Every finding on record at Saint Anthony

Based record review and interview, the facility failed to ensure professional standards of quality were maintained related to a nurse administering the incorrect medications to a resident, taking medications from a resident's pill card and attempting to administer to a different resident, and working under the influence of drugs for 1 of 1 resident reviewed for medication administration. (LPN 1 and Resident B)The deficient practice was corrected on 1/26/26, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern on 1/17/26. At that time, the nurse was suspended pending investigation and then her employment was terminated. On 1/26/26, all staff were provided with in-service education related to medication administration. The in-service included ensuring all nurses had access to Capsa (medication dispenser)/emergency drug kit (edk), education related to the five rights of medication administration, process for contacting pharmacy, cut off times for delivery, Capsa usage, ordering/reordering medications, and not borrowing medications.Finding includes:A Report of Concern form, indicated an incident occurred on 1/17/26 at 6:00 p.m. that was reported to the Director of Nursing Services by Resident B's family member. The description of the concern indicated the nurse smelled like weed, and the wrong medications were in the medicine cup being administered to Resident B. The Department Findings indicated the Executive Director (ED) came to the building when she was made aware of the concern. The nurse was pleasant and did not smell like marijuana. She did appear to be impaired. The nurse was sent home pending the investigation. The Follow Up/Resolution, indicated the nurse was suspended and provided education, and all medications were reviewed and a medication count was completed on the carts.The investigation indicated, At 9:30 p.m. on Saturday, January 17, the Director of Nursing Services (DNS) received a call from the building stating that there was a family looking for her threatening to call the police. DNS contacted the family per the request. Family indicated that the nurse assigned to their loved one appeared to be impaired. DNS spoke with both nurses on the unit and the nurse in question was removed from the unit for the remainder of the shift. The ED was notified and went to the building to observe the nurse. At that time, the nurse did not appear impaired. She did not smell like alcohol or any other substance. She stated that she had no issues or upset families during the shift. The ED spoke with both CNAs on the unit, the other nurse and two residents that were awake and alert and oriented. No one had any concern related to the condition of the nurse during the shift. There was nothing out of the ordinary that took place. Based on the assessment and staff interviews, the ED decided to place the nurse on leave pending the outcome of the investigation. The ED did not feel it would be appropriate to send the nurse for drug testing. Upon taking a statement from the family member that raised the concern, she stated that the nurse smelled like weed and attempted to give her grandmother the wrong medications. She had a picture of the medicine cup with a blue round pill with F5 on it. The resident did not take the medication. In speaking with the nurse, she stated that she did not give the wrong medications. She stated that this resident had orders for famotidine, so she pulled it from another resident. The pictured medication that she pulled was actually identified as finasteride 5 milligrams. Additionally, while the ED was speaking with the nurse, the nurse admitted to smoking marijuana before work. The nurse remains on leave until next steps can be reviewed with the team.The statements from LPN 1 indicated, 1/17/26 at 9:50 p.m.: No issues with new resident. It was a good shift. The family was here with her. They were nice. 1/18/26: I took the cup with her medications into the room. [strikethrough] The resident had requested something for her stomach. [strikethrough] Her meds weren't delivered yet. She had orders for famotidine but did not have any so I took some from the cart. The resident did not take the pills. The family was in the room and questioned what the pills were and took the cup. [strikethrough] I was not impaired. I did smoke weed before coming to work. [strikethrough] 1/19/26: I came in the room with the medication in the cup. The daughter questioned why I was giving her blue pills. I told her it was the famotidine for her GERD (gastroesophageal reflux disease). When asked where she found it, she stated she found it in the cart.Resident B's closed record was reviewed on 4/8/26 at 10:24 a.m. Diagnoses included, but were not limited to, gastroesophageal reflux disease without esophagitis (GERD).The Discharge Minimum Data Set assessment, dated 1/22/26, indicated the resident was cognitively intact.The January 2026 Physician's Order Summary indicated the resident received famotidine oral tablet, 20 milligrams, 1 tablet twice a day for GERD.There were no Physician's Orders for finasteride.The Care Plan, dated 1/22/26, indicated the resident had an alteration in gastrointestinal status related to gastroesophageal reflux disease (GERD). Interventions included, but were not limited to, administer medications as ordered.During an interview on 4/8/26 at 1:12 p.m., the Executive Director indicated Resident B's family had requested to talk to her. They had left a note at the desk saying the nurse smelled like marijuana and the same nurse had brought in a cup of pills to give the resident and the family had questioned what the blue pill was in the cup. The nurse said it was famotidine, but it was not. The family was upset that the nurse had brought in the wrong medication to the resident. The medication cart was searched, and it was determined to be Resident E's medication, finasteride. When the ED had arrived, the nurse did not seem to be impaired. It was the end of the shift for the nurse. The nurse was no longer employed at the facility after the incident occurred. The nurse also retracted her statement about smoking marijuana prior to her shift and then the nurse proceeded to say that she had never said that. The nurse never had any prior history or allegations against her in her file. After the incident, all nurses were in-serviced on medication administration.The FINASTERIDE - finasteride table, film coated drug label, from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=aa3fcd1a-02a1-49db-b40e-75e623d730e1&audience=consumer, indicated, INDICATIONS AND USAGE.indicated for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate.3 DOSAGE FORMS AND STRENGTHS, 5 mg blue colored, round, biconvex, film-coated tablets, marked F5 on one side and plain on other side.The FAMOTIDINE 20 MG - famotidine 20 mg tablet, coated drug label, from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=5a66206b-35b1-4d86-8574-a1e45cb0772f, indicated, USES.relieves heartburn associated with acid indigestion and sour stomach, prevents heartburn associated with acid ingestion and sour stomach brought on by eating or drinking certain food and beverages.Product Information.Product Characteristics, Color White, Shape Round, Size 8 mm, Imprint Code 124.The Medication Pass Guidelines, that was part of the in-servicing for all nursing staff, indicated, .3. Medication Administration.e. Residents identified per facility policy and procedure prior to giving med. F. Resident is properly positioned. G. Medication dose preparation. 1)Nurse verified medication, strength, and labeled directions for use against the MAR.h. Manufacturer specifications are observed.3. Correct medication administered.This citation relates to Intake 2728361.410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(1)

Based on observation and interview, the facility failed to ensure medications were kept in a locked medication cart at all times during a medication pass observation. (RN 1, 3A Cart)Findings include:1. On 4/8/26 at 9:32 a.m., RN 1 was observed preparing medications for a resident. She retrieved the medications from the cart, popped the pills into a medication cup, prepared a dose of Miralax in water, and then walked into the resident's room to administer the medications. The cart was left unlocked and out of sight of the nurse at the time. The nurse returned to the cart and prepared the next resident's medications. 2. On 4/8/26 at 9:41 a.m., RN 1 was observed preparing another resident's medications. She had retrieved the medications from the cart, popped the pills into a medication cup, and went into the resident's room to administer the medications. The cart was left unlocked and out of sight of the nurse at the time. The nurse returned to the cart to prepare more medications.During an interview on 4/8/26 at 9:51 a.m., RN 1 indicated she was supposed to lock the cart any time she stepped away from the cart.The Executive Director was notified of RN 1 leaving the cart unlocked on 4/8/26 at 9:59 a.m., and provided no further information.A facility policy titled, Medication Storage, and noted as current, indicated, .I. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.This citation relates to Intake 2728361.410 IAC (Indiana Administrative Code) 16.2-3.1-25(m)

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to blood sugar levels not obtained and insulin doses not administered as ordered by the physician for 2 of 9 residents reviewed for quality of care. (Residents C and J)Findings include:1. Resident C's record was reviewed on 12/22/25 at 10:20 a.m. The diagnoses included, but were not limited to, diabetes mellitus.A Quarterly Minimum Data Set (MDS) assessment, dated 10/20/25, indicated no cognitive impairments and the resident had received insulin for the past seven days. A Care Plan, dated 3/12/25 and revised on 12/19/25, indicated a diagnosis of diabetes. An intervention, dated 3/12/25, indicated medication would be administered as ordered by the physician.A Physician's Order, dated 5/21/25, indicated Lispro (insulin), seven units was to be administered with meals daily. The insulin was to be held (not administered) if the blood sugar was less than 100. The Lispro and blood sugar checks were scheduled for 8:00 a.m., 12:00 p.m., and 5:00 p.m.The Medication Administration Record (MAR), dated 9/2025, indicated there were no blood sugar results and the Lispro had not been administered at 12:00 p.m. on 9/3/25 and 5:00 p.m. on 9/19/25. The blood sugar result on 9/26/25 at 5:00 p.m. was 92 and the seven units of insulin had been administered.The MAR, dated 10/2025, indicated the Lispro had not been administered at 8:00 a.m. on 10/11/25 with a blood sugar of 106, on 10/15/25 with a blood sugar of 101, on 10/18/25 with a blood sugar of 154, and on 10/23/25 with a blood sugar of 101. The insulin had not been given at 12:00 P.M. on 10/18/25 with a blood sugar of 158, on 10/19/25 with a blood sugar of 147, and on 10/27/25 with a blood sugar of 158.The MAR, dated 11/2025, indicated the Lispro had not been administered at 8:00 a.m. on 11/24/25 with a blood sugar of 121. The Lispro had not been administered at 12:00 p.m. on 11/7/25 with a blood sugar of 148 and on 11/24/25 with a blood sugar of 139. The Lispro had not been administered at 5:00 p.m. on 11/10/25 with a blood sugar of 109, on 11/14/25 with a blood sugar of 106, and on 11/18/25 with a blood sugar of 204.A Physician's Order, dated 9/9/25, indicated Lantus (insulin), 30 units was to be administered subcutaneous (sq) twice a day. The blood sugar was to be obtained and the Lantus administration was scheduled for 8:00 a.m. and 8:00 p.m. The MAR, dated 9/2025, indicated there were no blood sugar levels obtained and no insulin administered on September 16, 19, and 21, 2025 at 8:00 p.m.A Physician's Order, dated 10/20/25, indicated Glargine (insulin), 20 units was to be administered daily. The blood sugar was to be obtained and the Glargine administered at 8:00 p.m.The blood sugar level had not been obtained and the insulin had not been administered on 10/23/25 at 8:00 p.m.The MAR, dated 11/2025, indicated the 20 units of Glargine had not been administered and the blood sugar level had not been obtained at 8 p.m. on 11/3/25, 11/14/25, 11/24/25, and 11/25/25.A Physician's Order, dated 10/20/25, indicated Glargine 30 units was to be administered at 8:00 a.m. daily.The MAR, dated 11/2025, indicated the 30 units of Glargine insulin had not been administered at 8:00 a.m. with a blood sugar of 121 on 11/24/25.During an interview on 12/23/25 at 8:46 a.m., the Executive Director acknowledged the missed doses of insulin and provided no further information. 2. Resident J's record was reviewed on 12/23/25 at 8:59 a.m. The diagnoses included, but were not limited to, diabetes mellitus.A Quarterly MDS assessment, dated 11/19/25, indicated no cognitive impairments and insulin had been received in the past seven days.A Care Plan, dated 8/15/22 and revised on 11/25/25, indicated diabetes mellitus. An intervention, dated 8/15/22, indicated medications were to be administered as ordered by the physician. A Physician's Order, dated 3/14/23, indicated Lispro insulin was to be administered three times a day. The amount of insulin administered depended on the result of the blood sugar (sliding scale). The doses were ordered as follows:Blood sugar 150-199 give two unitsBlood sugar 200-249 give four unitsBlood sugar 250-299 give six unitsBlood sugar 300-349 give eight unitsBlood sugar 350-400 give 10 unitsBlood sugars over 400, give 10 units and notify the physician.The MAR, dated 10/2025, indicated on 10/8/25 at 6:00 a.m., the blood sugar was 155 and no insulin was administered. On 10/22/25 at 6:00 a.m. the blood sugar was 185 and no insulin had been administered.The MAR, dated 11/2025, indicated the blood sugar at 4:00 p.m. was 244 and no insulin had been administered. On 11/30/25, the 4:00 p.m. blood sugar was 290 and no insulin had been administered.The MAR, dated 12/2025, indicated the 6:00 a.m. blood sugar was 222 and no insulin had been administered.A Physician's Order, dated 4/17/25 indicated 25 units of Glargine insulin was to be given at bedtime.The MAR, dated 10/2025, indicated the Glargine had not been administered on 10/30/25 at 8:00 p.m. The MAR, dated 11/2025, indicated the Glargine had not been administered on 11/30/25 at 8:00 p.m.During an interview on 12/23/25 at 10:45 a.m., the Administrator indicated she had no further information about the missed dosages of the insulin.A facility medication administration policy, dated 12/12/23 and received as current from the Executive Director, indicated medications were to be administered as ordered by the physician.This citation relates to Intake 2668269.3.1-37

Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for self-administration of medications and an assessment to self-administer their own medications for 1 of 2 residents reviewed for self-administration of medication. (Resident 144) Finding includes: During an observation of Resident 144 on 6/10/25 at 11:13 a.m., there were three small medication cups on the bedside table and night stand containing multiple Tums (an antacid medication). There were also two large Tums medication bottles and an inhaler at the bedside. The resident indicated at the time that she would take the Tums medication whenever she ate and as she needed them for heartburn. On 6/11/25 at 10:24 a.m., Resident 144 was observed in bed. The Tums medication and inhaler were observed at the bedside. On 6/12/25 at 9:57 a.m., Resident 144 was observed in bed. The Tums medication and inhaler were observed at the bedside. Resident 144's record was reviewed on 6/11/25 at 10:33 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, asthma, and gastroesophageal reflux disease (GERD). The Annual Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. The current June 2025 Physician's Order Summary indicated the resident received albuterol sulfate 108 microgram per actuation (mcg/act) 2 puff inhale orally every 4 hours as needed, patient may keep at the bedside and calcium carbonate tablet 500 milligrams every 6 hours as needed. There were no orders for self-administration of the Tums medication. There were no self-administration of medication assessments completed for the resident to keep Tums or the inhaler at the bedside. There were no care plans related to self-administration of medications. During an interview on 6/16/25 at 4:30 p.m., the Director of Nursing had no further information to provide. A policy titled, Self-Administration of Medications, indicated, .1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment . 3.1-11(a)

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to antianxiety and antiplatelet medications for 2 of 32 MDS assessments reviewed. (Residents 107 and 375) Findings include: 1. Resident 107's record was reviewed on 6/12/25 at 10:22 a.m. Diagnoses included, but were not limited to, schizoaffective disorder, general anxiety disorder, and dementia with behavioral disturbance. The Quarterly MDS assessments, dated 5/23/25, 5/7/25, and 2/13/25, indicated the resident had not received any antianxiety medications. A Care Plan, updated 5/28/24, indicated the resident had schizoaffective disorder and was currently receiving antipsychotic, antidepressant, anticonvulsant, and antianxiety medications. A Physician's Order, dated 12/2/22, indicated Klonopin (clonazepam, an antianxiety medication) 0.5 mg (milligrams) two times a day. The Medication Administration Record (MAR), dated 5/2025, indicated the resident had received the antianxiety medication twice daily. During an interview on 6/12/25 at 1:42 p.m., the MDS Coordinator indicated the resident was receiving antianxiety medication. It had been coded as an anticonvulsant because that was how it was classified in the computer charting system. She would make corrections. 2. The record for Resident 375 was reviewed on 6/16/25 at 9:44 a.m. Diagnoses included, but were not limited to, history of stroke, congestive heart failure, and chronic kidney disease. The admission MDS assessment, dated 6/4/25, indicated the resident had not received any antiplatelet medications in the past seven days. The current Physician's Order Summary indicated to give ticagrelor (Brilinta, an antiplatelet medication) 90 mg every 12 hours. The MAR, dated 5/2024 and 6/2025, indicated the resident had received the antiplatelet medication twice daily beginning on 5/30/25. During an interview on 6/16/25 at 2:17 p.m., the MDS Coordinator indicated the MDS was incorrect and needed to be modified. 3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to twice weekly showering and nail care for 2 of 3 residents reviewed for ADLs. (Residents 52 and 105) Findings include: 1. During an interview on 6/10/25 at 10:00 a.m., Resident 52 indicated she did not always receive showers twice a week. Resident 52's record was reviewed on 6/11/25 at 10:37 a.m. Diagnoses included, but were not limited to, heart failure, chronic kidney disease, and stage 3 pressure ulcer of the sacral region. The Quarterly Minimum Data Set assessment, dated 4/30/25, indicated the resident was cognitively intact for daily decision making. The resident had an impairment affecting range of motion to one side of the lower extremities. She was dependent on staff for toileting, showering, bed mobility, and transfers. A Care Plan, revised on 5/1/25, indicated the resident needed assistance with activities of daily living. Interventions included, but were not limited to, the resident required total assistance for bathing/showering, provide additional assistance as needed. The Shower CNA Task was reviewed from 3/27-6/10/25. The resident was scheduled for showers every Tuesday and Friday evening. The Shower CNA Task lacked documentation of the resident receiving a shower on 4/11/25, 4/25/25, 5/2/25, 5/16/25, and 6/6/25. During an interview on 6/12/25 at 1:30 p.m., the Director of Nursing indicated she did not receive her showers twice weekly and was unable to provide any further documentation. A policy titled, Showers, indicated .1. residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety . 2. During an observation and interview on 6/10/25 at 9:23 a.m., Resident 105 was sitting in her bed. She indicated she had asked for someone to cut her toenails and it had not happened yet. At the time, both of the resident's feet were observed with long toenails. Resident 105's record was reviewed on 6/11/25 at 8:53 a.m. Diagnoses included, but were not limited to, edema and type 2 diabetes mellitus. The admission Minimum Data Set assessment, dated 3/18/25, indicated the resident was cognitively intact for daily decision making. The resident was dependent on staff for toileting, showering, and transfers. She required a substantial to maximal assist for personal hygiene. A Care Plan, revised on 6/6/25, indicated the resident required assistance with activities of daily living. Interventions included, but were not limited to, nail care on bath day and as necessary and report any changes to the nurse. The shower sheets were reviewed from April to June 2025. There was no documented nail care performed during that timeframe. During an interview on 6/16/25 at 4:30 p.m., the Director of Nursing had no further information to provide. 3.1-38(b)(2) 3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident 100) Finding includes: On 6/9/25 at 11:36 a.m., Resident 100 was sitting in a wheelchair in the hallway. A dark purple discoloration was observed to the top of his right hand. On 6/11/25 at 9:32 a.m., Resident 100 was observed lying in bed with his eyes closed. The dark purple discoloration was still observed to the top of his right hand. Record review for Resident 100 was completed on 6/12/25 at 1:18 p.m. Diagnoses included, but were not limited to, anemia, atrial fibrillation, heart failure, hypertension, and dementia. The Annual Minimum Data Set (MDS) assessment, dated 6/4/25, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance with bed mobility, transfers, and upper body dressing. The resident had received an anticoagulant (blood thinning) medication. A Care Plan, dated 5/31/22 and revised 6/10/25, indicated the resident was at risk for abnormal bleeding secondary to anticoagulant therapy for atrial fibrillation. An intervention included to inspect skin during care for bruising or increased bruising and to notify the nurse of abnormal findings. The June 2025 Physician's Order Summary (POS) indicated the resident had received Eliquis (blood thinner) 2.5 mg (milligrams) twice a day. A Weekly Skin Assessment, dated 6/11/25, indicated the resident had no new skin area concerns. The record lacked any documentation to indicate the resident's discoloration had been assessed or was being monitored. During an interview on 6/12/25 at 2:53 p.m., the Wound Nurse indicated she was unaware of the resident's discoloration to the top of his hand and staff should have assessed the area. A facility policy for discolorations was not provided. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure residents with a history of falls with injuries had preventions in place to prevent more falls/injuries related to a resident's call light not in reach and a Dycem (non slip mat) and non-skid strips were not in place as ordered for 2 of 2 residents reviewed for falls. (Residents 95 and 117) Findings include: 1. On 6/11/25 at 9:35 a.m., Resident 95 was observed sitting in a wheelchair next to her bed in her room watching television. The resident had darkened discolorations to the top and right side of her head and right hand. The resident also had a visible lump to the top of her head. The resident indicated she had fallen recently out of her wheelchair when she was trying to reach for something out of her nightstand. The resident's call light was not visibly in reach to the resident. The resident indicated she was unsure where her call light was located. On 6/11/25 at 11:28 a.m., Resident 95 was observed sitting in her room in the same position. The resident's call light was still not in reach to the resident. The call light cord was halfway underneath the resident's mattress and the call button at the end of the cord was not visible. The resident indicated she was unsure where her call light was located. Record review for Resident 95 was completed on 6/11/25 at 9:49 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, anemia, atrial fibrillation, hypertension, dementia, depression, and anxiety. The Significant Change Minimum Data Set (MDS) assessment, dated 5/19/25, indicated the resident was cognitively intact. The resident required a substantial maximal assistance to propel herself in her wheelchair and was dependent for bed mobility and transfers. The resident had no falls since the previous assessment. A Care Plan, dated 8/16/23 and revised 5/28/25, indicated the resident was at risk for falls or fall related injuries. An intervention included to keep the call light and frequently used personal items within reach. A Progress Note, dated 6/8/25 at 8:15 a.m., indicated the resident was calling for help. When the nurse entered the room she found the resident laying on her right side next to the bed and nightstand with her wheelchair behind her. The resident was sent out to the hospital. During an interview on 6/11/25 at 11:29 a.m., LPN 1 indicated the resident was able to use her call light and the call light should be in reach at all times. The resident had fallen recently while attempting to reach for something. She would locate the resident's call light and make sure it was within the resident's reach. 2. On 6/9/25 at 11:35 a.m., Resident 117 was observed lying in bed. He had sutures to his left eye area and a sling in place to his left arm. On 6/11/25 at 12:05 p.m., the resident was seated in the recliner in his room. There were no non-skid strips observed to the floor anywhere near his recliner. There were non-skid strips on the floor on the other side of the room, near the dresser. There was no Dycem observed to the resident's wheelchair. The resident indicated he had fallen recently and gone to the hospital. On 6/11/25 at 2:13 p.m., the resident was seated in the recliner in his room. There were no non-skid strips observed to the floor anywhere near his recliner. There was no Dycem observed to the resident's wheelchair. Record review for Resident 117 was completed on 6/11/25 at 9:18 a.m. Diagnoses included, but were not limited to, fracture of left humerus, type 2 diabetes mellitus, and congestive heart failure. The admission MDS assessment, dated 4/4/25, indicated the resident was cognitively intact and required a substantial/maximal assist with bed mobility and transfers. A Care Plan, updated 6/9/25, indicated the resident was at risk for falls or fall related injury. The interventions included: Dycem to wheelchair seat and non-skid strips in front of recliner. An Indiana Department of Health (IDOH) Reportable Incident, dated 6/1/25, indicated the resident was found on the floor in his room. He indicated he was trying to pull his pants up from sitting on his recliner and fell. He was sent to the emergency room for evaluation and was found to have a left humerus fracture. The Interdisciplinary Team (IDT) recommendation was non-skid strips in front of the recliner. The resident returned to the facility on 6/5/25. A Progress Note, dated 6/6/25 at 1:47 p.m., indicated the resident was yelling out and was found sliding out of his wheelchair. Staff was able to assist him back to the wheelchair. A Dycem was placed in the wheelchair to prevent sliding out. During an interview on 6/11/25 at 3:47 p.m., the Director of Nursing was made aware of the Dycem and non-skid strips not in place. She indicated the resident's daughter may have moved the recliner. During an interview on 6/11/25 at 3:54 p.m., the Executive Director indicated she had placed the non-skid strips in front of the recliner herself, and the recliner had been near the dresser. Someone must have moved the recliner since then. The resident did not like the Dycem and was noncompliant with interventions frequently. She had provided him with education on Friday. A current facility policy, titled Incidents, Accidents & Supervision, indicated, .Supervision. The resident will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: .3. Implementing interventions to reduce hazards and risks. 4. Monitoring for effectiveness and modifying interventions when necessary . 3.1-45(a)

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen not administered as ordered for 1 of 1 resident reviewed for respiratory care. (Resident 51) Finding includes: On 6/10/25 at 9:21 a.m., Resident 51 was observed lying in her bed. She had a nasal cannula in place and oxygen was flowing at 5 liters per minute (lpm). On 6/11/25 at 9:59 a.m., the resident was again observed in bed with oxygen flowing at 5 lpm. The resident's record was reviewed on 6/11/25 at 8:45 a.m. Diagnoses included, but were not limited to, dementia, asthma and chronic obstructive respiratory disease. The admission Minimum Data Set assessment, dated 5/16/25, indicated the resident had severe cognitive impairment, and was dependent for bed mobility, transfers and toileting assistance. The current Physician's Orders indicated the resident was to receive oxygen at 3 lpm continuously. During an interview on 6/11/25 at 10:00 a.m., LPN 4 indicated the resident's oxygen should be set at 3 lpm. She entered the room and adjusted the oxygen to the correct flow rate. 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to ensure a medication cart drawer was closed and locked while unattended for 1 of 5 medication carts observed. (1A Medication Cart) Finding includes: On 6/12/25 at 9:00 a.m., QMA 1 was observed preparing Resident 18's medications. She finished preparing the medications, locked the medication cart, and entered Resident 18's room at 9:12 a.m. The bottom drawer on the right side of the medication cart was not pushed in all the way and medications were visible. QMA 1 administered the medications to Resident 18 and returned to the medication cart at 9:18 a.m. During an interview on 6/12/25 at 9:18 a.m., QMA 1 indicated she was not aware the drawer had not been closed all the way. During an interview on 6/12/25 at 1:16 p.m., the Director of Nursing was made aware the medication cart drawer had been left open. The medication storage policy was requested. A current facility policy, titled Medication and Biological Storage Requirements, indicated, .2. The facility is required to secure all medications in a locked storage area and to limit access to only authorized or licensed personnel consistent with state or federal requirements and professional standards of practice. a. Storage areas may include, but are not limited to, drawers, cabinets, medication rooms, refrigerators, and carts . 3.1-25(m)

Based on record review and interview, the facility failed to ensure residents on the Memory Care Unit were treated with respect and dignity, related to a staff member yelling and using foul language in the hallway where residents could hear the staff member. This had the potential to affect all the residents on the Memory Care Unit. (Terminated Employee 1 and Resident G). The deficient practice was corrected on 12/16/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A facility initiated staff to resident incident reported to the Indiana Department of Health (IDOH), dated 12/6/24, was reviewed on 1/15/25 at 1:03 p.m. The incident indicated an altercation between Terminated Employee 1 and Resident G. Review of the facility's finished investigation of the incident, dated 12/11/24, indicated staff to resident abuse had not occurred. Terminated Employee 1 was immediately placed on administrative leave and was instructed to leave the building. She admitted to using some profanity in front of the residents. A typed statement from the ED, dated 12/6/24 at 9 p.m., indicated CNA 2 indicated Resident G had grabbed Terminated Employee 1's hair. CNA 2 and RN 1 assisted and and separated the resident from Terminated Employee 1. Terminated Employee 1 was upset and called RN 1 a, f****** b**** when RN 1 instructed her to leave the facility. A typed statement from the ED, dated 12/6/24 at 9 p.m., indicated RN 1 and CNA 2 assisted Terminated Employee 1 with freeing the grasp Resident G had on her hair. Terminated Employee 1 called RN 1 a f****** b**** when she was instructed to leave the facility. The ED and Administrator were contacted immediately. A typed statement from the Administrator and Executive Director (ED), dated 12/9/24, indicated Terminated Employee 1 indicated during the incident with Resident G the employee began to yell out profanity due to the pain of the resident pulling her hair. She stated, get this b**** off of me. The co-workers assisted with the resident and the employee's hair was released. Terminated Employee 1 then indicated she was yelling at RN 1, f*** you b**** because she was upset about the incident. During an interview on 1/15/25 at 2:18 p.m., RN 1 indicated Terminated Employee 1 was not violent with the resident and the altercation was a reaction from the CNA and not purposeful harm. Terminated Employee 1 had refused to leave the unit/facility when instructed to do so and was yelling foul language and calling her a b****, and saying f*** you as she was walking down the hallway. There were residents in the hallway and the common area when this occurred and could hear Terminated Employee 1 using the foul language. She indicated the incident occurred on the Memory Care Unit and the residents on the unit have diagnoses of Alzheimer's disease and/or dementia. The deficient practice was corrected by 12/16/24 after the facility implemented a systemic plan that included the following actions: staff were interviewed, head to toe assessments were completed on all the residents with severely impaired cognitive status on Memory Care Unit with no negative findings, all residents who had a moderate to intact cognitive status on the units Terminated CNA 1 had worked in the past 30 days were interviewed to determine if there were concerns. There were no negative findings. All staff members were educated on abuse prevention/policy and reporting abuse. The background checks for all CNA's were audited and validated they were completed with no outstanding background check. Weekly audits have been and continue to be completed for abuse concerns of five random residents are to be completed until it is deemed compliant in the QAPI (quality assurance and performance improvement) meeting. Weekly audits have been and continue to be completed of five random staff members in regards to how they respond to aggressive dementia residents and the abuse policy until deemed compliant in the QAPI meeting reviews. All grievances were reviewed fro the last 30 days to identify trends and no trends were found. Resident G has psychosocial follow up assessments with no concerns or change of behavior. This citation relates to Complaints IN00449543 and IN00449574. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure care-planned interventions to prevent injuries due to a fall were in place, related to a non-slip pad not on the wheelchair pad when the resident was sitting in the wheelchair and a mat not placed on the floor next to the bed when the resident was lying in bed, for 1 of 3 residents reviewed for falls and fall interventions. (Resident D) Finding includes: Resident D was observed on 1/14/25 at 9 a.m., 10:05 a.m. and 11:31 a.m., sitting by herself in the wheelchair in her room. During an observation on 1/14/25 at 11:35 a.m., QMA 3 and CNA 4 assisted the resident from the wheelchair to the bed. The resident was assisted to stand from the wheelchair. A non-slip pad was not under the resident in the wheelchair. During an interview at the time of the observation, QMA 3 and CNA 4 indicated they were unsure if a non-slip pad was to be on the wheelchair pad and both indicated it was not on the wheelchair. The resident was assisted in a lying position on the bed and incontinence care was completed. She was positioned for comfort in bed and CNA 4 indicated the resident would be assisted up in the wheelchair before lunch. QMA 3 and CNA 4 left the room. The floor mat was not placed on the floor next to the resident's bed and was left leaning against the wall in the room. During an interview on 1/14/25 at 12:26 p.m., CNA 4 indicated the staff have care cards available with the interventions to be used to prevent falls and other care information. Review of the care card with CNA 4 indicated a non-slip pad was to placed on the wheelchair. The floor mat next to the bed was not on the care card. CNA 4 indicated the care cards were not always kept up to date. Resident D's record was reviewed on 1/14/25 at 10:15 a.m. The diagnoses included, but were not limited to, dementia and repeated falls. A Quarterly Minimum Data Set assessment, dated 12/24/24, indicated a moderately impaired cognitive status and a past fall. A Care Plan, dated 2/10/20, indicated a risk for falls and a history of falls. The interventions included on 11/5/24, a non-slip pad would be applied to the seat of the wheelchair and on 3/15/20, a mat was to placed on the floor next to the bed. This citation relates to Complaints IN00449543 and IN00449574. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the posted Nurse Staffing information was up-to-date and current. THis had the potential to affect all residents in the facility. Finding includes: The Nurse Staffing Information was posted on the desk by the front door of the facility and was observed on 1/13/25 at 9:13 a.m. The information posted was dated 1/8/25. During an interview on 1/13/25 at 9:15 a.m., the Administrator indicated either the Scheduler or the Nursing Supervisor was responsible for posting the current Nurse Staffing Information daily. This citation relates to Complaints IN00449509 and IN00450162.

Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 10/8/24 at 2:05 p.m., Resident D's room was observed. There were no non-skid strips on her bathroom floor. The record for Resident D was reviewed on 10/8/24 at 11:15 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertensive chronic kidney disease, type 2 diabetes mellitus, osteoarthritis, dementia, and repeated falls The Quarterly Minimum Data Set (MDS) assessment, dated 8/29/24, indicated the resident was severely cognitively impaired and required substantial assistance with activities of daily living. A Care Plan, updated 10/23/23, indicated the resident was at risk for falls. An intervention, dated 9/23/24, indicated non-skid strips were to be placed on the bathroom floor, near the toilet. An Indiana Department of Health reportable incident, dated 9/9/24, indicated new bruising was found under the resident's eye and on both arms. Staff reported the resident had behaviors of hitting/ punching/kicking walls, bumping into objects as she self-propelled in her wheelchair, and self-transferring without assistance. A Nurse's Note, dated 9/22/24 at 4:01 p.m., indicated the resident was propelling herself in her wheelchair on the unit, in and out of rooms, banging on exit door and yelling. A Fall IDT (interdisciplinary team) Note, dated 9/23/24 at 1:30 p.m., indicated the resident was found sitting on her bathroom floor, yelling for help, with her wheelchair nearby. The suggested new intervention was to place non-skid strips on the bathroom floor, near the toilet. A Nurse's Note, dated 10/6/2024 at 11:21 a.m., indicated the resident was observed propelling herself in her wheelchair to both exit locations, banging her hands on and kicking the doors. During an interview on 10/8/24 at 2:10 p.m., CNA 1 indicated she thought the resident had non-skid strips on her bathroom floor. After observing the bathroom, CNA 1 confirmed there were no non-skid strips on the floor. During an interview on 10/9/24 at 11:00 a.m., the Administrator indicated the non-skid strips were just placed on the resident's bathroom floor. A facility policy, titled Fall Management, received as current from the facility on 10/9/24, stated, .Fall risk will be assessed upon admission, quarterly and with significant change . All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other interventions to prevent future falls . This citation relates to Complaint IN00443996. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 2 of 3 residents reviewed for nutrition. (Residents F and C) Findings include: 1. Record review for Resident F was completed on 10/8/24 at 2:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, [NAME] syndrome (body makes too much cortisol hormone), diabetes mellitus, and end stage renal disease. The Admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact. The resident required partial assistance with eating. A Care Plan, dated 8/14/24, indicated the resident was at risk for complications and symptoms of hypoglycemia or hyperglycemia due to diabetes. An intervention included to document the resident's meal and snack intake. An IDT Risk Review, dated 10/3/24, indicated the resident's most recent weight on 10/3/24 was 203 pounds. The previous weight on 9/24/24 was 227 pounds. The resident's meal intakes had recently declined related to depression. The Task Meal Consumption Logs were documented with percentage of meals eaten. The last 30 days lacked documentation for the following meals: - Breakfast on 9/11, 9/14, 9/15, 9/19, 9/20, 9/21, 9/22, 9/23, 9/25, 9/26, 9/27, 9/29, 10/1, 10/3, 10/4, and 10/5/24. - Lunch on 9/15, 9/20, 9/21, 9/22, 9/25, 9/27, 9/29, 10/1, 10/3, 10/4, 10/5, and 10/7/24. - Dinner on 9/11, 9/13, 9/14, 9/16, 9/17, 9/18, 9/19, 9/20, 9/22, 9/24, 9/25, 9/26, 9/27, 9/28, 9/30, 10/1, 10/3, 10/4, 10/5, 10/6, and 10/7/24. During an interview on 10/9/24 at 2:46 p.m , the Director of Nursing (DON) indicated she was unable to provide any documentation the resident's meal consumption logs were completed on the above dates. 32788 2. On 10/9/24 at 12:28 p.m., Resident C was observed sitting up in her bed. A CNA was seated at the resident's bedside assisting her with eating lunch. The record for Resident C was reviewed on 10/8/24 at 3:45 p.m. Diagnoses included, but were not limited to Alzheimer's disease, chronic kidney disease, and coronary artery disease. The Quarterly Minimum Data Set (MDS) assessment, dated 9/23/24, indicated the resident was cognitively impaired and required substantial assistance with eating. A current Care Plan, updated 6/26/24, indicated the resident had potential nutritional risk related to her mechanically altered diet. An intervention indicated to document food and fluid intakes. The resident's weight on 9/18/24 was 170 and on 9/24/24 was 154. The food consumption task documentation, dated 9/10/24 through 10/8/24, indicated there was no meal consumption documented for the following days and meals: 9/10/24 breakfast and lunch 9/13/24 dinner 9/14/24 breakfast and lunch 9/15/24 breakfast and lunch 9/16/24 dinner 9/18/24 breakfast and lunch 9/20/24 breakfast and dinner 9/21/24 breakfast and dinner 9/22/24 dinner 9/27/24 dinner 9/29/24 breakfast and lunch 10/2/24 breakfast and lunch 10/5/24 dinner During an interview on 10/9/24 at 11:07 a.m., the Director of Nursing (DON) was made aware of the missing food consumption documentation and indicated she would look into it. No further information was provided. This citation relates to Complaint IN00441181. 3.1-46(a)(1) 3.1-46(a)(2)

Based on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to not monitoring the resident's pulse as ordered prior to administering a blood pressure medication for 1 of 3 residents reviewed for unnecessary medications. (Resident F) Finding includes: Record review for Resident F was completed on 10/8/24 at 2:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, [NAME] syndrome (body makes too much cortisol hormone), diabetes mellitus, and end stage renal disease. The Admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact. The October 2024 Physician's Order Summary indicated an order for metoprolol succinate (treats high blood pressure) 100 mg (milligrams) one time a day. Hold the medication for heart rate less than 60. The September and October 2024 Medication Administration Records indicated the metoprolol succinate was administered at 7:00 a.m. on 9/3, 9/4, 9/7, 9/8, 9/15, 9/20, 9/28, 10/1, 10/4, 10/5, and 10/6/24. The record lacked any documentation the pulse was monitored prior to the medication being administered on the above dates. During an interview on 10/9/24 at 11:07 a.m., the Director of Nursing indicated she was unable to provide any documentation the pulse was monitored before the medication was administered on the above dates. This citation relates to Complaint IN00441181. 3.1-48(a)(3)

Based on observation, record review, and interview, the facility failed to ensure dependent residents received the activities of daily living (ADL) care needed related to showers not given as scheduled, facial hair unshaven, and soiled sheets on a resident's bed for 5 of 8 residents reviewed for ADL care. (Residents 76, 121, 52, C, and 45) Findings include: 1. On 5/13/24 at 2:53 p.m., Resident 76 was observed lying in his bed. His hair appeared greasy and there was visible white debris observed. His beard had visible food debris. On 5/14/24 at 9:11 a.m., the resident was observed lying in bed. His hair was greasy with white debris observed. The resident's record was reviewed on 5/15/24 at 12:50 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular accident, diabetes mellitus and vascular dementia. The Annual Minimum Data Set assessment, dated 2/8/24, indicated the resident had moderate cognitive impairment and required extensive assistance for bed mobility and toileting. The current ADL Care Plan indicated the resident needed total assistance for bathing/showering due to activity intolerance, hemiplegia, and physical debility. The shower book indicated he was to receive a shower twice weekly on Wednesday and Saturday. Shower sheets for the past 30 days were reviewed as follows: 4/20/24: bed bath 5/1/24: bed bath 5/4/24: bed bath 5/11/24: bed bath 5/15/24: bed bath There were no documented showers, bed baths, or refusals for 4/24, 4/27 or 5/8/24. During an interview on 5/15/24 at 2:26 p.m., CNA 8 indicated if a resident refused a shower, then a bed bath was offered. If they refused the bed bath, a refusal form should be completed and the nurse was to be notified. During an interview on 5/16/24 at 11:15 a.m., the Director of Nursing indicated there were no additional shower sheets available. 2. During an interview on 5/13/24 at 11:17 a.m., Resident 121 indicated he was not getting showers twice weekly as scheduled. The residents record was reviewed on 5/16/24 at 11:45 a.m. Diagnoses included, but were not limited to, congestive heart failure, unspecified dementia, and diabetes mellitus. The Annual MDS assessment, dated 3/15/24, indicated he was cognitively intact and required extensive assistance for bed mobility and limited assistance for toileting and transfers. The current ADL Care Plan indicated he needed total assistance with bathing/showering related to activity intolerance and dementia. The shower book indicated he was to receive a shower twice weekly on Monday and Thursday. Shower sheets for the past 30 days were reviewed as follows: 4/24/24: shower 4/29/24: shower 5/2/24: shower 5/9/24: shower There were no documented showers, bed baths, or refusals for 4/18, 4/22, 5/6 or 5/13. During an interview on 5/16/24 at 11:15 a.m., the Director of Nursing indicated there were no additional shower sheets available. 32664 3. On 5/14/24 at 10:17 a.m., Resident 52 was observed lying in bed. The resident had long facial hair observed to her chin. The resident indicated the staff would sometimes shave her and was unsure the last time she was shaved. On 5/15/24 at 11:09 a.m., Resident 52 was observed lying in bed. The resident was still observed with long facial hair to her chin. The record review for Resident 52 was completed on 5/15/24 at 11:10 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, heart failure, hypertension, diabetes mellitus, dementia, and stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 4/29/24, indicated the resident was cognitively intact. The resident was dependent for bathing, transfers and mobility. The resident required substantial/maximal assistance for personal hygiene. A Care Plan, dated 1/27/24 and revised 1/30/24, indicated the resident needed assistance with activities of daily living. An intervention included the resident needed an extensive assistance x 1 person for personal hygiene. During an interview on 5/15/24 at 2:04 p.m., CNA 2 indicated the resident was given 1 shower a week and 1 bed bath a week. She was to be shaved weekly with her bathing or when her facial hair was observed. CNA 2 had given the resident a bed bath the day before and did not shave the resident, but she should have shaved her. 45666 4. On 5/14/24 at 9:39 a.m., Resident C was observed in bed wearing only a t-shirt and appeared disheveled. He had no brief on and the linens under him were soiled. On 5/14/24 at 10:16 a.m., Resident C was observed in bed wearing only a t-shirt. He had no brief on and the linens under him were soiled. Resident C's record was reviewed on 5/14/24 at 2:16 p.m. Diagnoses included, but were not limited to peripheral vascular disease and type 2 diabetes mellitus. The Admission Minimum Data Set (MDS) assessment, dated 4/5/24, indicated the resident was severely cognitively impaired. He was dependent on staff for toileting hygiene and required substantial/maximal assistance for personal hygiene and shower/bathing. A Care Plan, dated 4/1/24, indicated the resident needed assistance with activities of daily living. Interventions included, but not limited to, the resident required extensive assistance for toilet use. The Shower Sheets from April and May 2024 indicated the resident had refused on 4/13/24, received a shower on 4/15/24, refused on 4/27/24, and received a shower on 4/28/24. There was nothing further documented. During an interview on 5/16/24 at 10:02 a.m., the Administrator had no further information to provide. 5. During an interview on 5/13/24 at 11:34 a.m., Resident 45 indicated she was not receiving showers twice a week. Resident 45's record was reviewed on 5/16/24 at 1:13 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, anxiety disorder, and bipolar disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the resident was moderately cognitively impaired for daily decision making. She required substantial/maximal assistance for showering. A Care Plan, dated 9/22/23, indicated the resident needed assistance with activities of daily living. Interventions included, but were not limited to, the resident required extensive assistance with showering and had fluctuations in needs and provide additional staff assistance as needed. The Shower Sheets were reviewed for April and May 2024 and indicated the resident received a shower on 4/5/24, 4/9/24, 4/16/24, 4/19/24, 4/23/24, 5/7/24, and 5/14/24. During an interview on 5/20/24 at 2:37 p.m., the Director of Nursing had no further information to provide. This citation relates to Complaint IN00431905. 3.1-38(a)(3)(D) 3.1-38(b)(2)

Based on observation and interview, the facility failed to ensure medications were properly stored for 4 of 5 medication carts observed. (1A Medication Cart, 2C Medication Cart, 2B Medication Cart, and 3D Medication Cart) Findings include: 1. On 5/20/24 at 9:13 a.m., the 1A Medication Cart was observed with RN 2. There were approximately 20 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 2. On 5/20/24 at 9:26 a.m., the 2C Medication Cart was observed with LPN 2. There were approximately 40 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 3. On 5/20/24 at 9:33 a.m., the 2B Medication Cart was observed with RN 3. There were approximately 12 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 4. On 5/20/24 at 9:47 a.m., the 3D Medication Cart was observed with LPN 3. There were approximately 4 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. During an interview on 5/20/24 at 10:48 a.m., the Director of Nursing indicated all of the nursing staff was responsible to making sure the medication carts were cleaned. 3.1-25(j) 3.1-25(o)

Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for self-administration of medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 111) Finding includes: On 5/14/24 at 9:21 a.m., Resident 111 was observed in her room in bed. There was a medication cup noted with multiple pills in it on the table next to her. The resident indicated the nurses always had left her morning medications for her to take after she had eaten her breakfast. Resident 111's record was reviewed on 5/15/24 at 1:22 p.m. Diagnoses included, but were not limited to, dementia, heart disease, and anxiety disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 4/5/24, indicated the resident was cognitively intact for daily decision making. She had taken antidepressants, anticoagulants, diuretics, and opioid medications in the last 7 day look back period. An Interdisciplinary Team (IDT) note, dated 5/14/2024 at 9:18 a.m., indicated the IDT met to review the resident and determined the resident was able to self-administer prescribed medications prepared by the nurse or QMA. The medications to be self-administered were furosemide 40 milligrams (mg) everyday, l-methylfolate 15 mg daily, levothyroxine 75 micrograms daily, macrobid 100 mg twice daily until complete, memantine 5 mg daily, norco 5-325 mg every four hours as needed (PRN), potassium 10 milliequivalents daily, pregabalin 200 mg twice daily, rivastingmine 1.5 mg twice daily, senna docusate 8.6 mg every 12 hours PRN, sumatriptan 100 mg every 2 hours PRN, tobramycin 1 drop in both eyes until complete. There were no physician orders for self-administration of the medications. During an interview on 5/16/24 at 11:09 a.m., the Administrator indicated there should have been an order to self administer the medications. 3.1-11(a)

Based on record review and interview, the facility failed to notify the family/representative of a significant weight loss, a weight loss, and a new order for a nutritional supplement for 2 of 7 residents reviewed for nutrition. (Residents 59 and 143) Findings include: 1. Resident 59's record was reviewed on 5/14/24 at 2:42 p.m. Diagnoses included, but were not limited to, Lewy body dementia, psychotic disorder, depressive disorder and diabetes mellitus. The resident resided on the locked dementia unit. The Quarterly Minimum Data Set (MDS) assessment, dated 3/29/24, indicated the resident had severe cognitive impairment and required limited staff assistance for bed mobility and transfers, and could eat independently after set up. The Current Physician Orders indicated the resident was on a regular diet. There were no nutritional supplements or fortified food ordered. The resident's weights were as follows: 2/5/24: 232 pounds (lbs) 2/11/24: 230 lbs 2/18/24: 218 lbs 2/25/24: 217 lbs 3/6/24: 217 lbs This was a weight loss of 15 lbs, 5%, in one month. There was no documentation the family had been notified. A Quarterly Nutrition Review, dated 3/29/24, indicated the resident had a significant weight loss of 5% in 30 days. The resident did not receive snacks, supplements or fortified food. The resident's weight had been stable since 2/18. The resident's intake of food and fluid was estimated to meet needs at the time. There were no new nutritional recommendations at the time. The resident's continued weights were as follows: 4/2/24: 220 lbs (+3 lbs) 5/3/24: 203 lbs 5/7/24: 203 lbs (reweigh) This was an additional weight loss of 14 pounds, for a total weight loss of 29 pounds, 12.5%, since her admission on 2/5/24. There was no documentation the family had been notified. During an interview on 5/17/24 at 12:52 p.m., a family member indicated she had been notified yesterday, 5/16/24, of the current 17 pound weight loss. She had not been notified of additional weight losses. She was unaware of the significant weight loss that occurred from 2/5/24-3/6/24. During an interview on 5/17/24, the Director of Nursing indicated there was no documentation the family had been notified of the initial significant weight loss. 2. Resident 143's record was reviewed on 5/17/24 at 1:55 p.m. Diagnoses included, but were not limited to, Alzheimer's dementia, iron deficiency, and chronic lymphocytic leukemia. The Quarterly MDS assessment, dated 3/11/24, indicated the resident had significant cognitive impairment, required limited assistance with bed mobility and transfers, and could eat independently after set up. The resident's weights were as follows: 11/1/23: 124 lbs 3/6/24: 116 lbs This was an eight pound, 6.45% loss, in four months. There was no documentation the family had been notified. A Physician's Order, dated 3/23/24, indicated to give a health shake with breakfast daily for weight loss. There was no documentation the family had been notified of the new order. During an interview with a family member on 5/20/24 at 1:03 p.m., she indicated her mother was not on a special diet and had not lost any weight that she was aware of. She indicated she was not aware of the eight pound weight loss or new order for health shake daily. During an interview with the Administrator on 5/20/24 at 3:00 p.m., she indicated there was no documentation the family had been notified. The policy, Resident Weight Monitoring, indicated, .The resident's physician and family/guardian will notified of any verified significant weight change . 3.1-5(a)(3)

Based on record review and interview, the facility failed to notify Emergency Medical Services (EMS) when CPR (cardiopulmonary resuscitation) was initiated on a resident who was found unresponsive, without vital signs, and had an Advance Directive indicating the desire for CPR (full code status). The staff ceased CPR without an order from the Resident's Physician, resulting in the death of a resident for 1 of 8 residents reviewed for Advanced Directives. (Resident B) The Immediate Jeopardy began on [DATE] when an Agency LPN chose not to notify EMS and initiated CPR with a CNA, then ceased the CPR without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Finding includes: Resident B's record was reviewed on [DATE] at 12:34 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Out of hospital DNR (do not resuscitate) declaration (Advance Directive), dated [DATE], indicated the resident was a full code and desired CPR. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Note, dated [DATE] at 3:37 p.m., indicated an admission into Hospice care and the resident remained a full code. The Guardian wanted to review the DNR paperwork and would let the Hospice staff know her wishes for the resident's code status. A Nurse's Note, dated [DATE] at 7:56 p.m., indicated the resident was found unresponsive and no vital signs were present. CPR was initiated by Agency LPN 1 and Agency CNA 1. CPR was unsuccessful and was stopped. The Burial Permit, dated [DATE], indicated the time of death was at 7 p.m. During an interview on [DATE] at 2:34 p.m., the Administrator indicated the Guardian had taken the DNR information home to look over before making a decision on the code status. A decision had not been made at the time and the resident remained a full code. Agency LPN 1 had stopped CPR because the resident was Hospice. On [DATE] at 3:30 p.m., Agency LPN 1 indicated she was under the impression that residents on Hospice were not to be transferred to the hospital. She had found the resident unresponsive and initiated CPR. She and Agency CNA 1 had alternated performing CPR on the resident for 45 minutes. The CPR was unsuccessful and it was stopped. EMS had not been notified because they would have transferred the resident to the hospital and they would have performed life saving measures. On [DATE] at 4:08 p.m., Agency CNA 1 indicated he had entered the resident's room to check on her. She was unresponsive and had just been admitted into hospice care. Agency LPN 1 was notified and CPR was initiated. Agency LPN 1 had stated, we are not getting her back, and she stopped the CPR. He was unsure how long CPR had been administered and unsure if EMS had been notified. On [DATE] at 11:49 a.m., the Administrator indicated that Hospice services were to begin on [DATE]. The Hospice Agency had not left a binder for the facility. On [DATE] at 12:35 p.m., the Hospice Agency Coordinator indicated binders were provided to the facility at the time of admission into Hospice, which included the plan of care and all notes. The binder was left at the facility. The Hospice Agency always discussed the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospice Notes, dated [DATE] and received from the Hospice Agency on [DATE], indicated the full code status was discussed with the Guardian via telephone due to the Guardian unable to meet with Hospice until the next day. Post Form (do not resuscitate declaration and order) was discussed and decisions were to be made. The resident would remain a full code until the form was completed. The Guardian voiced understanding. Hospice spoke with the Wound Nurse and Agency LPN 1 at the change of shift and informed of the code status at the time of admission. Both nurses voiced understanding. The form was signed by Agency LPN 1 on [DATE]. A facility Cardiopulmonary Resuscitation (CPR) Policy, dated ,d+[DATE] and received from the Administrator as current, indicated facility staff must provide basic life support, which included CPR, prior to the EMS arrival and in accordance with the advance directives. The Licensed Nurse was to designate a staff member to call 911 and the Crash Cart was to be obtained. A facility policy, titled, Death of a Resident, Documenting, dated ,d+[DATE] and received from the Administrator as current, indicated a resident may be declared dead by a Licensed Physician or Registered Nurse (RN) with Physician authorization. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility reviewed the Advance Directives for all residents in the facility, ensured the code status was available in the electronic record and inserviced staff including how to identify the code status of the resident by the name plate outside the resident's door. The facility educated 68 employees and Agency employees on Advance Directives, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 37 staff members were interviewed and were knowledgeable of the CPR policy and procedures. The Director of Nursing (DON)/ Designee will continue to educate remaining staff and all Agency staff of the CPR policy and procedures and education will continue monthly. The facility also initiated protocols for the DON/ Designee to audit all residents who have expired to ensure the facility policies and procedures have been followed for Advance Directives. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been inserviced and monitoring of the implemented systems was ongoing. This Federal tag relates to Complaint IN 167.

Based on observation, record review, and interview, the facility failed to ensure pressure ulcers and skin conditions were assessed, assessed timely, and assessed correctly. They failed to ensure treatments for the pressure areas were obtained timely and treatments were completed as ordered by the Physician for 3 of 4 residents reviewed for pressure ulcers. (Residents C, E, and D) Residents C and E had a worsening in stage of their pressure ulcer areas related to delays in treatment and assessments. Findings include: 1) Resident C's record was reviewed on 3/23/22 at 4:05 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) assessment, dated 2/10/22, indicated a severely impaired cognitive status, extensive assistance of two for bed mobility, dependent on two for transfers, extensive assistance of one for hygiene and dependent on one for bathing. The resident was incontinent of bowel and bladder and had one unstageable deep tissue injury (DTI) upon re-entry to the facility. A Care Plan, dated 2/9/22, indicated a left heel pressure ulcer. The interventions included, the skin condition would be assessed and documented, assistance was to be provided for bed mobility and toileting, bowel and bladder incontinence was to be monitored, and the treatment was to be completed as ordered. A Nurse's Progress Note, dated 2/3/22 at 9:59 a.m., indicated a left heel DTI, which measured 5 cm (centimeters) by 4 cm was present upon re-admission from the Hospital on 2/3/22 and skin prep (protective film) was applied. A Nurse's Progress Note, dated 2/3/22 at 9:29 p.m., indicated a large DTI on the left heel and the Wound Nurse was to assess the area. Transfer orders from the Hospital, dated 2/3/22, indicated a wound to the left heel. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's Transfer Order had not been transcribed to the MAR/TARs (Medication Administration Record/Treatment Administration Records), dated 2/2022. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was the first treatment to the left heel completed by the facility per the MAR/TARs, dated 2/2022. The weekly left heel wound measurements were as follows: On 2/3/22 at 9:59 a.m., 5 cm x 4 cm, DTI. On 2/10/22 at 10:02 a.m., 5 cm x 4 cm, DTI, unchanged. 100% necrotic. A handwritten paper, dated 2/17/22 and no time written, was presented by the Wound Nurse with the measurements of 5.5 cm x 7 cm and no description of the wound. A Nurse's Progress Note, dated 2/18/22 at 9:18 a.m., indicated the resident was extremely lethargic and not waking up. The Nurse Practitioner was notified and an order was received to transfer the resident to the emergency room . There was no Transfer Form completed and sent with the resident that indicated the status of the resident and the skin condition of the resident. The emergency room Provider Notes indicated the resident was seen on 2/18/22 at 10:19 a.m. An emergency room Nurse's Progress Note, dated 2/18/22 at 12:29 p.m., indicated a skin assessment was completed. Wounds were located on the left heel and sacrum. The emergency room Nurse had taken pictures of the left heel and sacrococcygeal area on 2/18/22. No measurements were documented. The measuring tool held up to the areas indicated the sacrococcygeal area was approximately 12 cm long with an area on the inner right buttock and the left heel was approximately 6 cm x 7 cm. The Hospital Wound Nurse Notes, dated 2/18/22 at 5:42 p.m., assessed the sacrococcygeal area as red/tan, non-blanching [CONDITION(S)], the wound was 2 cm x 3 cm with 0.2 cm depth, there was full thickness loss and it was staged at three. A picture of the wound was taken on 2/21/22. The left heel was first assessed on 2/18/22 at 5:40 p.m. and was described as red, necrotic, eschar, purple, measured 7 cm x 8.8 cm and was unable to be staged. there was 90% eschar on the heel. There was a picture of the heel which indicated it was taken on 2/21/22. The right heel, was first assessed on 2/18/22 at 5:40 p.m. and was red/purple and intact. It measured 5 cm x 4 cm and was classified as a DTI. On 3/24/22 at 11:53 a.m., the Wound Nurse indicated she was unsure why the treatment orders for the left heel from the hospital were not transcribed and why treatment to the left heel was not started until 2/11/22. She indicated the left heel was necrotic not a DTI, and it was not assessed correctly on 2/10/22 when it was marked with DTI. On 3/29/22 at 3:15 p.m., the Corporate RN indicated the area on the right heel was not present in the emergency room . The tags on the wound pictures were dated 2/21/22 not 2/18/22 and the amount of time she was in the emergency room could have caused those areas and the other areas to decline. 2) Resident E was observed sitting in a reclining chair in her room on 3/29/22 at 9:03 a.m. She wore bilateral heel protectors and had a dressing on her left heel. Resident E's record was reviewed on 3/29/22 at 9:16 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 1/30/22, indicated a long and short term memory problem, dependent on two for bed mobility and transfers, and dependent on one for bathing. The resident had a urinary catheter and was always incontinent of bowel. There were no pressure or venous/arterial wounds. A Care Plan, dated 3/17/22, indicated a pressure ulcer on the coccyx. The interventions included, assess and document areas, assist with bed mobility, provide incontinence care, notify Physician of worsening or no improvement in the he wound, and wound treatment as ordered. A Care Plan, dated 3/24/22, indicated a left heel pressure area. The interventions included to assist with bed mobility and wound treatments as ordered. A Nurse's Progress Note, dated 2/8/22 at 6:21 a.m., late entry for 1 a.m., indicated a 4 cm in diameter raised, hard area was found to the right of the coccyx. There was no break in the skin. The Physician would be notified of the area. There were no further Nurses' Progress Notes or assessments of the area to the right of the coccyx. On 3/11/22 at 6:41 a.m., a Nurse's Progress Note, indicated an area on the right buttock, was a stage 1 (non-bleachable red area, not opened), 0.5 cm x 0.5 cm with a depth of 0.2 cm, with a small amount of bloody drainage and sure prep was applied. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no treatment order for the right buttock/sacrum area until 3/17/22. The Physician ordered a [MEDICATION(S)] dressing to be applied to the area after cleansing on Tuesday, Thursday, Saturday, and as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no assessment of the left heel on 3/15/22. On 3/17/22 at 11:10 a.m., the Wound Nurse's Progress Note indicated an acquired sacrum pressure area. The area was measured at 2.7 cm x 3 cm with 0.3 cm depth, and was now a stage 3 with a small amount of serous drainage. A [MEDICATION(S)] dressing (dressing for superficial wounds) was applied. On 3/17/22 at 11:13 a.m., the Wound Nurse's Progress Note indicated an acquired DTI present on the left heel. The area was measured at 5 cm x 7 cm. and skin prep was applied. The resident was transferred and admitted into the hospital on 3/23/22 due to lethargy and decreased responses. She returned to the facility on [DATE]. A Nurse's Progress Note, dated 3/25/22 at 5:17 p.m., indicated a return admission to the facility. A red open area was observed on the sacrum. There was no assessment of the resident's left heel or a complete assessment of the area on the sacrum. There were no transfer orders from the hospital for treatments to the left heel or sacrum area. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The heel had not been treated from 3/25/22 to 3/27/22 and the sacrum had not been treated from 3/25/22 to 3/28/22. On 3/29/22 at 1:29 p.m., the Wound Nurse and the Corporate RN were interviewed. The Wound Nurse indicated she was unable to find follow up charting on the area of the right buttock from 2/8/22 and the next charting on the right buttock was 3/11/22. She indicated if the wound had a depth of 0.2 cm, it would not be a stage 1. The right buttock and the sacrum pressure ulcer was the same area. She would have looked at the area on 3/14/22 and was unable to remember the measurements. She was also unable to recall if she knew there had not been a treatment ordered for the area. She indicated she had not assessed the open areas since the resident returned from the hospital on 3/25/22 and would complete the assessments on 3/31/22. The Corporate Nurse indicated they would be completed on 3/29/22. The Corporate RN indicated, from 3/11/21 until 3/17/21, there had been no treatment order for the sacrum area. The nurse had documented on 3/25/22 there was a red open area on the coccyx. There was nothing documented about the left heel. There were no measurements. He indicated the nurses were not to measure or stage the areas and only the Wound Nurse was to measure and stage the areas. The Wound Nurse was to do this on the next business day. The nurses were to follow hospital transfer orders, and if treatments were not ordered, they were to notify the physician for orders. He indicated the pressure ulcers would be assessed today by the Wound Nurse and acknowledged no treatment had been ordered for the areas until 3/27/22 and 3/28/22. On 3/29/22 at 3:15 p.m., the Corporate RN presented a paper with the left heel measurements of 2 cm by 1.8 cm with no depth and the sacrum measurements of 3 cm x 2.5 cm with 0.2 cm depth. 3) During an observation on 3/23/22 at 9:57 a.m., CNA 3 and Agency CNA 4 were completing incontinent care. The buttock had excoriation with small open areas. There was a discoloration of the sacrum/coccyx area approximately 10 cm x 10 cm with an open area on the right lower buttock approximately 3 cm x 3 cm superficial. Agency LPN 2 entered the room and applied [MEDICATION(S)]/zinc ointment to the buttock area. She indicated there was no dressing ordered for the buttock area. Resident D's record was reviewed on 3/24/22 at 1:18 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 12/23/21, indicated a long and short term memory problem, extensive assistance of two for bed mobility, dependent on tow for transfers, and extensive assistance for all other activity of daily living. Was always incontinent of bowel and bladder, had no unhealed pressure ulcers, and no moisture associated skin damage (MASD). A Care Plan, dated 3/7/22, indicated impaired skin integrity of the right and left buttock, MASD. The interventions included, wound treatment as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR dated 3/2022, indicated [MEDICATION(S)] ointment apply to buttocks topically every shift for wound healing. Scheduled for Days, Evenings, and Night Shift. The TAR indicated the treatment had not been completed on Day Shift on March 18, 19, 20, 22, 24, and 25, 2022 and on Evening Shift on 3/26/22. A skin management policy, dated 10/2019, and received from the Administrator as current, indicated a head to toe assessment would be completed by a licensed nurse upon admission/re-admission and no less than weekly. The licensed nurse was responsible for assessing any and all skin alterations. Alterations were to be reported to the Physician/Nurse Practitioner and the Responsible Party/family. Treatment orders were to be obtained. All alterations in skin integrity were to be documented in the medical record. Residents were where admitted or readmitted with alterations in skin integrity were to have areas documented on the admission evaluation. The wound Nurse was to be notified and would complete a further evaluation of the wounds on the next business day. This Federal tag relates to Complaints IN 167 and IN 539. 3.1-40(1) 3.1-40(2) 3.1-40(3)

Based on observation, record review, and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to meal consumption records not completed, weights not obtained as ordered, supplements not provided as ordered, and interventions not put in to place timely with significant weight loss for 3 of 4 residents reviewed for nutrition and weight loss. (Residents B, E and D) The Registered Dietician/Dietary Manager did not assess residents timely to assist in preventing weight loss, which resulted in significant weight losses for residents B and E. Finding includes: 1) Resident B's record was reviewed on 3/23/22 at 12:34 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admitted was 11/22/21. A Modification of Admission/Medicare 5 day Minimum Data Set (MDS) assessment, dated 11/29/21, indicated long and short term memory problems, no behaviors, required extensive assistance of one for bed mobility and transfers, supervision for eating, held food in her mouth, no significant weight loss or gain, and was on a mechanically altered diet. A Care Plan, dated 11/29/21, indicated she was a nutrition risk. The interventions included, document food intake, honor preferences, serve diet as ordered, obtain weights, and mechanical soft diet. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/22/21, [MEDICATION(S)] (antidepressant) 15 milligrams for appetite On 12/1/21 to 2/4/22, mechanical soft diet, with thin consistency fluids On 1/20/22 to 2/3/22, Ensure Plus (supplement) 1 can three times a day On 2/4/22, regular puree diet with nectar thick fluids and Ensure Clear (supplement) three time a day The monthly weights were as follows: On 11/22/21, 129.6 pounds On 12/8/21, 120 pounds (7.4% loss) On 1/17/22, 117.1 pounds (9.6% loss) On 2/2/22, 107.3 pounds (17.2% loss) A Nurse's Progress Note, dated 11/24/21 at 9:08 a.m., indicated a new order was received from the dietician to upgrade the diet to a mechanical soft diet and to discontinue the puree diet. A Nurse's Progress Note, dated 1/21/22 2:45 p.m., indicated a poor appetite. A Nurse Practitioner's Progress Note, dated 1/28/22 at 1:05 p.m., indicated the resident was very weak and the staff reported she is not eating or drinking very much. Discussed goals of care and resident's decline with the Power of Attorney (POA). The Daily Skilled Nurses' Notes indicated: On 12/3/21 at 9:56 p.m., refused meals, stated she doesn't like the food. On 12/24/21 at 1:24 p.m., refused breakfast today. On 1/4/22 at 8:40 p.m., very weak, appetite poor. On 1/20/22 at 11:19 a.m., poor appetite. On 1/21/22 at 2:45 p.m., no appetite this shift. The November 2021 Meal Intake Forms indicated: On 11/23/21, 0-25% for breakfast, lunch and supper. On 11/24/21, 0-25% for breakfast and lunch, and 26-50% for supper. On 11/2521, refused breakfast and lunch and 0-25% for supper. On 11/26/21, 0-25% for breakfast, refused lunch, and 26-50% supper. On 11/2721, 26-50% breakfast, refused lunch, and supper not documented. On 11/28/21, no intake was documented for breakfast, lunch, and supper. On 11/29/21, 26-50% breakfast, refused lunch, and no intake was documented for supper. On 11/3021, 0-25% breakfast, no intake documented for lunch and supper. The December 2021 Meal Intake Forms indicated On 12/1/21, 0-25% for breakfast, lunch, and supper. On 12/2/21, 26-50% breakfast, 0-25% lunch and supper. On 12/3/21, 26-50% breakfast, no intake was documented for lunch and supper. On 12/4/21, refused breakfast and lunch and 0-25% for supper. On 12/5/21, 0-25% for breakfast lunch, and supper. On 12/6/21, 0-25% for breakfast, lunch, and supper. On 12/7/21, refused breakfast, 0-25% lunch and supper. On 12/8/21, 26-50% breakfast, lunch, and supper. On 12/9/21, 0-25% breakfast, refused lunch, 0-25% supper. On 12/10/21, 0-25% breakfast, refused lunch, supper not documented. On 12/11/21, 26-50% for breakfast and lunch and 0-25% for supper. On 12/12 21, 51-75% for breakfast, lunch and supper not documented. On 12/13/21, 26-50% for breakfast, lunch and supper not documented. On 12/14/21, 0-25% breakfast, refused lunch, 0-25% supper. On 12/15/21, 0-25% breakfast, lunch, and supper. On 12/16/21, 0-25% breakfast and lunch, and 26-50% supper. On 12/17/21, 26-50% breakfast, 76-100% lunch, 51-75% supper. On 12/18/21, 26-50% breakfast, refused lunch, and supper not documented. On 12/19/21, refused breakfast and lunch, and 26-50% supper. On 12/20/21, refused breakfast and lunch, and 0-25% supper. On 12/21/21, 0-25% breakfast, refused lunch, and 0-25% supper. On 12/22/21, 0-25% breakfast, lunch, and supper. On 12/23/21, refused breakfast and lunch, and 26-50% supper. On 12/24/21, 0-25% breakfast, refused lunch, and 0-25% supper. On 12/25/21, 0-25% breakfast, lunch, and supper. On 12/26/21, 26-50% breakfast, no documentation for lunch and supper. On 12/27/21, 0-25% breakfast and lunch, no documentation for supper. On 12/28/21, refused breakfast, 0-25% lunch, and refused supper. On 12/29/21, 0-25% breakfast, lunch, and supper. On 12/30/21, 0-25% breakfast and lunch and 51-75% supper. On 12/31/21, 0-25% breakfast and lunch, and 26-50% supper. The January 2022 Meal Intake Forms indicated: 1/1/22, 0-25% breakfast and lunch, 51-75% supper. 1/2/22, 0-25% breakfast, lunch and supper. 1/3/22, 26-50% breakfast and lunch, 51-75% supper. 1/4/22, breakfast and lunch not documented, 51-75% supper. 1/5/22, refused breakfast, 0-25% lunch, and 26-50% supper. 1/6/22, no documentation of intake for breakfast, lunch, and supper. 1/7/22, 51-75% breakfast, lunch, and supper. 1/8/22, 0-25% breakfast, lunch, and supper. 1/9/22, 0-25% breakfast, refused lunch, no documentation for supper. 1/10/22, breakfast and lunch not documented, 0-25% supper. 1/11/22, nothing documented for breakfast, lunch, and supper. 1/12/22, 0-25% breakfast and lunch, no documentation for supper. 1/13/22, 0-25% breakfast, no documentation for lunch, 0-25% supper. 1/14/22, refused breakfast and lunch, and 0-25% supper. 1/15/22, 0-25% breakfast, lunch, and supper. 1/16/22, 0-25% breakfast, lunch not documented, 51-75% supper. 1/17/22, refused breakfast, 51-75% lunch and supper. 1/18/22, nothing documented for breakfast, lunch, and supper. 1/19/22, nothing documented for breakfast and lunch, refused supper. 1/20/22, nothing documented for breakfast and lunch, 26-50% supper. 1/21/22, 0-25% breakfast, no documentation for lunch, and 26-50% supper. There was no Dietary assessment from the Registered Dietician or Dietary Manager located in the record. No new interventions were initiated due to the poor appetite and continued significant weight loss until 1/20/22. The Guardian had not been notified of the significant weight loss until 1/28/22. On 3/23/22 at 4:15 p.m., the Administrator indicated there were no Registered Dietician or Dietary Manager assessments completed. She indicated the Nurse Practitioner had spoken to the Guardian about the resident's appetite and condition on 1/28/22, 1/31/22, and 2/3/22 and Ensure Plus was initiated on 1/20/22. 2) Resident E's record was reviewed on 3/29/22 at 9:16 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was hospitalized from 1/30/22 to 2/3/22 and 3/23/22 to 3/25/22. A Quarterly MDS assessment, dated 1/30/22, indicated long and short term memory problems, extensive assistance with bed mobility, dependent on staff for transfer, extensive assistance needed with eating, had no significant weight loss or gain, and was on a therapeutic diet. A Care Plan, dated 9/30/21 and revised on 3/26/22, indicated a she was a nutrition risk. The interventions included, document food and fluid intakes, honor food preferences, provide diet and supplements as ordered (added 3/26/22), puree diet and the Registered Dietician was to evaluate and make diet change recommendations as needed (added 3/26/22), and the Physician would be notified of significant weight changes. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/8/22, weekly weights for four weeks On 3/9/22, complete a three day calorie count. On 3/25/22, reduced carbohydrate puree diet On 3/28/22, fortified pudding with lunch and dinner, fortified cereal with breakfast, 2 cal supplement 120 milliliters was to be given twice a day, The weights were as follows: On 1/28/22, 128 pounds On 2/3/22, 132.1 pounds On 2/13/22, 130.1 pounds On 3/11/22, 108 pounds On 3/26/22, 112.6 pounds On 3/27/22, 112.6 pounds The weekly weights for four weeks were not completed as ordered on 2/8/22. There was a 16.9% weight loss from 2/13/22 to 3/11/22. A Dietary Progress Note, dated 2/10/22, indicated it was a Quarterly Assessment. The resident received a carbohydrate controlled mechanical soft diet. She consumed 51-75% of breakfast, 51-75% lunch, and 51-75% supper. She received no supplements or fortified food. No [CONDITION(S)] was noted and she had 7% weight gain in 180 days, which was not significant in the time frame. The Dietary Intake Forms indicated: On 2/4/22, breakfast and lunch - 76-100%, supper - 51-75%. On 2/5/22, no intake documented for breakfast and lunch, supper 51-75%. On 2/6/22, no documentation of intakes for breakfast, lunch, and supper. On 2/7/22, no documentation of intakes for breakfast, lunch, and supper. On 2/8/22, breakfast - 26-50%, 0-25% for lunch and supper. On 2/9/22,no breakfast and lunch, and supper 51-75%. On 2/10/22, breakfast and lunch - 26-50%, and supper 51-75%. On 2/11/22, no breakfast and lunch, and supper 51-75%. On 2/12/22, no intakes documented. On 2/13/22, no intakes documented. On 2/14/22, breakfast and lunch 51-75%, and no supper. On 2/15/22, no intake. On 2/16/22, no intake. On 2/17/22, no intake breakfast and lunch, and supper 76-100%. On 2/18/22, 75-100% breakfast and lunch, and no supper. On 2/19/22, no intake. On 2/20/22, no intake. On 2/2122, 75-100% breakfast and lunch, and supper 26-50%. On 2/22/22, 26-50% breakfast, lunch and supper. On 2/23/22, 26-50% breakfast, 0-25% lunch, no supper. On 2/24/22, no intake. On 2/25/22, 51-75% breakfast, 0-25% lunch, and no supper. On 2/26/22, no intakes documented. On 2/27/22, no intakes documented. On 2/28/22, breakfast and lunch 76-100%, and no supper. On 3/1/22, 0-25% breakfast and lunch, and 51-75% supper. On 3/2/22, breakfast and lunch 76-100%, no supper. On 3/3/22, no intake. On 3/4/22, breakfast and lunch 75-100%, and supper 51-75%. On 3/5/22, breakfast 76-100%, no lunch and supper. On 3/6/22, refused breakfast, 50-75% lunch, and 26-50% supper. On 3/7/22, 26-50% breakfast and lunch, and no supper. On 3/8/22, 0-25% breakfast and lunch, and no supper. On 3/9/22, 0-25% breakfast, refused lunch, and no supper. On 3/10/22, refused breakfast, 0-25% lunch, and refused supper. On 3/11/22 - no intake. A Nurse's Progress Note, dated 3/11/22 at 10 a.m., indicated she continued to have very poor appetite. She was now fed by the staff. Weight was obtained twice with a mechanical lift and showed a weight loss. The Power of Attorney was notified and a three day calorie count had been started on 3/8/22. A Physician's Progress note, dated 3/11/22 at 11:44 a.m. , indicated a significant weight loss. She refused to eat or drink most of the time as reflected on the three day calorie count. Impression & Plan: [MEDICATION(S)] (diuretic) discontinued and unintentional weight loss, consider appetite stimulant. Also consider reducing or eliminating [MEDICATION(S)]/[MEDICATION(S)] (diabetic medication) due to poor intake. The three day calorie count indicated the following intakes: 3-day cal count March 9-11, 2022 On 3/9/22 - 100% pancake, 25% cereal and 50% supplement 25% potato/noodle, 100 milk and juice 25% dessert 50% sandwich, 25 % vegetable, 100% juice On 3/10/22 - 5 bites of pancake 5% meat, 100% juice, 75% desert 100 % juice, 50% juice, 100% supplement On 3/11/22 - 25 % toast, 100 juice , 100 ensure 25% soup, 25% vegetable, 25% bread, 100% juice, 100% dessert 50% soup, 25% vegetable There were no dietary notes, assessment, and/or recommendations until 3/26/22. A Registered Dietician's Progress Note, dated 3/26/22, indicated a significant change in weight. The weight was 113 and usual body weight was 123. The Body Mass Index was 18.7. A weight change of 17% in 1 month, 11% in 90 days, and 8% in 180 days. Calorie needs were 1398-1677 with 67 grams of protein and fluids of 1677 cc. (cubic centimeters). Intakes were less than 51% and fluid intake was less than 1000 cc's. Recommendations of fortified cereal and fortified pudding with lunch and dinner, and 2 cal supplement 120 cc's twice a day. On 3/29/22 at 1:38 p.m., the Dietary Manager indicated the total calories taken by the resident on the three day calorie count had not been completed. The Registered Dietician placed the resident on fortified foods and supplements, which were not started until 3/28/22. On 3/29/22 at 1:56 p.m., the Dietary Manager indicated she had never completed the three day calorie count form before. She had given a list of weight losses to the Registered Dietician a few weeks ago. There was nothing initiated when the significant loss occurred. 3) During an observation of the noon meal on 3/24/22 at 12:39 p.m., Resident D was sitting in a high back reclining chair in the dining room. CNA 3 attempted to assist the resident with her noon meal several times and the resident would not take a bite or drink. She kept her eyes closed and would not open her mouth. CNA 3 indicated the resident was too sleepy and she had her good days and bad days. Resident D's record was reviewed on 3/24/22 at 1:18 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 12/23/21, indicated long and short term memory problems, extensive assistance with eating, and no significant weight loss or gain. A Care Plan, dated 7/5/21, indicated a concern with nutritional intakes. The interventions included, provide and serve diet as ordered, serve supplements as ordered, and the Registered Dietician would evaluate as needed. The monthly weights are as follows: 7/5/21 - 124 pounds 9/3/21 - 122 pounds 11/8/21 - 123 pounds 12/6/21 - 119 pounds 2/2022 - 112.4 pounds, provided by the Administrator by a handwritten and undated CNA sheet 3/8/22 - 118 pounds. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication/Treatment Administration Records, dated 3/2022, indicated the Ensure had not been given on 3/10/22 at 7 a.m., 3/11/22 at 4 p.m., 3/12/22 at 7 a.m., 3/15/22 at 4 p.m., 3/16/22 at 7 a.m., 3/18/22 at 7 a.m., 3/20/22 at 7 a.m., and 3/22/22 at 7 a.m. The four ounces of the mighty shake had not been given on March 10, 12, 16, 18, 19, 20, and 22, 2022. A facility policy for weight monitoring, dated 10/2018 and received from the Administrator as current, indicated the resident's physician and family/guardian would be notified of any verified significant weight change. Residents with verified significant weight change would be followed by the Interdisciplinary Team. Weekly weights would be taken on a designated day each week. Residents were to be reweighed if a change of plus or minus three pounds in a week was noted. This Federal tag relates to IN 167. 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure a resident's pressure ulcer was treated as ordered by the Physician resulting in the pressure ulcer deteriorating from a DTI (deep tissue injury) to a 100% necrotic area (Resident C). The facility also failed to thoroughly and timely assess pressure ulcers for 2 of 5 residents reviewed for pressure ulcers. (Residents D and G) Findings include: 1. Resident C's closed record was reviewed on 9/8/2020 at 9:45 a.m. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 2/2/2020, indicated the resident had a severely impaired cognition status, required extensive, two person assist for bed mobility and was totally dependent on staff for transfers, bathing and dressing. The Nurses' Progress Notes indicated: On 2/18/20 at 1:47 p.m., the resident had been transferred to the emergency room due to having critical laboratory results. There was no further documentation noted regarding return. On 2/18/20 at 6 p.m., the facility Nurse observed a dark brown/purple area to the left heel. The area was non tender. The Nurse Practitioner was on the unit at the time and a new order was received for a dressing to the heel. Prevalon boots (pressure relieving) placed on the resident. The Pressure Ulcer Weekly Measurement Form, dated 2/18/20, indicated the left heel measured 5 cm (centimeters) by 5 cm, was unstageable, and was brown/purple colored. The Wound Physician's Note, dated 2/27/20, indicated the left heel measured 6 cm by 7 cm, was an unstageable deep tissue injury, and ordered skin prep for 30 days. The Treatment Administration Records (TARS), dated 2/2020 and 3/2020, indicated from 2/27/20 to 3/8/20, the skin prep was to be administered to the right heel every shift. The TARs indicated by initials the treatment was completed to the right heel. The Pressure Ulcer Weekly Measurement Form, dated 3/5/20, indicated the left heel measured 8 cm by 6 cm with worsening necrotic tissue present, and was now 100% black. A Physician's Progress Note, dated 3/5/2020 at 1:42 p.m., indicated the wound was deteriorating and the Wound Physician was consulting on the wounds. A Nurses' Progress Note, dated 3/8/20 at 11:30 p.m., indicated the resident had been transferred and admitted to the hospital for other medical conditions. Interview with RN 2 on 9/9/2020 at 2:56 p.m., indicated the Treatment Administration Records for February and March had a treatment for [REDACTED]. RN 2 was the Wound Nurse at that time and indicated she had put the order in the computer incorrectly and she could not remember if the resident had received the correct treatment to her left heel. 2. Resident D's closed record was reviewed on 9/9/20 at 10:54 a.m. The [DIAGNOSES REDACTED]. An Admission/5-Day Minimum Data Set (MDS) assessment, dated 4/1/20, indicated a moderately impaired cognition status, extensive assistance of two for bed mobility, dependent for transfers, and unhealed pressure ulcers. A Care Plan, dated 3/27/20, indicated there were two pressure ulcers on the left ankle. The interventions indicated the pressure ulcers were to be assessed, assessments were to be documented, and the wound would be treated per the physician's orders [REDACTED]. A Braden Scale assessment, dated 3/26/20, indicated a risk for pressure ulcers. An Admission Nursing Assessment, dated 3/26/20 at 1:40 p.m., indicated the left ankle had two pressure areas, both measured 1.2 centimeters (cm) by 5 cm and they were about one inch apart. There were no further assessments of the left heel, no Physician notification of the areas, and no treatments were ordered. A Wound Assessment form, dated 4/12/20, indicated there was an unstageable (covered with slough or eschar) pressure area on the left heel. The wound bed was black/brown and measured 0.8 cm by 0.4 cm. The next Wound Assessment was dated 4/23/20 and indicated there had been no change in the size or description of the pressure area on the left heel. During an interview with LPN 2 on 9/9/20 at 2:40 p.m., she indicated there were only wound sheets for the left heel. There were no further measurements of the left ankle. No documentation was noted for the heel for notification of Family of areas on the ankle & heel. There was no documentation to indicate the Physician was notified of the ankle and heel areas. There were no orders for treatment of [REDACTED]. 3. Resident G's closed record was reviewed on 9/9/20 at 3:25 p.m. The [DIAGNOSES REDACTED]. A Quarterly MDS assessment, dated 3/21/20, indicated a severely impaired cognition status, extensive assistance for bed mobility and transfers, was at risk for pressure ulcer, and had no pressure ulcers present. physician's orders [REDACTED]. A Nurse's Progress Note, dated 4/15/20 at 10:08 p.m., indicated an open area was observed on the buttocks, the area was excoriated, and a coccyx wound barrier was applied. There was no assessment describing the open area and the open area was not measured. There was no documentation that indicated the resident was seen by the Wound Team, as ordered by the Physician. During an interview on 9/10/20 at 10:57 a.m., LPN 2 indicated she was unable to locate a thorough assessment of the open area with a description and measurement of the area. During an interview on 9/10/20 at 3:30 p.m., the Administrator acknowledged the Quality Assurance and Performance Improvement plan (QAPI) was put into place on June 3, 2020 and the plan was to decrease the number of nosocomial pressure ulcers and prevention of new pressure ulcers. The QAPI plan was initiated 3-4 months after the above issues. A facility policy, dated 10/2019, titled, Skin Management, received from the Administrator as current, indicated, .The licensed nurse is responsible for assessing any and all skin alterations as reported by the direct caregivers on the shift reported .Treatment order will be obtained. All alterations in the skin integrity will be documented in the medical record .All newly identified areas after admission will be documented on the weekly pressure/non-pressure evaluation .The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day . This Federal Tag relates to Complaints IN 997, IN 436, IN 482 and IN 724. 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision to prevent a fall, related to a resident who was a high risk for falls, was left unattended in the bathroom and fell . The resident received a head laceration and hematoma, which required sutures and an admission into the hospital, for 1 of 4 residents reviewed for accidents and hazards, in a total sample of 5. (Resident #F) Findings include: Resident #F's record was reviewed on 01/07/15 at 12 p.m. The resident's [DIAGNOSES REDACTED]. A Fall Risk Screening Tool, dated 10/02/14, indicated the resident was a high risk for falls with a score of 13 (score of 10 or above represents high risk). A 14-Day Minimum Data Set Assessment, dated 10/15/14, indicated the resident's cognition was severely impaired, required limited assistance with ambulation in the room, extensive assistance with toilet use, required staff assistance with moving from seated to standing position and walking, and had no falls since admission into the facility. A care plan, dated 10/22/14, indicated the resident was a fall risk, was unaware of safety needs, and had fallen on 10/25/14, 12/04/14, and 12/09/14. The interventions included, 10/25/14-sensor pad at all times and 12/04/14-Velcro self releasing lap buddy to the wheelchair. A CNA Care Card, dated 10/03/14, indicated the resident was a fall risk, required assistance of one for elimination and mobility and had a sensor pad at all times. A Nurses' Note, dated 12/09/14 at 1:23 a.m., indicated, "12:30 a.m., CNA was assisting res. (resident) to the BR (bathroom) et (and) res. was sitting on toilet et lost her balance et fell off of toilet hitting her head. Upon writers assessment mod. (moderate) amt. (amount) of bright red blood to (R) (right) side of back of res. head with laceration...12:40 a.m. (Physician's Name) notified of fall. Order received to sent res. to ER via 911..." A Nurses' Note, dated 12/09/14 at 3:22 a.m., indicated the resident had been admitted into the hospital. A CT Scan of the head, dated 12/09/14, indicated the resident had a hematoma in the right posterior thalamus (part of the brain), which measured, 1.2 cm (centimeters) x 1.1 cm x 1.0 cm. and a small right parietal scalp hematoma. A Physician's Note, dated 12/09/14, indicated the resident had a small right scalp laceration from the fall and had staples on the small high parietal laceration. A Physician's Note, dated 12/09/14 at 6:33 p.m., indicated the resident was in the Intensive Care Unit at the hospital with a head injury due to the fall. The Physician indicated the resident had fallen many times and the [DIAGNOSES REDACTED]. The resident was discharged from the hospital back to the facility on [DATE]. A Non-Pressure Skin Condition Report, dated 12/10/14, indicated the resident returned with 3 cm long laceration on the right side of the head, which had two stitches. The facility's follow up investigation of the fall on 12/09/14, dated 12/16/14, indicated on 12/09/14 at 12:30 a.m., the CNA responded to the resident's safety alarm sounding and observed the resident attempting to get out of bed. The CNA assisted the resident to the bathroom and while sitting on the toilet the resident lost her balance and fell on to the floor. The CNA indicated she was obtaining an incontinent brief from the resident's closet (located in the resident's room, not in the bathroom) and could not reach the resident in time. The follow up indicated the care plan had been updated with the intervention not to leave the resident unattended in the bathroom. During an interview on 01/07/15 at 1:45 p.m., the Director of Nursing (DoN) indicated the CNA was in the resident's room at the time of the fall, but was not in the bathroom. She indicated the CNA was getting a brief out of the closet at the time of the fall. The DoN indicated the CNA should have put the call light on for assistance. The DoN indicated, the staff have been re-educated after the fall, not to leave fall risk residents alone in the bathroom. This Federal Tag relates to complaint IN 660. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to investigate the cause and prevent worsening of an existing pressure ulcer for 1 of 3 residents reviewed for pressure ulcers of the 7 who met the criteria for pressure ulcers. This resulted in a deterioration of the wound from a Stage I when the resident was admitted to a Stage III pressure ulcer. (Resident #46) Findings include: Observation on 12/2/14 at 2:13 p.m., Resident #46 was sitting in a wheelchair in her room with a pillow behind her back. Observation on 12/3/14 at 9:51 a.m., Resident #46 was sitting in a recliner in her room watching television with a pillow placed behind her back. Observation of a Stage 3 pressure ulcer wound and treatment of [REDACTED].#1 and the 3A Unit Manager was completed on 12/4/14 at 11:00 a.m. Resident #46 was sitting in a recliner and leaned forward while LPN #1 began to pull the residents shirt up to get to the bandage of the wound. A bandage with tape was noted to the center of the residents back. LPN #1 began to remove the dressing to the residents back. A wound was observed. The wound was raised with an area measuring approximately the size of half a tennis ball. The wound bed was noted to have green/yellow slough (dead tissue). The area around the wound was reddened and purple with swelling around the site. There was a small amount of red blood noted to the wound. LPN #1 indicated there was no warmth noted to the wound. After the wound observation was completed, Resident #46's back brace was observed. The back brace attached with Velcro around the body and fastened in the front. The back of the brace was noted to have wires that intertwined in the middle of the back. Record review for Resident #46 was completed on 12/2/14 at 2:47 p.m. The residents [DIAGNOSES REDACTED]. The Minimum Data Set Admission assessment completed on 11/4/14 indicated the resident was cognitively intact. The assessment indicated the resident was an extensive one person assist for transfers, bed mobility, locomotion, toileting and hygiene. The resident had two stage 1 pressure ulcers, and one stage 3 pressure ulcer. The resident was admitted to the facility on [DATE] with a Physician order [REDACTED]. A care plan with effective dates of 10/29/14-11/12/14 indicated, Pressure Sores/Skin Care/back brace 10/28/14 admit coccyx and upper mid back wound. The Goal was to prevent pressure sores and skin breakdown. The interventions included to follow facility skin care protocol, report to charge nurse any redness or skin breakdown immediately, and treatment as ordered. The care plan lacked any documentation to indicate the stage of the back wound. A care plan dated 11/13/14 indicated, Pressure Sores/Skin care admitted with coccyx and upper back wound on 10/28. The coccyx wound was resolved. The Goal was to heal current wounds and prevent further skin breakdown. The interventions included to follow facility skin care protocol, low air loss mattress, back brace to be donned during ambulation and therapy only. The care plan lacked any documentation to indicate the stage of the back wound. A wound/skin healing record for the pressure ulcer began on 10/28/14. The record indicated a Stage 1 pressure ulcer began on the upper back on 10/28/14. The size measured 2 cm (centimeters). There was no exudate (drainage) or odor. The wound bed had [MEDICATION NAME] tissue (tissue covering body). Surrounding skin was pink, surrounding tissue/wound edges were normal for skin. No pain was indicated. The comments section it indicated the periwound measured 6.0 cm x 4.7 cm. A physician order [REDACTED]. A physician order [REDACTED]. On 11/6/14 the Wound/Skin healing record indicated the wound had increased to a Stage 2 measuring 1.3 cm x 1.3 cm x <0.1 cm. There was no exudate or odor noted. The assessment was not completely filled out. No indication of the wound bed, surrounding skin color, wound edges or pain was assessed. The assessment did not indicate the plan of care had been updated nor the physician was notified. The assessment was also not signed. A pressure ulcer record sheet dated November 2014 indicated on 11/6/14 the wound was pink/red/purple and an open area was noted. The physician was notified with no change in treatment. On 11/10/14 the Wound/Skin healing record indicated the wound had increased to a Stage 3 measuring 2.2 cm x 2 cm x 0.4 cm. There was a small amount of serosanguineous (blood tinged) drainage. No odor noted. The wound bed was not marked as assessed. The surrounding skin color was dark red/purple. The surrounding tissues/wound edges were maceration (softening and breaking down of skin). Pain indicated yes and was demonstrated by moaning/crying. A Nursing Note dated 11/10/14 at 8:48 p.m., indicated the Nurse Practitioner had seen the resident for complaints of pain during the afternoon. New orders for an x-ray of the [MEDICATION NAME] spine and scheduled pain medications was received and noted. The resident was also to lie in bed with brace off for an hour at least twice during the day. A Nursing Note dated 11/11/14 at 2:19 pm., indicated the resident was complaining of pain to her side and back related to the brace. The Orthopaedic Physician was contacted and made aware of the residents complaints of pain. The nurse suggested a decrease in the number of hours the brace was worn. The Orthopaedic Physician indicated the resident needed to keep the brace on while up in a chair and may have it off if lying down. The Physician was reminded of the wound to the resident's back and possibility of progression. Order to keep brace on remained. A physician order [REDACTED]. The back brace was ordered to be only on when the resident was ambulating and when doing therapy. On 11/13/14 the Wound/Skin healing record indicated the wound was assessed as an unstageable wound measuring 3.2 cm x 2.5 cm and the depth was undetermined. There was a small amount of serosanguineous drainage, with no odor. The wound bed had [MEDICATION NAME] tissue, granulation tissue (new tissue), and black/brown eschar (dead tissue). The surrounding skin color was bright red and dark red/purple. The surrounding tissue/wound edges had peripheral tissue [MEDICAL CONDITION] (swelling) and rolled edges. The assessment indicated pain was not assessed. Under the comments section the periwound measured 6.0 cm x 4.5 cm x undetermined. On 11/17/14 the Wound/Skin healing record indicated the wound was assessed as a stage 3 measuring 5.0 cm x 3.0 cm x undetermined. There was no drainage or odor noted. The wound bed had granulation tissue and 25% slough. The surrounding skin color was dark red/purple. The surrounding tissue/wound edges had peripheral tissue [MEDICAL CONDITION]. No pain was noted. The response to treatment indicated the wound had deteriorated. Under the comments section the periwound measured 7.5 cm x 6.2 cm. On 11/20/14 the Wound/Skin healing record indicated the wound was assessed as a stage 3 measuring 5.0 cm x 3.0 cm x undetermined. There was no drainage or odor noted. The wound bed had granulation tissue and black/brown eschar. The surrounding skin color was dark red/purple. The surrounding tissues/wound edges had peripheral tissue [MEDICAL CONDITION]. The pain assessment was not filled out. Under the comments section the periwound measured 7.6 cm x 6.4 cm. On 11/24/14 the Wound/Skin healing record indicated the wound stage was not filled out. The wound measured 4.8 cm x 2.8 cm. There was no drainage or odor noted. The wound bed had granulation tissue and slough. The surrounding skin color was dark red/purple. The surrounding tissues/wound edges had peripheral tissue [MEDICAL CONDITION]. The pain assessment was not filled out. On 11/28/14 the Wound/Skin healing record indicated the wound was assessed as a stage 3 measuring 3.8 cm x 1.9 cm x <1.0 cm. There was a small amount of serosanguineous drainage noted with no odor. The wound bed had slough. The surrounding skin color was dark red/purple. The surrounding tissues/wound edges was noted normal for skin. The assessment indicated pain was evident to the wound. The response to treatment was marked as improved. On 12/1/14 the Wound/Skin healing record indicated the wound was assessed as a stage 3 measuring 3.5 cm x 2 cm x undetermined. There was no drainage or odor noted. The wound bed had [MEDICATION NAME] tissue and black/brown eschar. The surrounding skin color was bright red and dark red/purple. The surrounding tissues/wound edges had peripheral tissue [MEDICAL CONDITION]. The assessment indicated no pain was evident. The record lacked any documentation indicating an investigation was completed as to why the resident had a wound that was deteriorating until the wound became a Stage 3 ulcer. A Physician's Progress Note dated 12/2/14 indicated an exam of a spine wound. The wound was swollen with no drainage or odor. A culture was done for a suspected infection. A Pathology report dated 12/4/14 indicated the culture results were moderate Staphylococcus Aureus, Susceptibility in progress, Culture in progress. The report status was pending. Interview with the Nurse Practitioner on 12/2/14 at 3:26 p.m., indicated the staff told her the wound was caused from wearing the back brace. She further indicated the back brace made the wound increase in stage from wearing it all the time. Interview with 3 B Unit Manager on 12/3/14 at 11:15 a.m., indicated she assumed the wound progressing from a stage 1 to a stage 3 was from the back brace, but nothing was done about the brace until the wound went to a Stage 3. She further indicated she spoke with the orthopaedic doctor when the wound went to a Stage 3 and the doctor did not want to do anything with the brace. She then indicated she spoke with the medical director on 11/11/14 and the order was changed for back brace to be worn only with therapy and ambulation. The record lacked any documentation indicating an investigation of the brace as being the cause of the wound until the wound progressed to a Stage 3. Interview with the 3 B Unit Manager on 12/4/14 at 10:28 a.m., indicated when the residents wound went to a stage 2 on 11/6/14 and the wound progress assessment report should have been completed and signed but was not done. Interview with the 3A Unit Manger on 12/4/14 at 10:33 a.m., indicated she could not find the pressure ulcer care plan had been updated when it progressed to a stage 2 and it should have been updated. Interview with LPN #1 and the 3A Unit Manager on 12/4/14 11:00 a.m., indicated the wound was noticed on 12/2/14 to be reddened/purple and elevated. The Nurse Practitioner examined the resident and ordered a culture to be done and an antibiotic given for possible abscess. Interview with the resident on 12/4/14 at 11:34 a.m., indicated when she first started wearing the brace she told the nurses it hurt, but the nurses told her she had to wear the brace. The resident indicated the wires in the back of the brace rubbed her back. Interview with PT #1 on 12/5/14 at 9:07 a.m., indicated the resident was in therapy for strengthening, gait training, and bed mobility. He further indicated the resident complained of pain with the brace and he let the nurses know the resident had complained of pain. Interview with COTA #1 on 12/5/14 at 9:13 a.m., indicated the resident was in therapy for strengthening, endurance, balance, transfers and bed mobility. She further indicated the resident would complain of pain with the brace. She indicated she would readjust the brace, because sometimes it would ride up on the resident and then she would let the nurse know the resident was complaining of pain. A policy titled Pressure Ulcer/Wound Assessment and received from the Director of Nursing on 12/3/14 at 3:22 p.m., indicated.Policy: Wound assessment is a continuous process that serves to provide information about wound status, staging, its etiology, and the efficacy of the interventions.Pressure ulcers/wounds shall be measured and assessed weekly. Stage II through Stage IV pressure areas will be assessed daily to determine healing/deterioration.Record and date all information and document on the Pressure ulcer record. Notify physician when the condition warrants An email was received from the Director of Nursing on 12/5/14 at 5:25 p.m. This information was received after the survey team had completed the exit conference and left the facility. The email included an Unavoidability Statement for Impaired Skin Integrity signed by the Nurse Practitioner dated 12/5/14. The statement indicated the resident had intractable back pain with a compression fracture and accentuated Kpyhotic curvature of [MEDICATION NAME] spine. The patient was seen by the orthopaedic to wear back brace at all times when out of bed to give support of compression fracture, back pain, and to assist with activities of daily living and care. The benefits of wearing the brace out weigh the risks of not wearing it. The patient had developed a pressure area from wearing brace constantly while out of bed. The patients risk of pressure was high secondary to kyphosis, low zinc level and low pre-[MEDICATION NAME] level. The patient had previous pressure area to kyphosis in [MEDICATION NAME] area. The brace was used to support and enhance quality of living although high risk of pressure to area is possibility. 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident received adequate assistance to prevent accidents, related to not following the facility's policy for 2 assistance with the use of a mechanical lift, for a resident who required a mechanical lift for transfers. The resident was admitted into the hospital with a laceration to the head and a subdural hematoma (bleeding of the brain), after the incorrect transfer was completed, for 1 of 3 residents reviewed for mechanical lift transfers in a total sample of 3. (Resident #E and CNA #1) Findings include: Resident #E's record was reviewed on 10/09/14 at 10:36 a.m. The resident's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment, dated 03/21/14, indicated the resident had long and short term memory problems, no behaviors, was dependent on two assistance for transfers, and had no falls. A care plan, dated 03/21/14, indicated the resident was at a risk for falls and the interventions included to use a mechanical lift with two assistance for all transfers. A care card (information to care for the resident), dated 07/11/14, and received from the Director of Nursing (DoN) on 10/09/14 at 3 p.m., indicated the resident required a mechanical lift with the assistance of two for transfers. A clinical note, dated 07/17/14 at 8:32 p.m., indicated, "Staff noticed a skin tear to res. (resident) left thumb, writer into (sic) assess, a skin tear noted to left thumb 1 x .2 cm (centimeter), a small amount of bleeding noted...Unknown how it happened. MD (Medical Doctor) updated...message left on POA machine..." A clinical note, dated 07/18/14 at 9:53 a.m., indicated, "3:40 a.m. writer summoned into residents (sic) room...resident is drulling (sic) and nonresponsive (sic). While doing assessment Resident (sic) open slightly one one (sic) would not move any body parts. Reassessment to hand found left thumb steri strips in place and then noticed further laceration to left thumb and first digit. Vitals taken...Instructed CNA to continue with residents personal care. After a few minutes writers (sic) summonded (sic) back in the room. CNA found small amount of blood underneath residents (sic) head. Writer cleaned area around back of neck and noticed a small of (sic) dried blood no active bleeding. Writer and CNA continued to asses (sic) area then noticed a laceration behind the right ear area clean no active bleeding...sendin (sic) resident ER (sic)...5:30 am (sic) received called (sic) from ER...Massive Brain Bleed..." The hospital notes, dated 07/18/14, indicated the resident's [DIAGNOSES REDACTED]. The notes indicated the resident had five staples used to close the 4.5 cm (centimeter) wound behind the right ear and the CT of the head indicated the resident had a left frontal lobe hemorrhage and the resident did not appear to have excessive bruising or other extremity injuries. An emergency room note, dated 07/18/14 at 5:53 a.m., indicated the facility was notified about the CT scan and the facility had stated they did not know if the resident had fallen or not and the CNA had gone in to the resident's room about 3:30 a.m. to turn the resident and discovered the laceration to the back of her right ear. An emergency room note, dated 07/18/14 at 6:14 a.m., indicated they had contacted the facility again, and the Nurse for the resident indicated the resident had been in bed all night and upon checking the resident, the resident was less responsive, and blood was seen on the pillow, and with turning the resident the wound to the head was observed. The Nurse could not recall if the side rails were up and had informed the emergency room she had not noticed any objects in the bed, which may have caused the bleeding. The emergency room note, dated 07/18/14, indicated the resident was admitted into the facility with the [DIAGNOSES REDACTED]. A Hospital History and Physical, dated 07/18/14, indicated, "...laceration behind the right ear. The staff at the nursing home state that they are unsure how the patient sustained a laceration to the back of her head. She also has a small laceration to the right hand as well. Nursing home staff also states that she she (sic) does not ambulate and they found her laying in bed...the patient has a large 4 cm laceration over the area of the mastoid process (behind the ear)...The patient has a skin tear to the web space between the thumb and index finger on the right hand...CT brain...Hemorrhage measures up to approximately 4.5 cm...x 3.3 cm wide x 3.7 cm high...There is rightward midline shift..." A facility investigation, dated 07/18/14, indicated the Nurse and the CNA (CNA #1) had found the resident unresponsive and drooling, noted a skin tear to the left thumb and then noticed a small amount of blood on the pillow. The investigation indicated there was no blood found on the clothing or bed sheets. The investigation indicated a CNA had transferred the resident to bed alone using the mechanical lift on the evening of 07/17/14. The investigation indicated the CNA had not followed the facility's lift/transfer protocol and a stain on the mechanical lift pad may have been blood. The investigation indicated the Local Police Department had been notified of the incident and due to the ongoing investigation, the resident's room, mechanical lift, and the lift pads had been secured. The investigation indicated attempts to contact CNA #1 during the continued investigation was unsuccessful and a certified letter had been sent to her for continued investigation of the incident. A typed interview with CNA #1 on 07/18/14 at 10:30 a.m., typed by the DoN, indicated CNA #1 had transferred the resident with a mechanical lift on 07/17/14 a little before 8 p.m. CNA #1 indicated she had transferred the resident by herself. The interview indicated CNA #1 denied the resident had hit anything or fell during the transfer and the resident had a discoloration of the left hand but the skin had not broke until the resident was placed in bed. CNA #1 indicated she had to change the resident's gown because of the blood from the hand skin tear. CNA #1 indicated she had provided incontinence care due to loose bowel movements 2-3 times and there was no blood noted during any of those times. CNA #1 admitted to using only one assistance for the mechanical lift transfer. A typed note by the DoN, dated 07/18/14 at 3:30 p.m., indicated CNA #2 (also worked the evening of 07/17/14) had fed the resident dinner and denied seeing any type of head injury or blood. CNA #2 indicated CNA #1 had not asked her for help with the residents on 07/17/14. A handwritten note, dated 07/21/14 and written by the DoN, indicated CNA #2 had noticed a spray bottle of disinfectant and Lysol on the bin outside of the resident's room around 8 p.m. on 07/17/14. A hand written note, written and signed by CNA #3, dated 07/18/14, indicated she came in at 10:23 (p.m.) and CNA #1 had given her report and said everything was normal, but (Resident #E) had a skin tear on her left thumb. CNA #3 indicated she had looked in on the resident and the resident looked, "okay". She indicated she was in and out of Resident #E's room three or four times and the resident looked, "okay". CNA #3 indicated she had gone into the resident's room around 1:00 (a.m.) to check the resident for incontinency,the resident was dry, and the resident acted normal. CNA #3 indicated she then gone into the resident's room at 3:45 a.m. and she noticed she was unresponsive and drooling and she went and reported the change to the Nurse on duty. She indicated after the Nurse assessed the resident, she continued to change the resident's incontinent brief and when she rolled the resident to the side, she noticed blood on the bed and her pillow. CNA #3 then immediately reported this to the Nurse. CNA #3 indicated she moved the resident's hair around and found a gash behind the resident's ear. The Police report, no date listed for date assigned, indicated the incident was reported on 07/18/14 at 3:51 p.m., indicated, "...I noticed that the bed linen sheets were missing as well as any signs of blood stains on the bed. A small amount of what appeared to be blood was on the floor by the bedroom entry door, as well as on the left side of the padded section of the top hoist used to hoist the patient from the bed to the chair...(DoN Name) advised that the hoist was used during the morning after the above victim was transported to (Hospital Name)..She further advised that the bed sheets were also taken during transport..." During an interview on 10/09/14 at 2:06 p.m., the DoN indicated she and the Administrator at the time of the incident had called CNA #1 and received a statement from her and then had her re-enact the transfer with the mechanical lift. She indicated the area behind the back of the ear was difficult to see and during the night, the lights were not always turned on due to the resident sleeping, so the blood may not have been seen with the earlier checks on the resident. She indicated after CNA #1 came back in to the facility to do the re-enactment, the facility could not get a hold of Terminated CNA #1 again. The DoN indicated she had checked the corners of the room, the bed, the window ledge and the resident's clothes and could not find blood or signs of any possible cause of injury. She indicated the trauma had occurred, but the facility could not say how it occurred. She indicated they could not definitely prove the injury came from the improper transfer with the mechanical lift. She indicated the resident had no change in behavior or crying out through out the night of 07/17/14-07/18/14. During an interview on 10/09/14 at 3:42 p.m., the DoN indicated the facility had completed the annual competency audits for mechanical lifts and other tasks in June 2014. She indicated the facility started mechanical lift audits and inservices on 07/25/14 and the majority of the staff had been audited and inserviced by 08/18/14. She indicated some staff had been on leave of absence and the last of the staff were inserviced on 09/02/14. The DoN indicated the facility was continuing to audit mechanical lift transfers randomly on all shifts five times a week and if there are concerns, it was discussed daily in the meeting and re-education was given. A facility policy, dated 02/12, titled,"Mechanical Lift (Full Body)" and received from the Administrator as current, indicated, "...It is the policy of the facility that one person is required to maneuver lift and a second person is required to guide the resident during the transfer..." This Federal Tag relates to complaint IN 538. 3.1-45(a)(1) 3.1-45(a)(2)