Every finding on record at River Terrace Health Campus

Based on observation, record review and interview, the facility failed to ensure the kitchen was clean and in good repair for 2 of 2 observations. This deficient practice had the potential to affect 44 of 44 residents who received meals from the kitchen.Findings include:During the initial tour of the kitchen on 3/2/26 at 10:20 a.m., the following concerns were observed:Under the right long rack and center rack, next to the wall in the walk-in freezer, there were a handful of frozen french fries on the floor.The outside of the six white bins holding sugar, oatmeal, thickener, bread flour, bread crumbs, and all purpose flour, had brown dirt and streaks going down the front, back and sides of the bins.The inside shelf of the deep fryer had a moderate amount of yellow crumbs on the inside shelf above the oil. Around the outside front, and both sides of the fryer had heavy grease streaks which ran the length of the fryer.The left oven had a moderate build-up of orange brown spills on the inside bottom and oven door.The inside of the hot box (where the cooks put the hot items they have just finished cooking to keep warm) on all three sides and the tray shelves had a moderate amount of orange brown spills.The floor under the left sink of the 3 compartment sink had an area which measured 3 feet by 2 feet of soap suds. This area extended out from the drain to the front of the sink. In an interview with the Dietary Manager on 3/5/26 at 10:15 a.m., he indicated the soap suds were probably from the sink which overflowed with suds on to the floor.The shelf under the dishwasher held the red buckets used for wiping down counters, the shelf had a heavy amount of white and orange spots.The water faucet above the garbage disposal had a heavy dripping from it even after it was tightened.The top of the dishwasher had a heavy build-up of lime and food particles.Inside doors and the strip of underneath the convection oven where the doors closed had a heavy build-up of dark brown dried on grease.2. During the second observation of the kitchen, while accompanied by the Dietary Manager, on 3/5/26 at 9:55 a.m., the following concerns were identified:The same issues identified on 3/2/26 at 10:20 a.m., remained a concern with the exception of the walk-in freezer as the frozen French fries had been picked up. The left oven which had the moderate build-up of orange brown spills inside and on the oven door had been cleaned up and the soap suds on the floor under the 3 compartment sink were also cleaned up.The faucet to the 2 compartment sink had a heavy dripping from it even after it was tightened.The complete inside of the 3 compartment sink had a heavy amount of white and brown streaks which was greasy to the touch and able to be wiped clean.The grill grates had a very heavy accumulation of black crust on them.The wall behind the grill had multiple brown orange streaks which ran the length of the wall downward.The steel shelf just below the hood vents above the grill and stove had a heavy accumulation of brown grease.The Dietary Manager indicated at this time, that Maintenance had fixed the faucet to the 3 compartment sink before, but he had not notified them of it or the 2 compartment sink faucets leaking The Evening and Morning Cooks Checklist, for 2/25/26 to 2/27/26 and for 3/2/26 to 3/5/26, indicated the following task had been completed: Hot Box had been wiped out daily with no build up.The Morning [NAME] had cleaned the hood vents on 2/25/26 and 3/4/26. The grill grates were due to be cleaned and scraped on 3/6/26. It was last cleaned on 2/27/26.The Morning [NAME] was assigned to wipe down the wall behind the fryer and oven, including the top piece by the vents sometime on 3/5/26. It was last cleaned on 2/26/26.The Evening and Morning Aides Checklist, for 3/2/26 to 3/4/26, indicated the compartment sinks had been cleaned out in the dish area daily.The Prep Check List, for 3/2/26 to 3/4/26, indicated the ovens had been wiped out inside and out with no residue on 2/25/26 and 3/4/26.The review of the facility's current policy on Cleaning List Completion and Storage SOP (standard operating procedure) included, but was not limited to, Purpose: The purpose of this Standard Operating Procedure (SOP) is to provide clear instructions for the completion and storage of cleaning list in the (name of Hardware) software.Procedure:.Using manufacturer suggested procedure and protocols, Directors will create daily and weekly checklist for employees to complete on a daily basis to cover all aspects of standard cleaning and maintenance within the department.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to ensure the medical provider addressed the consultant pharmacist's recommendations for 2 of 45 residents reviewed for Drug Regimen Review. (Residents 36 and 44)Findings include:1.The record for Resident 36 was reviewed on 3/3/26 at 1:50 p.m., The resident's diagnoses included, but were not limited to, Alzheimer's disease with late onset (a progressive irreversible neurological disorder that destroys memory, thinking skills, and eventually the inability to perform simple tasks); major depressive disorder ( a serious mental health condition characterized by at least 2 weeks of persistent severe sadness, loss of interest, and fatigue, which significantly disrupt daily life); hallucinations (seeing, hearing, smelling feeling things that seem real but are created by the mind without external stimuli) and tremors (an involuntary quivering moment). The Consultant Pharmacist Review, dated 2/9/26, indicated the resident was admitted on [DATE] with a physician's order for Propranolol Tablet (for tremors). The resident was prescribed 1 tablet by mouth once daily. The hospital records indicated the resident should be on the Extended Release Capsule. The facility needed to clarify the order. To the provider, he indicated for the recommendations be responded to according to the regulation: the resident was a hospice resident with protocol anxiolytic/hypnotic orders for PRN (as needed) Lorazepam Concentrate (for anxiety and restlessness) 2 MG (milligrams) per milliliter. The Federal regulations require that all PRN psychoactives (non-antipsychotics) initially be limited to 14 days (regardless of the Hospice status). The order may be extended, by a prescriber, if the following two conditions are met and documented in the chart: 1. Rationale for extending the order beyond the 14 days. 2. How long the order was to remain an active order by providing a stop date. Neither of the recommendations had been responded to by the facility and or the provider. The admission Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had short and long term memory issues, had poor recall, and was severely impaired in cognitive skills for daily decision making. Had trouble concentrating, frequently short tempered and easily annoyed, had occasional behaviors towards others, put others at significant risk for physical injury and disrupted care and living environment, occasional rejection of care; had no hallucinations or delusions; and used anti-psychotic, anti-depressant and anti-anxiety medications daily. The psychotropic medications were contraindicated for reduction. The care plan, dated 2/10/26, indicated the resident demonstrated significant cognitive deficits with further deterioration due to the nature of the disease process. The approaches included, but were not limited to, reorient resident to activity and task; medications per orders; and observe cognitive functioning with care and contact and to refer significant decline or change to the physician as needed. The care plan, dated 2/10/26, indicated the resident demonstrated inappropriate behaviors including, biting, hitting, urinating on the floor and putting self on the floor. The approaches included, but were not limited to, determine the cause for the inappropriate behavior and to refer to the physician as needed for intervention; observe for what triggered the inappropriate behaviors and alter the environment as needed. The Consultant Pharmacist Fall Review, dated 2/17/26, indicated the following recommendation: A fall review was performed for the resident for a falls that occurred on 2/15/26. After evaluation, please consider the following: Resident had a history of 2 or more falls which occurred in the last 2 days and was receiving the benzodiazepine: Lorazepam PRN. Please add buspirone 5 mg bid (twice daily) to help control anxiety and restlessness and attempt to reduce the risk for future falls. There was no response from the physician related to the buspirone. During an interview with the Director of Health Services (DHS), dated 3/4/26 at 10:15 a.m., she indicated the recommendations had not yet been addressed by the physician since he was on vacation when the resident arrived. The review of the record for Resident 36, on 3/4/26 at 2:10 p.m., indicated the physician made his rounds that afternoon. The physician responded to the recommendation by denying the request to add buspirone and increased the resident's Seroquel. 2. The record for Resident 44 was reviewed on 3/5/26 at 8:50 a.m. The resident's diagnoses included, but were not limited to. Alzheimer's dementia late onset, severe Parkinson's (a neurodegenerative disorder that destroys dopamine cells) and essential hypertension (high blood pressure). The admission MDS assessment, dated 1/14/26, indicated the resident had long and short memory issues; had poor recall; and was severely impaired for cognitive daily decision making. He had periods of inattention with an altered level of conscious which fluctuated. The resident required maximum to dependent assistance for all ADLSs, mobility and transfers. He also had no impairment in functional range of motion to bilateral upper and lower extremities and no falls prior to or after admission. A Consultant Fall Drug Review, dated 2/9/26, indicated the resident was receiving Oxybutynin for overactive bladder or urinary incontinence. This medication was not recommended for use in older adults due to the risk of increased sedation and anticholinergic effects. Documentation in the medical records indicated the resident was frequently incontinent. Please consider discontinuing. If Oxybutynin was continued, please provide risk versus benefit analysis for clinical rationale. 2/9/26 Pharmacy Drug Review for Fall: indicated to please see recommendations and respond according to the recommendation: the resident was receiving Oxybutynin for overactive bladder or urinary incontinence. This medication was not recommended for use in older adults due to risk of increased sedation and anticholinergic effects. Documentation in the medical records indicated that resident was frequently incontinent. Please consider discontinuing. If Oxybutynin was continued, please provide risk versus benefit analysis for clinical rationale. A Consultant Pharmacy Monthly Review, dated 2/20/26, indicated please take the following action: the resident had an order for daily donepezil (Aricept). Please change the hour of administration of this medication to bedtime per manufacturer's recommendation to minimize side effects. Neither recommendation had been responded to by the physician until 3/4/26 when the physician gave new orders for the Oxybutynin to be discontinued and to change the time of administration of donepezil from daytime to nighttime. The review of the facility's current policy, dated 12/16/24, on Pharmacy Recommendations Standard Operating Procedure, included, but was not limited to, Pharmacy Consultants will provide pharmacy recommendations to the campus and/or physician through the Pharmacist Drug Regimen Review observation.Campus will address pharmacy recommendations by: 1. Print open pharmacy recommendations and give them to the provider. 2. The medical provider will respond to the recommendation and sign. 3. Campus staff will update the observation in the EHR (electric health record), and mark as complete. 4. Update orders if appropriate. Scan the signed copy into the chart. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(i)

Based on observation, record review, and interview, the facility failed to ensure the facility was staffed to provide adequate care for the residents related to toileting and as needed pain medication. This deficient practice had the potential to affect 41 of 41 residents residing in the facility. Findings include: An observation of the 2nd floor 200 Hallways, on 3/26/25 at 7:08 p.m., indicated no staff were observed on the right-side Hallway of the 2nd floor. On the right-side Hallway of the 2nd floor five call lights were alarming, Resident H was lying on the floor in her room between her wheelchair and the bathroom doorway. The resident was yelling for help, and no staff were insight or within hearing distance. A staff member was located at 7:09 p.m. and notified of the resident lying on the floor yelling for help. The resident indicated to Certified Nurse Aide (CNA) 3 she had fallen and needed help. During an interview and observation, on 3/26/25 at 7:12 p.m., Resident C was sitting in her bed. The resident had a nasal canula with oxygen being administered. CNA 3 indicated Resident C's oxygen tubing was not long enough to reach the bathroom and the resident had to go to the bathroom. She did not have a bed side commode and would have to go to the basement to get one. At, 8:52 p.m., Resident C was apologizing to staff for being incontinent. There was no bedside commode in the resident's room or extension to the resident's oxygen tubing. During an interview, on 3/26/25 at 7:13 p.m., CNA 3 indicated she had not seen the nurse on her hallway for a while and did not know where she had gone. The CNA had been helping with a resident that required a full body mechanical lift on the other side of the 2nd floor. During an interview and observation, on 3/26/25 at 7:16 p.m., Resident G indicated staff would try to help, but they were worked hard. He has had to wait from 20 to 40 minutes for a call light to be answered. Earlier today a staff member removed his empty water cup and indicated they would return with more water. After waiting over an hour and a half he never seen his water cup again and he was thirsty. During an interview, on 3/26/25 at 7:28 p.m., Qualified Medical Aide (QMA) 5 indicated it was very hard to get your work completed. There were residents that required two staff for mobility. Earlier a resident required a full body mechanical lift and the CNA from the other side of the 2nd floor had to come over to help. During an interview, on 3/26/25 at 8:03 p.m., Resident E indicated she had turned her call light on for assistance to go to the bathroom and the CNA indicated she was the only one on the floor and could not help her. The resident was advised the facility did not have a walker or wheelchair for her to use at that time. After waiting over an hour the resident contacted her family member at home. The resident's family member indicated the resident called him and asked him to come and get her help. During an interview on 3/26/25 at 8:14 p.m., RN 4 walked onto the hallway and answered one call light. At 8:15 p.m. the nurse walked past two of the other call lights. At 8:26 p.m., the nurse walked away from the hallway. At 8:28 p.m., the nurse returned and then walked to her medication cart. Then the nurse stood at her medication cart and was looking at the computer screen on the cart. She did not answer any of the three call lights alarming. At 8:29 p.m., the Clinical Support Nurse walked onto the hallway and answered one of the three call lights going off. At 8:30 p.m., the Clinical Support Nurse went into a second room and answered the resident's call light. At 8:38 p.m., the Administration Staff came and answered a resident's call light. At 9:24 p.m., the Administration Staff came back to the floor and answered another resident's call light that had been alarming. During an interview and observation, on 3/26/25 at 10:01 p.m., Resident D was observed sitting in her wheelchair on the right side of her bed. The resident had been sitting in the same position and location starting from 7:18 p.m. through 10:01 p.m. The resident indicated she had needed to go to the bathroom and has not seen any staff. She did not know what to do or where to go. During an interview, on 3/26/25 at 10:07 p.m., CNA 3, indicated the day shift staff had toileted Resident D before they left their shift. The day shift ended at 6:00 p.m. CNA 3 indicated the resident had not been toileted since the day shift left. During a confidential interview, from 3/26/25 through 3/28/25, Staff 12 indicated it was very hard to care for the residents when you were the only one on the hallway. The extra wheelchairs, walkers, and bed side commodes were in the basement, and you could not leave the floor without any staff to gather the supplies. During a confidential interview, from 3/26/25 through 3/28/25, Staff 13 indicated it was very hard to care for the residents when you were the only one on the hallway. On day shift some days residents did not receive their scheduled baths and, on the evening,/night shift it was the worst. The residents did not get toileted as often as they needed. During a confidential interview, from 3/26/25 through 3/28/25, Staff 14 indicated there were days she was not able to care for the resident like she wanted to. With three residents requiring a full body mechanical lift you had to find help to provide care. When you found help then it left no one to toilet the residents on the other side of the floor. Record review of the Facility Assessment Tool, dated 7/12/24, indicated the facility's resident profile had 18 rehab to home licensed beds and 39 long term care licensed beds. During an interview, on 03/28/24, the facility Administrator indicated they did not have a policy for staffing. Cross Reference F697: The facility failed to ensure a resident with complaints of pain received as needed pain medication in a timely manner. Cross Reference F677: The facility failed to ensure residents who were dependent on staff for activities of daily living received the care and services needed related to incontinence care. This citation relates to Complaint IN00454644. 3.1-17(a)

Based on interview and record review, the facility failed to provide activities of daily living (ADL) related to incontence care and personal assistance for 4 of 5 residents reviewed for ADL care. (Residents E, D, G, and C) Findings include: 1. During an interview, on 3/26/25 at 8:03 p.m., Resident E indicated she had turned her call light on for assistance to go to the bathroom and the Certified Nurse Aide (CNA) indicated she was the only one on the floor and could not help her. The resident was advised the facility did not have a walker or wheelchair for her to use at that time. After waiting over an hour the resident contacted her family member at home. The resident's family member indicated the resident called him and asked him to come and get her help. The clinical record for Resident E was reviewed on 03/28/25 at 11:07 a.m. The resident's diagnoses included, but were not limited to, femur fracture, Type 2 diabetes mellitus, diverticulosis, and hypertension. During a confidential interview, from 3/26/25 through 3/28/25, Staff 12 indicated it was very hard to care for the residents when you were the only one on the hallway. The extra wheelchairs, walkers, and bed side commodes were in the basement, and you could not leave the floor without any staff to gather the supplies. 2. During an interview and observation, on 3/26/25 at 10:01 p.m., Resident D was observed sitting in her wheelchair on the right side of her bed. The resident had been sitting in the same position and location starting at 7:18 p.m. through 10:01 p.m. The resident indicated she had needed to go to the bathroom and did not know what to do or where to go. The resident's bilateral lower legs, ankles, and feet were swelling with edema (buildup of fluid in the tissues). The resident's call light was laying across the resident's bed approximately two feet from her wheelchair. During an interview on 3/26/25 at 10:07 p.m., CNA 3 indicated the day shift staff indicated they toileted the resident before they left their shift before 6:00 p.m. The resident was not toileted since day shift left. The current CNA from the other hallway and her were working their way around both sides of the hallway to toilet and place the residents in bed. They started on the other side of the floor and now are getting to Resident D's side of the building. An observation on 3/26/25 at 10:21 p.m., Resident D was provided toileting care. CNA 3 walked up to Resident D and indicated her legs were swollen and it would help when she laid down. CNA 3 and CNA 4 pushed Resident D's wheelchair into the bathroom area. CNA 4 walked back into the resident's bedroom area collected a gait belt from the resident's supplies on her bedside stand. The CNA opened the plastic wrap on the resident's gait belt and walked back into the bathroom. The resident was assisted to a standing position and the resident's soiled depend was removed. The resident had been slightly incontinent of bowel. The resident's buttocks and upper thighs were dark red with some deep purple areas. The CNA's placed the resident on the toilet and after a couple of minutes the resident's bottom was cleaned and she was dressed for bed. The clinical record for Resident D was reviewed on 03/28/25 at 10:00 A.M. The resident's diagnoses included, but were not limited to, dementia, anxiety, hypertension, low back pain, chronic pain, weakness, disorientation, and insomnia. The Nursing Progress Note, dated 3/28/25 at 10:20 a.m., indicated Resident D was alert and oriented. The resident's speech was clear, and she was able to make her needs known. The resident had weakness and used a wheelchair for mobility. The resident's bilateral lower legs had no edema present. The resident was incontinent, and staff provided fall prevention and safety management. 3. During an interview and observation, on 3/26/25 at 7:16 p.m., Resident G indicated staff try to help, but they are working hard. He has had to wait from 20 to 40 minutes for a call light to be answered. Earlier today a staff member removed his empty water cup and indicated they would return with more water. After waiting over an hour and a half he never seen his water cup again and he was thirsty. The resident was observed to have no water cup or any other type of drink present in his room. At 7:42 p.m., the resident was observed to have received a cup of water by a staff member. The clinical record for Resident G was reviewed on 03/28/25 at 10:07 a.m. An Admission Minimal Data Set (MDS) assessment, dated 3/11/25, indicated the resident was alert and oriented. The resident required maximal assistance of staff and the use of a wheelchair for mobility. The resident's diagnoses included, but were not limited to, congestive heart failure, hypertension, peripheral vascular disease and renal failure. 4. During an interview and observation, on 3/26/25 at 7:12 p.m., Resident C was sitting in her bed. The resident had a nasal canula with oxygen being administered. CNA 3 indicated Resident C's oxygen tubing was not long enough to reach the bathroom and the resident had to go to the bathroom. She did not have a bed side commode and would have to go to the basement to get one. The resident's oxygen tubing was observed, and the tubing was not long enough to reach the bathroom. There was no bedside commode in the resident's room. During an observation, on 3/26/26 at 8:52 p.m., Resident C was apologizing to staff for being incontinent. There was no bedside commode in the resident's room. During an interview, on 3/26/25 at 10:47 p.m., the Administrator indicated they would get Resident C a longer oxygen tube to reach the restroom. She did not know why that had happened. Resident C was normally continent of bladder and bowel. The clinical record for Resident C was reviewed on 3/28/25 at 10:00 a.m. The resident's diagnoses include, but were not limited to, aspiration pneumonia, compression fracture of T5 and T6 vertebra, acute kidney failure, hypertensive heart disease with heart failure, asthma, and anemia. The Nursing Progress Note, dated 3/27/25, indicated the resident was alert and oriented. She was able to make her needs known. The resident required oxygen use and was continent and incontinent. During an observation, on 3/28/25, at 3:00 p.m., an associate staff member was in the bathroom with Resident C. The resident did not have any oxygen on and was assisted with a wheelchair back to her bedside chair. During an observation and interview, on 3/28/25 at 4:18 p.m., Resident C indicated she was only half breathing and normally she wore oxygen. She continued to cough and puff as she was talking. The Resident Bladder Continence policy, dated 5/10/16 with a reviewed date of 12/17/24, indicated the purpose statement was to provide measures for a resident who is incontinent to receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible .Toileting and continence interventions shall be communicated to care givers via the resident profile . This citation relates to Complaint IN00454644. 3.1-38(a)(2)(C) 3.1-38(a)(2)(D)

Based on record review and interview, the facility failed to ensure a resident's pain medication was administered timely after being requested for 1 of 3 residents reviewed for pain management. (Resident F) Findings Include: During an interview on 3/26/25 at 7:47 p.m., Resident F indicated he had waited for hours to receive pain pills, and it was the worst on evening shift. Once the pain increased so high it was hard for the medication to get control of the pain. The clinical record for Resident F was reviewed on 3/26/25 at 11:00 p.m., The resident's diagnoses included, but were not limited to, right femur fracture, chronic kidney disease, Type 2 diabetes mellitus, and anemia. The Nursing Progress note, dated 3/22/25 at 5:46 p.m., indicated the resident was alert and oriented. He required the extensive assistance of one staff member for transfers. He had a right hip fracture and incision. The resident rated his pain level a 6 out of 10 with a scale of 1 being the lowest and 10 being the highest pain level. The Nursing Progress note, dated 3/23/25 at 11:23 p.m., indicated the resident complained of having pain at a level of 6 out of 10. The Nursing Progress note, dated 3/24/25 at 4:18 a.m., indicated the resident's pain medication was administered as requested and effective. The resident requested his pain medication to be given at every six hours due to the pain becoming out of control if he waited. The Nursing Progress note, dated 3/24/25 at 9:27 p.m., indicated the resident complained of pain at a level of 6 out of 10 The Nursing Progress notes, dated 3/27/25 at 10:13 p.m., indicated the resident complained of having pain at a level of 6 out of 10. The physician's order, dated 3/22/25 through 3/29/25, indicated the resident was to receive hydrocodone 10/325 mg (milligrams) every six hours as needed for pain. The March 2025 Electronic Medication Administration Record (EMAR) indicated the resident received his hydrocodone 10/325 mg on the following days and times: - On 3/22/25 at 8:15 p.m., the resident received his hydrocodone 10/235 mg (pain medication). - On 3/23/25 at 3:59 a.m. and 10:04 p.m., the resident received his pain medication. - On 3/24/25 at 3:54 a.m., 12:04 p.m., and 9:23 p.m., the resident received his pain medication. - On 3/25/25 at 3:12 p.m. and 8:57 p.m., the resident received his pain medication. - On 3/26/25 at 5:39 p.m., the resident received his pain medication. The March 2025 EMAR indicated the charted pain medication reasons and comments were documented as followed: - On 3/22/25 at 8:15 p.m., the resident's received his prn medication related to pain. - On 3/23/24 at 2:09 a.m., the resident's pain medication was effective. - On 3/23/25 at 3:59 a.m., the resident received his pain medication related to pain. - On 3/23/25 at 6:00 a.m., the resident's pain medication was effective. - On 3/24/25 at 12:43 p.m., the resident pain medication was somewhat effective. - On 3/26/25 at 9:34 p.m., the resident pain medication was effective. The physician's order, dated 3/22/25 through 3/25/25, indicated the staff were to monitor the resident's pain twice a day for 72 hours post admission. The March 2025 EMAR indicated the resident pain was monitored on the following days and times: - On 3/22/25 on the 6:00 p.m. to 10:00 p.m. shift, the resident rated his pain at a level 8 out of 10. - On 3/24/25 on the 6:00 a.m. to 10 :00 a.m. shift, the resident rated his pain at a level 0 out of 10. - On 3/24/25 on the 6:00 p.m. to 10:00 p.m. shift, the resident rated his pain at a level 7 out of 10. - On 3/25/25 on the 6:00 a.m. to 10:00 a.m. shift, the resident rated his pain at a level 0 out of 10. - On 3/25/25 on the 6:00 p.m. to 10:00 p.m. shift, the resident rated his pain at a level 7 out of 10. During an interview, on 3/26/25 at 7:28 p.m., QMA 6 indicated it was very hard to get your work completed and medications were sometimes administered late. The Pain Observation and Management policy, dated 5/11/16 with a reviewed date of 12/17/24, indicated .initiate a plan of care related to chronic, acute or breakthrough pain .Evaluate the effectiveness of pain management interventions and modify as indicated . The Specific Medication Administration Procedures policy, revised 11/18, indicated .when administering an .(PRN) medication, document reason for giving, observe for medication actions/reactions and record efficacy . This citation relates to Complaint IN00454644. 3.1-37(a)

Based on interview, observation, and record review, the facility failed to ensure staff provided proper transfer techniques during transfers for 2 of 4 residents reviewed for activities of daily living. (Residents 183 and 14) Findings include: 1. During an observation on 1/15/25 at 9:13 a.m., Resident 183 was tearing up and moaning due to pain. He was unable to move his right shoulder and indicated he was in severe pain. The record for Resident 183 was reviewed on 1/17/25 at 10:24 a.m. The resident's diagnoses included, but were not limited to, primary osteoarthritis of the left shoulder, spinal stenosis, lumbar region without neurogenic claudication, and radiculopathy of the lumbar region. The Admission Minimum Data Set (MDS) assessment, dated 8/15/24, indicated the resident was cognitively intact. The resident required partial to moderate assistance for transferring safely. The care plan, dated 1/13/25, indicated Resident 183 had impairment in functional status related to weakness. The interventions included, but were not limited to, encourage the resident to be independent as safely as possible, provide assistance as needed with self-care and mobility functional tasks, therapy to evaluate and treat as needed and ordered. The nurse's note, dated 1/14/25 at 12:21 a.m., indicated the resident had continued complaints of right shoulder pain. The pain started the previous night when he was being transferred, per the resident. He was able to move without difficulty. He continued to use his right upper extremity when transferring and to push up from sitting position to standing. The resident was requesting an X-ray of his right shoulder. The nurse's note, dated 1/16/25 at 10:33 a.m., indicated the resident experienced weakness to his right upper extremity and complained of pain. The resident rated his pain level at a 6 to 8 on the 1 being the lowest to 10 being the highest pain scale in his right shoulder. The nurse's note, dated 1/17/25 at 3:30 p.m., indicated the resident spoke with the physician and requested an increase in his pain medication. A new order was received to discontinue the Norco 5-325 mg (milligram) and increase the Norco to 7.5-325 mg. During an interview and observation on 1/17/24 at 9:45 a.m., the resident was sitting up in his chair eating breakfast. He indicated he was still hurting, but not quite as bad if he didn't move his shoulder. During an interview on 1/17/24 at 1:15 p.m., Licensed Practical Nurse (LPN) 12 indicated staff should not be pulling residents by the arm. They should always use a gait belt to transfer the resident. It would be helpful if the facility provided more gait belts. There were a lot of new Certified Nursing Aides (CNAs), and they were still learning. During an interview on 1/21/24 at 8:15 a.m., RN 3 indicated the resident informed him a CNA had pulled him up by his arm and that was why he was having pain in his shoulder. The CNAs were supposed to transfer the residents with a gait belt and all the residents should have a gait belt in their rooms. 51675 2. The record for Resident 14 was reviewed on 1/15/25 at 11:00 a.m. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side; unspecified dementia; anxiety; cognitive communication deficit; and repeated falls. The Quarterly MDS assessment, dated 10/27/24, indicated the resident's cognition was severely impaired. The resident required maximal staff assistance with all ADL's (Activities of Daily Living). The care plan, dated 8/12/23, indicated the resident had impairment in functional status regarding bed mobility, transfers, toileting, and eating due to diagnosis of dementia. The interventions, dated 8/12/23, included, but were not limited to, encourage resident to be as independent as safely possible; dated 8/30/24, use a mechanical lift for transfers. A progress note, dated 8/30/2024 at 10:03 a.m., indicated the staff was giving Resident 14 a shower. The resident's shirt was removed, and bruising was observed under both arms. Bruising was observed to be from transfers and blood thinners. A Lift evaluation was completed, and the full body mechanical lift was to be used for all transfers. The Interdisciplinary Team (IDT) note, dated 8/30/24 at 12:23 p.m., indicated the resident was a two-person extensive assist for transfers. The resident presented with bruising under both arms congruent with staff lifting the resident under her arms. The resident was assessed and shook her head no when staff asked if she was hurting or was in any pain. The resident was ordered Eliquis and Aspirin and the physician was notified. A lift evaluation was completed. The resident was ordered to have a full body mechanical lift for transfers to avoid any further bruising of complications. The discharge summary from the hospital, dated 9/5/24, indicated that bruising was secondary to the resident taking a blood thinner and improper transfer at the extended care nursing facility. The care plan, dated 12/14/23, indicated the resident needed assistance with ADLs to assist with communication of the resident care needs. The interventions, dated 12/14/23, included, but were not limited to, transfers to be completed with a mechanical lift. During an interview on 1/16/25 at 9:30 a.m., RN 3 indicated the resident required the use of a full body mechanical lift for all transfers due to a history of bruising during transfers. During an interview with Certified Nursing Aide (CNA) on 1/17/25 at 10:30, the CNA indicated that it had been a long time since she had done a transfer. This resident was a two-person extensive assist prior to starting the use of the mechanical lift. The CNA indicated that two aides would transfer the resident from the bed to the chair by hooking their arms under the resident's armpits. The CNA did not indicate the use of a gait belt. During an interview on 1/17/25 at 1:24 p.m., CNA 5 indicated a gait belt was always used during a transfer. The Resident Transfer policy, dated 12/16/24, indicated .3. Campuses determine the amount of assistance required for transfers and record this on the nursing Admission Observation, the CareAssist profile, and the Resident Care Plan to provide communication to all staff regarding safe transfers. 3.1-38(a)(2)(B)

Based on observation, record review, and interview, the facility failed to ensure non-pressure wounds were documented on the Treatment Administration Record, and wound treatments were performed in a timely manner as ordered by the physician for 1 of 6 residents observed for Quality of Care. (Resident 13) Findings include: The record for Resident 13 was reviewed on 1/16/25 at 1:53 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease, severe morbid obesity due to excess calories, type 2 diabetes mellitus with diabetic chronic kidney disease, SIRS (systemic inflammatory response syndrome) of non-infectious origin with acute organ dysfunction, muscle weakness, difficulty in walking, and unsteadiness on his feet. The Quarterly MDS (Minimum Data Set) assessment, dated 11/28/24, indicated the resident was cognitively alert and oriented. The nurse's note, dated 10/11/24 at 10:47 a.m., indicated that during the weekly skin assessment, the resident was observed to have an open, draining area to the left shin with redness around the area. The MD was made aware and new orders were received to culture any drainage and administer 100 mg (milligrams) of doxycycline BID (twice daily) for 10 days. The Wound Management note, dated 10/11/24 at 3:02 p.m., indicated the facility acquired diabetic ulcer to the left shin was observed. The wound measured 3.5 cm (centimeters) long by 1 cm wide with light seropurulent exudate. The nurse's note, dated 10/13/24 at 2:13 a.m., indicated the resident continued to receive the antibiotic for cellulitis. The resident indicated the wound was painful. The nurse was waiting for the wound culture results from the lab. The physician's order, dated 10/22/24, indicated to observe the open area to the left lower extremity dressing every shift for draining on the dressing and dislodgement twice daily. The October 2024 Treatment Administration Record (TAR), indicated on the resident's weekly skin assessments dated 10/4/24, 10/18/24, and 10/25/24 the resident had no skin impairments. On 10/11/24, the resident had one new skin impairment. The Wound Management note, dated 10/24/24 at 1:32 p.m., indicated the resident's diabetic ulcer measured 3.5 cm long by 2 cm wide with moderate serous exudate. The depth was partial thickness (loss of epidermis and into but not through the dermis). The wound was stable. The physician's order, dated 10/25/24, indicated to cleanse the wound to the left lower extremity with wound cleanser or normal saline, apply collagen silver to the wound and cover with a bordered SAD (suction assisted dressing) daily. The care plan, dated 11/1/24, indicated the resident had a diabetic ulcer to the left shin. The interventions, dated 11/1/24, included, but were not limited to, assess and record the condition of the skin surrounding the diabetic ulcer, observe and report signs of infection such as localized pain, redness, swelling, tenderness, drainage, odor, and fever, provide treatment per the MD order, notify the MD if the treatment was not effective, conduct the weekly skin assessments, measurement, and observe the diabetic ulcer and record. The Wound Management note, dated 11/14/24 at 5:31 a.m., indicated the diabetic ulcer measured 1 cm long by 0.5 cm wide with a partial thickness depth. There was no drainage. The CAR (Corrective Action Request)/Wound note, dated 11/14/24 at 12:14 p.m., indicated that the wound had improved, was healing appropriately, and the current treatment would continue. The nurse's note, dated 11/20/24 at 4:02 p.m., indicated the MD assessed the wound to the left shin. New orders were received for doxycycline for 10 days BID and to culture the wound. A culture was obtained. The CAR/Wound note, dated 11/21/24 at 12:15 p.m., indicated the area showed improvement, was healing appropriately, the current treatment was to be continued, and the wound care center representative was at the facility and observed the wound. The staff were advised to continue the current treatment. The nurse's note, dated 11/22/24 at 2:32 p.m., indicated the wound culture results were received and sent to the MD. No changes to the treatment orders were received. The nurse's note, dated 11/25/24 at 2:45 a.m., indicated the resident continued to receive doxycycline, related to the wound infection on the left shin. The treatment was completed as ordered at bedtime. Redness to the wound remained, with a raised area on the distal end of the wound. There was no active drainage observed. Staff would continue to monitor the wound for changes. The Wound Management note, dated 11/26/24 at 11:11 a.m., indicated the diabetic ulcer measured 1 cm long by 1 cm wide by 0.1 cm deep. There was a moderate amount of serosanguineous exudate, 95% granulation tissue and 5% slough. The wound was stable. The Wound Culture of the left lower extremity, dated 11/27/24, indicated Staphylococcus aureus (bacterium commonly found on the skin and in the nose). The November 2024 TAR indicated the resident's weekly skin assessments on 11/1/24, 11/8/24, 11/15/24, 11/22/24, and 11/29/24, indicated no skin impairments. The nurse's note, dated 12/9/24 at 3:39 a.m., indicated the treatment and monitoring were continued to the resident's left lower extremity wound. The skin remained to be red with dry flaky skin on the peri wound. The dressing was changed as ordered with yellowish drainage observed on the wound prior to cleaning. No increased warmth or swelling were present. The Wound Management note, dated 12/12/24 at 1:25 p.m., indicated the diabetic ulcer measured 0.8 cm long by 0.6 cm wide with full thickness depth (through dermis and down to the subcutaneous tissue or muscle). There was a moderate amount of serosanguineous exudate, 95% granulation tissue and 5% slough. The wound was stable. The CAR/Wound note, dated 12/18/24 at 3:40 p.m., indicated the current treatment of collagen silver to the wound bed and cover with SAD were continued. The area had improvement and was healing appropriately. The December 2024 TAR indicated the resident's weekly skin assessments on 12/6/24, 12/13/24, 12/20/24, and 12/27/24, indicated the resident had no skin impairments. The CAR/Wound note, dated 1/2/25 at 11:35 a.m., indicated the current treatment of collagen silver to the wound bed and cover with SAD were continued. The area had improvement and was healing appropriately. The current treatment would continue until healed. The Wound Management note, dated 1/2/25 at 3:20 p.m., indicated the diabetic ulcer measured 1 cm long by 1 cm wide. There was a light amount of serosanguineous exudate. The nurse's note, dated 1/10/25 at 8:13 p.m., indicated the resident was unstable on his feet and had a temperature of 102 degrees F (Fahrenheit). The resident was alert, had no confusion, and was oriented, but had been sleeping all day, and was not of his normal character. The resident's blood sugar was 175 mg/dL (milligrams per deciliter). He was shaky, diaphoretic, denied stomach pain, and was without appetite. Both lower extremities had warmth and redness, without odor or drainage present on the dressing. The MD was notified, and the resident was started on 100 mg of doxycycline BID for 10 days. Lab work of a CBC (complete blood cell count) and CHEM-8 (blood test to measure 8 different substances in the blood) were obtained. The MD was to be contacted immediately if the resident became hypotensive or tachycardic. The Wound Management note, dated 1/10/25 at 11:33 a.m., indicated the diabetic ulcer measured 0.3 cm long by 0.2 cm wide. There was full thickness depth, and the wound was improving. The nurse's note, dated 1/12/25 at 6:40 a.m., indicated the MD assessed the resident related to his condition and lab work. New orders were received for a Midline IV (intravenous) to be placed and to begin Clindamycin and Rocephin (ceftriaxone). The resident was to continue to receive the doxycycline. The physician's order, dated 1/12/25, indicated to administer 100 mg doxycycline hyclate twice daily for 10 days until 1/22/25. The physician's order, dated 1/12/25, indicated to administer 1 gram of ceftriaxone intravenously daily. The medication was unavailable on 1/12/25 and it was started on 1/13/25. The ceftriaxone was discontinued on 1/14/25. The nurse's note, dated 1/13/25 at 12:58 p.m., indicated the Midline dressing was soaked with blood. Flushing was performed and no resistance occurred. The dressing was changed and secured. One gram of IV Ceftriaxone was administered. The pharmacist contacted the nurse and indicated that 900 mg of Clindamycin was not available, but they had 600 mg and 300 mg. The MD was informed, and an order was received to administer 600 mg of Clindamycin IV every 8 hours for 3 days. The physician's order, dated 1/13/25, indicated to administer 600 mg clindamycin intravenously every 8 hours for 3 days. The resident received two doses. The nurse's note, dated 1/14/25 at 5:59 p.m., indicated the MD assessed the resident. New orders were received to discontinue the midline and IV medication and continue 100 mg of doxycycline twice daily. The nurse's note, dated 1/20/25 at 1:03 a.m., indicated the resident continued to have redness to the bilateral lower extremities. The resident reported occasional pain on the lower extremities. The dressing was changed on the left lower extremity wound. The January 2025 TAR indicated the resident's weekly skin assessments on 1/3/25, 1/10/25, and 1/17/25, indicated the resident had no skin impairments. The review of the January 2025 TAR on 1/21/25 at 9:38 a.m., indicated that the left lower extremity dressing changes had been performed during the night shift on 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, and 1/20/25. During an observation on 1/16/25 at 8:46 a.m., Resident 13's last dressing change to the left shin, was dated 1/14/25 with no time, but illegible staff initials. The resident indicated that he thought the nurse did the dressing change every other day. The dressing corners were curled, and the dressing border appeared discolored. The skin just below the left shin dressing was dark pink in color at the width of the dressing. During an observation on 1/17/25 at 8:35 a.m., the resident's dressing dated 1/14/25 was still in place to the left shin. The corners of the dressing were curled, and the dressing border appeared discolored. The skin just below the left shin dressing was dark pink in color, at the width of the dressing. During an observation on 1/21/25 at 8:43 a.m., the resident's dressing to the left lower extremity shin was dated 1/19/25 with no time indicated. The resident was unsure of the last dressing change. The top left corner of the dressing was peeling up. Slight redness to a dark pink color to the skin was visible at the bottom of the dressing. During an observation and interview on 1/21/25 at 8:46 a.m., RN 3 indicated the MD would have seen the resident last Wednesday on 1/15/25, because he came to the facility on Wednesdays. The RN felt that the wound had improved and was smaller than it had been. The nurse indicated the dressing appeared to have been changed and when he saw the date on the dressing, he indicated that the dressing must not have been changed last evening. The wound was quarter sized with a yellow slough at the bottom half edge of the wound bed. There was a slight clear drainage present. Redness around the edges of the wound was present. During an interview on 1/21/25 at 2:20 p.m., RN 3 indicated he would follow the physician's orders, obtain the measurements and assess the wounds. If he found that a dressing change had not been performed, he would follow up with the physician. The most current facility policy titled, Guidelines for Medication Orders, last revised 12/17/24 was provided on 1/21/25 by the Director of Nursing. The policy included, but was not limited to, . 1. Each resident shall be under the care of a licensed physician . 2. A current list of orders will be maintained 9. Treatment orders . a. When recording treatment orders specify . 1. What is done, location and frequency and duration of treatment . 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure pressure ulcer dressing changes were completed per the physician order; a new pressure area was measured, tracked or treated; and interventions were in place related to floating a resident's heels for a resident at risk for pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. (Resident 14) Findings include: The record for Resident 14 was reviewed on 1/15/25 at 11:00am. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cognitive communication deficit; repeated falls; and unspecified severe protein-calorie malnutrition. The Quarterly Minimum Data Set (MDS) assessment, dated 10/27/2024, indicated the residents' cognition was severely impaired. The resident required staff assistance with Activities of Daily Living (ADL) The resident was out of the facility from 9/3/24 through 9/5/24, and was admitted to hospice services on 10/15/24. The care plan, revised on 6/18/24, indicated that the resident was at risk for skin breakdown related to impaired mobility, incontinence, edema, history of pressure wound, diagnosis. The interventions, included, but were not limited to: ted hose as ordered, on in morning and removed in the evening, dated 6/26/24; carrot to be placed in left hand at all times (revision on 1/12/24 the carrot was discontinued due to non-compliance), avoid shearing skin during positioning, turning, and transferring, conduct weekly skin assessment (pay particular attention to bony prominences), encourage and assist to turn and reposition for comfort and as needed, float heels as resident will allow, keep linens clean and dry, keep resident as clean and dry as possible, minimize skin exposure to moisture, pressure reducing cushion to chair, pressure reducing mattress to bed, use lifting device as needed for bed mobility (e.g. lift sheet, etc.), and use moisture barrier product to perineal area as needed. The care plan, dated 10/14/24, indicated that the resident required increased caloric intake, protein, and/or nutrient needs related to presence of impaired skin integrity. The interventions included, but were not limited to, the dietitian was to re-evaluate as indicated, encourage fluids, labs as ordered by the physician, obtain weight as ordered or as needed, provide diet as ordered, and provide supplements, vitamins, and/or minerals as ordered. The care plan, dated 11/1/24, indicated Resident 14 had a Kennedy terminal ulcers/Skin Failure: to the left thigh, right hip, left ankle, and Coccyx. The left thigh pressure ulcer was healed on 11/7/24. The interventions included, but were not limited to, treatment as ordered, notify the physician as needed, provide preventative measures as recommended, observe and treat pain per physician's orders, hospice referral as appropriate, and collaborate with physician and hospice provider as appropriate in managing pain. The physician's order, dated 7/31/23, indicated to encourage the resident to float her heels while in bed twice a day; encourage the resident to turn and reposition while in bed twice a day. The physician's order, dated 9/2/24, indicated staff were to observe the coccyx dressing to the resident's open area(s) every shift for drainage on dressing and dislodgement twice daily. The physician's order, dated 9/6/24, indicated to cleanse the resident's coccyx wound with cleanser or normal saline apply skin prep, apply calcium alginate to wound bed, apply Flagyl to wound bed, pack with normal saline soaked gauze, and cover with foam (gentle or life) dressing twice a day. The physician's order, dated 9/17/24, indicated staff were to clean the resident's area to the left lower buttocks with wound cleaner. Apply Medihoney to the area, and cover with a foam gauze daily. The physician's order, dated 10/2/2024, indicated the staff were to observe the resident's left ankle, dressing to open area(s) every shift for drainage on dressing and dislodgement. The physician's order, dated 10/2/2024, indicated staff were to observe the resident's hip on the right side every shift. Staff may peel back and view the area to monitor if the area has opened twice a day. The Wound Evaluation form, dated 10/3/24, indicated the resident's coccyx wound was first observed on that 10/3/24, and it was not present on admission. The resident's wound measurements dated 10/3/2024 at 3:24 p.m., were as followed: - Coccyx wound was 3.3 cm long X (by) 4.5 cm wide - Left ankle wound was 4.1 cm long X 3.2 cm wide - Right hip wound was 0.1 cm long X 0.1 cm wide A nurse's note, dated 10/11/24, indicated that the resident had an area to coccyx with yellow slough to the wound bed. The peri-wound was intact. The wound dressing was reapplied. The physician was made aware of the wound to the coccyx. A nurse's note, dated 10/11/2024, indicated that the resident had open areas to both gluteal folds. The open areas were measured 0.5cm x0.5cm. The physician's order, dated 10/21/24, indicated cleanse wound with cleanser or normal saline, apply skin prep, apply calcium alginate to wound bed, apply Flagyl to wound bed, pack with normal saline soaked gauze, and cover with foam (gentle or life) dressing PRN. The resident's wound dressings were to be changed as needed or when the dressing became dislodge or soiled. The Wound Evaluation form, dated 10/25/24 at 1:46pm, indicated the resident's wound measurements dated 10/25/24 were as followed: - Coccyx wound was 3.4 cm long X 2.9 m wide - Left ankle wound was 2.3 cm long X 3.2 cm wide - Right hip wound was 0.8 cm long X 1.1 cm wide A wound culture collected of the coccyx on 11/8/2024 6:15 PM showed mixed anaerobic organisms, none predominating. The physician's order, dated 12/21/24, indicated staff were to clean the resident's left lower buttock area with wound cleaner, apply Medi-honey to area, cover with foam gauze, and change the dressing for soilage or dislodgement. The Wound Evaluation form, dated 1/7/25 at 1:46pm, indicated the resident's wound measurements dated 1/7/25 were as followed: - Coccyx wound was 3.3 cm long X 4.4 cm wide, - Left ankle wound was 4.1 cm long X 3.3 cm wide, - Right hip wound was 0.2 cm long X 0.1 cm wide, - Left Buttock wound was 1.7 cm long X 1.7 cm wide. The Wound Evaluation form, dated 1/14/25 between 10:37 am and 10:45 am, indicated the resident's wound measurements dated 1/14/25 were as followed: - Coccyx wound was 6.5 cm long X 5 cm wide, - Left ankle wound was 4.25 cm long X 3.75 cm wide, - Right hip wound was 1.25 cm long X 1 cm wide, - Left buttock wound was 2 cm long X 2.5 cm wide. - left outer buttock red/non blanchable, and a new small open area was observed to the top of coccyx. There were no wound notes to indicate a fifth area (left outer buttock/top of coccyx) had been measured, tracked or treated. During observation on 1/15/25 at 09:20 am The resident was in bed with her eyes opened, concave mattress in place, the resident's bilateral heels were not floated and lying directly on the resident's bed. During observation on 1/16/25 11:00 am, the resident was resting in bed on her left side with her eyes closed. The resident's bilateral heels were not floated and lying directly on the resident's bed. The physician's order, dated 1/16/25, indicated the resident was to have a weekly skin assessment completed. The nurse must complete the skin observation tool and document any new areas on the form and complete a change in condition every Thursday. During an observation of Resident 14's wound care on 1/17/25 10:09 a.m., Licensed Practical Nurse (LPN) 4 completed hand hygiene, put on two pairs of gloves on, and pulled the resident's curtain for privacy. The resident was lying in her concave mattress with pillows propped under both sides of the buttocks and a pillow was in-between the resident's legs. The resident's pants were taken off and the nursing staff rolled the resident to the right side. Certified Nurse aide (CNA) 5 was assisting the nurse. The resident's coccyx dressing dated 1/15/25 was removed and the dressing had a moderate amount of green drainage. The peri-wound was reddened, the wound bed contained slough, and the nurse reported that the wound tunneled. There was a small open area observed to the top of the resident's coccyx. There was no treatment ordered at the time of the dressing change. The resident's dressing for the left buttock was dated 1/15/25 and was removed by the nurse. The left buttock wound had a small amount of eschar and the peri-wound was reddened. The resident's dressing for the left ankle was dated 1/15/25 and was removed by the nurse. The old dressing was soaked through with yellow drainage and slough was noted in the wound bed. A Clinical at-Risk (CAR) /Wound Interdisciplinary Team's (IT) progress note dated, 01/17/25 at 1:16 p.m. indicated the resident had no wounds on admission. During a confidential staff interview from 1/15/24 to 1/22/24, the staff member indicated the resident's wounds had gotten bad at one point. The staff member did not believe the residents pressure wounds were Kennedy ulcers and indicated most pressure wounds could be prevented if the staff would turn and reposition the residents every two hours. During an interview on 01/17/25 09:15 a.m., LPN 4 indicated the resident's wounds were to have the dressings changed daily. Hospice would come in once to twice a week to do the dressing changes. All of the resident's wounds came at once. During an interview with the Executive Director (ED), Director of Nursing (DON), and Clinical Support 6 on 1/21/25 11:00 a.m., the Clinical Support Nurse 6 indicated that the resident's wounds could not be classified as Kennedy ulcers due to the length of the time the pressure ulcers have been treated. The DON indicated that the wound to the coccyx was not a historic chronic wound. When asked about prevention interventions, treatment and the amount of skin wounds, the DON and clinical support indicated We really haven't figured that out. The DON indicated that the resident was on an air mattress and now had a BRODA chair. The family did not want the resident to take a multi-vitamin or any protein supplements. The ED reported that the resident was on hospice as of 10/15/2024 and had a decline in health since October. The most current facility policy titled, Guidelines for General Wound and Skin care policy, last revised 2/23/23 was provided on 1/21/25 by the Director of Nursing. The policy included, but was not limited to, , The purpose of this policy is to provide measures that will promote and maintain good skin integrity .The policy included, but was not limited to, .2. Turn/reposition residents who are immobile .4 Use pillows or wedges for positioning .14. Perform the wound treatment .18. Date, time and initial all dressings .20. Document type of wound . 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident (Resident B) received Lantus (long-acting diabetic medication) as ordered by the physician for 1 of 3 residents reviewed for pharmacy services. Findings include: The clinical record for Resident B was reviewed on 12/9/24 at 8:05 p.m. The resident's diagnosis included, but was not limited to, diabetes. The Care Plan, dated 11/18/24, indicated the resident was at risk for hypoglycemia/hyperglycemia due to diabetes mellitus and staff were to administer the resident's medications as ordered. The Admission Order, dated 11/14/24, indicated the resident was to receive Lantus insulin, 20 units subcutaneous at bedtime. The EDK (emergency drug kit) record indicated, on 11/14/24 at 9:33 p.m., a Lantus Solostar insulin pen was removed for Resident B. The November 2024 Medication Administration Record indicated the resident received 20 units of the Lantus insulin at bedtime on 11/14/24. The progress note, dated 11/16/24 at 11:57 a.m., indicated the resident was sweating and her blood sugar was 504. The physician was notified with a new, one time, order for 8 units of Novolog (short acting insulin) insulin and 20 units of Lantus insulin. The resident was also to resume the normal timing of her Lantus at bedtime. The resident's Medication Administration Record lacked documentation of the administration of the Lantus insulin on 11/15/24. The record was documented that the resident did not receive the insulin due to the medication being unavailable. During an interview on 12/10/24 at 12:01 p.m., RN (Registered Nurse) 6 indicated she admitted the resident on 11/14/24. She pulled the Lantus from the EDK to administer, which had several doses in it. She placed the insulin pen in a bag, put the resident's name on it and then placed pen in the top left drawer. During an interview on 12/10/24 at 12:22 p.m., the ADON (Assistant Director of Nursing) indicated she had gone to the EDK and the Lantus was not available. She called pharmacy to have it sent stat and it was delivered after she left on 11/16/24. She did not notify the physician as he usually had a standing order that if a resident was not symptomatic then the medication can be administered when it arrived from pharmacy. She checked the medication cart and could not find any Lantus. She had been in and out of the resident's room several times and the resident was not symptomatic. The family was in the room all night and never asked about it. During an interview on 12/10/24 at 1:03 p.m., the DON (Director of Nursing) indicated the resident had moved rooms. The residents' medications were moved to the other cart but staff did not move the insulin. The resident did have insulin available for administration on 11/15/24. On 12/10/24 at 2:00 p.m., a current copy of the document titled Medication Administration - General Guidelines dated 11/18 was provided. It included, but was not limited to, Policy .Medications are administered as prescribed in accordance with good nursing principles and practices .Procedure .If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room and facility (e.g., other units) are searched The Past noncompliance began on 11/15/24 between 7:00 p.m. and 11:30 p.m. The deficient practice was corrected by 11/18/24 after the facility implemented a systemic plan that included the following actions: All nurses were educated on room moves which included room moves that involved changing medication carts (11/18/24); Ongoing audits were implemented to ensure all medications are moved when residents moved rooms (11/18/24). This Citation relates to Complaint IN00447558 3.1-25(g)(2)

Based on record review and interview, the facility failed to ensure 2 of 5 residents or responsible parties were provided written notice of Transfer/Discharge upon transfer to an acute care facility. (Residents 10 and 14) Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact A nurse's note, dated 12/13/23 at 10:36 p.m., indicated the resident was short of air with oxygen levels between 78 and 84% (percent) on room air and between 88 and 90% on 2 liters of oxygen. The physician was made aware and gave a new order for the resident to be transferred to the hospital. The resident's daughter was made aware and was agreeable. A nurse's note, dated 12/19/23 at 2:40 a.m., indicated the resident returned from dialysis extremely weak, shaking uncontrollably and unable to talk. The physician was notified and a new order was received to transfer the resident to the hospital. A transfer packet was sent with the resident to the hospital. Documentation was lacking that the resident or the responsible party were given written notice at either transfers to the hospital of the reasoning for the resident to be transferred to the hospital or which hospital. 2. The clinical record for Resident 14 was reviewed on 11/30/23 at 12:58 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation; acute and chronic respiratory failure with hypoxia; fluid overload, unspecified; hypertensive heart disease with heart failure; and unspecified atrial fibrillation. The Quarterly MDS assessment, dated 9/19/23, indicated the resident was cognitively intact. A nurse's note, dated 2/26/23 at 4:56 p.m., indicated the resident complained of not being able to breathe and not feeling well. The resident was also pale and indicated he felt too weak to stand to go to the bathroom. The physician was notified and new orders were received to send the resident to the emergency room . The family was notified. A nurse's note, dated 4/24/23 at 9:54 a.m., indicated that when the nurse entered the resident's room, he was observed to be holding his right side of chest and side and indicated he couldn't move his legs. The resident continued to complain of chest pain which was unrelieved with medication. EMS (Emergency Medical Services) was called and transported the resident to the hospital. His family member was called and indicated would meet him at the hospital. A nurse's note, dated 5/8/23 at 5:02 a.m., indicated the resident complained of pain at 2:00 a.m. PRN (as needed) pill given but the resident continued to complain of worsening pain and was losing the ability to use his legs and had nausea. The resident was asked several time if he wished to go to the hospital for evaluation but the resident declined as he thought they couldn't do anything for him. The note indicated staff would continue to monitor. A nurse's note, dated 7/19/23 at 11:33 a.m., indicated the resident's physician was in to see him and spoke with him about Hospice. After listening to the resident, new orders were given to transfer the resident to the hospital for respiratory difficulties and edema. Documentation was lacking that the resident or the Responsible party were given written notice at either transfers to the hospital of the reasoning for the resident to be transferred to the hospital or which hospital. During an interview with RN 3 on 12/1/23 at 10:45 a.m., she indicated that when she sent a resident out to the hospital, she completed the Transfer/Discharge form and put it into the packet to hand to the EMS workers when the resident was transferred. She indicated she did not give the form to the resident nor to their responsible party at time of transfer. During an interview with RN 4 on 12/1/23 at 10:55 a.m., she indicated she completed the Transfer/Discharge form, made a copy and attached it to the residents' paperwork being sent with them. She indicated she did not give it to the resident nor the responsible party. During an interview with the Social Worker on 12/1/23 at 11:30 a.m., she indicated she was not responsible for talking to or completing the Transfer/Discharge form to give to the resident or responsible party. During an interview with the Director of Health Services (DHS) on 12/1/23 at 11:35 a.m., she indicated nursing went over the Transfer/Discharge form with the resident or Responsible party as to why the resident was going to the hospital and which one if they were able to understand and there was time to do so and had them sign it. She further indicated that if residents did not have family to come in much, the nurses did not always make attempts to call or mail the forms to them. During an interview with the resident on 12/1/23 at 12 p.m., the resident did not remember anyone going over the Transfer/Discharge form with him or asked him to sign something. 3.1-12(a)(6)(A)

Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 5 of 8 months reviewed. (April, May, June, August and October 2023). This deficiency had the potential to affect all 36 residents currently residing in the facility. Findings include: Review of the April to December 2023 Licensed Nursing schedule indicated the following days were short of 8 hours consecutive RN coverage: - On 4/1 (Saturday) only 6.25 hours, - On 4/2 (Sunday) only 6.25 hours, - On 4/15 (Saturday) only 6 hours, - On 4/16 (Sunday) only 6 hours, - On 4/29 (Saturday) only 6 hours, - On 4/30 (Sunday only 6.5 hours. - On 5/13 (Saturday) only 6 hours, - On 5/27 (Saturday) only 7.75 hours, - On 5/28 (Sunday) only 6.0 hours. - On 6/10 (Saturday) only 5.5 hours. - On 8/12 (Saturday) only 6 hours, - On 8/26 (Saturday) only 6 hours. - On 10/7 (Saturday) only 6 hours, - On 10/8 (Sunday) only 6 hours. During an interview on 11/27/23 at 10:00 a.m., the Executive Director (ED) indicated there were no nursing waivers. During an interview with the ED on 12/1/23 at 3:15 p.m., she indicated they thought they had it all covered. 3.1-17(b)(3)

Based on observation, record review, and interview, the facility failed to ensure proper storage and disposal of medications for 2 of 2 medication storage rooms reviewed for medication storage. (200 A Hall Medication Room and 200 B Hall Medication Room) Findings include: 1. During an observation on 11/30/23 at 12:13 p.m., of the 200 A Hall Medication Storage Room with RN 11 the following concerns were observed: - In the refrigerator there was one bottle of Humulin R injection solution 100 units/mL which indicated a staff members name as the recipient. - In a basket in the cabinet under the right side of the sink there were three unlabeled bottle of nystatin 100,000 units per gram powder, and one container of magic butt cream with a partially destroyed label, which indicated it was prepared on 2/11/22 and best used by 8/11/22. - In a clear bag there were several tubes of topical creams, including 1 open tube of mupirocin 2% cream, 2 tubes of venelex ointment, and 1 open tube of metronidazole gel 0.75%, and one bottle of nystatin powder. There were no labels on any of the medications. During an interview on 11/30/23 at 12:15 p.m., RN 11 indicated she thought the topical treatments in the bag belonged to a resident who was no longer at the facility and had been discharged for a few weeks. Medications were usually destroyed within a few days of discharge, all of the medications which were unlabeled in the 200 A Hall Medication Storage Room should have been pulled and destroyed or discarded by now. 2. During an observation on 11/30/23 at 12:29 p.m. with LPN (Licensed Practical Nurse) 16 of the 200 B Hall Medication Storage Room, the following concerns were observed: - In a cabinet above the sink there was one unlabeled bottle of ceftriaxone 1 gram for injection. LPN 16 indicated the medication should be in the Pyxis as it was not a house stock medication and did not belong to any residents. She was not sure why it was in the cabinet. - In a drawer under the sink, there was an opened bottle of Tums with the label ripped off. LPN 16 indicated she did not know who the medication belonged to. - In the freezer there was no thermometer to measure the temperature. - In a file shelf against the wall was a very old looking discolored storage bag. Inside the bag was an opened, unlabeled bottle of aspirin 325 mg, one bottle of allopurinol 100 mg tablets which was dated 9/4/22 with a use by date of 9/4/23 which which was nearly full, one bottle of omeprazole 20 mg which was dated 9/13/22, with a use by date of 9/13/23. The medication bottles indicated they belonged to Resident 19. The record for Resident 19 was reviewed on 11/30/23 at 1:00 p.m. The diagnoses included, but were not limited to, arthritis, crystal arthropathy, gout, and diversticulosis. The physician's orders, indicated the resident received the following medications: - Allopurinol 100 mg twice daily for gout which started on 10/6/22. - Aspirin 81 mg daily, which started on 4/26/23. - Pantoprazole 40 mg daily, which started on 9/11/23. Resident 19 did not have current orders for omeprazole or aspirin 325 mg, During an interview on 11/30/23 at 12:35 p.m. LPN 16 indicated the bottles in the bag were Resident 19's home medications she had admitted with. If there were expired and had come from the pharmacy they would be sent back, but she was not sure on the process for a resident's home medications. During an interview on 11/30/23 at 12:51 p.m., the Director of Health Services (DHS) indicated the unlabeled medications in the medication storage rooms were not house stock medications. Medications should be cleaned out regularly. They did have Resident 19's medications in the medication storage room. She would see if the resident would let her dispose of it now since it was expired. She did not know where the freezers thermometer was, the only thing she could think is they'd had a resident have a new fridge and maybe they used that one and put it in hers. She would be having one put in there that day. They should not have unlabeled medications in the cupboard. The Medication Storage in the Facility policy, included, but was not limited to, . C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label . F. Medications labeled for individual residents are stored separately from floor stock medications when not in a medication cart . H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal . G . All expired medications will be removed from the active supply and destroyed in the facility regardless of amount remaining . 3.1-25(j) 3.1-25(o)

Based on record review and interview, the facility failed to assess and re-evaluate 2 of 2 residents for self-administration of respiratory treatments or medications (inhalers). (Residents 10 and 14) Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact and had no impairment in functional range of motion of upper extremities. The December 2023 monthly physician's order, indicated the resident had an order, dated 12/22/22, for albuterol sulfate solution for nebulization, 1 vial inhalation for SOA (shortness of air) every 6 hours PRN (as needed). The Medication Administration Record (MAR), dated between September and November 2023, indicated the following days the resident self-administered his breathing treatment: - September : 9/13, 9/18, 9/25, 9/27, and 9/29. -October: 10/2, 10/8, 10/9, 10/13, 10/16, 10/17, 10/19, 10/23, 10/30 and 10/31. - November: 11/8, 11/10, 11/14, 11/17, 11/21, 11/24, and 11/28. Documentation was lacking of an initial assessment of the resident's ability and a physician's order for self administration of the breathing treatment. During an interview with the Director of Health Services (DHS) on 12/1/23 at 1:55 p.m., she indicated the resident did not have a Self Administration of Medication assessment. 2. The record for Resident 14 was reviewed on 11/30/23 at 12:58 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation; acute and chronic respiratory failure with hypoxia; fluid overload, unspecified; hypertensive heart disease with heart failure; and unspecified atrial fibrillation. The Quarterly MDS assessment, dated 9/19/23, indicated the resident was cognitively intact and had no impairments in upper body functional range of motion. The December 2023 monthly physician's order indicated the resident had the following orders, dated 7/25/23 : - arformoterol solution for nebulization, 1 vial for inhalation twice daily for COPD. - ipratropium-albuterol solution for nebulization, 1 vial for inhalation every 6 hours for COPD. The MARs, dated July through November 2023, indicated the following days the resident self-administered his arformoterol solution breathing treatment: - July: 7/26, 7/27, 7/30, and 7/31. - August: 8/1, 8/2, 8/4, 8/5, 8/6, 8/7, 8/8, 8/9 twice, 8/10. 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/20, 8/21, 8/22 twice, 8/23, 8/24, 8/26, 8/27, 8/28, 8/29, and 8/30. - September: 9/1, 9/2, 9/4, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/13, 9/15, 9/16, 9/18, 9/19, 9/20, 9/21, 9/22, 9/23, 9/24, 9/25, 9/26, 9/27, 9/28. 9/29, and 9/30. - October: 10/1, 10/2, 10/3, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/13, 10/14, 10/16 twice, 10/17, 10/19, 10/20, 10/21, 10/22, 10/23, 10/27, 10/28, 10/29 and 10/30. - November: 11/2, 11/3 times 2, 11/4, 11/5, 11/6, 11/7,11/8 twice, 11/10, 11/11, 11/13, 11/14, 11/16, 11/17, 11/18, 11/19, 11/21, 11/22, 11/24, 11/25, 11/26, 11/27, 11/28, and 11/30. The MARs, dated July through November 2023, indicated the following days the resident self-administered his ipratropium-albuterol solution for nebulization: - July: 7/27, 7/28 times 2, 7/29, 7/30, and 7/31. - August: 8/1 twice, 8/2, 8/3 twice, 8/4, 8/5 twice, 8/6 times 2, 8/7 three times, 8/8 thee times, 8/9 twice, 8/10, 8/11 twice, 8/12 twice, 8/13, 8/14, 8/15, 8/16, 8/17 twice, 8/19, 8/20 twice 2, 8/21 four times, 8/22 twice, 8/23 three times, 8/24 twice, 8/25 twice, 8/27, 8/28 twice, 8/29 twice, 8/30, and 8/31 twice. - September: 9/2, 9/3 twice, 9/4 three times, 9/5 three times, 9/6, 9/7 twice, 9/8 twice, 9/9, 9/10 three times, 9/11 twice, 9/12, 9/13, 9/14 times 2, 9/16 twice, 9/17, 9/19 twice, 9/20 twice, 9/22, 9/23, 9/24, 9/25, 9/26 three times, 9/27 twice, 9/28, 9/29, and 9/30 twice. - October: 10/1 twice, 10/2 twice, 10/3 twice, 10/4 twice, 10/6 twice, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12 twice, 10/13, 10/14, 10/15 twice, 10/16 four times, 10/17, 10/18, 10/19, 10/20, 10/21 three times, 10/22, 10/23, 10/24 twice, 10/27, 10/28, 10/29 twice, 10/30 twice, and 10/31. - November: 11/1, 11/3 twice, 11/4 twice, 11/5 twice, 11/7, 11/8, 11/10, 11/11, 11/12 twice, 11/13 twice, 11/14, 11/15, 11/17, 11/18, 11/20 twice, 11/21 twice, 11/23 twice, 11/24 four times, 11/25, 11/26 twice, 11/27 twice, and 11/28 twice. A Self-Administration of Medication assessment, dated 9/21/21, was completed for the resident to self-administer his breathing treatments. Documentation was lacking of the assessments having been re-evaluated quarterly and PRN when changes occurred (i.e. hospitalization s). A physician's order was also lacking. During an interview with RN 4 on 12/1/23 at 2:00 p.m., she indicated she had let the residents administer their own breathing treatments and inhalers. A physician's order was needed in order to do so and she thought the residents had one. During an interview with RN 3 on 12/1/23 at 2:05 p.m., she indicated she had let the residents administer their own breathing treatments and inhalers. A physician's order was needed in order to do so. During an interview on 12/1/23 at 3:30 p.m., the DHS indicated she did not realize the nurses were letting the residents do their own respiratory treatments. The facility's current Guidelines for Self-Administration of Medications, included, but was not limited to, Purpose- To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is part of their plan of care. Procedures: 1. Residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the observation [name of company]- Self-Administration of medication within the electronic health record (EHR). Results of the assessment will be presented to the physician for evaluation and an order for self-medication. a. That order should include the type of medication(s) the resident is able to self-medicate, Oral meds, oral meds with the exception of ., nebulizer treatment only, all medications including .inhalers .5. Periodic verification of administration compliance will be observed by nursing staff .7. The Assessment will be reviewed quarterly, and PRN with change of condition. The assessment will be documented in the EHR. 3.1-11(a)

Based on record review and interview, the facility failed to ensure 3 of 5 residents or responsible parties were provided written notice of and signed the facility's bed hold policy upon transfer to an acute care facility. (Residents 10,14 and 31) Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact A nurse's note, dated 12/13/23 at 10:36 p.m., indicated the resident was short of air with oxygen levels between 78 and 84% (percent) on room air and between 88 and 90% on 2 liters of oxygen. The physician was made aware and gave a new order for the resident to be transferred to the hospital. The resident's daughter was made aware and was agreeable. A nurse's note, dated 12/19/23 at 2:40 a.m., indicated the resident returned from dialysis extremely weak, shaking uncontrollably and unable to talk. The physician was notified and a new order was received to transfer the resident to the hospital. A transfer packet was sent with the resident to the hospital. Documentation was lacking that the resident or the Responsible party were given or had the facility's bed hold policy explained to them and had them sign a copy of it for either transfers. 2. The clinical record for Resident 14 was reviewed on 11/30/23 at 12:58 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation; acute and chronic respiratory failure with hypoxia; fluid overload, unspecified; hypertensive heart disease with heart failure; and unspecified atrial fibrillation. The Quarterly MDS assessment, dated 9/19/23, indicated the resident was cognitively intact. A nurse's note, dated 2/26/23 at 4:56 p.m., indicated the resident complained of not being able to breathe and not feeling well. The resident was also pale and indicated he felt too weak to stand to go to the bathroom. The physician was notified and new orders were received to send the resident to the emergency room . The family was notified. A nurse's note, dated 4/24/23 at 9:54 a.m., indicated that when the nurse entered the resident's room, he was observed to be holding his right side of chest and side and indicated he couldn't move his legs. The resident continued to complain of chest pain which was unrelieved with medication. EMS (Emergency Medical Services) was called and transported the resident to the hospital. His family member was called and indicated would meet him at the hospital. A nurse's note, dated 5/8/23 at 5:02 a.m., indicated the resident complained of pain at 2:00 a.m. PRN (as needed) pill given but the resident continued to complain of worsening pain and was losing the ability to use his legs and had nausea. The resident was asked several time if he wished to go to the hospital for evaluation but the resident declined as he thought they couldn't do anything for him. The not indicated staff would continue to monitor. A nurse's note, dated 7/19/23 at 11:33 a.m., indicated the resident's physician was in to see him and spoke with him about Hospice. After listening to the resident, new orders were given to transfer the resident to the hospital for respiratory difficulties and edema. Documentation was lacking that the resident or the Responsible party were given or had the facility's bed hold policy explained to them and had them sign a copy of it for any of the transfers. During an interview with RN 3 on 12/1/23 at 10:45 a.m., she indicated that when she sent a resident out to the hospital, she completed the Transfer/Discharge form with the bed hold policy and put it into the packet to hand to the EMS workers when the resident was transferred. She did not explain or give the form to the resident or to their Responsible party to sign at time of transfer to the hospital. During an interview with RN 4 on 12/1/23 at 10:55 a.m., she indicated she completed the Transfer/Discharge form, including the facility bed hold policy, made a copy and attached it to the residents' paperwork being sent with them. She did not explain or give it to the resident or the responsible party. 35732 3. The record for Resident 31 was reviewed on 11/29/23 at 9:19 a.m. The diagnoses included, but were not limited to, displaced fracture of surgical neck of the left humerus, multiple fractures of the pelvis, type II diabetes, hypo-osmolality and hyponatremia, and disorders of bone density and structure. The nurse's note, dated 11/8/23 at 7:00 p.m., indicated the physician's office was called and notified the of pre surgery labs which indicated the resident's had a sodium of 118. The Medical Director was notified, and a new order was received to send her to the emergency room (ER) due to a seizure risk. The resident's family member was notified and stated he would take the resident to ER and would be here in 10 minutes. Report was called to the hospital ER. The transfer paperwork was sent with the resident. The nurse's note, dated 11/9/23 at 2:17 a.m., indicated the hospital was called for a status on the resident and informed she was being admitted for a critical sodium. Review of the Resident Transfer Form dated 11/8/23, lacked documentation indicating the form was signed and dated by the resident or the resident's family member. During an interview with the Social Worker on 12/1/23 at 11:30 a.m., she indicated she was not responsible for talking to or completing the Transfer/Discharge form and bed hold policy to give to the resident or Responsible party. During an interview with the Director of Health Services (DHS) on 12/1/23 at 11:35 a.m., she indicated nursing went over the bed hold policy with the resident if they were able to understand and there was time to do so. They would have the resident sign the bed hold policy and then scanned it into their charts. If there was not time or the resident was not capable of understanding, then nursing would call or told the family (if present) that the facility would hold the bed for their return. Nursing documented this conversation by writing Family notified. She indicated the note did not specifically indicate that the family was actually told about the bed hold policy. If residents did not have family that came in, nursing did not always make several attempts to call or mail the forms to the responsible party to sign. The facility's current Bed Hold policy, dated effective 9/24/18, included, but was not limited to, Short Definition: Residents and responsible parties have the right to be informed of the campus bed hold policy and state plan regarding bed hold. 3.1-12(a)(25) 3.1-12(a)(26)

Based on record review and interview, the facility failed to develop a Self-Administration of Medication plan of care for 2 of 2 residents who were self-administering respiratory treatments and inhalers. (Residents 10 and 14). Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. The Quarterly Minimum Data Set (MDS) assessment, dated 12/27/22, indicated the resident was cognitively intact and had no impairment in functional range of motion of upper extremities. The December 2023 monthly physician;s order indicated the resident had an order, dated 12/22/22, for albuterol sulfate solution for nebulization, 1 vial inhalation for SOA (shortness of air) every 6 hours PRN (as needed). The MARs indicated that during the months of September to November 2023, the resident had multiple self-administrations of his respiratory medication. Documentation was lacking of plan of care to address Self-Administration of Medication. 2. The clinical record for Resident 14 was reviewed on 11/30/23 at 12:58 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation; acute and chronic respiratory failure with hypoxia; fluid overload, unspecified; hypertensive heart disease with heart failure; and unspecified atrial fibrillation. The Quarterly MDS assessment, dated 9/19/23, indicated the resident was cognitively intact and had no impairments in upper body functional range of motion. The December 2023 monthly physician's order indicated the resident had the following orders, dated 7/25/23: - arformoterol solution for nebulization, 1 vial for inhalation twice daily for COPD. - ipratropium-albuterol solution for nebulization, 1 vial for inhalation every 6 hours for COPD. The MARs indicated that during the months of July to November 2023, the resident had multiple self-administrations of his respiratory medications. Documentation was lacking of plan of care to address Self-Administration of Medication. During an interview with RN 4 on 12/1/23 at 2:00 p.m., she indicated she had let the residents administer their own breathing treatments and inhalers. During an interview with RN 3 on 12/1/23 at 2:05 p.m., she indicated she had let the residents administer their own breathing treatments and inhalers. During the final exit meeting with the facility on 12/1/23 at 3:30 p.m., the Director of Health Services (DHS) indicated she did not realize the nurses were letting the residents do their own respiratory treatments. The facility's current Guidelines for Self-Administration of Medications, included, but was not limited to, Purpose- To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is part of their plan of care. Procedures: 1. Residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the observation Trilogy- Self-Administration of medication within the electronic health record (EHR) .6. A Self-Administration plan of care will be initiated and updated as indicated . Cross Reference F554 3.1- 35(a) 3.1-35(b)(1) 3.1-35(d))(1) 3.1-35(d)(2)

Based on interview and record review, the facility failed to ensure showers were provided for dependent residents for 2 of 5 residents reviewed for Activities of Daily Living. (Residents 8 and 22) Findings included: 1. The clinical record for Resident 8 was reviewed on 12/1/23 at 11:00 a.m. The diagnoses included, but were not limited to, lack of coordination, abnormalities of gait and mobility, unsteadiness on his feet, generalized weakness, and hemiplegia affecting the right dominant side. The Quarterly MDS (Minimum Data Set) assessment, dated 11/5/23, indicated the resident was cognitively intact. He required maximal assistance with bathing. The care plan, dated 2/28/22, indicated the resident had impairments in functional status regarding bed mobility, transfers, toileting, and eating related to CVA (cardiovascular accident) with hemiplegia. The interventions included, but were not limited to, mobility bars to bed (dated 8/12/23), keep nails trimmed (dated 5/1/23); and the resident required set up and assist with eating, stand up lift assist with transfers, assist with bed mobility, and assist with toileting requiring 1 to 2 person staff assistance. Therapy to evaluate and treat as needed and ordered and encourage the resident to be as independent as safely as possible (dated 2/28/22). Review of the Point of Care History indicated the following: - September - the resident received a shower on 10/19/23 at 10:16 a.m. The documentation indicated he received a bed bath the rest of the days. - October - the resident had a shower on 10/16/23 at 7:38 p.m. The documentation indicated the received a bed bath the rest of the days. - November the resident received bed baths and no showers were documented. During an interview on 11/27/23 10:26 a.m., the resident's family member indicated Hospice did not give the resident her bath and the facility didn't either on Friday. She had to wait until the following week to get a bath. During an interview on 11/29/23 at 10:00 a.m., the DHS (Director of Health Services) indicated the residents were to receive two showers a week. She did not know why the Resident 8 wasn't getting his showers. During an interview on 11/30/23 at 8:42 a.m., the DHS indicated when hospice wasn't available to give the resident a shower the facility should give the resident a shower. During an interview on 12/1/23 at 12:02 p.m., the Corporate MDS Support Nurse indicated she did not know why Resident 8 wasn't getting his showers. The residents should be getting a shower two times a week. 2. The clinical record for Resident 22 was reviewed on 11/27/23 at 10:26 a.m. The diagnoses included, but were not limited to, surgical aftercare following surgery; diverticulitis of the small intestine with perforation and abscess without bleeding; perforation of the intestine; heart disease; interstitial pulmonary disease; unspecified dementia; psychotic disturbance; mood disturbance; anxiety; abnormalities of gait and mobility cognitive communication deficit; difficulty in walking; muscle weakness; and unsteadiness on feet. The Quarterly MDS (Minimum Data Set) assessment, dated 8/24/23, indicated the resident rarely or never understood. The resident was dependent for all (ADL's) activities of daily living. The care plan, dated 9/28/22, indicated the resident had impairments in functional status regarding bed mobility, transfers, toileting, and eating related to dementia. Interventions included, but were not limited to, stand assist lift, the resident required set up and assistance with eating, 1 to 2 staff assistance with transfers, 1 to 2 staff assistance with bed mobility, and 1 to 2 staff assistance with toileting, medications per physician order, therapy to evaluate and treat as needed and ordered, encourage the resident to be as independent as safely as possible. The nurse's note, dated 11/25/23 at 2:40 p.m., indicated the resident's family member reported that the hospice aide did not show up to bath the resident. The nurse spoke with the hospice Clinical Director, and she indicated the CNA staff were not available on the weekends, but they would be in on Monday. The nurse's note, dated 6/20/23 at 2:56 p.m., indicated the resident's family member requested the resident to have a shower on Mondays in addition to Hospice aides giving a shower on Wednesday and Friday. During an interview on 11/30/23 at 3:10 p.m., the Hospice Clinical Manager indicated the CNA (Certified Nurse Aide) did not see the Resident 22 on 11/24/23 for her shower. The facility called on Saturday the 25th and she talked to the nurse and told her hospice did not have any CNA's working the weekends and the CNA would be back next week. The facility should give the residents a shower if a hospice CNA was not available. During an interview on 12/1/23 at 11:30 a.m., CNA 6 indicated the residents should get a shower two times a week. She did not know why the resident had not received her showers. During an interview on 12/1/23 at 11:35 a.m., CNA 5 indicated if hospice was unable to give the residents a shower the facility CNAs should do the shower. The Guidelines for Bathing policy, included, but was not limited to, .4. Bathing shall occur at least twice a week unless resident preference states otherwise . 3.1-38(a)(3)

Based on record review, and interview, the facility failed to ensure a resident received adequate supervision and interventions were properly implemented to prevent accidents for 2 of 3 residents reviewed for accidents. (Residents 8 and 23) Findings include: 1. The record for Resident 8 was reviewed on 11/28/23 at 8:15 a.m. The diagnoses included, but were not limited to, acute cholecystitis; ataxia following cerebral infarction occlusion and stenosis of left vertebral artery; type 2 diabetes mellitus; attention-deficit hyperactivity disorder; shortness of breath; lack of coordination; abnormalities of gait and mobility; unsteadiness on feet; difficulty in walking; muscle weakness; and hemiplegia affecting the right dominant side. The Quarterly MDS (Minimum Data Set) assessment, dated 11/5/23, indicated the resident was moderately cognitively intact. He required maximum assistance for ADL's (Activities of Daily Living). The care plan, dated 8/29/22 and revised on 2/22/23, indicated the resident was at risk for falls related to decreased mobility, weakness, a history of falls and impulsive. The interventions included, but were not limited to, make sure the resident was centered in bed prior to turning onto his side (dated 7/3/23), use a stand-up lift (date 4/12/23), two staff assistance with a walker, a dycem to his wheelchair, therapy to evaluate and treat as needed, staff to provide assistance with transfers, assure the floor was free of liquids and foreign objects, keep personal items and frequently used items within reach, keep the call light in reach and encourage and assist the resident to assume a standing position slowly (dated 2/22/23). The IDT (Interdisciplinary Team) note, dated 2/6/23 at 10:17 a.m., indicated Resident 8 fell on [DATE] at approximately 5:00 p.m. The resident was standing in front of his recliner to be changed with one staff assistance prior to the fall. His legs gave out and he was assisted to the floor. A full body assessment was completed at the time of the incident. The resident had no apparent injuries. The IDT felt that the root cause of the fall was 1 staff assistance without a walker in front of the resident. The interventions would be 2 staff members to assist and walker in front of resident when standing. The IDT note, dated 4/12/23 at 9:35 a.m., indicated the resident had a fall on 4/11/23 at approximately 12:01 p.m. Staff were changing the resident related to an incontinent episode using the stand assistance aid when the resident started to sit down. Staff encouraged the resident to allow them to put a wedge behind him, but he wouldn't allow them to, and staff assisted him to the floor. No injury was observed, he did not hit his head. The immediate and continuing intervention would be to use the stand-up lift. IDT felt that the root cause was that the resident was getting weaker in his legs and not to able to hold himself up to be changed. IDT also spoke with therapy and they felt he was becoming weaker. The nurse's note, dated 4/19/23 at 9:47 p.m., indicated staff were to provide assistance with the sit to stand with a sling used for transfers. The nurse's note, dated 5/15/23 at 6:28 p.m., indicated the resident was having difficulty standing in the stand-up lift for a long amount of time. The nurse's note, dated 6/30/23 at 11:34 p.m., indicated a staff member came and got the nurse and alerted her that the resident was on the floor. She observed the resident lying flat and face down on the floor. Per a staff member, the resident had been getting a bed bath and was rolled onto his side and slipped off the side of the bed. He couldn't hold himself up so went down on his bilateral knees to the floor. From there staff assisted the resident to a more comfortable position until assistance arrived. She was informed the resident did not hit his head. He denied pain or discomfort from the fall. An abrasion was observed to his right and left knee. Multiple staff members were able to assist the resident up per a Hoyer (full body) lift and back into the bed. The new intervention was to make sure the resident was centered in the bed prior to turning onto his side. The IDT note, dated 8/28/23 at 9:48 a.m., indicated the resident rolled out of bed onto the floor while trying to get out of bed. Staff reported he stated that he had his light on but did not want to wait for help. The resident rolled over and fell out of the bed onto his blanket. Resident 8 was impulsive. The immediate intervention was to put the resident in recliner. The long term intervention was to get the resident out of bed prior to breakfast. During an interview on 11/30/23 at 12:30 p.m., RN 11 indicated the fall interventions included the call light within reach, clutter free rooms, gripper socks, personal items within reach, toileting, incontinent care, and turning and repositioning every 2 hours. During an interview on 12/1/23 at 9:30 a.m., the Physical Therapy Director indicated she was aware the resident had three falls with staff in the room. The resident was seen by physical therapy from January to June of 2023. In May nursing did not send a referral to evaluate the resident for weakness. If they had received a referral the plan of care would be updated, and goals added. Nursing sent a referral to physical therapy in September and the resident was updated to a Hoyer lift for transfers. At 9:55 a.m., the Physical Therapy Director indicated the resident was already on the therapy schedule in May. They like to keep the resident as independent as possible but in September the resident started using a Hoyer Lift due to his weakness. The resident progressed from a sit to stand, then a sling was added to the sit to stand and then he progressed to a Hoyer Lift. The resident was able to stand with one staff assistance in February. His legs gave out and he was lowered to the floor by staff. The resident's new intervention at that time was changed to a two staff assistance. The resident had another fall on 4/11/23. The new interventions included using the sit to stand with a sling. She did not know if there were 2 staff members assisting the resident or if there was just one staff member. On 8/30/23 the resident rolled out of bed onto the floor. The DHS indicated the resident had just received a new mattress and he rolled over too far and fell out. She did not think a staff member was in the room with the resident and he rolled out on his own. The resident was switched to a Hoyer lift in September. 40240 2. The record for Resident 23 was reviewed on 11/29/23 at 10:09 a.m. The diagnoses included, but were not limited to, Parkinsonism, dementia, osteoarthritis, repeated falls, difficulty in walking, unsteadiness on feet, and muscle weakness. The Admission Observation, dated 2/17/23, indicated one of the resident's baseline care plan goals was to remain safe and free of major injury related to falls and elopement risk. Desired approaches included, non-skid footwear, proper fitting shoes, assess resident for normal routine, and do not leave unattended in the bathroom. The Fall event, dated 2/18/23 at 4:44 a.m., indicated the resident fell in the hallway and had no shoes on. The Admission MDS (Minimum Data Set) assessment, dated 2/23/23, indicated the resident was moderately cognitively impaired. The IDT note, dated 2/20/23 at 10:57 a.m., indicated the resident had an unwitnessed fall on 2/18/23 at approximately 4:30 a.m. Prior to the fall, the resident had been resting in bed. Staff observed the resident sitting on floor in front of door way to room. The resident was unable to tell staff what he was doing, as he had dementia. The IDT felt the root cause was the resident not having any socks or shoes on. The new intervention would be to offer and assist with putting on gripper socks at night. The care plan was reviewed and updated. The care plan, initiated on 2/20/23 and last revised on 11/17/23, indicated the resident was at risk for falls related to weakness, Parkinson's, history of falls, diagnosis, and impaired mobility. The intervention, dated 2/20/23, indicated to provide non-skid footwear. The Fall Event, dated 6/28/23 at 5:44 a.m., indicated the resident fell while toileting. He'd had recent confusion and would be tested for a UTI (urinary tract infection). The IDT note, dated 6/28/23 at 9:48 a.m., indicated they were waiting a response from the night shift note regarding a fall. On 6/28/23, the resident's risk for falls care plan was updated with new interventions for a medication review and obtaining laboratory testing. The IDT note, dated 6/29/23 at 11:14 a.m., indicated the resident had an unwitnessed fall on 6/28/23. Prior to the fall, the resident had been in bed. The resident got up to go to the bathroom. The resident fell in the bathroom. The resident reported hitting his head and had a small cut with a scant amount of bleeding above his left eye. First aid was performed and neurological checks were initiated. The immediate intervention was to put the resident back to bed. The IDT made the physician aware of recent discontinuation of a medication and it was restarted, and staff were to ensure the resident was wearing non-slip footwear when up. The care plan was not updated with the intervention to ensure the resident was wearing non-slip footwear when up. The IDT note, dated 11/8/23 at 2:11 p.m., indicated the resident had a non-witnessed fall on 11/5/23 at approximately 9:26 p.m. Prior to the fall, the resident had been in his room. Staff observed the resident on the floor in the bathroom. The resident had an abrasion to his right outer knee which was cleansed. Bacitracin and a dressing were applied. The IDT felt the root cause of the fall was the resident slipping while going to the restroom. The new intervention was to offer non-skid socks. On 11/8/23, the care plan was updated with an intervention to offer non-skid socks. During an observation on 11/27/23 at 7:50 a.m., Resident 23 was resident abed with normal socks on his feet. He did not have on non-skid socks or shoes. During an interview on 11/30/23 at 2:46 p.m. RN 11 indicated when a resident had a fall, the nurse was to assess them, notify family and the physician, initiate neurological checks if the fall was unwitnessed or the resident hit their head, and open a fall event. They would document the environment and do what they could to figure out the root cause of the fall. During an observation on 11/30/23 at 2:33 p.m., Resident 23 was resting abed. He was wearing a pair of tan, normal socks and was not wearing any shoes. During an observation on 12/1/23 at 11:00 a.m., Resident 23 was resting abed. He had normal socks in place and was not wearing any shoes. He indicated he'd not heard of gripper socks before. During an observation on 12/1/23 at 11:00 a.m., CNA (Certified Nurse Aide) 6 looked in the resident's room and could not locate any non-skid or gripper socks. His top draw was full of socks, none of which had non-skid bottoms on them. During this observation the resident voiced that he did not have any gripper socks if that was what the CNA was looking for. During an interview on 12/1/23 at 11:05 a.m., CNA 6 indicated she took care of Resident 23. She'd heard about a couple of his falls. He said he lost his balance. She did not know if he had any gripper socks, he normally wore shoes. She did not know where he kept his socks. She had not asked him to wear the non-skid socks before and did not know if they'd ever offered them. She could not recall seeing him with any. During an interview on 12/1/23 at 2:53 p.m., the DHS (Director of Health Services) indicated most of the resident's falls had been due to unsteadiness, he had not had any major fall. The IDT looked at the root cause and investigated the falls to determine interventions. When he was up the non-skid socks were definitely appropriate. If the fall was because he was slipping and he didn't have them on then obviously they were not ensuring them. CNA's needed to make sure they were on when the resident got out of bed. During an interview on 12/1/23 at 3:12 p.m., CNA 15 indicated she had not ever put gripper or non-skid socks on the resident. His family member usually dressed him. No one had ever asked her to ensure he had gripper socks on. She was not personally checking him during her shift to ensure he had them on and she was not aware it was one of his fall interventions. He had regular socks. Nurses were supposed to tell the CNAs his interventions. The Falls Management Program Guidelines policy, included but was not limited to, Procedure . b. Care plan interventions should be implemented that address the resident's risk factors. 2. Should the resident experience a fall the attending nurse shall complete the 'Fall Event' This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions . 3.1-45(a)

Based on record review and interview, the facility failed to ensure appropriate pain management related to standards of practice for administering narcotic pain medication as prescribed for 1 of 5 residents reviewed for pain management. (Resident 13) Findings include: The record for Resident 13 was reviewed on 11/28/23 at 2:00 p.m. The diagnoses included, but were not limited to, fibromyalgia, right lower quadrant pain, chronic bladder pain, pain in left knee, and systemic lupus erythematosus. The Quarterly MDS (Minimum Data Set) assessment, dated 8/25/23, indicated the resident was cognitively intact, experienced mild pain, and was on a scheduled pain medication regimen. The physician's order, dated 10/25/23, indicated the resident was to receive hydrocodone 10/325 mg (milligrams) four times daily for pain. The scheduled times were between 6:00 a.m. and 10:00 a.m., between 11:00 a.m. and 1:30 p.m., between 4:00 p.m. and 7:00 p.m., and between 8:00 p.m. and 11:00 p.m. The orders lacked documentation of any parameters for how far apart to administer the doses. The October MAR for the resident's hydrocodone-acetaminophen 10/325 indicated the following: - On 10/21/23 at 7:58 p.m., the 8:00 p.m. to 11:00 p.m. dose was administered early due to the resident's request. - On 10/22/23 at 7:59 p.m., the 8:00 p.m. to 11:00 p.m. dose was administered early due to the resident's request. The resident's Controlled Drug Use Record Sheet, dated 10/15/23, indicated the following: - On 10/21/23 at 4:00 p.m., the resident received a dose of hydrocodone-acetaminophen 10/325 mg. - On 10/21/23 at 8:00 p.m., the resident received a dose of hydrocodone-acetaminophen 10/325 mg. - On 10/22/23 at 5:48 p.m., the resident received a dose of hydrocodone-acetaminophen 10/325 mg. - On 10/22/23 at 8:00 p.m., the resident received a dose of hydrocodone-acetaminophen 10/325 mg. The November MAR for the resident's hydrocodone-acetaminophen 10/325 mg indicated the following: - On 11/5/23 at 6:38 p.m., the 8:00 p.m. to 11:00 p.m. dose was administered early due to the resident's request. - On 11/17/23 at 6:52 p.m., the 8:00 p.m. to 11:00 p.m. dose was administered early due to the resident's request. - On 11/18/23 at 6:49 p.m., the 8:00 p.m. to 11:00 p.m. dose was administered early due to the resident's request. - On 11/22/23 at 6:51 p.m., the 8:00 p.m. to 11:00 p.m. dose was administered early due to the resident's request. - On 11/25/23 at 3:37 p.m., the 4:00 p.m. to 7:00 p.m. dose was administered early due to the resident's request. The resident's Controlled Drug Use Record Sheet, dated 10/30/23, indicated the resident received doses of hydrocodone-acetaminophen 10/325 mg on 11/5/23 at 5:00 p.m. and 7:00 p.m. The resident's Controlled Drug Use Record Sheet for hydrocodone-acetaminophen 10/325 mg, dated 11/12/23, indicated the following: - On 11/17/23 the resident received doses of the medication at 1:30 p.m., 5:00 p.m., and 8:00 p.m. - On 11/18/23 the resident received doses of the medication at 5:00 p.m. and 8:00 p.m. - On 11/22/23 the resident received doses of the medication at 2:00 p.m., 5:00 p.m., and 8:00 p.m. - On 11/24/23 the resident received doses of the medication at 5:00 p.m. and 8:30 p.m. - On 11/25/23, the resident received doses of the medication at 11:00 a.m. and 4:00 p.m. - On 11/26/23, the resident received doses of the medication at 5:45 p.m. and 8:00 p.m. - On 11/27/23, the resident received doses of the medication at 5:00 p.m. and 8:00 p.m. The record lacked documentation of any notification to the physician or approval from the physician for the early administrations of the resident's hydrocodone-acetaminophen 10/325 mg. During an interview on 11/30/23 at 2:51 p.m., RN 11 indicated narcotics that were written for four times a day usually had set times to administer them. If a resident requested to have a medication early she would have to get an ok from the doctor for any medications at all. She would document it in the notes of the medication or in the progress notes. If a narcotic was given four times daily, it could be concerning if they were administered too closely together. If one person gave it towards the end of the time frame and another at the beginning they would run the risk of giving them too close together. The risks with giving them too close together included oversedation, increased risk for falls, changes in mental status and activities of daily living. During an interview on 12/1/23 at 9:41 a.m., the resident's physician indicated for anyone with pain medication the timing should not be too close together. Staff could over dose them if given too close together. If giving a medication four times daily, he would not want it to be given closer than 4 hours apart. If the doses were spread out there was a more steady level of the medication in the body. He expected staff to contact him if a resident requested an early administration and he did not recall any recent incidents where he'd been contacted or authorized an early administration. During an interview on 12/1/23 at 10:03 a.m., the Director of Health Services (DHS) indicated if a medication was being given four times daily the resident should be receiving it every six hours. She was not aware of the resident receiving early administrations. The Medication Administration Times Procedural Guidelines policy, included but was not limited to, . 2. Unless a specific time is designated by the attending physician medications shall be administered at the following times . d. QID [four times daily] - In the morning, around lunch time, around dinner time, and at bedtime . f. The nurse shall give the resident options of administration to ensure appropriate spacing of administration. i.e.: 'Would you like to stay up a little longer or shall I wake you up in an hour to give you your medication?' . 3.1-37(a)

Based on record review and interview, the facility failed to ensure behavioral care plans were updated to reflect allegations of suicidal statements and physical aggression for 1 of 5 residents reviewed for behavioral care. (Resident 23) Findings include: The record for Resident 23 was reviewed on 11/29/23 at 10:09 a.m. The diagnoses included, but were not limited to, Parksinsonism, dementia with behavioral disturbance, Parkinson's disease, and major depressive disorder. The care plan, initiated on 4/27/23 and last revised on 11/3/23, indicated the resident had altered behaviors included a history of delusions. The interventions included, but were not limited to, administer medications per orders, monitor the resident's behaviors with all hands on care and contacts, and psychiatric services as needed (all initiated on 4/27/23). The late entry nurse's note, authored on 7/27/23 at 9:52 a.m., was dated for 7/26/2023 at 6:20 p.m., indicated the resident's family member came to the DHS (Director of Health Services) and reported he was trying to scare her by saying he was going to jump off a bridge. The DHS spoke to the resident who denied saying that and said the family member didn't know what she was talking about. The resident denied thoughts or any plan. The SSD (Social Services Director) and ED (Executive Director) were notified. The SSD note, dated 7/27/23 at 12:48 p.m., indicated the resident denied thoughts of harming himself. The psychiatric NP (nurse practitioner) would be in the following week and would see the resident. The late entry nurse's note, authored on 7/31/23 at 11:19 p.m. and dated for 7/28/23 at 11:19 p.m., indicated the resident's family member came to the author in tears, indicating the resident had put his hand around her neck and squeezed. The resident had thought his family member was going to take him out of the facility that day, however it was going to be the following day. The resident became upset and told his family member he just wanted to strangle her, he then put his hand around her neck and squeezed. The SSD was notified. The physician had come in to see the resident, however his family member had taken him out to dinner in hopes of calming his anger down. She was advised to not take the resident out by facility staff, however she said she knew he would not hurt her and was just trying to make her feel bad. Staff told her to ensure she had a safe number to call and to call 911 if needed. The psychiatric NP would re-evaluate the resident. During an interview on 11/30/23 at 2:46 p.m., RN 11 indicated if a family member presented with concerns of a resident expressing self harm or harm to others, the resident would be placed in 1 on 1 and notify the doctor. She would monitor them at least for 72 hours if not longer. Social services would be notified as well. During an interview on 12/1/23 at 10:25 a.m., the SSD indicated anytime a resident made a statement like that she would go and see them and see if they had a plan. She would notify the doctor. Resident 23 had made several statements, however he could not get to a bridge and the windows did not open up to where he could jump out and harm himself. She did not see any increased monitoring after the family member reported the statement. The resident was known for making those kinds of statements. He was angry with his family member and said things to her. She did not come in as frequently, she usually visited in open spots. She did not see any care plans for suicidal statements or behaviors towards his family member. During an interview on 12/1/23 at 10:50 a.m., the DHS indicated if there was a true concern, the Interdisciplinary team would get involved right away. She always made sure the family member had a safety number and that she had someone she felt safe with if she was taking him out. She made sure she kept the call light in reach when in the room. They were aware he had behaviors towards the family member. She did not document the safety plan or the call light intervention, she had just talked with the family member about it. They would want that information on his care plan. During an interview on 12/1/23 at 11:00 a.m., CNA (Certified Nurse Aide) 6 indicated she was not aware of Resident 23 having any behaviors towards others, then indicated she was aware of concerns with his behavior towards his family member. The family member had told her something about him being a little aggressive. She was not aware of any history of the resident making statements of self harm or harm to others. She was not aware of instances of aggression until after the fact. No one had ever discussed with her specific interventions for that type of behavior. If she witnessed the behavior she would try to calm him down and ask her to leave the room, that way they could get him calmed down, and then she would let the nurse know so they could make an event and further investigate it. During an interview on 12/1/23 at 11:18 a.m., RN 3 indicated she was not aware of any behavioral issues with the resident. She had heard some stuff from his family member, like that people were breaking into the house and that it was exhausting, but was not aware of any history of self harm statements. She was not aware of any history of physical or verbal aggression towards the family member. She would expect to see it on the care plan. The Guidelines for Mental Health Wellness Program policy included, but was not limited to, . If behavior concerns are identified a baseline Behavior Plan of Care shall be developed. a. The plan of care shall address the identified root cause of the behaviors. 4. Behavior interventions shall be communicated to the interdisciplinary team for implementation . 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure staff irrigated a resident's (Resident B) Indwelling catheter with the correct dosage of acetic acid which resulted in burning pain and a transfer to the emergency department for 1 of 3 residents reviewed for Indwelling catheters. Findings include: During an interview on 9/27/23 at 2:40 p.m., Resident B was observed resting in bed with her eyes open. She indicated RN 2 came in her room and asked if the stuff for her catheter was in her room and Resident B told her no. A few minutes later, RN 2 came in her room with a big jug and said she had gotten some vinegar to irrigate her catheter. As soon as the vinegar hit up in there, she told RN 2 to stop because it was screaming burning. RN 2 replaced her catheter and then flushed it with normal saline. She ended up going to the emergency department (ED) due to the pain she had in her bladder. While at the ED, the physician explained to her that she had a chemical burn and that he needed to remove her catheter so he could insert lidocane (used for pain) gel. He then inserted a new catheter and she was given Tramadol (pain reliever) 25 mg (milligrams). After treatment she was sent back to the facility. She was only supposed to get 0.25% (percent) of vinegar but RN 2 used 5%. The clinical record for Resident B was reviewed on 9/27/23 at 12:08 p.m. The diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder and obstructive and reflux uropathy. The admission MDS (Minimum Data Set) assessment, dated 9/13/23, indicated the resident's cognition was intact. The physician's order, dated 9/17/23, indicated to irrigate Resident B's Indwelling catheter with acetic acid 0.25% daily, between 6:00 a.m. and 6:00 p.m., for a urinary tract infection. The September 2023 medication administration record indicated the resident's Indwelling catheter was irrigated, as ordered by the physician, by RN (Registered Nurse) 2. The Medication Error Event, dated 9/23/23 at 9:55 p.m., indicated RN 2 irrigated Resident B's Indwelling catheter with 5% vinegar non-diluted. The progress note, dated 9/23/23 at 11:14 p.m., indicated the resident was sent to the emergency department for complaints of bladder pain. The emergency department transfer report, dated 9/24/23 at 2:49 a.m., indicated Resident B reported her Indwelling catheter was irrigated with the wrong concentration of vinegar and has had burning pain since. The Foley currently in place was new but the pain had not resolved. At 3:54 a.m., the resident received Lidocaine 2%, 400 mg (milligrams)/20 ml (milliliters) uro-jet and Tramadol 25 mg for pain at 4:32 a.m. The emergency department transfer report lacked documentation of a chemical burn. During an interview on 9/27/23 at 1:56 p.m., the Director of Nursing indicated RN 2 could not find the acetic acid. She went to the kitchen and got a new container of vinegar and flushed with that. When the resident complained of burning, RN 2 changed the Indwelling catheter and irrigated with normal saline. The resident later complained of bladder pain and was sent to the emergency department. During an interview on 9/27/23 at 2:35 p.m., RN 5 indicated the 5 rights of medication administration included the right medication and the right dose. On 9/27/23 at 3:12 p.m., the Director of Nursing provided a current, undated copy of the document titled General Guidelines for Administration of Medication. It included, but was not limited to, Purpose .To maintain safety and comfort of the patient regarding the administration of medication .Procedure .When administering a medication, the following steps should be followed .Check the physician's order to verify dosage specifics .Make note of the five rights to assure the proper administration of the medication .Right medication .right dose The deficiency cited was corrected, on 9/25/23, prior to the start of the survey, when the facility completed staff education which included to check the physician's order to verify the specifics of the dosage, and to ensure the five rights of medication administration were followed to include the right medication and the right dose. This Federal tag relates to Complaint IN00418252 3.1-41(a)

Based on observation, interview and record review, the facility failed to ensure interventions and treatment were in place for a resident who was at an increased risk for developing pressure ulcers which resulted in a stage 3 pressure ulcer to both heels for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: The clinical record for Resident B was reviewed on 3/15/17 at 3:00 p.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 12/12/16, indicated the resident was an extensive, two person assist with bed mobility. On 3/16/17 at 9:10 a.m., Resident B was observed sitting up in a wheel chair with both feet wrapped with gauze and heel protector boots in place. The admission observation report, dated 11/13/16 at 3:15 p.m., indicated the resident had no skin impairment to the left or right heels. The readmission observation report, dated 11/28/16 at 3:44 p.m., indicated the resident had no skin impairment to the left or right heels. The occupational therapy note, dated 12/13/16, indicated the resident had a blister to the left and right heels, and nursing was informed of the areas. On 3/17/17 at 9:15 a.m. during an interview with Occupational Therapist 1, she indicated, while assisting the resident with a shower on 12/13/16, she observed blisters to the residents' left and right heels and informed RN (Registered Nurse) 2 at that time. The resident had limited strength and feeling to his lower legs and feet due to spinal stenosis. There was no skin assessment documented until four days after a nurse was notified. The skin event, dated 12/17/16, indicated the resident had a blister to the left inner heel, which measured 4.7 centimeters by 3.2 centimeters, and a blister to the right outer heel, which measured 5.3 centimeters by 4.0 centimeters. The treatment administration record (TAR) for December 2016 indicated, there was no treatment started until 12/17/16, to apply skin prep to the left inner heel blister and the right outer heel blister twice daily and to float both heels at all times. The skin care plan, dated 12/19/16, indicated the resident had an unstageable area to the left inner heel and right outer heel. The TAR for December 2016 indicated, on 12/23/16, to apply a non adherent dressing to ruptured blister twice daily. The TAR lacked documentation of which blister had ruptured and what was used to cleanse the wound. The MDS assessment, dated 12/27/16, indicated the dimensions of the resident's unhealed stage 3 or 4 pressure ulcer was 5.3 centimeters by 4.0 centimeters. The assessment failed to indicated the resident was on a turning and repositioning schedule. During an interview on 3/16/17 at 11:15 a.m., RN 2 indicated Resident B was reluctant to lie on his sides while in bed. The care plan for Resident B, post dated 12/17/16, created on 1/13/17, indicated staff were to assist the resident with turning and repositioning if needed. There was no care plan for staff to turn and position the resident until the created date on 1/13/17. The clinical record lacked documentation of staff assisting with turning and repositioning, offloading (process in which pressure is reduced) of heels, and resident education of the offloading of heels while in bed. The hospital history and physical (H&P), dated 1/24/17 at 6:00 p.m., indicated Resident B's chief complaint was heel/foot pain, [MEDICAL CONDITION], and bilateral heel ulcers and foot wounds. The patient has had foul odor with drainage to right heel ulcer noted by nursing today with tunneling and surrounding redness. He has an ulcer over the left heel and an open ulcer of left bunion with drainage reported. The draining stage 3-4 wound of the right heel with tunneling; dark, dry eschar over the left heel wound and a draining ulcer over the left bunion. The hospital assessment plan indicated the resident would be scheduled for a surgery debridement evaluation. The surgical consultation report, dated 1/25/17 at 7:20 a.m., indicated Resident B was admitted to the hospital for treatment of [REDACTED]. The resident had markedly decreased sensation in both feet and both heel ulcers involved necrotic tissue and subcutaneous tissue. The assessment plan indicated the ulcers clearly had gangrenous tissues and would need to be debrided. The hospital operative report findings, dated 1/25/17, indicated Resident B's wounds were with necrotic tissue and debridement of the necrotic areas were performed. On 3/17/17 at 12:45 p.m., the Director of Nursing provided a current copy of the document titled Guidelines for Pressure Prevention, dated 8/2/16. It included,but was not limited to, the following: .Purpose .to maintain good skin integrity and avoid development of pressure ulcers .float heels as needed .elevate heels off the bed . This Federal tag relates to Complaint IN 566 3.1-40(a)(1)