: On 8/7/24 at 3:39 P.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: Alzheimer's disease and depression. A current Care Plan indicated Resident B was at risk for adverse reactions and side effects related to receiving Zoloft for depression. The Care Plan was revised, on 7/17/24, and indicated the POA preferred no GDR (Gradual Dose Reduction) attempts be made. The interventions included, but were not limited to: .Administer antidepressant medications per orders . A Physician Order, dated 10/24/23, indicated Zoloft (Sertraline) 25 milligrams (mg) was started on 10/25/23 for depression. A Consultation Report, from the pharmacy, dated 3/1/24- 5/16/24, indicated the resident was taking Sertraline 25 mg for depression, which was due for a GDR evaluation. The report indicated the resident would benefit from a reduction of Sertraline. The form was signed by the Medical Director, but was undated. The form indicated the physician had accepted the recommendation, but the form did not indicate to discontinue the medication. The Medication Administration Record (MAR) for July 2024 indicated the Zoloft was discontinued on 7/23/24. A Nurse Practitioner Note, dated 7/29/24 at 5:31 P.M., indicated .Review of chart reveals that Sertraline 25 mg was discontinued on 7/23/24. Pt [patient] previously failed GDR of sertraline and episodes of aggravation well managed on low dose of Sertraline. Despite review of chart, unable to determine who discontinued Sertraline and why .restart Sertraline 25 mg, once daily The MAR indicated the Zoloft (Sertraline) was restarted on 7/30/24. A form titled Guest Satisfaction Concern/Suggestion, dated 7/31/24, was provided by the Administrator, on 8/9/24 at 9:50 A.M. The concern form had been filled out by a family member for Resident B regarding the discontinuation of Zoloft, without notification of the POA (Power of Attorney)/family for Resident B. The form indicated the pharmacy had requested to discontinue the Zoloft and the Medical Director had signed the request and discontinued the medication without consulting the Social Service Director and the prescribing physician. During an interview, on 8/9/24 at 11:35 A.M., the Administrator indicated he could not find the facility's notification to Resident B's family and/or POA regarding the medication change for the Zoloft. On 8/9/24 at 12:50 P.M., the Director of Nursing provided a policy titled, Notification of Change, dated 12/19/22 with revision on 2/14/24, and indicated the policy was the one currently used by the facility. The policy indicated .The facility must inform the resident; consult with the resident's practitioner; and notify, consistent with his or her authority, the resident representative(s) when there is a change in status .Information A change in status would include the following: An accident involving the resident .A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .Procedure .3. The licensed nurse will document in the resident electronic medical record the notification and the information that was provided, including any additional orders from the practitioner This citation relates to Complaint IN00440031. 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure a care plan regarding self care deficits and fall risk was implemented for 1 of 3 residents reviewed for staff assisted transfers. (Resident D) Finding includes: On 8/7/24 at 1:34 P.M., Resident D was observed being pushed in her wheelchair to her room, by her husband (Resident B). Resident D's husband was observed positioning the resident's wheelchair beside her bed, then positioned himself in front of Resident D in preparation to transfer her to the bed by himself. CNA 2 entered the room and informed Resident D's husband that she would transfer Resident D to her bed. CNA 2 was then observed to transfer Resident D to the bed, by herself, and reposition her for comfort. Resident B was alert to self only. On 08/7/24 at 2:05 P.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: Parkinson's Disease, dementia and difficulty walking. A Quarterly MDS (Minimum Data Set) assessment, dated 3/6/24, indicated the resident required substantial/maximal assistance for bed to chair transfers. A Care Plan, dated 8/24/19 and revised on 6/14/24, indicated the resident had a self-care deficit related to Parkinson's Disease and impaired cognitive function. The interventions included, but were not limited to: .Transfer: Guest requires extensive assist of 2 staff for transfers A Care Plan, dated 7/27/21 and revised on 7/17/24, indicated the resident was at risk for a fall related to muscle weakness, dementia and osteoarthritis. The interventions included, but were not limited to: .2 person assist for transfers During an interview, on 8/7/24 at 2:57 P.M., CNA 2 indicated Resident B was a 1 to 2 person assist for transfers, depending on her cooperation during care. CNA 2 had no idea why the Care Plan would say the resident was a 2 person transfer because she did not always need 2 persons to transfer Resident B and sometimes the Resident's husband would transfer her by himself, despite numerous signs in the room reminding him to call staff for assistance. On 8/9/24 at 1:48 P.M., the Director of Nursing provided policy titled, Care Planning, dated 6/24/21, and indicated the policy was the one currently used by the facility. The policy indicated .Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes immeasurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments This citation relates to Complaint IN00439575. 3.1-35(g)(2)

Based on observation and record review, the facility failed to ensure staff members were present when 3 residents were observed at the dining room table, eating and drinking who required supervision with meals. (Resident M, Resident J and Resident K) Findings include: During an observation, on 8/8/24 at 9:21 A.M., on the Penny Lane unit, CNA 3 exited the building. Resident J, Resident K and Resident M were observed at a long dining room table. All three residents were eating their breakfast and Resident K and Resident M had spouted/lidded cups. Each resident was observed eating and drinking without any assistance or supervision. There were no staff members located in the area of the dining table or in the hallway in view of the dining table. At 9:34 A.M., CNA 3 re-entered the building and went directly to a resident's room and all three residents continued to be unsupervised as they ate. At 9:30 A.M., CNA 3 entered the dining room. She indicated she was unaware the residents were left unsupervised and thought other staff members were in the dining room, as she was taking care of an emergency in another building. 1. On 8/9/24 at 2:50 P.M., P.M., a review of the clinical record for Resident M was conducted. The resident's diagnoses included, but were not limited to: dementia and Parkinson's Disease A Care Plan, dated 1/23/24, with revision on 8/2/24, indicated the resident was a nutritional risk related to his diagnoses of Parkinson's and dementia. The interventions included but were not limited to: .Provide resident with assistance with eating and drinking. A Quarterly Minimum Data Set (MDS) assessment, dated 4/22/24, indicated Resident M required supervision with eating and a helper who provided verbal cues or touching/steadying assistance. 2. On 8/9/24 at 2:58 P.M., a review of the clinical record for Resident J was conducted. The resident's diagnoses included, but were not limited to: dementia and dysphagia (difficulty swallowing). A current Care Plan, initiated on 12/8/23, indicated the resident was nutritionally at risk related to diagnoses of dysphagia, poor dentition and mechanically altered texture for ease of chewing/swallowing. The interventions included, but were not limited to: provide assistance with eating or drinking, as needed and provide diet of ground meat texture with thin liquids. A Quarterly MDS assessment, dated 3/8/24, indicated the resident required supervision with eating and a helper who provided verbal cues or touching/steadying assistance. 3. On 8/9/24 at 3:06 P.M., a review of the clinical record for Resident K was conducted. The resident's diagnoses included, but were not limited to: dementia and severe protein-calorie malnutrition. A current Care Plan, dated 3/21/23 with a revision on 8/7/24, indicated the resident was nutritionally at risk related to diagnosis of dementia and malnutrition with decreased intakes. The intervention included, but were not limited to: provide adaptive equipment-sippy cup, diet mechanical soft with no thin liquids and provide resident with assistance with eating and drinking. A Quarterly MDS assessment, dated 5/6/24, indicated the resident required supervision with eating and a helper who provided verbal cues or touching/steadying assistance. On 8/8/24 at 10:31 A.M., the Administrator provided a policy titled, Meal Service, dated 11/19/21, and indicated the policy was the one currently used by the facility. The policy indicated .6. At least one Nursing staff member will be stationed in the Dining Room during meal service to assist guests/residents with eating, to handle any emergency that might arise, and to monitor guest/resident meal acceptance 1.3-20(h)

Based on interview and record review, the facility failed to ensure a Care Plan had been updated timely for 1 of 3 residents reviewed for care plans. (Resident 9) Findings include: 1. The record for Resident 9 was reviewed on 6/19/24 at 10:29 A.M. The resident's diagnoses included, but were not limited to; mild protein calorie malnutrition and impaired cognitive function. A Quarterly Minimum Data Set (MDS) Assessment, dated 5/5/24 indicated the resident was not receiving Hospice services. A Dietary Progress Note, dated 6/7/24, indicated the resident's weight reflected a 9% significant weigh loss from three months ago and continued on a gradual trend down. His dietary interventions included, but were not limited ti, Boost, a nutritional supplement, twice a day. The dietary note, dated 6/7/2024, planned to increase the Boost supplement to three times a day and encourage good oral intakes. A Care Plan, dated 3/22/23 and revised on 5/8/24, indicated the resident was .at risk for a decline in condition, pain, depression, weight loss and other symptoms related to terminal prognosis: PVD [peripheral vascular disease] A goal listed for the resident was to be accepting of end of life condition. The interventions included, but were not limited to: Assess resident's coping strategies and respect resident wishes. Hospice provided by (name and phone number of Hospice Care provider. Contact with condition changes or questions. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Observe for adverse reactions & symptoms of end of life such as nausea/vomiting, difficulty breathing, agitation; Report findings to Hospice and physician. Provide guest/family/legal representative with Hospice information as needed. During an interview on 6/19/24 at 2:38 P.M., the MDS Coordinator indicated Resident 9 was not currently on Hospice services and probably had not been on Hospice since August of 2023. She indicated she had not updated the care plan to remove interventions regarding hospice and the Hospice agency's contact information. 3.1-35(e)

Based on observation, record review, and interview, the facility failed to provide nail and hand hygiene and grooming assistance to a resident unable to complete care for themselves for 1 of 2 residents reviewed for activities of daily living. (Resident B). Findings include: During an observation, on 6/17/2024 at 2:26 P.M., Resident B was observed seated in her chair with a brown colored substance build up underneath her fingernails on both hands. In addition, she had long, dark brown whiskers noted above her lip and on left side of face. During an observation, on 6/18/2024 at 9:37 A.M., Resident B was observed seated her chair with a brown colored substance underneath her fingernails on both hands. She also had dark brown whiskers noted above her lip and on the left side of her face. A record review for Resident B was completed on, 6/18/2024 at 2:03 P.M. The resiident's diagnoses included, but were not limited to: hemiplegia and hemiparesis, affecting right dominant side, diabetes mellitus type 2, Dementia, ostoearthritis and weakness. A Quarterly Minimum Data Set (MDS) assessment, dated 3/6/2024, indicated Resident B had moderate cognitive impairment and impaired Range of motion to one side of her upper extremities. She required substantial maximum assistance with grooming and personal hygiene needs. The Certified Nursing Assistant (CNA) documentation regarding manicures/nail care in the electronic health record from 6/1/2024-6/18/2024 indicated Resident B had no refusals of nail care. A Care Plan for late loss activities of daily living, dated 2/4/2024, indicated Resident B required maximum assistance with dressing, grooming and bathing. During an observation, on 6/19/2024 at 8:23 A.M., Resident B's fingernails remained dirty with brown debris under the nails, and her face remained unshaven with dark brown whiskers. During an interview, on 6/19/2024 at 8:49 A.M., CNA 5 indicated Resident B should have been shaved and her nails cleaned and trimmed when she had her shower and Resident B does not refuse care. During an interview, on 6/21/2024 at 1:56 P.M., the Director of Nursing indicated Resident B should have been shaved and her nails should have been trimmed on her shower day. On 6/21/2024 at 2:22 P.M., the Executive Director provided the policy titled, Activities of Daily Living (ADL) Program, dated 4/5/2024, and indicated the policy was the one currently being used by the facility. The policy indicated, .Bathing: Maintaining personal hygiene .vii. shaving, if applicable and x. trimming nails This citation relates to Complaint IN 00435388 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to obtain orders for wounds, change wound dressings as ordered, ensure recommended treatments for edema were completed and identify bruising for 2 of 15 residents reviewed for quality of care. (Residents 35 and 26) In addition, the facility failed to ensure a residents was free of medication errors for 1 of 5 residents reviewed for medication administration (Resident 18). Findings include: 1. During an observation, on 6/17/2024 at 9:40 A.M., Resident 35's left and right elbows were observed to have bandages, dated 6/9 and soilage could be seen seeping through the bandage on the left elbow. On 6/18/2024 at 12:35 P.M., the elbow bandages continued to have the date of 6/9 on them. A record review for Resident 35 was completed on 6/18/2024 at 1:58 P.M. The resident's diagnoses included, but were not limited to, pneumonia and diabetes mellitus type 2. A Patient Discharge Instruction Sheet, dated 6/6/2024, and a Hospital Discharge Patient Health Summary, dated 6/13/2024, indicated an order to apply moisturizer to the resident's bilateral upper extremity's scabbed areas and the left scapula twice a day. A Nursing Comprehensive Evaluation, on 6/13/2024, indicated: - Left elbow scab 2.5 centimeters by 1.5 centimeters -Right elbow scab 1.3 centimeters by 1.1 centimeters and 2.2 centimeters by 1.5 centimeters A Nurse's Note, dated 6/6/2024 at 7:42 P.M., indicated Resident 35 had multiple scabbed wounds on her elbows, knees, and scattered bruising on her bilateral upper extremities from the elbows to her hands. A Physician's Order, dated 6/14/2024, indicated lotion was to be applied to Resident 35's bilateral upper extremities and left scapula scabbed areas two times a day for wound care. A Care Plan, dated 6/6/2024, indicated Resident 35 had an actual skin impairment related to closed wounds on her elbows, left shoulder, and left flank. The goal included having no complications related to the closed wounds with scabs. An intervention indicated to observe the location, size, and treatment of the skin injuries, and to report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the physician. A Braden Scale (assessment to determine a resident's risk factor for developing impaired skin) assessment, dated 6/14/2024, indicated Resident 35 was at low risk for impaired skin development. During an observation, on 6/19/2024 at 1:02 P.M., Resident 35's elbow bandages were still dated 6/9. During an interview, on 6/20/2024 at 10:59 A.M., the Executive Director indicated the nursing staff should have pulled the dressing off to see what was underneath and should have applied the treatment orders for the elbow areas. During an interview, on 6/20/2024 at 2:01 P.M., LPN 6 indicated he had received orders for the elbow wounds. The elbow wounds were observed, and described by LPN 6 as follows: .1. The right elbow had a half centimeter diameter scabbed area, and had an opened area measuring 3/4 centimeter by 1 centimeter, epithelialized, blanchable redness. 2. The left elbow had a shallow open area 2 inches by 1.5 inches with serous drainage During an interview on, 6/20/2024 at 2:50 P.M., the Executive Director indicated Resident 35 should have had physician orders obtained for the elbow wounds. 2. During an interview, on 6/17/2024 at 2:10 P.M., Resident 26 complained of edema in her legs. Her legs were observed to be positioned flat on top of the mattress with no stockings or ace wraps on them. The ace wrap dressings were observed lying in the windowsill. A record review for Resident 26 was completed on 6/18/2024 at 12:14 P.M. The resident's diagnoses included, but were not limited to, chronic kidney disease, diabetes mellitus type 2, edema, and morbid obesity. An Admission MDS (Minimum Data Set) assessment, dated 4/10/2024, indicated Resident 26 was cognitively intact and the primary medical condition category was medically complex conditions. A Care Plan, dated 1/11/2024, indicated Resident 26 was .at risk for discomfort or adverse effects due to receiving diuretic therapy related to edema. The goal was for Resident 26 to be free of any discomfort or adverse side effects of the diuretic therapy. A Nurse Practitioner's Note, dated 6/1/2024 at 12:59 A.M., indicated the nursing staff were directed to apply ace wraps and elevate the resident's legs. Resident 26 was diagnosed with lymphedema in the left lower extremity which caused discomfort. During an observation on 6/18/2024 12:37 P.M., Resident 26 continued to complain of the edema to her legs. Her legs were observed to be positioned flat on the mattress with no stockings or ace wraps. Ace wraps were observed lying in the windowsill. Resident 26 indicated the staff used to wrap her lower legs. During an interview, on 6/20/2024 at 10:55 A.M., the Executive Director indicated Resident 26 could have been refusing (the application of the ace wraps), and the ace wraps may be a nursing measure. She indicated they should be completing the tasks unless Resident 26 was refusing. During an interview, on 6/21/2024 11:36 A.M., Resident 26 indicated she had not been refusing to have the ace wraps applied or to have her feet elevated. She indicated she felt the ace wraps would help her. A policy for following physician orders/recommendations was requested, on 3/21/2024 at 10:58 P.M. A policy was not provided for following physician recommendations and orders. 49994 3. On 6/19/2024 at 3:30 P.M., a review of the clinical record was completed for Resident 18. The resident's diagnoses included, but were not limited to, congestive heart failure, hypertension, and sinus bradycardia. A Quarterly Minimum Data Set (MDS), dated [DATE] indicated the resident's cognition was intact. The Physician's Orders for medications indicated the resient was to receive Carvedilol 6.25mg by mouth, twice per day, hold if heart rate is less than 50. A review of the resident's Medication Administration Record (MAR) indicated Carvedilol 6.25 mg was documented as given on the following dates and shifts, with the corresponding heart rates: Morning shift: - 5/3/2024 heart rate 36 - 5/6/2024 heart rate 32 - 5/11/2024 heart rate 45 - 5/19/2024 heart rate 33 - 5/27/2024 heart rate 35 - 5/29/2024 heart rate 39 - 6/11/2024 heart rate 35 - 6/12/2024 heart rate 34 - 6/15/2024 heart rate 34 - 6/19/2024 heart rate 33 Evening shift: - 5/3/2024 heart rate 36 - 5/11/2024 heart rate 42 - 5/19/2024 heart rate 45 - 5/20/2024 heart rate 32 - 5/21/2024 heart rate 32 - 5/28/2024 heart rate 35 - 6/11/2024 heart rate 35 - 6/15/2024 heart rate 34 - 6/18/2024 heart rate 35 A Care Plan, dated 7/12/2023, indicated the resident was at risk for cardiac complications related to multiple cardiovascular diseases. The residents goal included a goal for the resident to be free from signs and symptoms of cardiac complications through the review date. Interventions included: . observe, document, and report to physician as needed any signs or symptoms of cardiac distress: chest pain or pressure, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in capillary refill, color/warmth of extremities, vital signs as ordered, and notify the physician of abnormal readings as needed A Physician's Note, dated 6/8/2024, indicated the patient was last seen on 5/23/2024. During an interview, on 6/19/2024 at 3:39 P.M., the Administrator and DON both indicated the resident should not have received the Carvedilol 6.5mg when his heart rate was less than 50. During an interview, on 6/20/2024 at 9:23 A.M., Resident 18 indicated he was unsure of what medications he was prescribed. He indicated he was prescribed a heart pill named Coreg but was unsure if the medication was being held if his heart rate was less than 50. He indicated some nurses would check his pulse before administering the medication and some nurses would not. On 6/20/2024 at 11:48 A.M., the Administrator provided the policy titled, Medication Administration, dated 10/17/2023, and indicated it was the policy currently in use by the facility. The policy indicated: .Procedure: 5. If applicable and/or prescribed, take vital signs or tests prior to administration of the dose, e.g, pulse with digitalis, blood pressure with anti-hypertensive, etc . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to obtain a physician's order for an indwelling urinary ( Foley) catheter for 1 of 2 residents reviewed for catheters. (Resident 35) Finding includes: During an observation on 6/17/2024 at 10:51 A.M., Resident 35 was observed to have a Foley catheter. A record review was completed for Resident 35 on 6/18/2024 at 1:58 P.M. Diagnoses included, but were not limited to, obstructive uropathy and diabetes mellitus type 2. An Admission MDS (Minimum Data Set) assessment had not yet been completed for Resident 35. A Care Plan, dated 6/14/2024, indicated Resident 35 was a risk for a urinary tract infection and catheter related trauma. Interventions included, but were not limited to, provide catheter care per the policy. Resident 35 was seen by the physician on 6/15/2024. The Physician's Note did not reference the use of a Foley catheter. During an interview on 6/18/2024 at 2:27 P.M., Resident 35 indicated he had returned to the facility from his recent hospitalization with the Foley catheter. He indicated he had a prostate problem, and had completed self-catheterization at home prior to his admission to the facility. During an interview, on 6/20/2024 at 11:06 A.M., the Executive Director indicated Resident 35 should have had a physician's order for the Foley catheter and catheter care. A policy was provided, on 6/21/2024 at 1:41 p.m., by the Executive Director. The policy titled, Indwelling urinary catheter [Foley} care and management, indicated there was no reference regarding the need to have physician's order in the policy for a Foley catheter. 3.1-41(a)

Based on observation, record review, and interview, the facility failed to ensure respiratory equipment was stored properly for 1 of 2 residents reviewed for respiratory care. (Resident 26) Finding includes: During an observation, on 6/17/2024 at 9:48 A.M., Resident 26's Bi-Pap (non-invasive ventilation therapy equipment) mask was observed hanging over bedside table. A record review was completed, on 6/18/2024 at 12:14 P.M., for Resident 26. Diagnoses included, but were not limited to, obstructive sleep apnea, edema, asthma, and morbid obesity. An Admission MDS (Minimum Data Set) assessment, dated 4/10/2024, indicated Resident 26 was cognitively intact and the primary medical condition category was medically complex conditions. The MDS did not indicate a Bi-Pap machine was in use for Resident 26. A Physician's Order, dated 1/4/2024, indicated Resident 26 was to wear a Bi-Pap mask at night while he was sleeping for sleep apnea. A Care Plan, dated 1/11/2024, indicated Resident 26 had the potential for difficulty breathing for respiratory complications related to asthma, obstructive sleep apnea, and morbid obesity. During an observation, on 6/18/2024 at 12:36 P.M., the BiPap mask for Resident 26 was observed on top of the bedside table. During an observation, on 6/19/2024 at 1:13 P.M., the BiPap mask for Resident 26 was observed on top of the bedside table. During an interview, on 6/20/2024 at 10:57 A.M., the Executive Director indicated the BiPap mask should be stored at the bedside in a respiratory bag or a bag. A policy was provided, on 6/21/2024 at 1:41 P.M., by the Executive Director. The policy, titled, Noninvasive positive-pressure ventilation, respiratory therapy, did not include instructions regarding the storage procedure for the Bi-Pap mask. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure the appropriate antibiotic was prescribed at the appropriate time for the appropriate duration for a skin infection for 1 of 4 residents reviewed for antibiotic stewardship. (Resident 26) Finding includes: During an interview, on 6/17/2024 at 2:08 P.M., Resident 26 described an abdominal infection and a boil she had on her left thigh. A record review for Resident 26 was completed on 6/18/2024 at 12:14 P.M. The resident's diagnoses included, but were not limited to, chronic kidney disease, diabetes mellitus type 2, and morbid obesity. An Admission MDS (Minimum Data Set) assessment, dated 4/10/2024, indicated Resident 26 was cognitively intact and the primary medical condition category was medically complex conditions. A Physician's Order, dated 5/31/2024 at 12:30 P.M., indicated a wound culture was to be obtained. A Physician's Order, dated 5/31/2024 at 8:00 P.M., indicated the resident was to receive Keflex (cephalexin) (an antibiotic) 500 milligrams two times a day for a wound was to be administered. A Nurse Practitioner Note, dated 6/1/2024 at 12:59 A.M., indicated Resident 26 presented for a chronic care visit with concerns of a boil on her left inner side of her thigh. Resident 26 had a history of MRSA (Methacillan Resistant Staph Aureus) infection in 2004. The note indicated orders were given to culture the boil, complete lab tests and start the antibiotic, Keflex 500 mg twice a day for 7 days. The instructions indicated to change the antibiotic if the culture revealed a specific infection. A Care Plan, dated 6/3/2024, indicated Resident 26 had a wound to her left inner thigh. The interventions included, but were not limited to, administering antibiotics as ordered, and updating the physician with changes as needed. The wound culture and sensitivity results , dated 6/7/2024 at 9:42 A.M., indicated a growth at 48 hours of 4 plus gram negative bacteria. The organism was identified as Myr. odoratus/odoratimimus. The following antibiotics were susceptible for treatment of the organism: -Amikacin -Ceftazidime -Cefepime -Gentamicin -Tobramycin -Trimethoprim/Sulfamethoxazole -Piperacillin/Tazobactam A Nurse's Note, dated 6/17/2024 at 9:23 P.M., indicated Keflex 500 milligrams was held for clarification of a stop date. There was no note the physician or nurse practioner was notified regarding the wound culture results and the need to alter the antibiotic treatment. During an interview, on 6/21/2024 at 1:17 P.M., the Executive Director indicated the Keflex should have been stopped after 7 days and the physician should have been notified of the culture results to see if the antibiotic should have been changed. A policy was provided, on 6/17/2024 at 1:45 P.M., by the Executive Director. The policy, titled, Infection Control Antibiotic Stewardship & MRDOs [multidrug-resistant organisms], indicated Antibiotic stewardship referred to: .coordinated interventions designed to improve and measure the appropriate use of antimicrobials, by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration

Based on observation and interview, the facility failed to ensure the current ombudsman's name was listed on their Resident Right's poster, in 4 of 4 houses. (Strawberry Fields, Blueberry Hill, [NAME] and Penny Lane) This deficient practice had the potential to affect all 46 residents and/or their family members and visitors. Finding includes: On 6/20/24 at 1:25 P.M., a Resident Rights' poster was observed hanging in the Penny Lane house, opposite of the Director of Nursing's office. The poster had the wrong local Ombudsman's name on it. There was no posting of the State Ombudsman information observed anywhere else in the house On 6/21/24 at 10:21 A.M., a Resident Rights' poster was observed hanging on the wall in the Blueberry Hill house. The poster had the wrong local Ombudsman's name on it. On 6/21/24 at 10:25 A.M. a Resident Rights' poster was observed hanging on the wall in the Strawberry Fields House. The poster was only partially visible due as it was hung behind a dry erase board. It had the wrong Ombudsman's name printed on it. On 6/21/24 at 10:34 A.M., a Resident Right's post was observed hanging on a wall in the [NAME] house. The poster had the wrong Ombudsman's name on it. There was no other posting of the State Ombudsman information located in the house. On 6/21/24 at 3:00 P.M., the Administrator indicated she had no policy regarding the displaying of the local or State Ombudsman information for resident's and/or family members. During an interview, on 6/21/24 at 3:30 P.M., the previous local ombudsman, whose name and phone number were printed on the Resident Right's posters, indicated she had retired from her position, as the local ombudsman, approximately 4 years ago. 3.1-4(J)(3)(C)

Based on record review and interview, the facility failed to notify a resident's physician, responsible party, and the Director of Nursing timely of a fall with injury, for 1 of 3 residents reviewed for falls. (Resident B). Finding includes: On 3/13/24 at 11:48 A.M., Resident B's record was reviewed. Diagnoses included, but were not limited to, metabolic encephalopathy, intellectual disabilities, epilepsy, anxiety, abnormal posture, dysphasia, and lack of coordination. A Quarterly Minimum Data Set (MDS) assessment, dated 2/12/24, indicated Resident B had severe cognitive impairment, required extensive assistance with all areas of daily living, had mobility impairment to both upper extremities, and utilized a wheelchair for mobility. Review of Indiana Department of Health Incident Number 170 indicated, on 3/1/24 at 11:40 P.M., Resident B rolled out of bed and hit her head, causing a laceration above her right eye and swelling to the bridge of the nose. Care Plans indicated Resident B was at risk for falls and fall related injury. Interventions included to follow the facility's fall protocol. There was no documentation in the resident's record to indicate the resident's physician and responsible part were notified immediately after the fall with injury. On 3/13/24 at 2:50 P.M., during an interview with Resident B's responsible party, she indicated the facility notified her of the resident's fall on 3/2/24 at about 11:00 A.M. LPN 12 had notified her and reported the extent of the injury, and that she had obtained an order to send the resident to the hospital for evaluation. On 3/13/24 at 3:32 P.M., during an interview with LPN 8, she indicated she and RN 9 were notified by CNA 3 that Resident B fell out of bed, and both LPN 8 and RN 9 went to evaluate the resident. LPN 8 indicated they found the resident on the floor beside the bed. LPN 8 notified the resident's off-site health service at that time, but did not notify the resident's personal physician, responsible party, nor the Director of Nursing. LPN 8 indicated all 3 parties should have been called at the time of the fall. On 3/14/24 at 11:00 A.M., during an interview with LPN 12, she indicated she worked the day shift on 3/2/24 and arrived at work at 5:45 A.M., and did not find RN 9 in the building. She indicated CNA 10 notified her of Resident B's fall from the previous night. LPN 12 went to the resident's room to observe a large gash over the resident's right eye, and then cleansed the wound, applied steri-strips, notified the Director of Nursing, and notified the resident's responsible party. On 3/14/24 at 12:06 P.M., during an interview with the Director of Nursing (DON), she indicated she was first notified that Resident B fell out of bed on 3/2/24 at 11:00 A.M. Had she been notified immediately, she would have had the resident sent to the hospital for an evaluation due to the head injury. The responsible party, physician, and Director of Nursing should have been notified of the accident at the time of the accident. On 3/14/24 at 10:00 A.M., a policy titled, Incidents and Accidents for Guests/Residents or Visitors, dated 5/1/22, was provided by the Administrator as current. The policy indicated, .When an incident or accident is discovered,, the employee making the discovery will immediately notify his/her direct supervisor of the discovery .The licensed nurse must notify the responsible party and the attending physician of the Incident and Accident. On 3/14/24 at 2:30 p.m., a fall assessment policy, dated 9/22/23, was provided by the Administrator as current. The policy indicated, .If a potential head injury is present .the licensed nurse will notify the attending physician and the responsible party of the fall and document the notification in the medical record . This citation relates to Complaint IN00429796. 3.1-5(a)(1)

Based on record review and interview, the facility failed to provide adequate care and treatment related to lack of an assessment and neurological checks after a resident fell out of bed and sustained a head injury, for 1 of 3 resident reviewed for falls. (Resident B). Finding includes: On 3/13/24 at 11:48 A.M., Resident B's record was reviewed. Diagnoses included, but were not limited to, metabolic encephalopathy, intellectual disabilities, epilepsy, anxiety, abnormal posture, dysphasia, and lack of coordination. A Quarterly Minimum Data Set (MDS) assessment, dated 2/12/24, indicated Resident B had severe cognitive impairment, required extensive assistance with all areas of daily living, had mobility impairment to both upper extremities, and utilized a wheelchair for mobility. Review of Indiana Department of Health Incident Number 170 indicated, on 3/1/24 at 11:40 P.M., Resident B rolled out of bed and hit her head, causing a laceration above her right eye and swelling to the bridge of the nose. Care Plans indicated Resident B was at risk for falls and fall related injury. Interventions included to follow the facility's fall protocol. There was no documentation of any physical assessment or neurological checks completed for Resident B immediately after her fall. On 3/13/24 at 2:50 P.M., during an interview with Resident B's responsible party, she indicated the facility notified her of the resident's fall on 3/2/24 at about 11:00 A.M. She indicated LPN 12 had notified her and reported the extent of the injury, and that she had obtained an order to send the resident to the hospital for evaluation, and no assessments had been done through the night. On 3/13/24 at 3:32 P.M., during an interview with LPN 8, she indicated she and RN 9 were notified on 3/1/24 around 11:00 P.M., by CNA 3, that Resident B had fallen out of bed. LPN 8 and RN 9 went to evaluate the resident. They found the resident on the floor by the bed, and there was quite a bit of blood on the floor. The resident had a gash on her head above the right eye, but she was not able to assess the wound because the resident would not allow it. LPN 8 had notified Resident B's off-site health service and was instructed to do neurological checks through the night. LPN 8 indicated she and RN 9 returned the resident to her bed and attempted to do an assessment, but the resident would not let them see the injury. LPN 8 indicated she did not complete an assessment and she did not do any neurological checks. She did not know if RN 9 did an assessment or neurological checks. On 3/13/24 at 3:50 P.M., during an interview with LPN 7, he indicated on 3/1/24 at about 5:55 A.M., he was called by LPN 12 and asked if he knew anything about Resident B's fall the previous night. He indicated he was not aware of a fall and went to assist LPN 12 assess Resident B. LPN 7 indicated at the time of the assessment, he observed dried blood to the resident's face and a gash about 4 cm long above the right eye that had not been cleaned or treated. He indicated he cleaned the wound and assisted LPN 12 apply steri-strips to the wound. LPN 7 indicated there was no documentation of an assessment from night shift and no documentation of neurological checks. On 3/14/24 at 11:00 A.M., during an interview with LPN 12, she indicated she worked the day shift on 3/2/24 and arrived at work at 5:45 A.M., and did not find RN 9 in the building. She indicated CNA 10 notified her of Resident B's fall from the previous night. LPN 12 went to the resident's room to observe a large gash over the resident's right eye, and then cleansed the wound, and applied steri-strips to the gash. LPN 12 indicated at that time there was no documentation evidence that any assessment or any neurological checks had been completed, so she began their fall protocol, including neurological checks, at that time. On 3/14/24 at 12:06 P.M., during an interview with the Director of Nursing (DON), she indicated she was first notified that Resident B fell out of bed on 3/2/24 at 11:00 A.M. There were no neurological checks documented by the night shift nurse, and neurological checks should have been initiated immediately after the fall. On 3/14/24 at 2:30 p.m., a fall assessment policy, dated 9/22/23, was provided by the Administrator as current. The policy indicated, .When a fall occurs, the licensed nurse will evaluate the resident for injury. Do not move the individual until he/she has been examined by a nurse .The licensed nurse will complete: Incident/Accident Report in PCC [Electronic Medical Record] .Initiate the Post-Fall Evaluation .If a potential head injury is present, complete the Neurological Record. This citation relates to Complaint IN00429796. 3.1-37(a)

Based on observation and interview, the facility failed to provide the posting of nursing staff hours in 4 of 4 homes reviewed for nurse staffing information. Finding includes: During a tour of the Strawberry Lane, Blueberry Lane, Penny Lane, and Green [NAME] homes on 11/30/2023 from 9:21 A.M. to 10:43 A.M., a posting of the total number of staff and actual hours worked of nursing staff could not be located. During an interview on 11/30/2023 at 1:05 P.M., CAN 2 indicated that the homes do not have postings of the number of staff and actual hours worked. At 2:18 P.M., the Administrator indicated that the facility scheduler and the Director of Nursing were responsible to ensure the posting of the number of staff and actual hours worked were completed. She indicated that the third shift staff remove the prior days data from the homes and put up a new data sheet. She indicated the staffing numbers and actual hours worked should be posted in every home. A current policy titled, Required Regulatory Postings, was provided by the Administrator on 11/30/2023 at 2:46 P.M. The policy indicated, .The facility posts the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for guest/resident care for each shift. The information will be displayed in a prominent location that is clearly visible and accessible by guests/residents, family and staff This concern relates to complaint IN00422005.

Based on observation and interview, the facility failed to provide a clean environment for 23 of 37 rooms reviewed for environmental services. Findings include: During a tour of the Strawberry Lane home on 11/30/2023 from 9:21 A.M. to 9:31 A.M., the following was observed: -room [ROOM NUMBER] Had the wall gouged at foot of bed. -room [ROOM NUMBER] Had dust and debris throughout the flooring. During a tour of Blueberry Lane home on 11/30/2023 from 9:40 A.M. through 10:07 A.M., the following was observed: -room [ROOM NUMBER] Bathroom floor had debris and stains. A large amount of dust clumps and debris were behind the beds. -room [ROOM NUMBER] Debris on the bathroom floor. The gouges on wall were filled with plaster, but had not been sanded or painted. -room [ROOM NUMBER] Debris under bed and at the head of bed. The room entry wall had a long gouge in the drywall. -room [ROOM NUMBER] Dust clumps and debris on the floor. The bathroom floor had debris on floor. -room [ROOM NUMBER] Marred and gouged drywall on both walls in the entry of the room. -room [ROOM NUMBER] Marred drywall on the entry wall and the corner drywall had a gouge of missing drywall. -room [ROOM NUMBER] Dust clumps behind the bed and debris on floor. -room [ROOM NUMBER] The entry way wall had marred drywall. -room [ROOM NUMBER] Both entry way walls had gouged drywall. During a tour of the Penny Lane house on 11/30/2023 from 10:09 A.M. through 10:29 A.M., the following was observed: -room [ROOM NUMBER] The previous gouges were filled with plaster, but had not been sanded or painted. -room [ROOM NUMBER] Debris under bed. -room [ROOM NUMBER] Dust clumps behind the bed. -room [ROOM NUMBER] Marred drywall to entryway drywall. -room [ROOM NUMBER] Debris on floor. -room [ROOM NUMBER] Debris on floor. -room [ROOM NUMBER] Food debris on floor. -room [ROOM NUMBER] Debris on floor. -room [ROOM NUMBER] Debris on floor. During a tour of the Green [NAME] home on 11/30/2023 at 10:31 A.M. to 10:43 A.M., the following was observed: -room [ROOM NUMBER] Debris on floor. -room [ROOM NUMBER] Gouges in the wall behind recliner. -room [ROOM NUMBER] Gouges in the drywall of the entry way wall. During an interview with the Administrator on 11/30/2023 at 11:31 A.M., she indicated that housekeeping was an ongoing process since the last complaint survey on 9/21/2023 and 9/22/2023. On 11/30/2023 at 12:55 P.M., the administrator requested to see the dust clumps that had been observed previously in the day. The administrator observed the dust clumps in rooms [ROOM NUMBERS]. She indicated the aides had not done any cleaning on this day, and again indicated the issues of cleaning was a work in progress, During an interview on 11/30/2023 at 1:05 P.M., CNA 2 indicated the aides were responsible for housekeeping, laundry, janitorial services, cooking and serving the meals, resident activities, and resident care for the residents in each home. She indicated the staff have a checkoff list of general cleaning duties, but that list did not include resident room duties. She indicated the residents' rooms receive general cleaning on the residents' assigned shower days, including sweeping, mopping, dusting, and changing linens, but a deep clean was never completed. She indicated she felt there was not enough time to complete all the tasks the staff were assigned to complete. A policy titled, Housekeeping Services, was proved by the Executive Director on 11/30/2023 at 2:46 P.M. The policy indicated, I. Frictional Cleaning .C. Cleaning methods and machines that suspend dust from surfaces will be avoided, especially in guest/resident care areas. Damp mopping or use of chemically treated mop for reduction of airborne dust is recommended in guest/resident care areas .II. Routine Cleaning of Horizontal Surfaces .A. In guest/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soilage occurs This concern relates to complaint IN00422005. 3.1.19(f)(5)

Based on record review and interview, the facility failed to to identify multiple nitroglycerin patches during an admission skin assessment for 1 of 3 residents reviewed for hospitalization , and follow a Physician's order to obtain daily lab work for a resident receiving Coumadin therapy for 1 of 4 residents reviewed for anticoagulation therapy. (Residents C & Y) Findings include: 1. A record review of Resident Y was completed on 6/1/2023 at 10:19 A.M. Diagnoses included, but were not limited to: atrial fibrillation, pneumonia, and hypothyroidism. Resident Y admitted to the facility on [DATE]. A Nursing Comprehensive Evaluation was completed on 2/14/2023 at 3:29 P.M. The assessment indicated that a skin assessment was completed with skin conditions present. The assessment identified bruising to the left antecubital region, left hand, left forearm, left wrist, and right generalized bruising from the back of the hand to the elbow. There was no mention of patches being present on the assessment. A Skilled Care Note on 2/15/2023 at 11:11 P.M., indicated Resident Y was with shortness of breath while lying in bed, and had difficulty breathing, and an oxygen saturation of 89 percent. An SBAR (Situation, Background, Appearance, and Review) Assessment was completed on 2/16/2023 at 6:04 A.M. The assessment indicated Resident Y had shortness of breath, new onset irregular heartbeat, and new oxygen therapy. A Nurse's Note on 2/16/2023 at 7:05 A.M, indicated Resident Y was sent to the emergency room for evaluation and treatment. An Emergency Department Discharge Instructions, dated 2/16/2023, indicated Resident Y was seen for acute dyspnea, dysphagia, hyponatremia, and pleural effusion. On 2/16/2023 at 10:35 A.M., a Nurse's Note indicated Resident Y returned from the emergency room with an order to follow up with primary care and have sodium rechecked. On 2/16/2023 at 10:57 A.M., a Nurse's Note indicated Resident Y's oxygen saturation ranged from 82-88 percent. Oxygen was applied and the oxygen saturation recovered to 93 percent. Resident Y was falling asleep mid-sentence and oxygen saturation would drop in the 80's. Blood pressure was 190/100, pulse 60, and temperature was 98.2. Resident Y's daughter requested she be sent to the emergency room . On 2/16/2023 at 12:25 P.M., a Nurse's Note indicated to send to the emergency room for evaluation and treatment. A Hospital History and Physical dated 2/16/2023 at 5:30 P.M., indicated per the emergency department physician, Resident Y had some nitro patches on her body when she came to the hospital. A Cardiology Consultation Note dated 2/17/2023, indicated, .On 2/14/2023 she was discharged to [a extended care facility] Earlier in the on 2/15/2023, she was seen in the ER [emergency room ] at [hospital name] for apneic episodes, work up was negative and she was discharged back to the ECF [extended care facility]. She continued to have episodes of apnea in the nursing home and EMS [emergency medical services] was again called and instructed to bring the patient to [hospital name ER] for evaluation and treatment. EMS found her heart rate to be in the 40's. She received atropine en route. They also identified 5-6 nitro patches on the patient's left arm that were removed. It is unclear who placed these or where they were placed. After removal of the nitro patches her heart rate recovered to the 80's .The patient was admitted to the Hospitalist service and Cardiology was consulted for low heart rate During an interview on 6/6/2023 at 8:42 A.M., LPN 6 indicated a head-to-toe assessment would be completed on admission. If the resident had no cognitive impairment, she would look as much as she could and would ask the resident if they had any skin issues. She indicated with a shower and toileting being completed, the skin would be observed during those times. If the resident had cognitive impairment, she would do a full skin assessment. She indicated a Nursing Comprehensive Evaluation would be completed upon admission, and that included a skin assessment. This assessment helps set up the care plans. She indicated multiple skin patches should be found on the skin assessment. During an interview on 6/6/2023 at 10:33 A.M., the Director of Nursing indicated that a comprehensive nursing assessment would be completed on admission. All skin issues would be documented. He indicated excessive patches on the skin would be expected to be addressed. He had a thought of the nurse doing the skin assessment with her eyes closed. He indicated a medication error report and a report to the Indiana Department of Health was not completed. 2. A record review of Resident C was completed on 6/1/2023 at 9:10 A.M. Diagnoses included, but were not limited to: atrial fibrillation, hypertensive heart disease with heart failure, and atherosclerotic heart disease. A Hospital Discharge Plan, dated 5/12/2023, indicated a new prescription of warfarin 2 milligrams daily, enoxaparin 100 milligrams per milliliter with 90 milligrams to be administered twice daily to bridge until an INR (international normalized ratio) lab result of 2.0 could be reached, and a daily INR lab test until a therapeutic level of 2-3 could be reached. Resident C received warfarin 2 milligrams on 5/13/2023, 5/14/2023, and 5/15/2023. She also received enoxaparin 90 milligrams twice a day on 5/13/2023, 5/14/2023, and 5/15/2023. A Nurse's Note dated 5/15/2023 at 6:21 P.M., indicated Resident C was seen by the Medical Director for a routine visit. A new order was received to check the INR on 5/18/2023 due to anticoagulant use. On 5/15/2023 at 9:24 P.M., a Nurse's Note indicated an INR check was completed per nursing judgement due to bleeding. The INR was 4.8 (normal therapeutic range for anticoagulant therapy is 2.0-3.0). The facility nurse practitioner was notified and an order to hold warfarin, enoxaparin, and Plavix was obtained. A Care Plan, dated 5/15/2023, indicated Resident C was at risk for abnormal bleeding and bruising related to medication use. The goal was to be free from discomfort or adverse reaction related to anticoagulant, antiplatelet, and non-steroidal anti-inflammatory drug. The interventions indicated to obtain labs and diagnostics as ordered and report abnormal findings to the physician. On 5/16/2023 at 6:45 A.M., a Nurse's Note indicated the area to the right wrist continued to have occasional small amount of blood through the shift. There was no excessive bruising or bleeding noted. The facility nurse practitioner was notified and a new order for a stat comprehensive metabolic panel and a complete blood count was received. On 5/17/2023 at 5:26 P.M., a Nurse's Note indicated a call was placed to the Coumadin Clinic and left a message concerning holding blood thinners for two weeks. A Physician's Order on 5/18/2023, indicted warfarin 2 milligrams daily on Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday. Also ordered was warfarin 1 milligram daily on Thursday. During an interview on 6/6/2023 at 8:40 A.M., LPN 6 indicated INR results were placed in the chart. She indicated the facility has a Coagucheck machine to obtain INR results, and a laboratory was not always drawing the INR lab. On 6/6/2023 at 10:11 A.M., the Director of Nursing indicated an INR test result could be obtained in the facility per a Coagucheck testing system. He indicated INR results can be a combination of the Coagucheck and laboratory blood draw that are scheduled on Tuesdays and Thursdays. He indicated if a resident is admitted Thursday through Monday, he would call the practitioner and obtain an order to do a Coagucheck prior to the laboratory draw day. He indicated an INR log could be found in the front of the narcotic book. During a review of Resident C's international normalized ratio record, the DON indicated Resident C did not have an order for a daily INR. He indicated there were no labs completed prior to the Coagucheck that indicated a high INR. On 6/6/2023 at 10:42 P.M., the DON indicated obtaining the INR on 5/15.2023 was two days longer than it should have been. During an interview on 6/6/2023 at 10:53 A.M., LPN 9 indicated that she did not recall seeing an INR log for Resident C, and that results of testing was in the progress notes. On 6/6/2023 at 11:18 A.M., the DON indicated that INR results could not be located in the Medical Records office. On 6/6/2023 at 12:56 P.M., the Executive Director provided a policy titled, Anticoagulant Therapy. The policy was effective on 10/14/2021 with a review due on 10/14/2022. The policy indicated, .3. If using Coumadin for anticoagulant therapy, Confirm with the physician the desired INR and/or PT [prothrombin time] testing schedule and therapeutic range at the time of anticoagulant therapy order. Initiate and order anticoagulation therapy labs per physician's order On 6/6/2023 at 12:56 P.M., the Executive Director provide a policy titled, Skin Management. The policy indicted, .Upon admission/readmission all guests/residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record This Federal tag relates to Complaint IN00402210. 3.1-37(a)

Based on record review and interview, the facility failed to provide a pneumococcal vaccination timely for a resident whose Power of Attorney had indicated consent upon admission, subsequently the resident was assessed at a local hospital and diagnosed with multi-focal pneumonia. This affected 1 of 6 residents reviewed for immunizations. (Resident B) Finding includes: A record review of Resident B was completed on 5/31/2023 at 1:33 P.M. Diagnoses included, but were not limited to: pneumonia, dementia, and acute bronchitis. An Admission (5-day) Minimum Data Set (MDS) Assessment on 4/28/2023, indicated the pneumococcal vaccination was up to date. Resident B admitted to the facility on [DATE] with a recent history of COVID-19. The CHIRP (Childrens and Hoosiers Immunization Report Program) report indicated Resident B had received the PCV 13 (pneumococcal conjugate vaccine) on 10/26/2015. On 4/21/2023, the Power of Attorney (POA) signed a Pneumococcal Immunization Consent form that consented to accepting the PCV 13 and the PPSV 23 (Pneumococcal polysaccharide vaccine) vaccinations. A review of the April 2023 and the May 2023 Medication Administration Record (MAR) indicated that a pneumococcal vaccination had not been administered. A Nurse's Note dated 5/7/2023 at 2:24 P.M., indicated a Physician's Order was received to send Resident B to the hospital for altered level of consciousness and family request for transfer. A Hospital Admission Note on 5/11/2023, indicated besides other health issues, multi-focal pneumonia was discovered secondary to acute hypoxic respiratory failure. Resident B had shortness of breath and was hypoxic with oxygen saturation in the 70's upon admission to the emergency room . On 5/24/2023 at 8:23 A.M., a Nurse's Note indicated Resident B had a fever of 100.2 with an oxygen saturation of 91 percent. Her lung sounds were diminished in all lobes. An order was received for a stat chest x-ray and a CBC (Compete Blood Count). A Nurse's Note on 5/24/2023 at 9:10 A.M., indicated Resident B's POA did not want Resident B sent to the emergency room , and opted for treatment at the facility. A chest x-ray on 5/24/2023 at 10:50 A.M., indicated .patchy modest bilateral airspace disease. Pneumonia should be considered in the appropriate clinical setting. Recommend follow up examination to confirm resolution of findings During an interview on 6/5/2023 at 2:38 P.M, the Director of Nursing (DON) indicated consent for a pneumococcal vaccination would be obtained at admission. The vaccination should be idealistically administered within the first few days. He indicated if the resident has pneumonia or on antibiotics the vaccination would be held. The DON reviewed the medical record, and indicated Resident B had been admitted with a COVID-19 diagnose, but was not receiving any antibiotic or antiviral therapy. The DON indicated he hoped the resident would have received the vaccination prior to going to the hospital with pneumonia. He indicated it would be his hope she would have received the vaccination prior to going to the hospital for pneumonia. He indicated he could not find the pneumococcal vaccination administration under the immunization tab or the progress notes. A policy was provided on 6/6/2023 at 12:56 P.M. by the Executive Director. The policy was titled, Immunizations: Pneumococcal Vaccination (PPV) of Guest/Residents. The policy indicated, .The Advisory Committee on Immunization Practices (APIC) vaccinating persons at high risk for serious complications from pneumococcal pneumonia, including those [AGE] years and older and all guests/residents of nursing homes .Recognizing the major impact and mortality of pneumococcal disease on guests/guest/residents of nursing homes and the effectiveness of vaccines in reducing healthcare costs and preventing illness, hospitalization and death, this facility has adopted the following policy statements: 1. All guests/residents of our facility should receive the pneumococcal vaccine if they are [AGE] years of age or older or younger than [AGE] years with underlying conditions that are associated with increased susceptibility to infection or increased risk for serious disease and its complications This Federal tag relates to Complaint IN00409061. 3.1-18(a)

Based on interview and record review, the facility failed to ensure thorough assessments, interventions and treatments were implemented timely for 1 resident identified as being high risk for developing pressure ulcers who developed two Stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum and additional pressure ulcers to both heels, resulting in the resident having wound pain and fears of wound pain with toileting, depression, and requiring hospitalization for wound care and a severe UTI (Resident W). The immediate jeopardy began on 1/3/21 when Resident W was noted to have shallow open areas on her buttocks, and the facility failed to notify the physician, assess, monitor, and obtain treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Clinical Care Coordinator was notified of the Immediate Jeopardy on 5/13/21 at 5:20 P.M. The immediate jeopardy was removed on 5/14/21, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 5/12/21 at 11:52 A.M., the closed record for Resident W was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Form, dated 12/15/2020 at 4:29 p.m., indicated the resident was alert and oriented. She was admitted to the facility for rehabilitation following a fall at home which resulted in a [CONDITION(S)] and hospitalization for surgical repair. Resident W had a surgical wound on her left hip and a skin tear to her left elbow. She had no other wounds or pressure ulcers. An Admission MDS (Minimum Data Set) assessment, dated 12/21/20, indicated the resident required extensive assistance from 2 staff members for bed mobility and toileting. She was occasionally incontinent of bladder and frequently incontinent of bowel. She was at risk for pressure ulcers but had none at the time of assessment. A Care Plan, dated 1/13/21, indicated Resident W had potential for impairment to her skin integrity with the goal of being free from injury. Interventions, all dated 1/13/21, were as follows: encourage good nutrition and hydration in order to promote healthier skin; follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Notes indicated the following: -12/31/20 at 9:48 a.m., Resident W was found lying on the floor in front of her wheelchair. Had a 3 cm (centimeter) by 0.5 cm abrasion to her right buttock appears to be scar tissue that has split; no drainage from open area. -1/3/21 at 2:51 p.m., resident had shallow, open areas on her buttocks; barrier cream was applied and repositioned every 2 hours. -1/4/21 at 6:15 p.m., resident complained of pain on her bottom due to open sores. -1/5/21 at 4:15 a.m., resident continued to complain of pain from pressure sores on her left heel; pillow used to elevate left foot off of the mattress. -1/5/21 at 1:10 p.m., area on bottom covered with [MEDICATION(S)] (dressing); repositioned every 2 hours. -1/7/21 at 1:22 p.m., resident continued with poor meal intake following COVID-19 infection; had an open area to buttocks; supplements requested. The facility did not assess, monitor, or obtain treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A NN (Nurse Note), dated 1/8/21 at 1:38 p.m., indicated the resident had complained of pain in her buttocks; had open sores on her buttocks which were covered with dressings. She had 2 small loose stools that morning. At 4:22 p.m., the NP (Nurse Practitioner) visited to assess the resident's wounds; new orders were given for treatment to her buttocks and skin prep to her heels 2 times per day. She was to have heel protectors on both heels at all times when in bed. An NP progress note, dated 1/8/21 at unknown time, indicated the visit was for new wounds: -Left buttock had an unstageable pressure ulcer that measured 8 cm (length) X 5 cm (width). There was tunneling (A passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); moderate serous drainage, no odor, and 100% slough on the wound. -Right buttock had an unstageable pressure ulcer that measured 4 cm X 3 cm. There was tunneling at a depth of 4 cm at the 12 o'clock position and 0.5 cm at the 9 o'clock position. There was moderate serous drainage, no odor, 100 % slough covering the wound and the periwound was boggy. New orders were for Santyl to the wound bed, apply dry dressing and change daily. An additional order was given for a MVI (multi-vitamin) and skin prep wipes to both heels topically every morning and at bedtime for protection from skin breakdown. The progress note did not indicate the NP had looked at the resident's heels and there were no measurements nor wound assessments documented for the heels. Nurse Notes indicated the following: -1/10/21 at 5:06 a.m., resident with no new skin issues; left foot pressure sore and wound on buttock with a dressing. At 8:15 p.m., she had a loose stool and a blowout was reported by the day shift. -1/12/21 at 1:55 a.m., resident with no skin issues; left foot pressure sore and wound on buttocks with a dry dressing, Santyl ointment applied. -1/13/21 at 6:29 p.m., resident complained of pain in her bottom. -1/16/21 at 3:25 p.m., resident had a large wound on the left buttock that was deep, with extensive gray/green slough (Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture); no drainage; other wounds around perimeter; slough in wound bed. The periwound area showed [CONDITION(S)], was hot to touch, bright red, and painful to the resident. At 7:30 p.m., she complained of pain in her bottom and was repositioned. There was no documentation found to indicate the physician was notified of the [CONDITION(S)], temperature and color change, or other wounds around the periwound area. An NP progress note, dated 1/17/21 at unknown time, indicated the visit was for wound care: -Left buttock had an unstageable pressure ulcer that measured 8 cm X 5 cm. There was tunneling; moderate serous drainage, no odor, and 100% slough on the wound. -Right buttock had unstageable pressure ulcer that measured 4 cm X 3 cm. There was tunneling at 4 cm at the 12 o'clock position and 0.5 cm at the 9 o'clock position; moderate serous drainage, no odor, 100 % slough covering the wound and the periwound was boggy. Orders were to continue with Santyl to the wound bed, apply dry dressing and change daily. A NN dated, 1/22/21 at 11:22 a.m., indicated a new order had been given to change the liquid protein supplement to 1 time per day due to the resident's diarrhea. An NP progress note, dated 1/24/21 at unknown time, indicated the visit was for wound care. Patient's wound continues to decline: -Left buttock had a Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) that measured 8 cm X 9 cm X 2.5 cm (Depth). There was moderate serous drainage, no odor, and no slough. The edges of the wound were attached and periwound was normal however there was tunneling at a depth of 4 cm at the 12 o'clock position and 0.5 cm at the 9 o'clock position. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP was to look into use of wound vac placement. -Right buttock remained as an unstageable pressure ulcer that measured 4 cm X 4 cm. There was moderate serous drainage, no odor and 100% slough that was thick yellow and loosened up. Staff were to continue with Santyl and dry dressing changed daily. A physician order, dated 1/26/21, was for the resident to have an alternating air pressure mattress due to wounds on her buttocks. Nurse Notes indicated the following: -1/27/21 at 6:55 p.m., the resident's wound on her bottom was changed and it had a strong odor from it. She was given Tylenol for a pain rating of 10. She had refused to eat due to not wanting to have a bowel movement. At 10:28 p.m., resident was administered pain medication per her request and indicated my bottom is hurting so badly. The physician was not notified of the change in odor in the wound or the resident's increased pain. -1/28/21 at 9:01 a.m., the NP and rep (Representative) from the wound vac company were in to evaluate the wound to her coccyx and decision was made to apply a wound vac as soon as approved. -1/30/21 at 7:30 p.m., an indwelling urinary catheter was placed for wound healing. -2/1/21 at 1:49 p.m., resident was up with therapy and out to the dining room table then to the recliner in the living room area. She asked several times to go back to bed. -2/2/21 at 12:35 p.m., the wound vac dressing was applied to the resident's buttock wound under direction of wound vac company reps. Her wound measured 7.3 cm X 9 cm X 4.5 cm. She had undermining (The destruction of tissue or ulceration extending under the skin edges [margins] so that the pressure ulcer is larger at its base than at the skin surface) and tunneling at a depth of 3.3 cm at the 4:30 - 7 o'clock position and 3.0 cm at 12 - 2 o'clock. There was exposed bone in the center part of the wound; 10% slough in the wound bed; early granulating tissue and slight serosanguinous drainage. The resident tolerated the procedure but had pain and burning after normal saline was infused into the wound as part of therapy. -2/5/21 at 3:24 p.m., the wound vac was changed that morning. The periwound skin was reddened, blanchable, and macerated. The wound measured 8 cm X 8.5 cm X 4 cm. Bone was exposed in the wound bed, centrally. The wound bed had 25 % loosely adherent slough and 75% granulation tissue. There was tunneling at a depth of 4 cm from the 6-12 o'clock position and undermining from the 12-2 o'clock position. The resident complained of pain throughout the treatment and will consider premedication prior to the next change. -2/7/21 at 2:01 p.m., the resident complained of lower abdominal discomfort and had been hallucinating and yelling out. A new order was received for a UA (urinalysis) with C&S (culture and sensitivity) if indicated. -2/8/21 at 1:15 p.m., wound vac dressing was changed and the resident was premedicated for pain prior to the treatment. The left buttock wound measured 6 cm X 10 cm X 3.5 cm with undermining at a depth of 2.5 cm from the 11-3 o'clock position and 3 cm at the 6-8 o'clock position. The right buttock wound had increased slough, bone exposed in the middle section, slight serosanguinous drainage and macerated periwound. -2/9/21 at 3:57 p.m., resident had 3 loose, foul smelling stools on this day. The NP was notified due to resident in possession of personal supply of anti-diarrheal medication which she had used liberally. An order was obtained for an x-ray to rule out a partial stool blockage. -2/10/21 at 12:36 p.m., resident was up in the recliner chair with therapy and ate lunch in the chair. She wanted to go back to bed and didn't want to sit up long. -2/11/21 at 6:19 p.m., a new order was received for an antibiotic for UTI. The resident had complained of dysuria that morning. Her catheter was hanging dependently; urine was yellow in color and there was a moderate amount of sediment. -A NP progress note, dated 2/12/21 at unknown time, indicated the resident was visited for several issues which were: a wound on her bottom, UTI, poor appetite, and depression. New orders given to start [MEDICATION(S)] (anti-depressant) 25 mg (milligrams) by mouth 1 time per day for depression. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -2/16/21 at 8:26 a.m., indicated the resident had burning in her urethra and abdominal pain. -2/17/21 at 9:59 a.m., resident wasn't drinking her liquid protein supplement because it gave her diarrhea. At 11:40 a.m., the physician was in to visit and was updated on resident's condition and her refusal to drink her supplement due to diarrhea. No new orders received. -2/18/21 at 10:15 a.m., the resident had a necrotic scab to her left heel and evidence of a pressure wound to her right heel. Lotion was applied to both heels due to dryness. There was no assessment and measurements of the left heel wound completed nor documentation that the physician and family had been notified of the wound. -2/19/21 at 12:36 p.m., the wound vac was changed as ordered. Wound measurements were 5.5 cm X 7.5 cm X 4.0 cm; undermining: 11-4 o'clock at depth of 4.0 cm; 4 cm at 12 o'clock to 0.0 cm at 4' o'clock; 2 cm depth at 5-7 o'clock position. There was granulating tissue in the buttock wound area, periwound redness but no maceration at the wound edges. -2/20/21 at 2:30 p.m., the resident was incontinent of stool before lunch. -An NP progress note, dated 2/21/21 at unknown time, indicated the resident was seen for follow up of depression and pain. Patient had a wound on her bottom that is currently treated by wound vac. She related pain at an 8 out of 10 with her last pain medication that morning. The plan was to increase her [MEDICATION(S)] from 25 mg to 50 mg by mouth daily and increase her [MEDICATION(S)] (pain medication) to 50 mg every 6 hours as needed. -2/22/21 at 4:17 p.m., the wound vac dressing was changed. Wound measurements were: 6 cm X 8 cm X 3.5 cm; undermining: 11-4 o'clock at depth 1.0 to 3.5 cm and 2 cm depth at 5-7 o'clock position. The wound bed had granulated tissue, slight serosanguinous drainage, and exposed bone that was 0.5 cm in diameter. -2/23/21 at 12:28 p.m., indicated Santyl 250 unit/gm was to be applied topically every day for wound care per phone order. It was to be applied to the wound bed of the left heel and covered with a dry dressing. There was a necrotic (dead skin) area covering the entire wound but the scab had detached in some areas which caused the scab to move but still covered the entire wound. There were no measurements or assessment of the left heel wound and surrounding skin completed and there was no documentation that the family had been notified. -2/26/21 at 9:33 a.m., resident had 1 bout of watery diarrhea and was administered antidiarrheal medication. -2/26/21 at 12:18 p.m., the wound vac was changed to her coccyx wound. The wound measured 6 cm X 7 cm X (?); undermining with a depth of 2.5 cm from 12-4 o'clock position and 3.5 cm from 5-6 o'clock position. The wound bed was 50% pink and 50% granulation tissue; no exposed bone. The resident had multiple bouts of diarrhea on this day. -2/26/21 at 12:34 p.m., resident with another bout of watery diarrhea and was given antidiarrheal medication which was ineffective. -2/27/21 at 8:04 p.m., resident with loose stool after dinner and was administered antidiarrheal medication. -2/28/21 at 5:32 p.m., resident with periods of confusion; foley catheter in place and draining clear yellow urine. -3/1/21 at 7:25 p.m., resident with increased confusion at times; dip stick done which showed nitrates in urine. The NP was contacted and new orders received to administer [MEDICATION(S)] (antibiotic) 500 mg by mouth 2 times per day for UTI until 3/8/21. There were no orders for a urinalysis with culture and sensitivity to be done prior to the start of the antibiotic. On 3/4/21, Nurse notes indicated the following: -8:05 a.m., the resident's family member contacted the facility with concerns over the resident's condition and UTI. The family member indicated the resident had been more confused than usual. She was told that the resident had just started on an antibiotic the day before and she should not expect instant improvement. The family member continued to express concern with the resident and her kidney function. -9:20 a.m., the NP was contacted and told of the family members concerns. New orders were received for a CMP and CBC to be drawn that day. -11:53 a.m., the blood work was drawn and sent to the lab. -1:22 p.m., a call was received from the lab who reported the resident had a critically low potassium level of 2.3 mmol/L (normal levels were 3.6-5.0 mmol/L). The NP was notified immediately and new orders received for potassium supplements and to repeat the blood work on the following Monday morning. -8:28 p.m., the NP was notified of the family members concerns about the resident's irritable bowel syndrome with alternating diarrhea and constipation. The resident had had it for years but was not taking any medication specifically for this except for the antidiarrheal medication. The family member also indicated concerns with the resident having hallucinations and seeing things and people who were not present as well as her current kidney function which the NP indicated was great. The family member indicated the resident had not reported her pain well and was concerned about this. The NP indicated she would review the resident's records and visit with her the next day. -3/5/21 at 3:33 p.m., the resident's wound vac was changed. Wound measurements were: 7.0 X 4.5 X 3.0. There was undermining at 11-2 o'clock position with a depth of 2.5 at the 11 o'clock position, 3.0 cm depth at 12 o'clock and 0.0 depth at 1 o'clock positions. There was granulation in the wound bed; slight serosanguinous drainage and 0.5 cm exposed bone in the center of the wound. At 7:49 p.m., she was administered an antidiarrheal for loose stools. At 8:07 p.m., the NP was notified of the resident's hallucinations and staff were to continue to monitor her. There was no documentation found to indicate the NP or physician had been notified of the change in the wound following the resident's multiple loose stools. On 2/26/21, there had been no exposed bone in the wound, however, on 3/5/21, there was 0.5 cm of exposed bone in the center of the wound. There was no further documentation on the resident's condition until 3/7/21 at 12:25 p.m. when the family member contacted the facility about the resident's frightening hallucinations and confusion she was having. The resident was currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . At 12:34 p.m., the NP documented that she had been updated on the resident's condition; staff reported the diarrhea was better with only a small amount on Saturday and none on Sunday. The resident continued to receive potassium supplements however, her hallucinations appeared worse. New orders given to send the resident to the hospital for evaluation and treatment. On 5/13/21 at 8:53 A.M., hospital records were reviewed for Resident W's hospital visit beginning 3/7/21. Records indicated the resident had been seen and evaluated in the ER where she had presented from the nursing home with continued and progressive altered mental status. She had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . In the ER, she was found to have dehydration, a drug resistant UTI due to her indwelling foley catheter, low potassium, diarrhea, low magnesium, pressure injury to her left heel, stage 4 sacral decubitus ulcer, and [CONDITION(S)]. She was admitted to the progressive care unit where her wounds were evaluated. The wound on her coccyx measured 5.5 cm X 7 cm X 2 cm.; undermining from 10-3 o'clock; wound bed was pink with non-granulating tissue and visible bone. The wound edges were detached with undermining; periwound was red but blanchable and the wound had a foul odor. The unstageable wound on her left heel measured 2.8 cm X 2.8 cm and was covered with black stable eschar; wound edges were attached; periwound was normal skin color; no odor or induration; minimal amount of serosanguineous drainage found on the dressing. On 5/12/21 at 10:15 A.M., during the entrance conference, the Clinical Care Coordinator indicated the facility had been purchased from another company at the end of January 2021. She indicated the new facility's change over, transfer of records from one electronic health record to another, and policies became effective on 2/11/21. The new facility staff had identified facility wide systems issues including wound care and all residents residing in the buildings had skin checks done on 2/11/21. At 2:38 P.M., the Clinical Care Coordinator was questioned if there had been any further documentation found of the resident's left heel pressure sores after it was identified on 1/5/21 and she indicated there was no further documentation of the left heel until 2/18/21. There was no documentation completed on the right heel other than documentation on 2/18/21 that indicated there was evidence of a pressure wound to her right heel. She indicated the nurse should have notified the physician, family and IDT (Interdisciplinary Team) of the new area on the right heel, measurements taken, treatment orders obtained, and the wound monitored weekly until resolved. On 5/13/21 at 10:37 A.M., RN 3 (Registered Nurse) indicated he had been with the facility since it was first opened and had worked with Resident W since her admission. Wounds, wound assessments, and skin conditions were documented in the nurse notes and he had not been aware of any tracking device used to monitor wounds. He was not aware of any wound policies and when wounds were identified, the DON was notified. The previous facility had used wound NP's at various times and with various companies but there had not been a designated wound nurse or NP when Resident W was admitted to the facility. The NP who usually came to the facility was notified of the resident's wound to her buttocks on 1/8/21 when she saw the resident. RN 3 indicated he had not been aware of the resident's reported abrasion to her right buttock on 12/31/20. On 1/3/21, he observed the shallow open areas on her buttocks and applied barrier cream. He had not informed the physician or family of the wounds and did not measure the areas or further assess the wounds. He indicated he had documented on 1/5/21 at 1:10 p.m. that the resident had a [MEDICATION(S)] dressing covering her bottom but hadn't placed it himself nor was he aware of who had or why. On 1/8/21, he had obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 3 had documented on 2/18/21 at 10:15 a.m., that the resident had a necrotic scab to her left heel and evidence of a pressure wound to her right heel. He indicated he couldn't recall what the pressure wound to her right heel looked like but that he documented what he had seen at the time. On 5/13/21 at 9:45 A.M., the Clinical Care Coordinator indicated the previous facility owners had not made available to the new owners, the policies for wound care and was unable to provide copies of them. She provided a current copy of the facility's Skin Management policy which was effective on 2/11/21 and stated the following: It is the policy the facility should identify and implement intervention to prevent development of clinically avoidable pressure injuries. Resident with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . In Electronic Health Record facilities, the licensed nurse will document on skin and wound evaluation for pressure injury and vascular ulcers. Document weekly until the area is resolved. Photos may be taken .The licensed nurse will document preventative measures on the care plan/Kardex . will monitor, evaluate and document changes regarding skin condition in the medical record .If a new area of skin impairment is identified, notify the resident, responsible party, attending physician, DON The immediate jeopardy that began on 1/3/21 was removed on 5/14/21 when the facility assessed all residents in the facility for wounds/skin impairment, and continuing to inservice staff on wound/skin assessments and treatments, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the need for continued inservices and monitoring. This Federal tag relates to Complaint IN 283. 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on interview and record review, the facility failed to develop a care plan and provide care and services for 1 resident with a history of UTI's, newly placed indwelling urinary catheter, and frequent bowel incontinence. The deficient practice resulted in the resident having urinary tract pain, recurrent UTI's and hospitalization for a drug resistant UTI. (Resident W) Findings include: On 5/12/21 at 11:52 A.M., the closed record for Resident W was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) assessment, dated 12/21/20, indicated the resident required extensive assistance from 2 staff members for bed mobility and toileting. She was occasionally incontinent of bladder and frequently incontinent of bowel and had been diagnosed with a UTI in the last 30 days. She was at risk for pressure ulcers but had none at the time of assessment. A CAA (Care Area Assessment) dated 12/21/20, indicated the resident was alert and oriented and was able to make her needs known. She had recently suffered a fall which resulted in a fractured hip. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was occasionally incontinent of bladder and wore incontinent briefs. She required assistance with transferring on and off the toilet and was able to provide her own peri-care. A Care Plan, dated 12/28/20, indicated the resident had bladder incontinence. The goal was the resident would be continent during waking hours. Interventions were: encourage fluids during the day to promote prompted voiding responses; ensure the resident had an unobstructed path to the bathroom; monitor/document signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and eating patterns; and monitor/document/report prn any possible causes of incontinence such as bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, and medication side effects. There was no care plan developed for the resident's indwelling urinary catheter which had been inserted following development of stage 4 pressure ulcers to the resident's buttocks. There was no care plan for the resident's bowel incontinence. Nurse Notes indicated the following: -12/17/20 at 5:16 a.m., resident told staff that it [CONDITION(S)] when urinating and had antibiotics at the hospital for a UTI. -12/22/20 at 2:08 p.m., the resident was administered [MEDICATION(S)] tablet 5-325 mg (milligram) tablet-1 tablet every 6 hours for pain due to pain with urination. At 6:01 p.m., [MEDICATION(S)] 5-325 mg tablet was given for urinary tract pain. An order was obtained to administer [MEDICATION(S)] tablet (pain medication to treat pain/burning with urination) 99.5 mg; give 2 tablets by mouth every 8 hours as needed for urinary tract pain. -12/24/20 at 12:58 p.m., [MEDICATION(S)] was given, as ordered, for severe urinary tract pain on urination as well as [MEDICATION(S)], as ordered, for urinary tract pain. At 4:56 p.m., the resident complained of pain on urination and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . -12/26/21 at 5:50 a.m., resident complained of pain on urination and had history of UTI. Her urine was collected and dip done in-house and was positive for nitrates, leukocytes, and blood. The NP was notified and was waiting for additional orders. -12/27/20 at 1:25 p.m., a UA C&S (urinalysis with culture and sensitivity) was obtained and sent to the lab. The resident was started on [MEDICATION(S)] (antibiotic) 500 mg tabs-1 tablet by mouth 2 times per day for UTI for 7 days. -12/28/20 at unknown time, the urinalysis results indicated the resident's urine was turbid, contained blood, was positive for nitrates, white blood cells, red blood cells, and bacteria. The culture and sensitivity report indicated the resident was not on antibiotics and her urine culture had been contaminated with > 3 organisms; further work up was not indicated. The resident remained on [MEDICATION(S)] for 7 days as ordered. -1/8/21 at 1:38 p.m., indicated the resident had complained of pain in her buttocks; had open sores on her buttocks which were covered with dressings. She had 2 small loose stools that morning. An NP progress note, dated 1/8/21 at unknown time, indicated the visit was for new wounds. Resident W had unstageable pressure ulcers to her left and right buttocks. -1/28/21 at 11:34 a.m. and 1/29/21 at 8:49 a.m., [MEDICATION(S)] tablets were administered as ordered for complaints of urinary tract pain. -1/30/21 at 7:30 p.m., an indwelling foley catheter was placed per order for wound healing. She tolerated the procedure well and had amber, clear urine in the tubing. -2/3/21 at 1:39 p.m., a wound vac was noted to the resident's coccyx; the seal came loose during incontinent care. -2/7/21 at 2:01 p.m., the resident complained of lower abdominal discomfort. She had been hallucinating and yelling out. A new order was received for a UA C&S if indicated. -2/9/21 at 3:57 p.m., resident had 3 loose, foul smelling stools on this day. The NP was notified due to resident in possession of personal supply of anti-diarrheal medication which she had used liberally. -2/11/21 at 6:19 p.m., a new order was received for an antibiotic for UTI. The resident had complained of dysuria that morning. Her catheter was hanging dependently; urine was yellow in color and there was a moderate amount of sediment. The resident's UA C&S, which had been obtained on 2/8/21, showed the resident had large amounts of bacteria in her urine which were sensitive to [MEDICATION(S)] (antibiotic) which had been ordered. -2/16/21 at 8:26 a.m., the resident had burning in her urethra and abdominal pain. At 2:43 p.m., she was encouraged to continue drinking fluids which she indicated she had been doing. -2/17/21 at 9:59 a.m., resident wasn't drinking her liquid protein supplement because it gave her diarrhea. At 11:40 a.m., the physician was in to visit and was updated on resident's condition and her refusal to drink her supplement due to diarrhea. No new orders received. -2/18/21 at 9:46 a.m., [MEDICATION(S)] tablets were administered as ordered for complaints of pain to the lower back and lower urethral area. The resident had multiple bouts of watery diarrhea on 2/26 and 2/27/21. -2/28/21 and 3/1/21, the resident had periods of confusion which worsened at times. On 3/1/21 at 7:25 p.m., a dip stick was done on her urine and showed nitrates. The NP was notified and new orders received for [MEDICATION(S)] 500 mg tablets; give 1 tablet by mouth 2 times per day for 7 days for UTI. There was no UA C&S ordered. -3/4/21 at 8:05 a.m., Resident W's family member called the nurse and expressed concern about the resident's condition and UTI. The family member indicated the resident was more confused than normal and she was concerned about the resident's kidney function. At 8:28 p.m., the DON (Director of Nursing) spoke with the NP about the family members concerns which included the resident's irritable bowel syndrome which the resident allegedly had for years but wasn't taking any medication for. The family member had been concerned about the resident's hallucinations and disorientation. The resident had just been started on an antibiotic for a UTI. -3/5/21 at 7:49 p.m., the resident was having loose stools and hallucinations. -3/7/21 at 12:25 p.m., the resident's family member, again, expressed concerns about the hallucinations and talking out of her head that the resident was doing. The resident was sent to the ER for evaluation and treatment. On 5/13/21 at 8:53 A.M., hospital records were reviewed for Resident W's hospital visit beginning 3/7/21. Records indicated the resident had been seen and evaluated in the ER where she had presented from the nursing home with continued and progressive altered mental status. She had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . In the ER, she was found to have dehydration and UTI due to her indwelling foley catheter. A UA C&S indicated the resident's urine was positive for E. Coli bacteria (Escherichia coli-bacteria which live in the bowel) which were resistant to [MEDICATION(S)] and several other antibiotics. On 5/13/21 at 9:45 A.M., the Clinical Care Coordinator provided copies of Resident W's UA C&S's which had been obtained during the resident's stay at the facility. She confirmed there had been no UA C&S ordered or done for the resident's UTI diagnosed on [DATE] although the resident had received treatment with [MEDICATION(S)]. The resident had no care plan developed for the indwelling foley catheter or bowel incontinence from loose/diarrheal stools with interventions to prevent/minimize urinary tract infections and prevent contamination of the resident's wounds on her buttocks. On 5/13/21 at 4:27 P.M., the Clinical Care Coordinator provided a current copy of the facility policy titled Catheter Associated Urinary Tract Infection Preventions which indicated the appropriate care and maintenance of indwelling catheters which were not care planned for Resident W. This Federal tag relates to Complaint IN 283. 3.1-41(a)(2)