Every finding on record at Seymour Crossing

Based on record review and interview, the facility failed to ensure a resident was free from a significant medication error for 1 of 3 residents reviewed for significant medication errors. (Resident C) Findings include:During an observation and interview, on 08/10/2026 at 10:35 A.M., Resident C was sitting in a chair in his room playing on games on his cellphone. He indicated he was administered the wrong medications a few weeks prior. He said the nurse just handed him a cup of pills, so he took them. The next thing he remembered was waking up at the hospital. Resident C's clinical record was reviewed on 08/10/2026 at 9:30 A.M. A Quarterly Minimum Data Set assessment, dated 05/07/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes (a chronic metabolic disease where blood sugar levels stay too high ), anxiety (feelings of fear, dread, and uneasiness), and depression (mood disorder characterized by persistent sadness). A Progress Note documented by Licensed Practical Nurse (LPN) 2, dated 07/25/2026 at 9:00 A.M., indicated Resident C had received another residents medications from a human error at 8:00 A.M. Poison Control recommended the resident be observed closely. At approximately 8:30 A.M., Resident C was observed in bed flat with his eyes open, and unable to speak words. The resident's oxygen and blood pressure were low, so supplemental oxygen was applied. Resident C was then transferred to the local hospital by emergency medical services (EMS). During an interview, on 08/10/2026 at 9:56 A.M., LPN 2 indicated on 07/25/2026 Registered Nurse (RN) 3 informed her that she had made a medication error, and had given Resident E's medications to Resident C. A Hospital Record, dated 07/25/2026, indicated Resident C was brought to the Emergency Department for accidentally taking another residents medications. Medications included 125 milligrams (mg) of clozapine (an antipsychotic medication), 25 mg of losartan (a medication used to treat high blood pressure), and 10 mg of memantine (a medication is to treat moderate to severe confusion and memory loss) . A Progress Note, dated 07/25/2026 at 2:45 P.M., indicated Resident C returned to the facility by EMS. The emergency room observed him for 5 hours, and found no abnormalities. Resident E's clinical record was reviewed on 08/10/2026 at 11:15 A.M. An Annual Minimum Data Set assessment, dated 07/20/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes and schizophrenia (a serious mental health condition changes how a person thinks, feels, and acts). A current physician order, with a start date of 12/22/2026, indicated Resident E was to receive clozapine 100 mg tablet twice a day at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. to 10:00 P.M. A current physician order, with a start date of 12/22/2026, indicated Resident E was to receive clozapine 25 mg tablet twice a day at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. to 10:00 P.M. A current physician order, with a start date on 05/18/2026, indicated Resident E was to receive losartan 25 mg tablet once a day at 7:00 A.M. to 11:00 A.M. A current physician order, with a start date on 07/10/2024, indicated Resident E was to receive memantine 10 mg tablet once a day at 7:00 A.M. to 11:00 A.M. During an interview, on 08/10/2026 at 1:30 P.M., RN 3 indicated she had administered the medication error on 07/25/2026. She was preparing to administer medications to Resident E at her cart, and the resident walked away before taking his medications. She set the medication cup in the drawer to administer to Resident E when he came back. Resident C then walked up to the medication cart and requested his medications. While preparing Resident C's medications a third resident came up and began having a conversation with RN 3. While talking she handed a cup of medications to Resident C to take. When she looked back down at her cart she realized she had handed Resident C the wrong cup of medications. She handed him Resident E's medications that contained clozapine, losartan, and memantine. She informed LPN 2 of the medication error, and they began informing appropriate parties while monitoring Resident C. The current facility policy, dated 04/2025, titled, Medication Administration (medication pass procedure), was provided by the Director of Nursing on 08/10/2026 at 2:15 P.M. The policy indicated, .The 5 rights of medication performed: Right Resident, Right Medication, Right Dose, Right Route, Right Time . Prior to the start of the survey the deficiency was corrected on 07/27/2026, after the facility assessed for other medication errors, provided education to staff related to proper procedure for administering medications, and began ongoing monitoring audits in place for observing medication administration. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure a splinting device was applied as ordered for a resident with a hand contracture (a chronic condition where muscles and joints become stiff, frozen, or permanently tightened) for 1 of 1 resident reviewed for range of motion. (Resident 74)Findings include:Resident 74 was observed on 04/01/2026 at 2:10 P.M. The resident was lying in bed, with his right arm resting close to his side. The resident indicated his right side was impaired after a stroke (a medical emergency that occurs when blood flow to part of the brain was blocked that can cause neurological deficits). The resident was not wearing a splint device and indicated he never wore one. On 04/02/2026 at 1:22 P.M., the resident was observed sitting in his wheelchair in the lounge area on B-Hall. The resident's right arm was resting in his lap. There was no splinting device in place. On 04/06/2026 at 10:53 A.M., the resident was observed in his room in bed. The resident was holding his right hand with his left hand. The resident's splinting device was observed lying on the dresser, behind his television, next to his ball cap. The resident indicated he didn't think he had worn the splint for some time. On 04/06/2026 at 1:19 P.M., the resident was observed in the lounge area on B-Hall. The resident was in his wheelchair watching television. The resident was holding his right arm with his left. The resident was wearing his ball cap but was not wearing the splinting device. On 04/06/2026 at 1:22 P.M., the resident's splinting device was observed in his room on the dresser behind his television. During an interview, on 04/06/2026 at 1:24 P.M., Certified Nurse Aide (CNA) 2 indicated the resident wasn't wearing a splint. They usually put the splinting device on the resident, but they didn't document it anywhere. The CNAs would tell the nurse, and the nurse would check it off in the Electronic Medication Administration Record (EMAR). The resident's clinical record was reviewed on 04/06/2026 at 10:46 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/02/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, a stroke and hemiparesis/hemiplegia (one-sided body weakness or paralysis). An Occupational Therapy Note, dated 02/19/2026, indicated the resident was agreeable to the treatment plan and that he could not use his carrot (a soft splint designed to treat severe hand contractures by gently separating fingers from the palm) because he kept losing it. The Therapist donned a resting hand splint onto his right hand and educated the resident on the benefits of using the splint and the when to wear schedule. The resident was pleasant and cooperative, with good tolerance to the hand splint for the entirety of the treatment session with no redness observed. The Therapist recommended for the resident to use the splint to prevent further spasticity (involuntary muscle stiffness, tightness, or spasms), worsening contracture, and to prevent sores on the hand. The Therapist educated the staff on the schedule of when the resident was to wear the resting hand splint. The resident's current physician's orders included, but were not limited to: -An open-ended order, with a start date of 02/19/2026, staff were to apply the resident's resting hand splint to the resident's right hand at all times. The splint was to be removed only for hand washing and skin checks.-The resident's February, March, and April 2026 EMARs and Progress Notes lacked documentation to indicate the resident's splinting device was applied or any refusals of the resident wearing the splinting device. During an interview, on 04/07/2026 at 11:31 A.M., the Director of Nursing indicated the facility did not have a policy related to splint/brace devices. Nursing staff should ensure splint/brace devices were in place as ordered. It should be documented in the resident's clinical record. 410 IAC (Indiana Administrative Code) 3.1-42(a)(2)

Based on record review and interview, the facility failed to follow a physician's order related to laboratory services for 1 of 21 residents reviewed for laboratory services. (Resident 9)Findings include: The clinical record for Resident 9 was reviewed on 04/06/2026 at 10:54 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/13/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, diabetes (a chronic condition characterized by high blood sugar (hyperglycemia) due to the body's inability to produce or properly use insulin). A physician's order, dated 04/04/2024 through 12/22/2025, indicated the resident was to have a hemoglobin A1C (a test that measures average blood sugar levels over the past two to three months) completed every third month on the first Thursday. The resident had a hemoglobin A1C completed in April and July 2025. The clinical record lacked a hemoglobin A1C for the resident in October 2025.During an interview, on 04/07/2026 at 10:01 A.M., the Administrator indicated the facility could not provide a hemoglobin A1C laboratory result for the resident in October 2025. The laboratory test should have been completed per the physician's order. The laboratory had a requisition for the test, but they never came and obtained it and the facility didn't catch that the test was not completed. The current facility policy titled, Guidelines for Lab and Radiology Tracking with a revision date of 04/2024, was provided by the Director of Nursing on 04/07/2026 at 10:17 A.M. The policy indicated, .Suggested that one person be assigned to track labs in the facility.Daily order checks by medical records or designee will ensure all orders have been entered.The designated person will run the appropriate lab tracking report(s) daily.Using the appropriate report.Confirm that each lab and/or radiology test due has been obtained.410 IAC (Indiana Administrative Code) 16.2-3.1-49(a)

Based on interview and record review, the facility failed to ensure residents received mail on Saturdays. This had a potential to affect 69 of 69 residents that resided in the facility.Findings include:A meeting to discuss Resident Council was held on 04/02/2026 at 2:00 P.M., and was attended by Resident 16, Resident 57, Resident 59, and Resident 64. During the council meeting, the residents' indicated mail was not delivered on Saturdays. They had to wait until the following Monday to receive any mail that came in over the weekend. The Activity Director was present during the meeting (at the Resident Council President's request) and indicated she did not have a key to the mailbox and had not been delivering mail to the residents on Saturdays.Resident 16's clinical record was reviewed on 04/07/2026 at 1:30 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/25/2026, indicated the resident was cognitively intact.Resident 57's clinical record was reviewed on 04/07/2026 at 1:33 P.M. An Annual MDS assessment, dated 01/16/2026, indicated the resident was cognitively intact. Resident 59's clinical record was reviewed on 04/07/2026 at 1:35 P.M. A Quarterly MDS assessment, dated 01/15/2026, indicated the resident was cognitively intact.Resident 64's clinical record was reviewed on 04/07/2026 at 1:37 P.M. A Quarterly MDS assessment, dated 03/31/2026, indicated the resident was cognitively intact. During an interview, on 04/07/2026 at 10:24 A.M., the Activity Director indicated she had been filling in as the Activity Director since May of 2025 and became the permanent Activity Director in December of 2025. She worked Monday through Friday but was in the facility as the manager on duty every 5th or 6th weekend. The Activity Aides were in the facility every weekend. The mailbox key was provided to the Activity Director for Saturday mail access during the survey process. Activity Staff had not been able to deliver the mail to the residents on Saturdays prior to 04/02/2026. The current facility policy, titled Resident [NAME] of Rights, most recently revised on 12/17, was provided by the Director of Nursing on 04/07/2026 at 11:19 A.M. The policy indicated, .Residents have the right to.send and promptly receive mail.410 IAC (Indiana Administrative Code) 3.1-3(s)(1)

The facility failed to prevent misappropriation of a resident's money (Resident B) and the misappropriation of residents' pain medications (Residents C, D, F, and G) for 5 of 5 residents reviewed for misappropriation.Findings include:1.During an interview on 01/12/26 at 9:03 A.M. Resident B indicated she had over 4 hundred dollars stolen out of the top drawer of her dresser in the far-right corner of her room. She noticed it was missing last week and reported it to the staff working demanding to speak to the police. The police were called, and management said they would review the cameras to see who had entered her room. Resident B indicated she never left her room unless she was getting a shower or using the restroom. She had no roommate, and no family visits, so she had no idea who could have taken the money. She had a close friend who worked at the facility who counted the money with her the day after Christmas and there was 5 hundred and 10 dollars in the envelop. Then when her and the friend recounted the money at the end of last week there was only a little over 70 dollars left in the envelope.The clinical record for Resident B was reviewed on 01/12/26 at 11:45 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/12/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, and anemia. During an interview, on 01/12/26 at 9:44 A.M., Licensed Practical Nurse (LPN) 6 indicated she was close friends with Resident B and had counted the money with her on 12/26/25. There was 5 hundred and 10 dollars in the envelope. They both counted it and she wrote the amount on the outside of the envelope. On Friday 01/09/26 the resident asked LPN 6 to get her money out for her, and when they counted it together there was only 77 dollars left in the envelope. They searched her entire room and could not find it. They then alerted other staff members working in the building that Resident B had money missing, and no one was able to find it. This happened around 2:00 P.M. on Friday. The police were called and all the appropriate people in management were notified that the money was missing. Resident B had no family that visited her, and the only time she left her room was to get a shower. During an observation and interview, on 01/12/26 at 3:45 P.M., Resident B's money envelop was provided by the Administrator. The envelope had the date of 12/16/25 with $557 written and then marked out followed by 12/26/25 $510 written on it. The Administrator explained 77 dollars was still in the envelope meaning 433 dollars was still unaccounted/missing. During an interview, on 01/12/26 at 10:01 A.M., the administrator indicated he did not know Resident B had that much money in her personal procession, and he would have offered a lock box if he had known. The resident did not have family involved but had been close friends with LPN 6 for years.During an interview, on 01/12/26 at 2:35 P.M., the Business Office Manager indicated Resident B had a check written out of her account at the facility for 767 dollars to LPN 6 on 12/16/25. She indicated that LPN 6 went and cashed checks for Resident B and then would bring the resident back the cash. The facility only allowed residents to get up to 50 dollars in cash per day anything over 50 dollars the facility would write the resident a check and then the resident's family could cash it for them. During an observation and record review, on 01/12/26 at 2:37 P.M., a copy of the original check written from the business office related to the withdrawn from Resident B's account was observed. The check was from the petty cash account, dated 12/16/25, with the pay to order of listed as (LPN 6's name), and in the memo comment was Resident B's name. The check was written for seven hundred sixty-seven dollars and no cents.The resident statement account record, dated 12/16/25, indicated Resident B was advanced 767 dollars and the balance left was .81 (81 cents) in the account.During an interview, on 01/12/26 at 2:31 P.M., LPN 6 indicated Resident B made a large withdraw in December for over 7 hundred dollars and had the check written to her. The resident wanted the money to purchase some Christmas gifts for a friend and had a gift mailed to a loved one who lived out of State. After these purchases were made there was still 5 hundred and 10 dollars left in the envelope. During an interview, on 01/12/26 at 2:54 P.M., the Director of Nursing and the Administrator indicated the facility would provide transportation with the facility bus when a resident needed transportation for banking. They both were unaware the check was written for Resident B in LPN 6's name.2.a.The clinical record for Resident D was reviewed on 01/12/26 at 2:15 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/05/2025, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, Cerebral palsy an COPD.During an interview on 01/12/26 at 1:50 P.M. , Resident D indicated they did receive pain medications from the staff regularly, and it is always on time. She had never received any additional pills outside of her normal schedule. An open-ended physician's order, with a start date of 08/23/2024, indicated the resident received hydrocodone-acetaminophen, 5-325 mg, give one tablet every eight hours as needed for pain.The September 2025 Medication Administration Record for Resident D indicated LPN 6 administered one dose of narcotic pain medication on 09/27/25 at 9:30 A.M. Review of the September 2025 controlled substance record indicated LPN 2 signed out to administered Resident D's narcotic pain medication on 09/27/25 at 0800 (scribbled), 09/27/25 at 0850, and 09/27/25 at 1350. b.The clinical record for Resident C was reviewed on 01/12/26 at 3:00 P.M. An (MDS) assessment, dated 07/01/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, diabetes, depression, and Chronic Obstructive Pulmonary Disease (COPD). An open-ended physician's order, with a start date of 07/10/2025, indicated the resident was to receive hydrocodone-acetaminophen (narcotic pain medication), 5-325 milligrams (mg), one tablet every 12 hours (hrs) for left shoulder pain.The August 2025 controlled substance record indicated Resident C was administered a dose of the narcotic pain medication from LPN 2 on 08/25/25 at 8:00 A.M. and 1:20 P.M. The August 2025 medication administration record, indicated the resident's medication administration record lacked any documentation related to LPN 2 administration of the resident's narcotic pain medication on 08/25/25 at 8:00 A.M. and 1:20 P.M. The September 2025 medication administration record, indicated Resident C received hydrocodone-acetaminophen by LPN 2 between September 11 through September 16, 2025, on the following dates and times: 09/11/25 at 9:09 A.M. , 09/13/25 at 9:32 A.M., 09/14/25 at 9:07 A.M., 09/15/25 at 8:00 A.M., and 09/16/25 at 8:00 A.M. Review of the September 2025 controlled substance record indicated, from September 11 through September 16, 2025, Resident C was administered a dose of the narcotic pain medication by LPN 2 on the following dates and times: 09/11/25 at 8:10 A.M., 09/11/25 at 12:15 P.M., 09/12/25 at 8:10, 09/12/25 at 8:00, 09/13/25 at 8:00, 09/13/25 at 12:50 P.M, 09/13/25 at 1:30 P.M., 09/14/25 at 8:09 A.M., 09/15/25 at 7:43, 09/15/25 at 9:10, 09/15/25 at 12:50, 09/16/25 at 8:09 A.M., 09/16/25 at 10:10 A.M., and 09/16/25 at 1:30 P.M.c.The clinical record for Resident F was reviewed on 01/12/26 at 1:40 P.M. An (MDS) assessment, dated 08/06/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), depression, anxiety, and heart failure. A current physician's order, with a start date of 01/15/2025, indicated the resident was to receive oxycodone-acetaminophen (narcotic pain medication), 7.5-325 milligrams (mg), one tablet every 6 hours as needed for moderate to sever pain.The September 2025 medication administration record, indicated Resident F received oxycodone-acetaminophen by LPN 2 between on the following dates and times: 09/17/25 at 10:05 A.M.; and 09/25/25 at 10:22 A.M.Review of the September 2025 controlled substance record indicated, Resident F was administered a dose of the narcotic pain medication by LPN 2 on the following dates and times: 09/17/25 at 6:30, at 1:10 P.M.; and 09/25/25 at 6:50, 10:10, 1:41 P.M.d.The clinical record for Resident G was reviewed on 01/12/26 at 1:50 P.M. An (MDS) assessment, dated 09/02/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, COPD, stroke, depression, diabetes, and hypertension. A current physician's order, with a start date of 06/02/25, indicated the resident was to receive oxycodone-acetaminophen (narcotic pain medication), 10-325 milligrams (mg), one tablet every 6 hours as needed for moderate to sever pain.The September 2025 medication administration record, indicated Resident G received oxycodone-acetaminophen by LPN 2 on the following dates and times: 09/20/25 at 1:03 P.M. and 6:40 A.M.; and 09/24/25 at 8:41 A.M. (noted as effective). Review of the September 2025 controlled substance record indicated for Resident G indicated LPN 2 administered the resident's oxycodone on the following dates and times: 09/20/25 at 8:40, 10:10; 09/21/25 at 6:40, 11:00, at 1:30 P.M.; and 09/24/25 at 6:04, 10:18, and 1:44 P.M.During an interview, on 01/12/26 at 10:10 A.M., the Administrator and Director of Nursing (DON) indicated that LPN 2 began working at the facility the beginning of August 2025. Nothing flagged on her license upon hire, and she was with a nurse on orientation the first few weeks and did great. It was reported to the DON that it appeared LPN 2 signed out too many pills one weekend in September. Upon investigation the DON determined there were multiple instances where LPN 2 had signed out multiple pills in between scheduled doses of narcotics to residents. Interviews with residents involved determined they had all received their scheduled medications, but they did not receive any additional doses in between. The DON and Administrator confronted LPN2 with documentation showing medications being signed outside of the scheduled doses. LPN 2 admitted that she had been taking medications since about two weeks after she started at the facility. She admitted to taking them for herself, and that she knew she needed to get help. LPN 2 was terminated from the facility at that time. During an interview an observation, on 01/12/26 at 1:52 P.M., RN 7 indicated that narcotics were always kept in the medication carts on the units under a double lock and key. Medications were kept in numbered cards, and every time they were administered they were documented in the narcotic count book. A random count was observed of RN7's cart, and all narcotic counts were correct. A handwritten statement was provided by the DON on 01/12/26 at 2:10 P.M. The statement written by LPN 2 indicated the LPN began taking narcotic medications from the residents at the facility for self-use two weeks after being hired. The statement was signed by LPN 2 and dated 09/29/25 at 1:14 P.M. The current facility policy titled, Abuse Prohibition, Reporting, and Investigation, with a revision date of June 2023, was provided by the Administrator on 01/12/26 at 3:40 P.M. The policy indicated, .Misappropriation of Resident Funds or Property - Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent.

Based on observation and interview, the facility failed to maintain a safe and comfortable homelike environment for 5 of 7 residents reviewed. (Residents B, D, E, F, and G) Findings Include:1. During an interview, on 06/26/25 at 9:16 A.M., Resident B indicated that the air conditioning in the hallway and dining room was broken. Sometimes he had to go back to his room and stay out of the hallways, because it was so hot. He stopped going to activities in the dining room, and sometimes he didn't feel like eating in the dining room because the heat was excessive. The clinical record for Resident B was reviewed on 06/26/25 at 10:39 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, diabetes, and asthma. During an interview, on 06/26/25 at 11:58 A.M., the Maintenance Director indicated about two months ago the air conditioning unit that cooled the B hallway, kitchen, and Dining room would not start up. A company came an looked at it, and determined it needed replaced. The project was handed over to a project manager within the company. He had not documented the temperatures he was monitoring in the building. They did not have a thermometer to monitor the air temperature he had been relying on the thermostats to tell him the temperatures in the common area rooms. 2. During an observation, on 06/26/25 at 12:02 P.M., with the Maintenance Director the thermostat in front of the nurse's station on C Hallway was observed and read 81 degrees Fahrenheit. The thermostat by the front desk in the hallway that was connected to the main dining room, (approximant 15 to 20 feet from the Main Dining Room) was observed and read 82 degrees Fahrenheit. During an observation, on 06/26/25 at 12:20 P.M., the Main Dining Room had 14 residents eating, along with five residents eating in the restorative dining room that was within the main dining room. The door to the kitchen was propped open blowing heat towards the dining room. Resident D, Resident E, Resident F, and Resident G were all sitting in the restorative dining area having staff assist them to eat their meal. During an interview, on 06/26/25 at 12:33 P.M., the Maintenance Director indicated they did not a have a way to check the temperature in the main dining room at that time. He needed to go to the store and get one. The clinical record for Resident D was reviewed on 06/26/25 at 1:45 P.M. An Annual MDS assessment, dated 04/21/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, and non-Alzheimer's dementia. They required extensive staff assistance for transferring and was totally dependent on staff for all mobility. The clinical record for Resident E was reviewed on 06/26/25 at 1:50 P.M. An admission MDS assessment, dated 06/17/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cerebral palsy, unspecified intellectual disabilities, and unspecified encephalopathy. They were in a wheelchair, and required extensive staff assistance for transferring, and were totally dependent on staff for all mobility. The clinical record for Resident F was reviewed on 06/26/25 at 1:56 P.M. An admission MDS assessment, dated 04/25/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, and dementia. They required extensive staff assistance for transferring and were in a wheelchair.The clinical record for Resident G was reviewed on 06/26/25 at 2:02 P.M. A Quarterly MDS assessment, dated 05/29/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, and non-Alzheimer's dementia. They required extensive staff assistance for transferring and were in a wheelchair.During an observation, on 06/26/25 at 1:40 P.M., the thermostat by the front desk closest to the main dining room read 83 degrees Fahrenheit.The current undated facility policy, titled Emergency Operations Plan was provided by the Director of Nursing (DON) on 06/26/25 at 1:58 P.M. The policy indicated, .2. Ambient air temperatures will be monitored and documented for various locations throughout the building such as dining areas, lounges, and sampling of resident rooms. 3. If temperatures are not maintained between 71-81 degrees Fahrenheit , Maintenance Director will obtain alternative source of heating or cooling until repairs are completed. 4. If temperature reaches 82 degrees Fahrenheit or higher, the following precautions will be put into place: Draw all shades, blinds, and curtains in the rooms exposed to direct sunlight. Remove residents from areas exposed to direct sunlight .This citation relates to Complaint IN00462258.3.1-19(f)(5)3.1-19(j)

Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) on duty for eight consecutive hours a day for 2 of the 16 days reviewed. Findings include: The as worked nursing schedule from July to September 2024 indicated there had not been an RN on duty for eight consecutive hours on Saturday, 09/28/24, and Sunday, 09/29/24. During an interview on 02/26/25 at 3:25 P.M., the Director of Nursing (DON) indicated the schedule usually had an RN on duty for 8 hours each day. She was unsure why those two days did not have coverage. During an interview on 02/26/25 at 3:29 P.M., the Administrator indicated the facility did not have a policy for RN coverage, they followed State and Federal regulations. The facility did not currently have any nursing waivers. 3.1-17(b)(3)

Based on record review, interview, and observation, the facility failed to follow the physician's medication hold parameters for residents' cardiac medication administration and failed to follow the treatment orders for a resident's nephrostomy tube for 3 of 20 residents reviewed for Quality of Care. (Residents 18, 70, and 38) Findings include: 1. The clinical record for Resident 18 was reviewed on 02/26/25 at 1:30 P.M. An Annual Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, atrial fibrillation, hypertension, heart failure, and renal insufficiency. The resident received dialysis treatments. The resident's current physician's orders included an open-ended order, with a start date of 01/20/25, to administer midodrine (a medication for low blood pressure) 5 mg (milligrams) every 6 hours as needed for a systolic (the top number) blood pressure less than 110. The resident's vital signs record and Electronic Medication Administration Record (EMAR) for January and February 2025 indicated the resident did not receive the midodrine medication when their blood pressure was assessed and below 110 on the following dates and times: - On 01/24/25 at 1:00 P.M., the resident's blood pressure was 101/69, - On 01/27/25 at 12:07 P.M., the resident's blood pressure was 106/63, - On 01/29/25 at 12:08 P.M., the resident's blood pressure was 105/64, - On 02/01/25 at 5:41 A.M., the resident's blood pressure was 106/71, - On 02/09/25 at 7:22 A.M., the resident's blood pressure was 86/51, - On 02/12/25 at 11:42 A.M., the resident's blood pressure was 103/84, and - On 02/16/25 at 6:39 A.M., the resident's blood pressure was 92/51. During an interview, on 02/26/25 at 1:37 P.M., the resident indicated nursing staff checked his blood pressure a lot. His blood pressure was sometimes low after dialysis. He had an order for midodrine that was fairly new. He had only received the medication a few times. During an interview, on 02/26/25 at 2:11 P.M., the Infection Preventionist (IP) RN indicated if the resident's blood pressure was assessed and it was below 110, the medication should have been administered according to the MD order. 38769 2. The clinical record for Resident 70 was reviewed on 02/24/25 at 2:27 P.M. A Significant Change MDS assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension and cerebral palsy. A physician's order, dated 12/26/24 through 02/25/25, indicated the staff were to administer Lisinopril-Hydrochlorothiazide 10-12.5 mg. The staff were to hold the medication if the resident's systolic blood pressure was less than 130. The December 2024 and January 2025 EMAR/ETAR indicated the resident received the medication when their systolic blood pressure was less than 130 for the following dates and times: - On 12/27/24, when the resident's blood pressure was 122/71, - On 12/28/24, when the resident's blood pressure was 118/65, - On 12/30/24, when the resident's blood pressure was 118/72, - On 01/02/25, when the resident's blood pressure was 96/67, - On 01/03/25, when the resident's blood pressure was 123/73, - On 01/09/25, when the resident's blood pressure was 122/69, and - On 01/12/25, when the resident's blood pressure was 126/63. During an interview, on 02/26/25 at 1:53 P.M., LPN 3 indicated if a resident had hold parameters on their medications, then she would obtain the vital signs prior to administering the medications and if it was outside the parameter she would not give the medication. She would document in the EMAR that the medication was held. The current facility policy titled, General Dose Preparation and Medication Administration, dated 11/15/24, was provided by the DON on 02/26/25 at 1:37 P.M. The policy indicated, .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .If necessary, obtain vital signs . 3. During an observation on 02/26/25 at 9:24 A.M., the IP prepared a clean space for supplies in the resident's room to cleanse Resident 38's nephrostomy tubes (tubes placed in the back to drain urine from the kidneys). The IP cleansed around both nephrostomy tube insertion sites (left and right side) with normal saline soaked swabs and cleansed the skin surrounding the sites, where the old bandage was removed, with wound cleanser. An open-ended physician's order, with a start date of 02/13/25, indicated the staff were to cleanse around the nephrostomy tubes with warm soap and water, rinse, gently pat dry, and apply a split boarder gauze around the nephrostomy tubes. During an interview, on 02/26/25 at 10:00 A.M., the IP indicated the resident's order was to cleanse around the tubes with soap and water. She had used normal saline because that was what their policy said. She should have followed the orders of the physician and cleansed around the tubes with soap and water. The current facility policy titled, Nephrostomy Tube Care Dressing Change, Drainage Bag Change & Irrigation with a review date of 12/2012, was provided by the IP on 02/26/25 at 10:43 A.M. The policy indicated, .Verify resident and physician orders . During an interview, on 02/26/25 at 1:56 P.M., the Regional Support indicated they did not have a policy on following physician orders. It was just standard practice. 3.1-37(a)

Based on record review and interview, the facility failed to document meal consumptions for 2 of 4 residents reviewed for nutrition. (Residents 16 and 36) Findings include: 1. The clinical record for Resident 16 was reviewed on 02/24/25 at 10:13 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 01/31/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, non-Alzheimer's dementia, anxiety, and depression. The resident's meal consumption records lacked documented values on the following dates and times: - 01/10/25 at dinner, - 01/11/25 at lunch, - 01/15/25 at dinner, - 01/17/25 at dinner, - 01/22/25 at lunch, - 01/24/25 at breakfast and dinner, - 02/07/25 at lunch, - 02/08/25 at lunch, - 02/14/25 at lunch, and - 02/21/25 at breakfast and lunch. 2. The clinical record for Resident 36 was reviewed on 02/24/25 at 12:53 P.M. A Significant Change MDS assessment, dated 12/24/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, anemia, heart failure, hypertension, Non-Alzheimer's dementia, and depression. The resident had weight loss and was not on a prescribed weight loss regimen. The resident's meal consumption records lacked documented values on the following dates and times: - 01/10/25 at dinner, - 01/11/25 at lunch, - 01/15/25 at dinner, - 01/17/25 at dinner, - 01/22/25 at lunch, - 01/24/25 at breakfast and dinner, - 02/07/25 at lunch, - 02/08/25 at lunch, - 02/14/25 at lunch, - 02/21/25 at breakfast and lunch, and - 02/23/25 at lunch. During an interview, on 02/26/25 at 10:32 A.M., Certified Nurse Aide (CNA) 4 indicated after each resident meal the staff were to document their meal consumption into the computer system. The current facility policy titled, Delivery and Documentation of Meal Service and Between Meal Nourishment, was provided by the Director of Nursing (DON) on 02/26/25 at 1:37 P.M. The policy indicated, .It is the policy of this facility that residents receive their meals and nourishments in a timely, courteous, and helpful manner as well as accurately document nutritional intake and food substitutes .Reviewing and documenting food and fluid intake following each meal . 3.1-46(a)(1)

Based on interview and record review, the facility failed to follow pharmacy recommendations for 1 of 6 residents reviewed for medication irregularities. (Resident 65) Findings include: The clinical record for Resident 65 was reviewed on 02/24/25 at 11:14 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/06/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, cirrhosis, malnutrition, and anemia. A Pharmacy Consultation Report, issued on 01/2/25, indicated the resident received iron replacement therapy with ferrous sulfate 325 milligrams (mg) given every other day. The recommendation was to optimize the iron therapy with Ferrex 150 mg to be given daily and discontinue the ferrous sulfate. The recommendation was signed by the pharmacist on 01/02/25. The physician responded on 02/07/25 and agreed with the recommendation. The February 2025, Electronic Medication Administration Record (EMAR) indicated the resident's ferrous sulfate had continued to be given every other day and the EMAR lacked the physician's new order for Ferrex 150 mg every day. During an interview on 02/26/25 at 2:00 P.M., The IP Nurse indicated the signed recommendations were given to the nurse working on the resident's hall to transcribe the physician order. She wasn't sure why the medication changes weren't made for this resident. The current facility policy, titled Medication Regimen Reviews and Pharmacy Recommendations, with a revised date of 10/2018, was provided by the Director of Nursing on 02/26/25 at 2:41 P.M. The policy indicated, .Pharmacy recommendations should be reviewed with follow up by the physician within 30 days of the facility receiving .once reviewed by the physician the pharmacy recommendations will be filed in the resident's medical record . 3.1-25(i)

Based on observation, interview, and record review, the facility failed to prevent medication errors for 1 of 4 residents reviewed for medication administration. (Resident 69) Findings include: During an observation of medication administration on 02/24/25 at 11:46 A.M., Licensed Practical Nurse (LPN) 2 indicated she needed to administer insulin to Resident 69. The LPN opened the top drawer of the medication cart, removed a vial of insulin, an alcohol swab, and a syringe. She wiped the top of the vial with the alcohol swab, inserted the needle and drew up 2 units into the syringe. The LPN placed the vial back into the drawer and locked it. She never turned on the computer to look at the resident's insulin order. At 11:48 A.M., the LPN went into the resident's room and was asked to not administer the medication and to verify the order. At 11:49 A.M., LPN 2 went back to the medication cart and turned on the computer to Resident 69's Electronic Medication Administration Record (EMAR). The LPN indicated the resident's blood sugar had been 207. She documented the blood sugar value into the insulin sliding scale order and determined the resident needed 6 units of insulin. The LPN indicated the resident's insulin sliding scale order must have changed recently and proceeded to get new supplies to administer 6 units instead of 2 units. The nurse then went to the resident's room and administered 6 units to the resident. During an interview, on 02/26/25 at 11:36 A.M., LPN 3 indicated, when administering medications to residents, the nurse should follow the five rights of medication administration. The five rights were the right resident, right medication, right dose, right route, and right time. The clinical record for Resident 69 included a current, open-ended, physician's order, with a start date of 02/19/24, for the resident to be administered Aspart insulin per sliding scale. The sliding scale indicated the resident was to receive the following insulin per their blood sugar test results: - For a blood sugar result of 0 to 150, the resident was to have 0 units. - For a blood sugar result of 151 to 200, the resident was to have 3 units. - For a blood sugar result of 201 to 250, the resident was to have 6 units. - For a blood sugar result of 251 to 300, the resident was to have 9 units. - For a blood sugar result of 301 to 350, the resident was to have 12 units. - For a blood sugar result of 351 to 400, the resident was to have 15 units. - If the resident's blood sugar was greater than 400, the resident was to have 18 units, and the provider was to be notified. The current facility policy titled, General Dose Preparation and Medication Administration, with a revision date of 11/15/24, was provided by the DON (Director of Nursing) on 02/26/25 at 1:37 P.M. The policy indicated, .Only prepare medications for one resident at a time, using a 3-way-check (i.e., comparing the medication to the MAR and to the prescription label) .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident . The current facility policy titled, Medication Error, with a revision date of 11/2018, was provided by the DON on 02/26/25 at 1:37 P.M. The policy indicated, .It is the policy of this provider to ensure residents residing in the facility are free of medication errors . 3.1-48(c)(1)

Based on interview and record review, the facility failed to prevent a significant medication error for 1 of 5 residents reviewed for unnecessary medications. (Resident 278) Findings include: During an interview on 02/25/25 at 10:34 A.M., Licensed Practical Nurse (LPN) 5 indicated residents' laboratory (labs) collections were sent out to a company in Indianapolis or Kentucky and not kept local. The company would come, obtain the labs, and take them with them. They came to the facility Monday through Friday. The nurse was able to look at the residents' clinical record for the lab results, fax the results to the Nurse Practitioner (NP), and put a copy in the NP's binder at the facility. For residents that needed a PT/INR (Prothrombin Time/International Normalized Ratio, a test to measure how quickly your blood clots), the NP would order the lab test. The results were called to the physician before the next dose of medication was administered because the facility needed to know if the medication dose needed to be changed. During an interview on 02/26/25 at 10:46 A.M., the NP indicated she required the facility to send the residents' PT/INR results to her office the same day the lab was obtained to be able to either keep the same dose or change the dose for that night. The clinical record for Resident 278 was reviewed on 02/25/25 at 9:23 A.M. An Admission MDS (Minimum Data Set) assessment, dated 02/13/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, diabetes, anxiety, depression, and cerebrovascular accident. A physician's order, dated 02/14/25, indicated the staff were to obtain a PT/INR and it was to be sent to the local hospital for Coumadin therapy. A physician's order, dated 02/10/25 through 02/18/25, indicated the resident was to be administer Coumadin (Warfarin), 7.5 mg (milligrams), daily at 5:00 P.M. The February 2025 Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) indicated the residents PT/INR was obtained on 02/14/25. A Lab Report for a PT/INR indicated the lab was drawn on 02/14/25 at 10:05 A.M., and received in the lab on 02/15/25 at 12:04 A.M. The results, dated 02/15/25 at 8:59 A.M., indicated the PT/INR was high. The clinical record lacked any indication the physician was notified of the PT/INR results until 02/17/25. The February 2025 EMAR/ETAR indicated the resident had received the Coumadin medication of 7.5 mg, from 02/14/25 through 02/16/25. During an interview on 02/25/25 at 2:54 P.M., the Director of Nursing (DON) indicated the resident's PT/INR lab was completed on Friday, 02/14/25. The facility didn't receive the results until the following Monday, on 02/17/25. The staff should have called the NP on Friday, 02/14/25, before administering the Coumadin medication due to not having the PT/INR results. All of the staff had been educated on obtaining PT/INR results before administering the medication to see what the physician would like to do and to started monitoring residents that took Coumadin. The current facility policy titled, Coumadin/Warfarin Monitoring Policy and Tracking Log, with a revised date of 11/2018, was provided by the DON on 02/25/25 at 3:36 P.M. The policy indicated, .Residents who require Coumadin Therapy are receiving adequate monitoring .Prior to administering the Coumadin/Warfarin dose the licensed nurse should verify the most current PT/INR . The deficient practice was corrected, on (02/17/25, prior to the start of the survey and was therefore Past Noncompliance. The facility reviewed all the residents' laboratory results for timeliness, educated staff, and implemented a process to monitor the residents' ordered laboratory test and laboratory results for physician notification. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was clinical appropriate prior to medication being left unattended at bedside for a resident to self-administer for 1 of 3 residents reviewed for self-medication administration. (Resident C) Findings include: During an observation and interview on 12/10/2024 at 8:48 A.M., Resident C was in her wheelchair with her bedside table in front of her. A medicine cup filled with various colored pills sat on the table to her left and two separate medicine bottles with liquid drop medications laid on the bed in front of her. The resident indicated that she was in the restroom when the nurse brought her medications, so they were left on the table for her to take. She doesn't typically administer them herself, but sometimes she does. No staff were in the resident's room or within sight of the resident. During an interview on 12/10/2024 at 10:34 A.M., Qualified Medication Aide (QMA) 2 indicated on Resident C's unit there was a confused resident that wandered the hallway on a regular basis. During an interview on 12/10/24 at 12:04 P.M., Licensed Practical Nurse (LPN) 3 indicated that she was unaware of any residents that self-administered medications, and she never left medications unattended at a resident's bedside. Staff were to stay in the resident's room until the medication was taken. During an interview on 12/10/24 at 1:50 P.M., the Director of Nursing (DON) indicated Resident C lacked a care plan and an order for self-administration prior to the medication being left at bedside on 12/10/24. The clinical record for Resident C was reviewed on 12/10/24 at 11:11 A.M A Quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, seizure disorder, anxiety, and depression. The clinical record for Resident C lacked an assessment or an order to self-administer medications until after the observation on 12/10/24. The current facility policy titled, General Dose Preparation and Medication Administration with a review date of 04/30/24 and was provided by the DON on 12/10/24 at 1:50 P.M. The policy indicated, .Facility staff should not leave medications or chemicals unattended .Observe the resident's consumption of the medication(s) . 3.1-11(a)

Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse for 1 of 24 residents reviewed. (Resident 51) Findings include: The clinical record for Resident 51 was reviewed on 01/18/24 at 9:11 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 12/11/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, hypokalemia, renal insufficiency, and hemiplegia. During an interview on 01/22/24 at 10:32 A.M., LPN (Licensed Practical Nurse) 3 indicated there had been an incident involving the resident during wound care. CNA (Certified Nurse Aide) 4 was assisting the LPN by holding the resident on his side while the LPN provided a wound treatment to the resident's leg. During the procedure, the CNA yelled out something to the affect, don't scratch me or I will hit you in the face. The LPN was unsure of the exact wording but indicated her statement in the written report was correct. It happened very quickly. She did not see the resident scratch the CNA, but the resident had a history of combativeness. The LPN immediately had the CNA leave the room. Management was there in the building. The LPN got the CNA away from all the residents and management staff took control of the situation. During an interview on 01/22/24 at 10:39 A.M., the DON (Director of Nursing) indicated LPN 6 immediately walked the employee to the time clock and out of the facility following the incident. Then the DON, LPN 6, the IP (Infection Preventionist), and the Administrator started the investigation. The SSD (Social Services Director) started interviewing residents, a head to toe assessment was completed on Resident 51 and all other residents with low cognition levels. There were no other findings with any of the other residents. During an interview on 01/18/24 at 9:02 A.M., the Administrator and IP indicated the resident was aggressive at times. CNA 4 had only worked there a couple of months and had not had any inappropriate encounters verbally or physically with any of the residents prior to the incident on 11/11/23 at 12:29 P.M. Staff were in-serviced and re-educated following the incident. During an interview on 01/18/24 at 12:41 P.M., CNA 8 indicated they had not seen or heard staff members be abusive to residents. They were in-serviced and re-educated on abuse regularly. They were in-serviced about a week and a half ago. The employee record for CNA 4 (involved in the incident) was reviewed on 01/18/24 at 9:18 A.M., and indicated they were educated on abuse and had received 100% on the test dated 07/28/23. They were educated on Code of Conduct, the Elder Justice Act Policy, and had completed the required six hours of dementia training for 2023. Their criminal background check was completed and clear. The signed statement from LPN 3, following the incident, dated 11/11/23 at 12:29 P.M., was provided by the Administrator on 01/22/24 at 11:00 A.M. The record indicated the LPN had asked CNA 4 to help her with Resident 51 while she administered his treatment. The CNA turned the resident to his right side. As the LPN was applying a dressing to the resident, she felt the CNA's arm jerk away from the resident as the CNA repeated twice, If you scratch me again, I will punch you in the face. The LPN stopped the procedure and immediately escorted the CNA to the nurse's station, notified management, and management led the CNA away from the nurse's station. The current Abuse Prohibition, Reporting, and Investigation policy, with a revised date of June 2023, was provided following the Entrance Conference. The policy indicated, .It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse .This includes but is not limited to verbal abuse .American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees . The Past noncompliance began on 11/11/23 and the deficient practice was corrected on 11/17/23 prior to the start of the survey. The facility implemented a systemic plan that included the following actions: The facility completed staff education on the resident abuse and neglect policy, facility wide resident re-assessments completed for abuse, and a Resident Council Meeting in which staff reviewed the process of filing grievances, the types of abuse and the process for reporting. 3.1-27(b)

Based on interview, observation, and record review, the facility failed to ensure surgical wound treatments were administered appropriately and follow physician's orders related to hold parameters for cardiac medications for 3 of 18 residents reviewed for quality of care. (Residents 71, 14, 59) Findings include: 1. During an interview on 01/16/24 at 2:44 P.M., Resident 71 indicated she had bilateral nephrostomies (a surgical procedure where a tube was inserted into the kidney to drain urine) last month. The tube in the right kidney leaked urine all the time. Nursing staff didn't change the dressings at the insertion sites with any regularity. Recently, they had a meeting and she asked them to increase the dressing changes from once a day to twice a day. They still didn't always do it when they were supposed to. The resident's clothing on the right side was observed, with an area approximately four inches in diameter that appeared to be wet. The resident lifted her sweatshirt and the nephrostomy tubing on the right was observed. The tubing was wet, with urine dripping down the outside of the tube. The surgical site dressing was unable to be visualized. The resident's clinical record was reviewed on 01/22/24 at 3:25 P.M. An Admission MDS (Minimum Data Set) assessment, dated 12/13/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, heart failure, kidney disease, and malnutrition. The resident's current physician's orders included an open-ended order, with a start date of 01/15/24, staff were to cleanse both nephrostomy tube sites with normal saline, pat dry, apply a drain sponge, and cover with a transparent dressing, twice a day. On 01/18/24 at 12:43 P.M., the resident was observed in her room eating lunch. The resident indicated her nephrostomy tube on the right side did not leak in bed the night before, however, staff were supposed to change the dressings twice a day and they hadn't been changed since the day before yesterday. A wet area approximately two inches in diameter was observed on the resident's sweatshirt near the tube insertion site. The resident's dressings were observed on 01/18/24 at 2:36 P.M., with LPN (Licensed Practical Nurse) 2. The dressing on the left was clean, dry, and intact. The dressing on the right was intact, but soaked through, with a dark yellow/brown area approximately 2 by 2 inches visible through the dressing. Neither dressings were dated or initialed. LPN 2 removed the old dressings and cleansed the tube insertion sites. Both insertion sites were observed and were without signs of infection. The skin around the right insertion site was slightly reddened where the dressing had been in place. LPN 2 indicated she forgot to date and initial the dressings when she last changed them. The LPN indicated she last changed the resident's dressing the day before (yesterday). The LPN cleansed the sites and applied new dressings. The current facility policy, titled Dressing Change Clean Technique (Incision or Wound), with a most recent revision date of 07/2023, was provided by the DON (Director of Nursing) on 01/23/24 at 1:59 P.M. The policy indicated, .Apply treatment .Date and initial new dressing . 34232 2. The clinical record for Resident 14 was reviewed on 01/22/24 at 2:05 P.M. A Quarterly MDS assessment, dated 12/05/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, diabetes, and dementia. The EMAR/ETAR (Electronic Medication Administration Record/Treatment Administration Record) for January 2024, was provided by the DON on 01/23/24 at 2:34 P.M. The record included, but was not limited to, the following current, open-ended physician's order, with a start date of 07/25/23, staff were to administer Metoprolol Tartrate 12.5 mg (milligrams), every 12 hours. The medication was to be held if the resident's systolic blood pressure (top number) was less than 100 or the pulse was less than 60. The record indicated the medication was given on the following dates and times when the systolic blood pressure was less than 100 or the pulse was less than 60: - 01/01/24 from 6:00 P.M. to 10:00 P.M., when the pulse was 56, - 01/02/24 from 11:00 A.M. to 2:00 P.M., when the pulse was 57 and the blood pressure was 90/50, - 01/08/24 from 6:00 P.M. to 10:00 P.M., when the pulse was 50, - 01/09/24 from 6:00 P.M. to 10:00 P.M., when the pulse was 58, - 01/11/24 from 11:00 A.M. to 2:00 P.M., when the pulse was 54, - 01/20/24 from 11:00 A.M. to 2:00 P.M., when the pulse was 58, and - 01/21/24 from 11:00 A.M. to 2:00 P.M., when the pulse was 58. The Progress Notes were provided by the DON on 01/23/24 at 2:34 P.M. The record lacked documentation the medication was held on the above listed dates. 38769 3. The clinical record for Resident 59 was reviewed on 01/22/24 at 3:54 P.M. A Quarterly MDS assessment, dated 11/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, non-Alzheimer's dementia, anxiety, and depression. A current, open-ended physician's order, with a start date of 05/26/23, indicated the staff were to administer metoprolol tartrate 25 mg, every 12 hours. The medication was to be held if the systolic blood pressure was less than 110 or the pulse was less than 60. The November, December 2023, and January 2024 EMAR/ETAR indicated the medication was given the following dates and times when the systolic blood pressure was less than 110 or the pulse was less than 60: - 11/11/23 at 8:00 P.M., when the blood pressure was 106/58, - 11/14/23 at 8:00 A.M., when the blood pressure was 106/89 and the pulse was 55, - 11/23/23 at 8:00 P.M., when the blood pressure was 106/80, - 11/25/23 at 8:00 A.M., when the blood pressure was 110/63 and the pulse was 52, and at 8:00 P.M., when the blood pressure was 100/56 and the pulse was 56, - 12/07/23 at 8:00 A.M., when the pulse was 56, - 12/08/23 at 8:00 A.M., when the pulse was 57, - 12/16/23 at 8:00 A.M., when the pulse was 56, - 12/17/23 at 8:00 A.M., when the pulse was 59, - 12/29/23 at 8:00 P.M., when the blood pressure was 98/64, - 01/05/24 at 8:00 P.M., when the blood pressure was 106/64, - 01/06/24 at 8:00 P.M., when the blood pressure was 104/65, - 01/11/24 at 8:00 A.M., when the blood pressure was 108/59, and - 01/12/24 at 8:00 A.M., when the pulse was 59. During an interview on 01/23/24, RN 7 indicated when a resident had a medication that required a blood pressure or pulse checked prior to administering, she would obtain the blood pressure and pulse. If the vitals were out of the range required for the medication to be given the medication would be held, and she would document not administered in the EMAR. During an interview on 01/23/24 at 4:13 P.M., the Administrator indicated the facility did not have a policy for following physician's orders. It was a standard practice. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to implement a dressing change for a resident with a central line for 1 of 2 residents reviewed for dialysis. (Resident 49) Findings include: During an interview and observation on 01/16/24 at 12:03 P.M., Resident 49 had a dressing to his right upper chest. The bottom part of the dressing was cut, with the bottom of the dressing open and the central line ports were hanging out the bottom. The dressing was undated. The resident indicated the central line ports were used in the past for dialysis. During an observation on 01/18/24 at 9:34 A.M., the resident was lying in bed, asleep. There was a dressing visible to the right upper chest that was cut at the bottom. The bottom of the dressing was open and the central line ports were hanging out the bottom. The dressing was undated. During an observation on 01/18/24 at 12:34 P.M., the resident was lying in bed. There was a dressing visible to the right upper chest that was cut at the bottom. The bottom of the dressing was open and the central line ports were hanging out the bottom. The dressing was undated. During an interview on 01/23/24 at 9:19 A.M., LPN (Licensed Practical Nurse) 9 indicated the resident had a port in the right upper chest for dialysis. They were working on getting it removed as the resident didn't need to receive dialysis anymore. The port was monitored every shift. They made sure the dressing was clean, dry, and intact. There should have been an order to change the dressing since the resident's dialysis was discontinued on January 5th. The clinical record for Resident 49 was reviewed on 01/22/24 at 2:57 P.M. An Admission MDS (Minimum Data Set) assessment, dated 12/116/23, indicated the resident was moderately cognitively intact. The diagnoses included, but were not limited to, heart failure, anemia, heart failure, hypertension, renal insufficiency, diabetes, anxiety, depression, and schizophrenia. The resident received dialysis while a resident. A Hot Charting Event, dated 01/08/24, indicated the resident's dialysis was discontinued. The clinical record lacked indication the resident had orders to change the dressing to the central line since the resident was discharged from dialysis on 01/08/24. The Complete Care Plan, was provided by the Administrator on 01/23/24 at 9:48 A.M. A Care Plan, with a start date of 12/11/23, indicated the resident was receiving hemodialysis. The interventions included, but were not limited to, treatment as ordered. The current facility policy titled, Dialysis with a revision date of 11/2017, was provided by the Administrator on 01/23/24 at 9:38 A.M. The policy indicated, .to ensure that residents requiring dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care, and the residents' goals and preferences. The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice .PROCEDURE .Physician Orders will be received at time if admission specific to the resident .dialysis access care .Access sites are clean, dry, and dressing is changed with clean technique per physician order . The current facility policy titled, Central Line Sterile Dressing Change, with a review date of 08/2017, was provided by the Administrator on 01/23/24 at 9:48 A.M. The policy indicated, .Verify physician's order .Label the dressing with the date, time and initials .Document the dressing change and other pertinent information . 3.1-37(a)

Based on record review and interview that facility failed to follow the physician's orders, related to medications, for a resident with increased behaviors for 1 of 7 residents reviewed for unnecessary medications. (Resident 59) Findings include: The clinical record for Resident 59 was reviewed on 01/22/24 at 3:54 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, non-Alzheimer's dementia, anxiety, and depression. A Psychiatry Initial Consult, dated 05/31/23, indicated the resident was seen in his room with his partner of [AGE] years. She provided much of the history as the resident was a poor historian. He was alert and pleasantly confused at the time. He stated he slept and ate well. He did endorse anxiety and depression but could not elaborate on the cause. The plan was to discontinue the resident's Lexapro (an antidepressant medication) and start Zoloft (an antidepressant) 50 mg (milligrams) daily x 2 weeks then increase to 100 mg A physician's order, dated 05/31/23 through 06/28/23, indicated the resident was to take Zoloft 50 mg, once a day. A Progress Note, dated 06/14/23 at 12:21 P.M., indicated the resident continued to have episodes of combative episodes of hitting staff with care. A Progress Note, dated 06/16/23 at 9:49 P.M., indicated the resident was noted to be in bed per his choice. He was noted to be yelling out off and on that evening. A Progress Note, dated 06/17/23, at 8:18 A.M., indicated the resident was combative with care. He was hitting and scratching staff, screaming and calling out. A Psychiatry Progress Note, dated 06/28/23, indicated the resident was seen that day. His partner was present, and she stated the resident was still combative with staff at times. The staff reported he always had delusions, thinking that someone would hurt him, but he was being treated for a UTI (Urinary Tract Infection) at the time too. The Zoloft was never increased to 100 mg as ordered. A physician's order, dated 06/28/23 through 08/30/23, indicated the resident was to take Zoloft 100 mg, once a day. A Progress Note, dated 06/28/23 at 11:43 A.M., indicated the resident was seen by the Psychiatric NP (Nurse Practitioner). A new order was obtained to increase the resident's Zoloft to 100 mg, daily. During an interview on 01/23/24 at 2:40 P.M., the IP (Infection Preventionist) indicated the resident's Zoloft medication should have been increased per the physician's order. The order was not transcribed correctly. During an interview on 01/23/24 at 4:13 P.M., the Administrator indicated the facility did not have a policy for following physician's orders. It was a standard practice. The current facility policy titled, Psychotropic Management, wit a revised date of 7/22, was provided by the Administrator on 01/23/24 at 3:37 P.M. The policy indicated, .to ensure that a resident's psychotropic medication regimen helps promote the resident's highest practicable mental, physical, and psychosocial well-being with person centered interventions and assessment . 3.1-37(a)

Based on record review and interview, the facility failed to follow the physician's orders related to dementia care for 1 of 3 residents reviewed for Dementia Care. (Resident 59) Findings include: The clinical record for Resident 59 was reviewed on 01/22/24 at 3:54 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, non-Alzheimer's dementia, anxiety, and depression. A Psychiatry Progress Note, dated 07/05/23, indicated the resident was seen in his room. The staff reported increased incidents of the resident calling out for his family member when his partner was not there. He was screaming and yelling throughout the day and night, begging the staff to stay with him and not leave him. A new order was obtained to start Namenda (cognition-enhancing medication) 5 mg (milligrams), twice a day for moderate vascular dementia with mood disturbances. The July and August EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident received Namenda 5 mg daily. The clinical record indicated the medication was not increased until 08/30/23, for the Namenda 5 mg, to be given twice a day instead of once a day. During an interview on 01/23/24 at 2:40 P.M., the IP (Infection Preventionist) indicated the resident's Namenda medication should have been started at twice a day in July per the Nurse Practitioner's order. During an interview on 01/23/24 at 4:13 P.M., the Administrator indicated the facility did not have a policy for following physician's orders. It was a standard practice. 3.1-37(a)

Based on record review and interview, the facility failed to accurately reconcile residents' medications upon admission and readmission to the facility for 2 of 7 residents reviewed for unnecessary medications. (Residents 43 and 59) Findings include: 1. The clinical record for Resident 43 was reviewed on 01/22/24 at 12:21 P.M. The Admission MDS (Minimum Data Set) assessment, dated 12/20/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, fracture, atrial fibrillation, heart failure, and hypertension. The resident was admitted to the facility from the hospital on 12/13/23. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for December 2023 and January 2024 was provided by the DON (Director of Nursing) on 01/23/24 at 2:34 P.M., and included, but was not limited to, the following current physician's order: - Metoprolol Tartrate (a blood pressure medication) 12.5 mg (milligrams) every 12 hours for hypertension. Hold if the systolic blood pressure (top number) is less than 60. During an interview on 01/23/24 at 2:18 P.M., LPN (Licensed Practical Nurse) 6 indicated when a resident was admitted to the facility, the admitting nurse on the floor would put the physician's orders in the EHR (Electronic Health Record). She would review the orders when she came in to work on the following morning. They have a morning meeting with the nursing management team that included the IP (Infection Preventionist) /CEC (Clinical Education Coordinator), the DON, the ADON (Assistant Director of Nursing), the MDS coordinator, Medical Records, and the Unit Managers. They reviewed the entire admission packet that included, but was not limited to, the physician's orders. Resident 43's physician's orders came from his hospital discharge records, dated 12/13/23. If there were questions about the admitting orders, the admitting nurse would follow up with NP (Nurse Practioner) 10, who was over the building. When reviewing the Metoprolol order on the resident's EHR, LPN 6 did not want to comment on the physician's order because she did not enter the order into the computer, she indicated the IP had. LPN 6 reviewed the Progress Notes and could not find a note related to the order. During an interview on 01/23/24 at 2:28 P.M., the IP indicated the order was inappropriate and should have been to hold the medication for a heart rate under 60 beats per minute. The medication was given on the following dates and times when the heart rate was out of range: - 12/20/23 at 8:00 P.M., the heart rate was 51, - 12/29/23 at 8:00 A.M., the heart rate was 57, - 01/02/24 at 8:00 A.M., the heart rate was 58, - 01/03/24 at 8:00 A.M., the heart rate was 59, - 01/04/24 at 8:00 A.M., the heart rate was 58, - 01/06/24 at 8:00 A.M., the heart rate was 58, - 01/14/24 at 8:00 P.M., the heart rate was 58, and - 01/15/24 at 8:00 A.M., the heart rate was 54. The current Admission Medication Regimen Review policy, with a revised date of 10/01/18, was provided by the Administrator on 01/23/24 at 4:13 P.M. The policy indicated, .An electronic medication regimen review .will be performed within 72 hours of an agreed upon timeframe of admission by a licensed pharmacist per written authorization from the facility . 38769 2. The clinical record for Resident 59 was reviewed on 01/22/24 at 3:54 P.M. A Quarterly MDS assessment, dated 11/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, non-Alzheimer's dementia, anxiety, and depression. A physician's order, dated 05/26/23 through 10/18/23, indicated the resident was to receive trazodone (an antidepressant) 150 mg (milligrams). Staff were to administer 75 mg (1/2 of the tablet), at bedtime for insomnia. The resident was discharged to the hospital on 10/17/23. The resident returned to the facility on [DATE]. A current, open-ended physician's order, with a start date of 10/18/23, indicated the resident was to receive trazodone 150 mg, every evening at bedtime. A Psychiatry Progress Note, dated 01/17/24, indicated the resident's medication list included, but were not limited to, trazodone 150 mg, 1/2 tablet at bedtime to total 75 mg. During an interview on 01/23/24 at 2:54 P.M., the Social Service Director indicated when the Psychiatric NP (Nurse Practitioner) came to the building she would review the resident's medications. During an interview on 01/23/24 at 4:07 P.M., the DON (Director of Nursing) indicated the resident's trazodone order should have been addressed when he returned from the hospital to determine if it needed to stay at 150 mg or lowered back to the 75 mg. The current facility policy titled, MatrixCare Physician Order Policy, with a revised date of 8/2019, was provided by Medical Records on 01/23/24 at 4:38 P.M. The policy indicated, .Nursing managers and/or designated nurses will review the physician order report [re-caps] for accuracy, order omissions, and obtain any necessary order clarifications .For readmissions, if the resident has been out of facility less than 7 days, reconcile existing orders in MatrixCare with hospital re-admission orders. Make any necessary additions, subtractions, i.e., add any new orders, d/c [discontinue] orders that are not included in readmission orders . 3.1-37(a) 3.1-48(a)(1)

Based on record review and interview, the facility failed to address Pharmacy Recommendations in a timely manner for 3 of 7 residents reviewed for unnecessary medications. (Residents 51, 59, and 46) Findings include: 1. The clinical record for Resident 51 was reviewed on 01/18/24 at 9:11 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 12/11/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, hypokalemia, renal insufficiency, and hemiplegia. A Pharmacy Consultation Report, issued on 12/06/23, was provided by the Administrator on 01/23/24 at 1:20 P.M. The report indicated the resident's recent lab results showed a low concentration of potassium, 2.6 on 11/20/23, and 2.7 on 10/27/23. The recommendation was to, Please consider adding potassium chloride 20 MEQ (Milliequivelents) daily and repeating potassium level on 12/13/23. The recommendation was signed by the pharmacist on 12/06/23. The physician responded to the recommendation on 01/02/24. The potassium level was not checked until 01/15/24, when it was 3.1, and out of the preferred range of 3.4 to 5.1. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for December 2023 and January 2024, indicated the resident's recommended potassium was not started until 01/09/24. The Progress Notes for December 2023 and January 2024, indicated the NP (Nurse Practitioner), dated 01/09/24 at 6:31 A.M., indicated the NP addressed the Pharmacy Recommendation, dated 12/06/23, and ordered the potassium, 20 MEQ daily. During an interview on 01/23/24 at 12:55 P.M., the IP (Infection Preventionist) indicated she oversaw the pharmacy recommendations. Someone should have followed up on the pharmacy recommendation if she was not there. The resident's potassium level was not drawn on 12/13/23 per the pharmacy recommendation. She was unsure as to why the pharmacy recommendation was not addressed sooner. 38769 2. The clinical record for Resident 59 was reviewed on 01/22/24 at 3:54 P.M. A Quarterly MDS assessment, dated 11/17/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, non-Alzheimer's dementia, anxiety, and depression. A Pharmacy Consultation Report for Resident 59, was dated 12/06/23. The report indicated, the resident had a diagnoses of diabetes and hypertension, but does not receive an antihypertensive associated with improved kidney and cardiovascular outcomes. This individual received the following antihypertensive medications: metoprolol 25 mg every 12 hours, the blood pressure readings are consistently elevated. Recommendation: Please consider adding lisinopril 10 mg daily. The physician accepted the recommendation with a following modification: lisinopril 2.5 mg daily. The recommendation was signed by the NP (Nurse Practitioner) on 01/04/24. The clinical record indicated the resident started the lisinopril medication on 01/09/24. During an interview on 01/23/24 at 12:58 P.M., Infection Preventionist indicated for pharmacy recommendations she would get a report and could check it everyday. She would make a copy of the recommendation and put the rest of them in the binder for the NP. If she didn't hear a response back within a couple of days then she would check with the NP about the recommendations. If she was off work the DON (Director of Nursing) had access to the reports. The NP was in the building Monday through Friday and should have reviewed within 1 week. The recommendation dated 12/06/23, should have been reviewed and signed before 01/04/24. 38239 3. The clinical record for Resident 46 was reviewed on 01/22/24 at 3:45 P.M. An Admission MDS assessment, dated 12/18/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hypertension, stroke, anxiety, and diabetes. A Pharmacy Consultation Report, dated on 12/13/23, indicated the resident received medroxyprogesterone (a hormone used for birth control). The medication had a BOXED WARNING describing increased risk of stroke, deep vein thrombosis, pulmonary embolism, coronary events, dementia, breast cancer, and endometrial cancer. The Beers criteria recommended avoiding estrogen (oral and transdermal) in older women due to risk of cancer and a lack of cardioprotective and cognitive protective effect. The recommendation was to please reevaluate the use of medroxyprogesterone. The recommendation was signed by the pharmacist on 12/13/23. The physician responded on 01/11/24 and indicated they wanted to discontinue the medication. During an interview on 01/23/24 at 1:09 P.M., The IP Nurse indicated she did have to discuss that recommendation with the NP (Nurse Practitioner). The NP wasn't sure about discontinuing the birth control because the resident came to the facility with the order. Usually, the turnaround time for the NP or MD to respond to the pharmacy recommendations was so fast that they didn't need to make a progress note that indicated they were working on addressing a recommendation. The clinical record lacked documentation the recommendation was addressed before 01/11/24 when the medication was discontinued. The recommendation should have been addressed sooner. The current facility policy, titled Medication Regimen Review, dated January 2022, was provided by the Administrator on 01/23/24 at 4:13 P.M. The policy indicated, .The Consultant Pharmacist will make recommendations .on the date of the review .the Director of Nursing or designee .will notify the resident's physician/prescriber for review and consideration . 3.1-25(i)

Based on observation, interview, and record review, the facility failed ensure pressure ulcers were not acquired in the facility and wound treatments were implemented related to a Stage 3 pressure ulcer worsening to a Stage 4 pressure ulcer (Resident C), a Stage 2 pressure ulcer worsening to a Stage 3 pressure ulcer (Resident B), and failed to prevent a pressure ulcer for a resident who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. The clinical record for Resident C was reviewed on 04/05/21 at 11:39 A.M. The MDS (Minimum Data Set) assessment, dated 11/10/20, indicated the resident was moderately cognitively impaired. The resident did not reject care, or exhibit any other behaviors during the assessment review period. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for developing pressure ulcers, but had none at the time of the assessment. The resident utilized pressure relieving devices for their bed and wheelchair. A Progress Note, dated 11/17/2020 at 4:31 A.M., indicated there was an area of concern identified on the resident's right lower buttock. During an interview on 04/05/21 at 1:47 P.M., LPN (Licensed Practical Nurse) 3 indicated she observed the wound on Resident C's skin on 11/17/20. It was a pretty good sized wound. She assessed the wound, initiated a treatment, and notified the physician and family. The wound was healing nicely. The wound was documented on a New Skin Event form dated 11/17/20 at 12:46 P.M. The wound was described as a pressure area to the lower right gluteal fold that measured 7 cm (centimeters) long x (by) 4 cm wide. The depth of the wound was unable to be determined due to necrotic (dead) tissue. The wound was dark in color, with a small amount of light red drainage, and there was a slight odor. Preventive measures that were put into place included encouraging the resident to be in bed and not in their wheelchair, a low air loss mattress, and staff were to turn the resident every two hours when in bed. A Care Plan for the wound was initiated on 11/18/20. Interventions included, but were not limited to, encourage the resident to not pick at the wound or remove the wound dressing, encourage the resident to eat at least 75% (percent) of meals, encourage the resident to lay down between meals, and to administer wound treatments as ordered. A facility wound assessment, dated 11/26/2020 at 12:04 P.M., indicated the wound was an unstageable wound (wound was covered with dead tissue) that was 7 cm x 4 cm. The deepest part of the wound that was visible was 1 cm deep. There was a light amount of serosanguineous (pale red to pink, thin and watery) drainage. There was no odor. 40% of the wound was covered by slough (dead tissue, usually white or yellow in color), and 60% of the wound was granulation (healthy, red) tissue. The wound was improving. A facility wound assessment, dated 12/10/2020 at 1:36 P.M., indicated the wound was an unstageable wound due to slough and eschar (dead tissue, usually black in color and dry). The wound measured 6.8 cm x 4.3 cm. The deepest part of the wound that was visible was 4 cm deep. There was a light amount of serosanguineous drainage, and a moderately foul odor. 80% of the wound was covered by granulation tissue and 20% was covered by eschar tissue. The wound was stable. A facility wound assessment, dated 12/17/2020 at 4:31 P.M., indicated the wound was a Stage 3 (full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon, or muscle were not exposed) pressure ulcer that measured 4.2 cm x 4 cm and was 3.2 cm deep. There was a moderate amount of serosanguineous drainage, there was no odor. 80% of the wound was covered by granulation tissue and 20% was covered by eschar tissue. The wound was improving. The wound care initial evaluation/treatment plan for Resident C from the resident's first visit to the local wound clinic on 12/22/20 was reviewed on 04/06/21 at 2:45 P.M. The document indicated the provider's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . New wound care orders included, but were not limited to, .Patient may sit in her wheelchair for meals but to spend 2 hours in bed off wound in the morning and in the afternoon . A facility wound assessment, dated 12/24/2020 at 10:34 A.M., indicated the wound was a Stage 4 pressure ulcer that measured 2.5 cm x 2 cm and was 2.5 cm deep. There was a light amount of serosanguineous drainage. There was no odor, tunneling, or undermining. 100% of the wound was covered in granulation tissue. The wound was improving. A note on the assessment indicated the resident went to the wound clinic that week for an initial visit. The resident's treatment orders were changed, and the resident had a new order for a CT scan to rule out [CONDITION(S)]. (Later documents revealed [CONDITION(S)] was not present). A facility wound assessment, dated 12/31/2020 at 2:52 P.M., indicated the wound was a Stage 4 pressure ulcer that measured 2 cm x 1.2 cm, and was 2.5 cm deep. There was a light amount of serosanguineous drainage. There was no odor, tunneling, or undermining. 100% of the wound was covered in granulation tissue. The wound was improving. A facility wound assessment, dated 01/07/2021 at 05:37 P.M., indicated the wound was a Stage 4 pressure ulcer that measured 2.5 cm x 2 cm, and was 3.8 cm deep. There was a light amount of serosanguineous drainage. There was no odor, tunneling, or undermining. 100% of the wound was covered in granulation tissue. The wound was improving. A facility wound assessment, dated 02/11/2021 at 2:42 P.M., indicated the wound was a Stage 4 pressure ulcer that measured 1.7 cm x 0.5 cm, and was 0.5 cm deep. There was a light amount of serosanguineous drainage. There was no odor, and 3 cm of tunneling was documented. 100% of the wound was covered in granulation tissue. The wound was improving. A facility wound assessment, dated 02/25/2021 at 3:49 P.M., indicated the wound was a Stage 4 pressure ulcer that measured 0.5 cm x 0.5 cm, and was 0.7 cm deep. There was a light amount of serosanguineous drainage. There was no odor, tunneling, or undermining. 100% of the wound was covered in granulation tissue. The wound was improving. A facility wound assessment, dated 03/18/2021 at 11:26 A.M., indicated the wound was a Stage 4 pressure ulcer that measured 0.4 cm x 0.5 cm, and was 2.6 cm deep. There was a light amount of serosanguineous drainage. There was no odor, tunneling, or undermining. 100% of the wound was covered in granulation tissue. The wound was stable. A facility wound assessment, dated 04/01/2021 at 07:57 A.M., indicated the wound was a Stage 4 pressure ulcer that measured 1.2 cm x 1 cm, and was 0.8 cm deep. There was a light amount of serosanguineous drainage. There was no odor, tunneling, or undermining. 100% of the wound was covered in granulation tissue. The wound was stable. During a group interview on 04/06/21 at 10:47 A.M., the facility Wound Nurse and DON (Director of Nursing) indicated they determined the root cause of the pressure ulcer was because the resident was sitting in their wheelchair for long periods of time, they refused to lay down. The resident was also known to place objects behind them in their wheelchair and at their sides and in their clothes. In addition, the resident was ill with COVID-19, wasn't eating well, and was refusing supplements immediately prior to the identification of the wound. The wound went from a Stage 3 to a Stage 4 because the wound clinic identified the wound as a Stage 4 at the resident's initial visit. During an interview on 04/06/21 at 2:59 P.M., the DON indicated any physician's orders received by the facility would be entered into the computer and would show up on the resident's EMAR (Electronic Medication Administration Record) or ETAR (Electronic Treatment Administration Record). The DON indicated she did not feel the order for the resident to lay down in bed 2 hours in the morning and 2 hours in the afternoon was feasible. She felt they had every intervention in place that was feasible for that resident. There was no documentation in Resident C's clinical record that indicated the facility acknowledged the physician's order dated 12/22/20 for the resident to spend 2 hours in bed off of the wound in the morning and in the afternoon. The order was never on the EMAR or ETAR. The facility could provide no documentation that they sought clarification or the discontinuation of this physician's order. 2. During an observation on 04/06/21 at 9:38 A.M., the resident was laying in bed on his right side. LPN 4, let the resident know what she was doing and washed her hands appropriately. The old wound dressing was dated for 04/05/21 and was removed. Her gloves were changed and the area was cleansed with wound cleanser and the wound was patted dry. LPN 4 applied Santyl (a medication that removes dead tissue from wounds so they can start to heal) to the wound bed, covered with a foam dressing, and secured with tape. The skin around the wound was pink in color and the wound was quarter size with slough present. The clinical record for Resident B was reviewed on 04/05/21 at 10:15 A.M. A Quarterly MDS assessment, dated 01/04/21, indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for developing pressure ulcers. An impaired skin integrity care plan, dated 10/26/20, indicated the resident had a pressure wound to the left hip, dated 03/08/21, indicated the residents interventions included, but were not limited to, treatment as ordered, initiated 10/26/20. An IDT (Interdisplinary Team) Progress Note, dated 03/08/21, indicated the resident's left posterior hip was noted with a Stage 2 (loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or open/ruptured serum-filled blister) pressure area that was presenting with a beefy red wound bed and scant sanguineous exudate. A facility wound assessment, dated 03/08/21 at 4:03 P.M., indicated the wound was Stage 2 pressure ulcer to the left hip that measured 1.1 cm x 2.2 cm x 0.1 cm. The wound had light amount of serosanguineous exudate. There was no odor noted. A facility wound assessment, dated 03/18/21 at 12:29 P.M., indicated the wound was an unstageable pressure ulcer to the left hip that measured 3 cm x 2.1 cm x 0.2 cm. The wound had heavy amount of serous (clear, amber, this and watery) exudate. There was no odor present. 30% of the wound was covered by granulation tissue and 70% of the wound was covered by eschar. The wound was declining. The Nurse Practitioner and POA (Power of Attorney) were made aware of the decline in the wound and requested the resident be seen by the wound center. A facility wound assessment, dated 04/01/21 at 7:25 A.M., indicated the wound was a Stage 3 pressure ulcer to the left hip that measured 3 cm x 1.9 cm x 0.1 cm. The wound had a moderate amount of serous exudate. There was no odor present. 20% of the wound was covered by granulation tissue and 80% of the wound was covered by slough. The wound was improving. A physician's order, with a start date of 03/18/21, indicated staff were to cleanse the resident's left hip with a wound cleanser, pat dry, and apply Santyl to the wound bed. Cover the wound with calcium alginate and a foam dressing, once a day. A Wound Center Order Note, dated 03/25/21, signed by the Nurse Practitioner indicated, to gently cleanse the left hip with normal saline and gauze. Apply [MEDICATION(S)] (a wound medication) to the wound base, cover with plain foam, and secure in place, every other day and as needed. The clinical record lacked documentation that the wound center order was in place after 03/25/21. During an interview on 04/06/21 at 10:12 A.M., the DON indicated the resident's order for the left hip should have changed after going to the wound center. She believed the family wanted to stop going to the wound center and start hospice services so the treatment was never changed. The family had a care conference on 03/31/21, but there was no documentation prior to the care conference to clarify or hold the order from the wound center. 3. The dressing change for Resident D was observed on 04/06/21 at 1:57 P.M. Staff included Unit Manager 2 and LPN 3. Both of the resident's feet were elevated on a pillow with heels not touching a surface. The resident's wound was on the inner side of his right heel. The open area was approximately the size of a silver dollar with a red and white wound bed. The edges were dry and slightly scaly. The old dressing was stained with a moderate amount of yellow fluid. The LPN indicated the wound had started as a fluid filled intact blister. The resident's ankle was not swollen. One protective boot was applied to the right foot only following the dressing change. No other boots were observed in the immediate area. The two staff members turned the resident from his left side to his back. They rested both of the resident's feet on a pillow not allowing the heels to float freely. During an interview on 04/05/21 at 1:48 P.M., LPN 3 indicated in regard to the resident's present wound, the resident had a tendency to hang his feet off the side of the bed and rub his feet together. They implemented protective boots, although the resident was non compliant. The staff tried to keep the resident's feet elevated and off of the bed. The resident would sometimes take the boot off. When the resident was in bed they liked to lay in one spot. A blister developed where the resident rubbed his feet together. The staff would turn the resident in bed and the resident throws themselves back over again. The wounds in December were on the back of his heels. During an interview on 04/06/2021 at 3:23 P.M., LPN 3 indicated the purpose of floating someone's heels was to ensure the heels were off of the bed. The heels were not to touch the bed or another surface. The pillow used to float the heels should not be directly behind the knees. There should be distance between the heels and the bed. The heels should be floating off of the pillow. Sometimes they had residents who had one leg that was shorter than the other, like resident D, which made it difficult to float the heels. During an interview on 04/06/21 at 2:58 P.M. the facility Wound Nurse indicated the resident had [CONDITION(S)] in his feet and liked to sit up a lot. They often would throw their feet over the side of the bed and rub their feet together, sometimes throughout the night. It was reported to her that the resident had a fluid filled blister. The fluid was clear so the wound was automatically considered a Stage 2 pressure ulcer. They put a treatment in place that consisted of [MEDICATION(S)], absorbent pad, and gauze wrap to his right foot. They gave him an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff were telling her, the Wound Nurse, there were times when the resident would take the boot off and throw it but they encourage the resident to wear it. The Wound Nurse indicated she was off work with Covid in November and December around the time when the resident acquired the pressure ulcers on their heels and referred to the DON. During an interview on 04/06/2021 at 3:06 P.M., the DON indicated after the two wounds on the resident's heels were healed in December, to prevent further pressure ulcers, they had a physician's order for skin protective solution and to float the heels as the resident would allow. Prior to the pressure ulcer that developed in March of 2021, the resident had orders for skin protective solution and to float their heels. They also turned and repositioned the resident. The facility Wound Nurse indicate the resident transferred themselves from the bed to the wheelchair and to the toilet in February of 2021. The protective boots put the resident at a greater risk for falls so they were discontinued. The resident did not always use his call light when they needed to get up. They sometimes yelled out. They had skin protective solution and float heels interventions in place after discontinuing the protective boots. The position of the blister the resident currently had appeared to be from one foot resting on the other. When the wound heals they would have to put a preventative treatment in place. The most recent completed MDS assessment, a Significant Change assessment, dated 12/17/20, indicated the resident was severely cognitively impaired and needed extensive assistance of two staff members for bed mobility, transfers, toilet use, and bathing. The resident needed extensive assistance of one staff member for walking in their room, walking in the corridor, dressing, and personal hygiene. They were frequently incontinent of bowel and bladder. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They received scheduled pain medications. They had a pressure ulcer; a pressure reducing device for their chair and bed; was at risk for pressure ulcers, and had an unhealed pressure ulcer that was unstageable. The Wound Management assessments were provided by the Administrator on 04/04/21 at 4:05 P.M. Wound measurements are in centimeters and are as follows: Pressure Ulcer Right Heel identified 12/03/20 12/03/20---2 X 3, calloused/resurfaced, dark purple or rusty discoloration 12/10/20---2 X 3, calloused/firm, scaling Healed 12/17/20 Pressure Ulcer Left Heel identified 12/14/20 12/14/20---2 X 2, unstageable - Slough and/or Eschar 12/17/20---2 X 2, untraceable - Slough and/or Escarp 12/23/20---2 X 2, unstageable - Slough and/or Eschar 12/24/20---2 X 2, unstageable - Slough and/or Eschar 12/31/20---2 X 2, unstageable - Slough and/or Eschar Healed 01/07/21 Pressure Ulcer Right Heel Inner medial identified 3/29/21 03/29/21---4.5 X 4 X 0.1, edge of fluid filled has opened, light serous drainage remains, no signs or symptoms of infection 04/01/21---4.5 X 4 X 0.1, Stage 2, wound edges remain loose from base of foot 04/01/21---4.5 X 4 X 0.1, fluid filled area is coming loose from base of wound at distal end, fluid is seeping, outer layer of skin is intact 90% at this time. - The EMAR for November 2020, was provided by the Administrator on 04/06/21 at 12:00 P.M., and contained the following orders: Float heels as resident will allow while in bed, every shift, three times a day, start and end date 09/29/2020 - 11/03/2020 Protective boots to both feet, every shift, three times a day, start and end date 11/19/2020 - 02/17/2021 [MEDICATION(S)] solution, 10%, topical, once daily. Cleanse bilateral, (both) heels with soap and water, apply breadline, cover with absorbent pad, wrap with gauze and change every day for dark brownish/black areas to bilateral heels, start and end date 11/27/2020 - 01/08/21 - The EMAR (Electronic Medication Administration Record) for February 2021, was provided by the Administrator on 04/06/21 at 12:39 P.M., and contained the following orders: Protective boots to both feet, every shift, three times a day, start and end date 11/19/2020 - 02/17/2021 Skin protective solution to both feet including heels, toes, and ankles every shift, three times a day, - preventative measure, start and end date 01/08/2021 - open ended (continues) - The EMAR (Electronic Medication Administration Record) for March 2021, was provided by the Administrator on 04/06/21 at 12:11 P.M., and contained the following orders: Cleanse right heel with skin integrity (cleanser), apply skin protective solution to right heel, apply [MEDICATION(S)], cover with absorbent pad, wrap with gauze from ankle to toes then secure with tape, change daily and as needed, discontinue treatment when resolved, for fluid filled area to right heel, start date 03/24/2021 - open ended. Protective boots on at all times except during bathing for foot ulcer, every shift, three times a day, start date: 03/29/2021 - open ended Skin protective solution to both feet including heels, toes, and ankles every shift, three times a day, - preventative measure, start and end date 01/08/2021 - open ended (continues) No physician's orders were noted for floating the resident's heels after 11/03/2020. The Progress Notes were provide by the Administrator on 04/04/21 at 4:05 P.M. A note, dated 03/24/21 at 12:00 P.M., indicated LPN 3 documented the resident had an area of concern to his right inner heel. The area was an intact fluid filled blister that was purple/red in color. Staff, including the wound care nurse and ADON (Assistant Director of Nursing), were notified along with the family and the NP (Nurse Practitioner). No notes, for 10 days prior to the development of the ulcer on the resident's right heel, indicated the resident's heels were being floated to prevent new or the recurrence of pressure ulcers. The current SKIN MANAGEMENT PROGRAM policy, dated 7/20, indicated, .It is the policy of American Senior Communities to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers .and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing . This Federal tag relates to Complaint IN 139. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident's pain medication was available for administration, after admission to the facility, for 1 of 3 residents reviewed for pain. This deficient practice caused harm in one resident (Resident E). (Resident E's) expressed pain with no relief for 12 hours. Findings include: The clinical record for Resident E was reviewed on 2/2/17 at 2:20 p.m. [DIAGNOSES REDACTED]. The progress note, dated 1/24/17 at 4:15 p.m., indicated Resident E was admitted to the facility and physician orders [REDACTED]. The admission observation report, dated 1/24/17 at 4:15 p.m., indicated Resident E was oriented to person, place and time. The resident expressed almost constant pain located in the low back. The pain occurred morning, afternoon, evening, and night. She described the pain as penetrating, sharp, shooting, staffing, and throbbing. On a numeric scale the pain was a 9 out of 10, that being the worst. The 72 hour Admission Shift Charting, dated 1/24/17 at 6:47 p.m., indicated the resident complained of moderate to severe pain in the left leg, thigh, and groin area. The physician order, dated 1/24/17, indicated Resident E was to have [MEDICATION NAME] (pain medication) 4 milligrams, every 4 hours as needed, for moderate pain and a [MEDICATION NAME] (pain medication), 150 micrograms, every 72 hours. The progress note, dated 1/24/17 at 9:37 p.m., indicated the resident was grimacing, holding her left hip, and told the nurse she was in pain. The progress note, dated 1/24/17 at 10:55 p.m., indicated Resident E's daughter told the nurse that she needed her pain medication. The IDT (Interdisciplinary Team) Pain Interview, dated 1/25/17 at 12:53 p.m., indicated the resident had almost constant severe, horrible pain in the last five days. The pain had made it hard for her to sleep and limited the day-to-day activity. On 2/3/17 at 11:20 a.m., the Unit Manager provided a copy of the narcotic delivery sheet which indicated Resident E's pain medications did not arrive to the facility, from pharmacy, until 4:33 a.m. on 1/25/17. The clinical record lacked documentation of any other pain assessments for Resident E, and the Medication Administration Record [REDACTED] During a telephone interview on 2/2/17 at 11:56 a.m., Resident E indicated she did not receive any pain medication for over 12 hours, and, at about 1:30 a.m. on 1/25/17, she was crying because her pain was so bad. During an interview on 2/3/17 at 2:15 p.m., RN (Registered Nurse) 3 indicated Resident E was in pain around 12:30 a.m. on 1/25/17. This Federal tag relates to Complaint IN 670 3.1-37(a)

Based on interview and record review, the facility failed to provide the necessary care and services to provide appropriate treatment changes for a right upper extremity wound infection and a right axillary wound for 1 of 3 residents reviewed for quality of care (Resident A). This deficient practice resulted in harm when Resident A [MEDICAL CONDITION] (systemic blood infection) related to his wounds, requiring surgical intervention. Findings include: 1.a. Resident A's medical record was reviewed on [DATE] at 11:00 a.m. [DIAGNOSES REDACTED]. Resident A was transferred from the facility via ambulance on [DATE] at 2:55 a.m. and arrived at (Hospital 1) Emergency Department (ED/ER) on [DATE] at 3:14 a.m. The resident was transferred via ambulance from (Hospital 1) Emergency Department on [DATE] at 6:03 a.m. and was admitted to (Hospital 2) Intensive Care Unit (ICU) on [DATE] at 7:45 a.m. He expired on [DATE] in (Hospital 2) ICU. Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 of 15; indicating Resident A was cognitively intact. MDS assessment further indicated that Resident A required extensive, ,[DATE] person assist for bed mobility, transfers, toileting, and hygiene. MDS assessment indicated Resident A had no pressure ulcers or "other" wounds or skin problems. Non-Pressure Wound Skin Evaluation Report, dated [DATE], indicated, "Description: Area under Right armpit." Documentation indicated it was a new area, not present on admission, and was a "laceration." Measurements indicated, "1 (cm/centimeter) x 3.5 (cm) x 0.2 (cm)" with no tunneling (passageway of tissue destruction under the skin surface, with an opening at skin level from the edge of the wound) and "moderate purulent (pus) exudate (drainage) on dressing with minimal sanguineous (bloody) drainage on dressing." Non-Pressure Wound Skin Evaluation Report, dated [DATE], indicated, "Description: laceration to rt (right) armpit." Documentation indicated it was an existing area, originally noted on [DATE], and measured "1 (centimeters) x 3.5 (centimeters) x 0.1 (centimeters)" with no tunneling and "small amount of purulent drainage on dressing." Nursing Weekly Summaries, dated [DATE] and [DATE], did not indicate the laceration to Resident A's right axilla (armpit) under "Skin Assessment...Indicate any areas of skin integrity alteration the resident currently has." Nursing Weekly Summary, dated [DATE], indicated, "Open areas - laceration to R (right) Axilla (armpit)...If resident has an open area, do they have pain at the site: Yes (describe pain level) - ,[DATE]." Resident Progress Notes, dated [DATE] at 6:08 p.m., indicated, "dsg (dressing) to rt (right) underarm changed per order remains opened with small amount of red draining...." Resident Progress Notes, dated [DATE] at 9:20 p.m., indicated, "...dsg (dressing) changed under rt (right) arm had foul smell had some pain during lifting arm while changing." Resident Progress Notes, dated [DATE] at 2:02 p.m., indicated, "Dressing to right armpit changed, area bleeding prior to dressing change." Physician Telephone Orders and Medication Administration Records (MARs) indicated treatment orders for the right axilla wound were initiated on [DATE]. Treatment orders were discontinued and new orders initiated on both [DATE] and [DATE]. Physician Telephone Orders, dated [DATE], indicated, "...D/C (discontinue) skin prep order, [MEDICATION NAME] order to R armpit 2' (secondary to) another dressing ordered...." No additional orders were documented. The MAR indicated [REDACTED]. Resident Progress Notes, dated [DATE] at 4:29 a.m., indicated, "Res. (resident) noted to be lethargic at 12 a.m. med pass, took approx. (approximately) ,[DATE] minutes to get res. alert....At 2:10 a.m. this nurse went in to res. room to do dressing change to right bicep, area noted to be draining serosanguineous (abnormal wound drainage consisting of both blood and serous fluid) fluid, large knot noted under reddened area, knot measured 10 cm x 9 cm with reddened area peri-wound (around the wound). Res. lethargic and disoriented at that time...whimpering at times and stating 'please.' Unable to hold own head up at that time, body shaking frequently, area right bicep oozing large amounts of drainage....New order received at 2:30 a.m. to send res. to (Hospital 1) ER for eval. (evaluation) and treatment, res. VS (vital signs) ,[DATE], heart rate 126, resp. (respirations) 18....Transported to (Hospital 1) ER at 2:55 a.m." The following Resident Progress Note, dated [DATE] at 6:06 a.m., indicated, "Received call from (Hospital 1) ER, res. being transferred to (Hospital 2) due (to) (Hospital 2) having nephrologist on duty on weekend....res. WBC (white blood count) 22,000, K (potassium) 7 and the ER unable to properly place central line at this time due to condition of res." (Hospital 2) PT (Physical Therapy) Wound Care Forms, dated [DATE] at 4:31 p.m., indicated, "...Wound Data #1 Location: right lateral arm with 2 larger and 2 smaller open wounds. Diagnosis: [REDACTED]. Coloration: 100% yellow/necrotic. Exudate (drainage): Maximal, Purulent. Periwound (around the wound): [DIAGNOSES REDACTED] (redness). Wound Data # 2 Location: right axilla. Diagnosis: [REDACTED]. Measurements: unable to measure as noted above. Coloration: approx. (approximately) ,[DATE] eschar (thick, leathery, necrotic (dead) tissue, black or brown in color), remaining red. Exudate: Moderate, Serosanguineous (yellowish with small amounts of blood). Periwound: [DIAGNOSES REDACTED]....Pt (patient) will need surgica (sic) debridement (removal of dead, damaged, or infected tissue) of right UE (upper extremity) wounds." (Hospital 2) Nephrology Consult Note, dated [DATE] at 9:28 a.m., indicated, "Reason for Consultation: Acute kidney injury....Impressions: ...The cause of his acute injury appears to be ambient [MEDICAL CONDITION] (low blood pressure) due [MEDICAL CONDITION] from large right arm/axillary wound." (Hospital 2) Surgery Consult Note, dated [DATE] at 3:47 p.m., indicated, "Preoperative Diagnoses: [REDACTED]. Procedure: Incision and drainage of complex right shoulder abscess and right axillary wound....Operative Indications: ...Upon admission, he was found to have a large undermining wound on his right shoulder draining purulent fluid with 2 openings....Operative Findings: There was a large deep abscess cavity involving the right shoulder, extending approximately 6 x 5 cm in width and length and 7 cm in depth, extending down to the deltoid (shoulder) muscle and adjacent bone....There was some necrotic (dead) tissue superficially which was debrided (removing dead or infected tissue). In the right axilla, there was a superficial wound with central eschar measuring 6 x 4 cm. This necrosis involved only the skin and subcutaneous tissues (third of three layers of tissues)....Operative Procedure: ...I then explored these wounds and found a large amount of purulent fluid, approximately 50 - 75 ml (milliliter). This wound extended down to the bone and deltoid muscle and involved a very large space with dimensions as listed above. There were 2 openings and these were connected with significant undermining." An Incident Report Form, dated [DATE], and provided by the Administrator on [DATE] at 10:50 a.m., indicated, "...Review of wounds and treatment orders revealing discontinued order of treatment to Right underarm. Previous dressing change order was for change q (every) Tues (Tuesday) and Fri (Friday). Last dressing change had occurred on Friday, Sept. (September) 26 (2014) and next date would have been Tuesday, ,[DATE] (2014) when dressing would have been changed, but order had been discontinued." On [DATE] at 12:30 p.m., the Corporate Director of Nursing Services (CDNS) indicated, "As long as (a wound is) resolving, it doesn't require weekly documentation and measurement....If it's non-pressure, we document a non-pressure event...get measurements, a new order....On-going (assessment) is per weekly head-to-toe summary (Nursing Weekly Summary). We do charting by omission. If there's no documentation, we're going to assume it's healing without complications." Current Skin Management Program and IDT (Interdisciplinary Team) Weekly Review of Residents With Wounds Policy and Procedure was provided by the CDNS on [DATE] at 12:32 p.m. Policy indicated, "...Residents will have a skin assessment completed no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment." Procedure indicated, "...All alterations in skin integrity will be documented in the EMR (Electronic Medical Record) - New Skin Alteration Event...The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation event....The care plan will be initiated to include specific alterations in skin integrity...." Areas Requiring Weekly Documentation indicated, "Stage I, II, III, IV and unstageable pressure sores...Large skin tears...Post-operative surgical sites...Non-healing rashes, abrasions, and any skin conditions that are not resolving." The IDT Note indicated, "An IDT note must be written at least weekly on all wounds....The note should be written in EMR progress notes. The wound measurements are documented in the EMR...The note should refer specifically to each site and be general whether the site has worsened, remained unchanged or improved...The characteristics of the wound(s) should be detailed to include but not limited to (1) the peri-wound, (2) the bed of the wound, examples wound include; slough, debris, or eschar..., (3) odor, (4) and drainage. If the wound has worsened or improved the IDT should reference these changes and credit or change the current interventions....The nutritional status of a resident with an open area must be documented in the weekly note...." The Care Plan indicated, "An open area must have an individual care plan in addition to any previous at risk/preventative care plans associated to the residents care...." On [DATE] at 3:28 p.m. the Assistant Director of Nursing (ADON) indicated, "If they saw the order to d/c (discontinue the right axillary wound dressing on [DATE]), they might think, 'Great, I don't have to look at that anymore.' If he wouldn't lift his arm, they might not have even seen the old dressing." On [DATE] at 3:50 p.m., the CDNS indicated, "I don't know why the orders were changed. (The wound nurse) was not following her protocol because it was non-pressure....It's hard to know (without documentation what the wound looked like or why treatments were changed)." RN #1, the admitting ICU nurse at (Hospital 2) was interviewed via phone on [DATE] at 11:00 a.m. She indicated she admitted Resident A at 7:45 a.m. on [DATE] and cared for him on [DATE] and [DATE]. She indicated, "When he arrived, it was obvious he was unkempt, unclean. He had a very strong smell...." She further indicated that both Wound Care and Surgery consults were called during Resident A's ICU admission assessment. She indicated she could not recall a date indicated on the right axilla dressing, but stated, "It was saturated and foul...smelled like it had been there a while and were were all wearing masks." LPN #1 was interviewed on [DATE] at 12:54 p.m. She indicated she cared for Resident on [DATE] on day shift and stated, "His skin as far as I knew was fine. There were no dressing change ordered for him. As far as I know, we were doing a change under his right arm pit, but that had been discontinued by the wound nurse. The wound nurse usually looked at those and d/c's (discontinues) the orders...I think she even wrote 'resolved'." LPN #2 was interviewed on [DATE] at 1:30 p.m. She indicated she cared for Resident A during evening shift on [DATE] and [DATE]. She indicated, "One of the two days, they did a bed bath with him. I was in the room at the time helping turn him. I did see his right under arm. To the best of my recollection, it had a crack...a laceration appearance about a inch and a half to two inches long....No dressing...." 1.b. Resident A's Progress Notes, dated [DATE] at 12:27 a.m., indicated, "MD (physician) in to see resident per his request. Resident c/o (complained of) severe right shoulder pain....N.O. (new order) Icy Hot, Kenolog (steroid) / [MEDICATION NAME] (local anesthetic) injection for right shoulder as well. Pharmacy notified." Physician Visit Note, dated [DATE], indicated, "(Resident A) is seen today for followup of right shoulder pain....I am here today to inject his right shoulder....Assessment and Plan: 1. Right bicipital tendinitis (inflammation, irritation of a tendon)....The mixture of 40 mg (milligrams) [MEDICATION NAME] and 6 ml (milliliters) of 1% [MEDICATION NAME] were used, and approximately 2 ml of this was injected around the right bicipital tendon....3. ...Approximately 2 ml of mixture of 40 mg of [MEDICATION NAME] and 6 ml of 1% [MEDICATION NAME] were injected around the acromicoclavicular joint....4. ...The trigger point was identified over the trapezius muscle laterally...injected with a mixture of 2 ml of mixture of 40 mg of [MEDICATION NAME] and 6 ml of 1% [MEDICATION NAME] mixture previously used and injected under sterile technique....bandaids were applied to the injection sites." An Infection Control Individual Report, dated [DATE], indicated, "Description: [MEDICAL CONDITION] (bacterial skin infection) r (right) bicep. [DIAGNOSES REDACTED]. Signs and Symptoms: Drainage serous (site) - R (right) bicep....Redness (site) - R (right) bicep....Date medication ordered: [DATE]. Name of medication ordered: Bactrim DS (antibiotic) one PO (by mouth) BID (twice daily) x 10 days." Resident Progress Notes, dated [DATE] at 11:23 a.m., indicated, "N.O. (new order) rec'd (received) Bactrim DS (antibiotic) one PO (by mouth) BID (twice daily) x 10 days for area to r (right) bicep which is warm to touch with slight drainage noted." Nursing Weekly Summary, dated [DATE], indicated, "Skin Assessment: [MEDICAL CONDITION] (swelling): Yes (location) - ...upper bicep area...Open areas (description/site) - upper right bicep x 2." Resident Progress Notes, dated [DATE] at 8:59 a.m., indicated, "He (Resident A) is lethargic and refusing to even attempt to feed himself....Vitals are WNL (within normal limits) at this time. Resident's temperature indicated, "97.8 (degrees Fahrenheit)." Resident Progress Notes, dated [DATE] at 9:09 p.m., indicated, "Bed bath given at this time by writer and 2 CNA's....Skin noted to have open areas x 2 on R (right) bicep with redness noted. ATB (antibiotic) continues for [MEDICAL CONDITION] with no ASE (adverse side effects) noted. Open area noted to R armpit." Resident Progress Notes, dated [DATE] at 1:29 a.m., indicated, "New order received: ....Cleanse area to right bicep with normal saline, apply non-adherent pad, cover with gauze and tape." Resident Progress Notes, dated [DATE] at 4:29 a.m., indicated, "Res. (resident) noted to be lethargic at 12 a.m. med pass, took approx. (approximately) ,[DATE] minutes to get res. alert....At 2:10 a.m. this nurse went in to res. room to do dressing change to right bicep, area noted to be draining serosanguineous fluid, large knot noted under reddened area, knot measured 10 cm x 9 cm with reddened area peri-wound. Res. lethargic and disoriented at that time...whimpering at times and stating 'please.' Unable to hold own head up at that time, body shaking frequently, area right bicep oozing large amounts of drainage....New order received at 2:30 a.m. to send res. to (hospital) ER for eval. (evaluation) and treatment, res. VS (vital signs) ,[DATE], heart rate 126, resp. (respirations) 18....Transported to (hospital) ER at 2:55 a.m." The following Resident Progress Note, dated [DATE] at 6:06 a.m., indicated, "Received call from (Hospital 1) ER, res. being transferred to (Hospital 2) due (to) (Hospital 2) having nephrologist on duty on weekend....res. WBC (white blood count) 22,000, K (potassium) 7 and the ER unable to properly place central line at this time due to condition of res." (Hospital 2) PT Wound Care Forms, dated [DATE] at 4:31 p.m., indicated, "...Verify Wound Sites: Per Nursing (Comment: At time of consult/eval (evaluation) only anterior surface of body examined with right UE (upper extremity) and axilla wounds noted as pt (patient) with onset of Vtac ([MEDICAL CONDITION]) then emerent (sic) [MEDICAL TREATMENT], per nursing report later in the day, pt has significant wounds on posterior body....Wound Data #1 Location: right lateral arm with 2 larger and 2 smaller open wounds. Diagnosis: [REDACTED]. Coloration: 100% yellow/necrotic. Exudate (drainage): Maximal, Purulent. Periwound (around the wound): [DIAGNOSES REDACTED] (redness). Wound Data # 2 Location: right axilla. Diagnosis: [REDACTED]. Measurements: unable to measure as noted above. Coloration: approx. (approximately) ,[DATE] eschar, remaining red. Exudate: Moderate, Serosanguineous. Periwound: [DIAGNOSES REDACTED]....Pt (patient) will need surgica (sic) debridement of right UE (upper extremity) wounds." (Hospital 2) Nephrology Consult Note, dated [DATE] at 9:28 a.m., indicated, "Reason for Consultation: Acute kidney injury....Impressions: ...The cause of his acute injury appears to be ambient [MEDICAL CONDITION] due [MEDICAL CONDITION] from large right arm/axillary wound." (Hospital 2) Surgery Consult Note, dated [DATE] at 3:47 p.m., indicated, "Preoperative Diagnoses: [REDACTED]. Procedure: Incision and drainage of complex right shoulder abscess and right axillary wound....Operative Indications: ...Upon admission, he was found to have a large undermining wound on his right shoulder draining purulent fluid with 2 openings....Operative Findings: There was a large deep abscess cavity involving the right shoulder, extending approximately 6 x 5 cm in width and length and 7 cm in depth, extending down to the deltoid muscle and adjacent bone....There was some necrotic tissue superficially which was debrided. In the right axilla, there was a superficial wound with central eschar measuring 6 x 4 cm. This necrosis involved only the skin and subcutaneous tissues....Operative Procedure: I then explored these wounds and found a large amount of purulent fluid, approximately 50 - 75 ml. This wound extended down to the bone and deltoid muscle and involved a very large space with dimensions as listed above. There were 2 openings and these were connected with significant undermining." Resident A's primary care physician was interviewed on [DATE] at 2:15 p.m. via telephone. He indicated that Resident A had a history of [REDACTED]." The physician indicated that he had seen a photograph of Resident A's right deltoid and indicated, "I think it was an abscess. We had put him on antibiotics for what we suspected was [MEDICAL CONDITION]. I don't see how that could be pressure related." He indicated, "several months ago," Resident A had a "4 centimeter wide" wound located at "his chest wall lateral to his breast," stating it was "spontaneous" and related to Resident A's "skin integrity problem." The (Hospital 2) Social Worker was interviewed on [DATE] at 3:54 p.m. She indicated, "Nursing staff indicated (to me) issues as far as skin care....he went pretty quickly to surgury for his wounds...." RN #1, the admitting ICU nurse at (Hospital 2) was interviewed via phone on [DATE] at 11:00 a.m. She indicated she admitted Resident A at 7:45 a.m. on [DATE] and cared for him on [DATE] and [DATE]. She indicated, "When he arrived, it was obvious he was unkempt, unclean. He had a very strong smell....his right arm (wound) was pouring copious brown drainage....There were two (right deltoid wounds)...one quarter-sized black wound and one dime sized...it looked like an ulcer....I said 'Somebody please call wound care now.' ...(Intensive Care Physician) came in and said, 'What's that smell?' It was (the) copious amounts of pus coming from his arm....When Wound Care came in, they stuck a q-tip in and it was tunneling (passageway of tissue destruction under the skin surface) down past the cotton swab." LPN # 1 was interviewed on [DATE] at 12:54 p.m. She indicated she cared for Resident on [DATE] on day shift and stated, "His skin as far as I knew was fine. There were no dressing change ordered for him. As far as I know, we were doing a change under his right arm pit, but that had been discontinued by the wound nurse. The wound nurse usually looked at those and d/c's (discontinues) the orders...I think she even wrote 'resolved.' He did develop two boils that I was telling wound nurse about (could not recall date). At the time, I was told it was [MEDICAL CONDITION] and it was being treated with an antibiotic." The Corporate Director of Nursing Services (CDNS) was interviewed on [DATE] at 1:15 p.m. She indicated "(Resident A's) right bicep was becoming warm to touch...red...even a little [MEDICAL CONDITION]. It was almost like a pimple. The site was coming to a head, so when the nurse assessed him, there were 2 little pin holes where the infection was trying to come through. The doc (primary care physician) gave an order to clean and put a dressing on to try to contain drainage. When he got to the hospital, they noticed 2 separate ulcerative [MEDICAL CONDITION] near the right deltoid, measuring 3x3 cm....sounds like this was continuing to open....He was at (Hospital 1 Emergency Department) for 7 hours until they transferred him to (Hospital 2)...where it looked like it had opened even further." On [DATE] at 12:30 p.m., the CDNS indicated, "As long as (a wound is) resolving, it doesn't require weekly documentation and measurement....If it's non-pressure, we document a non-pressure event...get measurements, a new order....On-going (assessment) is per weekly head-to-toe summary (Nursing Weekly Summary). We do charting by omission. If there's no documentation, we're going to assume it's healing without complications." Current Skin Management Program and IDT (Interdisciplinary Team) Weekly Review of Residents With Wounds Policy and Procedure were provided by the CDNS on [DATE] at 12:32 p.m. Policy indicated, "...Residents will have a skin assessment completed no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment." Procedure indicated, "...All alterations in skin integrity will be documented in the EMR (Electronic Medical Record) - New Skin Alteration Event...The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation event....The care plan will be initiated to include specific alterations in skin integrity...." Areas Requiring Weekly Documentation indicated, "Stage I, II, III, IV and unstageable pressure sores...Large skin tears...Post-operative surgical sites...Non-healing rashes, abrasions, and any skin conditions that are not resolving." The IDT Note indicated, "An IDT note must be written at least weekly on all wounds....The note should be written in EMR progress notes. The wound measurements are documented in the EMR...The note should refer specifically to each site and be general whether the site has worsened, remained unchanged or improved...The characteristics of the wound(s) should be detailed to include but not limited to (1) the peri-wound, (2) the bed of the wound, examples wound include; slough, debris, or eschar..., (3) odor, (4) and drainage. If the wound has worsened or improved the IDT should reference these changes and credit or change the current interventions....The nutritional status of a resident with an open area must be documented in the weekly note...." The Care Plan indicated, "An open area must have an individual care plan in addition to any previous at risk/preventative care plans associated to the residents care...." On [DATE] at 2:10 p.m. the CDNS indicated, "If (residents) have potential for infection chronically, it goes on their long term care plan and then once they start antibiotic (for an infection), it gets a short term care plan on the bottom of the telephone orders. (Resident A) had a care plan for at risk for infection related to leukocytosis." There were no care plans related to the right axillary wound first noted on [DATE], or the "open areas" to the right bicep first noted on [DATE]. This Federal tag relates to Complaints IN 570 and IN 793. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to ensure facility staff followed the physician's orders and professional standards of quality in administering scheduled medications in a timely fashion for 1 of 3 residents in a sample of 4 who were reviewed for pain control medications, resulting in one resident becoming lethargic, and being sent to the local emergency room (ER) and treated for [REDACTED]. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 11-15-12 at 4:32 p.m. Her [DIAGNOSES REDACTED]. Review of her most recent Minimum Data Set (MDS) assessment, dated 10-1-12, indicated she had mild cognitive impairment. It indicated she had frequent, severe pain for which she received pain medications on a routine basis, as well as on an "as needed" or "prn" basis. Review of the nursing notes, dated 10-22-12 at 8:05 a.m., indicated "Noticed res (resident) during breakfast not eating, when attempted to talk to res, res was extremely hard to arouse. Res will open eyes for a second, and when responds unable to understand what she is saying..." The note then indicated vital signs were checked and the physician notified. The physician ordered for the resident to be sent to the local ER for evaluation and treatment. Notes indicated the resident's POA (power of attorney) was notified of the resident's change in condition and the ambulance was on site by 8:40 a.m. to transport the resident to the local ER. An "ED (Emergency Department) Physician Documentation" form, dated 10-22-12, indicated Resident #B was treated that date for lethargy and altered mental status with no respiratory distress. It indicated she was discharged back to the facility at 2:56 p.m. with a discharge [DIAGNOSES REDACTED]." A "Transport Report Form" from the local ER, dated 10-22-12, indicated the resident received 2 doses of [MEDICATION NAME], a medication used to manage or reverse opioid overdosage, and 1/2 liter of IV fluids. In interview with the Director of Nursing (DON) on 11-16-12 at 1:10 p.m., she indicated the facility conducted an investigation into the circumstances of the resident's status. A document entitled, "Employee Communication Form," dated 10-23-12, indicated on 10-22-12 at approximately 8:10 a.m., the DON was notified that RN #1 had administered Resident #B's 8:00 a.m. medications at approximately 6:00 a.m. This document indicated, "This noncompliant action resulted in a resident being transported to the emergency room and noted to have Narcotic Depression (sic.) The resident then received [MEDICATION NAME] x2 (twice) to reverse the Narcotic Depression." The DON indicated "If I recall, she clocked out at 6:34 a.m., but signed the meds out for 7:00 a.m. and told us she gave them around 6:00 a.m. She didn't want to stay over that morning and she said that was her way of helping the day nurse." A copy of RN #1's time clock documentation indicated she clocked in on 10-21-12 at 9:54 p.m. and clocked out on 10-22-12 at 6:34 a.m. In interview with the Administrator on 11-16-12 at 1:10 p.m., she indicated RN #1 "seemed to have no remorse whatsoever in regards to what happened to the resident or that she falsified records." The Administer indicated RN #1 was terminated from employment at the facility. In interview with Resident #B on 11-16-12 at 2:40 p.m., she indicated she was sent to the local ER "not too long ago. The doctor there told me the nurse (at the facility) gave me too much pain medicine...they gave me some kind of medicine that snapped me right out of it." In a written statement by RN #1, dated 10-23-12, she indicated, "On the night shift we start our 6A meds at 4A. On (10-22-12), I gave (initials of Resident #B) her [MEDICATION NAME] at 4A and then her 8A meds at 6A When I worked 2-10 (p.m.), we started our 8P meds at 6P, so I did not think this was wrong & that I was doing anything wrong...I was trying to help the day nurse out before I had to leave..." In a written statement from LPN #1, dated 10-23-12, she indicated, "When I got to work at 5:55A, (name of RN #1) was sitting at the nurse's desk waiting on relief. When we were getting report, (name of RN #1) told me she had already gave all 8A meds on the short hall on (name of hallway) because she was going to be mandated to stay and (name of RN #1) stated, 'I am not staying over.'" Review of Resident #B's physician orders and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#B's narcotic count log indicated the [MEDICATION NAME] was signed out by RN #1 as administered on 10-22-12 at 6:00 a.m., the [MEDICATION NAME] was signed out by RN #1 as administered on 10-22-12 at 7:00 a.m. and the [MEDICATION NAME] CR was signed out by RN #1 as administered at 7:00 a.m. Other medications ordered for a morning dose and initialed as administered by RN #1 on 10-22-12 were as follows: -[MEDICATION NAME] 10 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 240 mgER on ce daily by mouth at 8:00 a.m. -[MEDICATION NAME] 100 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] 875 mg twice daily by mouth for 10 days for [MEDICAL CONDITION] (start date of 10-18-12) at 9:00 a.m. and 9:00 p.m. -[MEDICATION NAME] 25 mg three times a day for 7 days for dizziness (start date of 10-18-12), at 6:00 a.m., 2:00 p.m. and 10:00 p.m. -[MEDICATION NAME] 800 mg three times daily by mouth at 8:00 a.m., 12 noon and 4:00 p.m. -[MEDICATION NAME] sulfate 325 mg once daily by mouth at 8:00 a.m. -Chloroseptic throat spray or generic brand, sprayed on throat four times daily at 6:00 a.m., 12 noon, 6:00 p.m. and 12 midnight. -potassium chloride 20 milliequivalents, 2 tablets, once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 40 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 25-200 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -folic acid 1 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] Nasal Spray 0.05%, 1 spray each nostril once daily at 8:00 a.m. -[MEDICATION NAME] 40 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] 150 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] Diskus 250/50 1 inhalation by mouth twice daily at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] Handihaler, inhale contents of 1 capsule once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 0.083% (2.5mg in 3 milliliters of saline) 1 vial via nebulizer four times daily at 8:00 a.m., 12 noon, 4:00 p.m. and 8:00 p.m. -[MEDICATION NAME] 5% Patch, apply one patch daily topically at 7:00 a.m. and remove daily at 7:00 p.m. -[MEDICATION NAME] 6.25 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] 10 mg daily by mouth at 8:00 a.m. The Administrator provided a document entitled, "Charge Nurse Position Description" on 11-16-12 at 4:45 p.m. This document indicated, "...administers medications and specialized treatments...as prescribed to residents on unit according to physician orders and in compliance with facility policies and procedures..." This document was signed by RN #1 on 6-1-12. The Administrator provided a document entitled, "Medication Pass Procedure" on 11-16-12 at 4:45 p.m. This document indicated under the heading of "Skill," "Meds administered within 60 minutes before and/or after scheduled time ordered," that RN #1 had successfully passed this skill. This document was signed by RN #1 on 6-9-12 and the instructor. The 2010 edition of "Nursing Spectrum Drug Handbook," preface, indicated, "Nurses are legally responsible for applying and ensuring the 'five rights' of drug administration...right patient...right drug...right dosage...right time...right route." This Federal tag relates to Complaint IN 544. 3.1-35(g)(1) 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure narcotic medications were given as ordered by the physician and not too close in administration time to other narcotic and/or anti-anxiety medications which resulted in 1 of 3 residents in a sample of 4 who were reviewed for pain control being sent to the local emergency room (ER) and treated for [REDACTED]. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 11-15-12 at 4:32 p.m. Her [DIAGNOSES REDACTED]. Review of her most recent Minimum Data Set (MDS) assessment, dated 10-1-12, indicated she had mild cognitive impairment. It indicated she had frequent, severe pain for which she received pain medications on a routine basis, as well as on an "as needed" or "prn" basis. Review of the nursing notes, dated 10-22-12 at 8:05 a.m., indicated "Noticed res (resident) during breakfast not eating, when attempted to talk to res, res was extremely hard to arouse. Res will open eyes for a second, and when responds unable to understand what she is saying..." The note then indicated vital signs were checked and the physician notified. The physician ordered for the resident to be sent to the local ER for evaluation and treatment. Notes indicated the resident's POA (power of attorney) was notified of the resident's change in condition and the ambulance was on site by 8:40 a.m. to transport the resident to the local ER. An "ED (Emergency Department) Physician Documentation" form, dated 10-22-12, indicated Resident #B was treated that date for lethargy and altered mental status with no respiratory distress. It indicated she was discharged back to the facility at 2:56 p.m. with a discharge [DIAGNOSES REDACTED]." A "Transport Report Form" from the local ER, dated 10-22-12, indicated the resident received 2 doses of [MEDICATION NAME], a medication used to manage or reverse opioid overdosage, and 1/2 liter of IV fluids. In interview with the Director of Nursing (DON) on 11-16-12 at 1:10 p.m., she indicated the facility conducted an investigation into the circumstances of the resident's status. A document entitled, "Employee Communication Form," dated 10-23-12, indicated on 10-22-12 at approximately 8:10 a.m., the DON was notified that RN #1 had administered Resident #B's 8:00 a.m. medications at approximately 6:00 a.m. This document indicated, "This noncompliant action resulted in a resident being transported to the emergency room and noted to have Narcotic Depression (sic.) The resident then received [MEDICATION NAME] x2 (twice) to reverse the Narcotic Depression." The DON indicated "If I recall, she clocked out at 6:34 a.m., but signed the meds out for 7:00 a.m. and told us she gave them around 6:00 a.m. She didn't want to stay over that morning and she said that was her way of helping the day nurse." A copy of RN #1's time clock documentation indicated she clocked in on 10-21-12 at 9:54 p.m. and clocked out on 10-22-12 at 6:34 a.m. In interview with the Administrator on 11-16-12 at 1:10 p.m., she indicated RN #1 "seemed to have no remorse whatsoever in regards to what happened to the resident or that she falsified records." The Administer indicated RN #1 was terminated from employment at the facility. In interview with Resident #B on 11-16-12 at 2:40 p.m., she indicated she was sent to the local ER "not too long ago. The doctor there told me the nurse (at the facility) gave me too much pain medicine...they gave me some kind of medicine that snapped me right out of it." In a written statement by RN #1, dated 10-23-12, she indicated, "On the night shift we start our 6A meds at 4A. On (10-22-12), I gave (initials of Resident #B) her [MEDICATION NAME] at 4A and then her 8A meds at 6A When I worked 2-10 (p.m.), we started our 8P meds at 6P, so I did not think this was wrong & that I was doing anything wrong...I was trying to help the day nurse out before I had to leave..." In a written statement from LPN #1, dated 10-23-12, she indicated, "When I got to work at 5:55A, (name of RN #1) was sitting at the nurse's desk waiting on relief. When we were getting report, (name of RN #1) told me she had already gave all 8A meds on the short hall on (name of hallway) because she was going to be mandated to stay and (name of RN #1) stated, 'I am not staying over.'" Review of Resident #B's physician orders [REDACTED].#B's narcotic count log indicated the [MEDICATION NAME] was signed out by RN #1 as administered on 10-22-12 at 6:00 a.m., the [MEDICATION NAME] was signed out by RN #1 as administered on 10-22-12 at 7:00 a.m. and the [MEDICATION NAME] CR was signed out by RN #1 as administered at 7:00 a.m. Other medications ordered for a morning dose and initialed as administered by RN #1 on 10-22-12 were as follows: -[MEDICATION NAME] 10 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 240 mgER on ce daily by mouth at 8:00 a.m. -[MEDICATION NAME] 100 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] 875 mg twice daily by mouth for 10 days for [MEDICAL CONDITION] (start date of 10-18-12) at 9:00 a.m. and 9:00 p.m. -[MEDICATION NAME] 25 mg three times a day for 7 days for dizziness (start date of 10-18-12), at 6:00 a.m., 2:00 p.m. and 10:00 p.m. -[MEDICATION NAME] 800 mg three times daily by mouth at 8:00 a.m., 12 noon and 4:00 p.m. -[MEDICATION NAME] sulfate 325 mg once daily by mouth at 8:00 a.m. -Chloroseptic throat spray or generic brand, sprayed on throat four times daily at 6:00 a.m., 12 noon, 6:00 p.m. and 12 midnight. -potassium chloride 20 milliequivalents, 2 tablets, once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 40 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 25-200 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -folic acid 1 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] Nasal Spray 0.05%, 1 spray each nostril once daily at 8:00 a.m. -[MEDICATION NAME] 40 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] 150 mg once daily by mouth at 8:00 a.m. -[MEDICATION NAME] Diskus 250/50 1 inhalation by mouth twice daily at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] Handihaler, inhale contents of 1 capsule once daily by mouth at 8:00 a.m. -[MEDICATION NAME] 0.083% (2.5mg in 3 milliliters of saline) 1 vial via nebulizer four times daily at 8:00 a.m., 12 noon, 4:00 p.m. and 8:00 p.m. -[MEDICATION NAME] 5% Patch, apply one patch daily topically at 7:00 a.m. and remove daily at 7:00 p.m. -[MEDICATION NAME] 6.25 mg twice daily by mouth at 8:00 a.m. and 4:00 p.m. -[MEDICATION NAME] 10 mg daily by mouth at 8:00 a.m. The 2010 edition of "Nursing Spectrum Drug Handbook," indicated to closely observe the use of [MEDICATION NAME] for CNS (central nervous system) depression, especially in the elderly, or when used in combination with other medications that can cause drowsiness, such as [MEDICATION NAME] or [MEDICATION NAME]. The Administrator provided a document entitled, "Charge Nurse Position Description" on 11-16-12 at 4:45 p.m. This document indicated, "...administers medications and specialized treatments...as prescribed to residents on unit according to physician orders [REDACTED].#1 on 6-1-12. The Administrator provided a document entitled, "Medication Pass Procedure" on 11-16-12 at 4:45 p.m. This document indicated under the heading of "Skill," "Meds administered within 60 minutes before and/or after scheduled time ordered," that RN #1 had successfully passed this skill. This document was signed by RN #1 on 6-9-12 and the instructor. This Federal tag relates to Complaint IN 544. 3.1-35(g)(2)

Based on observation, interview and record review, the facility failed to ensure physician orders [REDACTED]. (Resident #F) Findings include: The clinical record of Resident #F was reviewed on 1-7-13 at 2:00 p.m. Her [DIAGNOSES REDACTED]. Her admission Minimum Data Set assessment, dated 12-21-12, indicated she was cognitively intact. On 1-7-13 at 11:03 a.m., the Director of Nursing Service (DNS) provided a copy of a document indicating a medication error had been identified by the facility for Resident #F on 1-5-13. Review of the nursing progress notes, dated 1-5-13 at 2:50 p.m., indicated, "[MEDICATION NAME] (medication for diabetes) 5 mg (milligram) received BID (twice daily.) Medication corrected immediately. MD notified, DNS and resident aware. Resident is own POA (power of attorney). No new orders given from MD. Fingersticks (blood sugar results) within normal range. Head to toe assessment performed with no new findings. Vital signs taken upon finding [MEDICATION NAME] 5 mg given BID. All vital signs WNL (within normal levels)." Review of the physician's admission orders [REDACTED]. Review of the December 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the January 2013 recapitulation orders indicated to administer [MEDICATION NAME] 5 mg once daily by mouth. In the section which identifies the time in which the medication is to be administered, the typed administration time of "4pm" was marked out with a line and the time of "8am" was written in above the typed time. Review of the January 2013 MAR indicated [REDACTED]. The January 2013 MAR indicated [REDACTED]. On 1-8-13 at 11:40 a.m., an observation of a count of the current supply of Resident F's [MEDICATION NAME] 5 mg was conducted with the Corporate Nurse and the DNS. A 30-day supply of this medication was dated 12-18-12 with 5 tablets remaining. This would indicate 4 additional tablets were administered to the resident, which would be consistent with 4 days of use twice daily, as opposed to the ordered once daily. In interview with the DNS on 1-8-13 at 11:44 a.m., she indicated the medication error was related to the MAR paperwork is a multi-part document. She indicated the nurse who reviewed the January 2013 recapitulation orders did mark out the 4:00 p.m. dose and replaced it with the 8:00 a.m. administration time. She indicated that due to the multi-part document, this information did not properly transfer to the actual MAR for Resident #F as this is the last portion of the multi-part document. The DNS provided a copy of a policy entitled, "Medication Order Changes," with a revision date of 7-2011. This policy indicated, "Purpose: To establish a uniform procedure to be followed to ensure physician's medication order changes are carried through. To ensure residents receive medications as ordered by the physician...When the directions of a medication currently in use have been changed, the nurse will...If only part of the order is changing, the entire previous order must be discontinued and the entire new order must be written...Immediately enter the new medication order on the resident's MAR/TAR (Treatment Administration Record) form. Draw a line through the medication being change (sic) and document 'd/c'd order changed,' the date, time, and his/her signature/initials. Do not alter existing order." This federal tag was cited on 11-19-12. The facility failed to implement a systemic plan of correction to prevent recurrence. This federal tag relates to complaint IN 544. 3.1-35(g)(2)

Based on observation, interview and record review, the facility failed to obtain a laboratory test ordered by the physician to monitor the effects of [MEDICATION NAME] (blood thinner) therapy after an increase in the [MEDICATION NAME] dose, failed to assess for bruises and complete any follow-up assessment of the 20 bruises after they were found or assessed for any new bruising for 1 of 6 residents reviewed for [MEDICATION NAME] therapy in a sample of 9. (Resident #A) The IJ (Immediate Jeopardy) began on 7/24/12, when the facility failed to monitor the effects of [MEDICATION NAME] and failed to obtain the physician ordered PT/INR lab to monitor the effects of the [MEDICATION NAME]. The DON (Director of Nursing), Administrator and Corporate Nurse were notified of the immediate jeopardy at 4:17 p.m. on 8/23/12. The immediate jeopardy was: removed on 8/24/12, but 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. Findings include: Resident #A's record was reviewed on 8/22/12 at 1:10 p.m. Resident #A's [DIAGNOSES REDACTED]. Resident #A's MDS (Minimum Data Set), assessment, dated 8/3/12, indicated the following: - BIMS (Brief Interview for Mental Status) was 10, with a range of 8-15, indicating moderately impaired cognition - bed mobility, extensive assistance, one person physical assist - transfer, extensive assistance, one person physical assist - walk in room, extensive assistance, one person physical assist - walk in corridor, activity did not occur - toilet use, extensive assistance, one person physical assist - personal hygiene, extensive assistance, one person physical assist - bathing, physical help in part of bathing activity, one person physical assist - mobility devices, wheelchair - urinary continence, occasionally incontinent - bowel continence, always continent Resident #A had a "[MEDICATION NAME]/[MEDICATION NAME] PT ([MEDICATION NAME] Time)/INR) (International Normalization Ratio) (bleeding times) Tracking Log" record. The log had sections for current dose, PT/INR results, MD notification, and dosage change/comments. The record had been completed on 6/18/12 and included: [MEDICATION NAME] 3 mg (milligram), daily. PT, 22.1 and INR, 2.14. Comments 3 mg [MEDICATION NAME] daily. The entry on 6/18/12 was the last entry on the "[MEDICATION NAME]/[MEDICATION NAME] INR Tracking Log" Resident #A's PT/INR lab on 7/16/12 indicated PT, 12.7 and INR, 1.22. Resident #A's physician orders, dated 7/17/12, indicated "discontinue [MEDICATION NAME] 3 mg, "Start, [MEDICATION NAME] 4 mg, by mouth, daily and check PT/INR levels, (normal, PT , 9.5-11.8/INR, 0.9-1.1) in 1 week on 7/24/12." Resident #A's, "care plan update" written by the facility under the physician's orders [REDACTED]. Goal, will continue without problem. Interventions, give medication as ordered, obtain labs as ordered, notify, physician as needed, monitor for adverse side effects, monitor for abnormal bruises and notify Power of Attorney." Resident #A's MAR (Medication Administration Record), indicated from July 17, 2012 through August, 12, 2012 Resident #A had received 4 mg of [MEDICATION NAME] daily. Resident #A's physician orders, dated 8/12/12 at 8:30 p.m., indicated "STAT lab PT/INR and CBC (Complete Blood Count)" Resident #A's "care plan update" written by the facility under the physician's orders [REDACTED]. Goal, skin normal no bruising. Interventions, STAT lab PT/INR and CBC, skin checked by nurse 1 time/week and observe for increased bruising." Resident #A's PT/INR was obtained on 8/12/12, indicated PT, 130.2 and INR 13.73. Resident #A's physician orders, dated 8/13/12, indicated "Hold [MEDICATION NAME] (indefinite time), give Vitamin K (to reduce PT/INR) 10 mg IM (intramuscular) now and recheck PT/INR on Wednesday 8/15/12" Resident #A's "care plan update" written by the facility under the physician's orders [REDACTED]. Goal, maintain PT/INR, within normal limits. Interventions, Hold [MEDICATION NAME] (indefinite time), give vitamin K 10 mg IM now, recheck PT/INR on Wednesday 8/15/12, and monitor for signs symptoms of bleeding." Resident #A's PT/INR on 8/15/12, indicated PT, 12 and INR 1.16. Resident #A's care plan, dated 11/21/11, indicated "Problem, resident is at risk for abnormal/excessive bleeding due to use of anticoagulant medication [MEDICATION NAME]. Goal, (long term goal target date: 02/23/2012, resident will be free from signs of hemorrhage/abnormal bleeding. Interventions, call light within reach at all times, labs as ordered, medication as ordered, notify MD and family of any status changes and as needed, observe for adverse effects of medication such as blurred vision, nausea, decreased appetite, headache, joint pain and shortness of breath, observe for signs of bleeding: blood tinged sputum, excessive bruising, bruise increasing in size, oozing from superficial injuries, bleeding gums." Resident #A's nursing notes, dated 8/12/12 at 12:05 p.m., included, "vitamin K 10 mg, IM given in left deltoid.... Resident educated to call for assist, use extra caution to prevent bumping or scratching self." Lippincott Williams and Wilkins, Nursing 2012 Drug Handbook, indicated for [MEDICATION NAME] a "Black Box Warning" of "Can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding." Resident #A's nursing's notes indicated the following: (Resident #A's 7/16/12 INR lab results were INR, 1.22) - 7/17/12 at 10:05 a.m., indicated "new order discontinue [MEDICATION NAME] 3 mg, by, mouth, daily. Start [MEDICATION NAME] 4 mg, by mouth, check PT/INR in 1 week on 7/24/12." - 8/12/12 at 8:00 p.m., indicated "CNA reported to this nurse that resident had family in room and they wanted to know where bruises came from. So read through a week of nurse's notes and nothing found related to bruises or cause. Talked with shift supervisor and we talked with family and family very upset. Called physician and received order for STAT lab draw. Family notified. Resident does have multiple bruises on bilateral arms, back, abdomen and right foot. Some are dark purple, some are various, shades of blue and green. Shift supervisor and this writer did head to toe assessment. Will continue to monitor. - 8/12/12 at 9:50 p.m., complete blood count, PT/INR, drawn...sent to lab for STAT run - 8/12/12 at 9:52 p.m., all bruises were measured with assistance of shift supervisor with the assistance of staff and recorded on the wound skin evaluation report. - 8/12/12 at 11:30 p.m., lab results from lab, PT, 130.2, INR, 13.7 and hemoglobin (red blood cells that carry oxygen) 10.5 (normal values, 12.0-16.5), hematocrit 32.4 (normal values, 36-43.) - 8/12/12 at 11:35 p.m., call placed to lab to contact, physician informed of PT/INR results. New order received: 1. Hold [MEDICATION NAME] (indefinite time). 2. Give vitamin K, 10 mg IM now. 3. Recheck PT/INR Wednesday. - 8/12/12 at 12:05 p.m.," vitamin K, 10 mg, IM given in left deltoid.... Resident educated to call for assist, use extra caution to prevent bumping or scratching self." Resident #A's "Wound Skin Evaluation Report," dated 8/12/12, indicated the following bruises: - right elbow, 9 cm X 5 cm - right anterior upper arm, 6 cm X 3 cm - right posterior upper arm, 5 cm X 3 cm - right forearm, 5 cm X 3 cm - left wrist, 3 cm X 1 cm - left forearm, 0.5 cm X 0.5 cm - left forearm, 3.5 cm X 2.5 cm - left upper arm, 6.5 cm X 4.5 cm - left posterior upper arm, 8 cm X 2.5 cm - left posterior upper arm, 3 cm X 2 cm - left posterior upper arm, 1 cm X 0.5 cm - left upper medial arm, 6 cm X 3 cm - right foot/toe, 7.3 cm X 3 cm - left knee, 1.5 cm X 1 cm - left medial back, 3 cm X 1 cm - left medial back, 1 cm X 0.5 cm - left medial back, 3 cm X 1.5 cm - left medial back, 2 cm X 1 cm - left lower back, 2.5 cm X 1 cm - left lower back, 2 cm X 1 cm During an observation on 8/22/12 at 1:15 p.m., Resident #A was observed in bed with the head of the bed in the up position, her right upper arm, just above her elbow had a large approximately 8 cm (centimeters) X 5 cm, dark purple bruise. Her lower right arm had 3 bruises with some fading of dark purple bruising at varies sizes. The largest area was approximately 6 cm X 3 cm, the next to the largest was, approximately 4 cm X 2 cm and the smallest bruise on her wrist was approximately 3 cm X 1 cm. During an interview on 8/22/12 at 1:30 p.m., Resident #A indicated she had so many bruises because of the blood thinner she was taking. An interview with Resident #A's family member on 8/22/12 at 9:00 a.m., indicated the bruising on Resident #A was found on 8/12/12 by two family members and when the facility was informed of the bruising and looked at all the bruises all over her entire body the facility's response was the resident was on blood thinners. The family member indicated the resident was covered with bruising and there had not been a problem like that in the past. The family member stated "On 8/12/12 when the family informed the facility of the bruising the facility acted like the bruising was normal because the resident was on blood thinners." The family indicated the resident did not know how she acquired the bruising but her foot was hurting her so bad and her foot was swollen, and black. The family member also indicated prior to the bruising on 8/12/12, the resident required 2 staff members for her transfers, 1-2 staff for bed mobility and toilet use, bathing took a total of 2 staff and dressing was with the assistance of one staff. During an interview on 8/22/12 at 2:00 p.m., LPN #1 indicated Resident #A had multiple bruises and a hematoma on her foot that came from her PT/INR being too high. During an interview on 8/22/12 at 5:30 p.m., the Director of Nursing (DON) indicated the physician had ordered an x-ray for Resident #A's foot, but the physician felt the [MEDICAL CONDITION] and bruising on her right foot was from the blood pooling in her foot because of the effects of the high PT/INR and the x-ray of the resident's foot was negative. During an interview on 8/22/12 at 6:00 p.m., the DON indicated a PT/INR for 7/24/12 had not been done. She stated "I called the lab and they did not have any record of it being ordered." The DON also indicated there was no weekly skin assessments completed on Resident #A. During an interview on 8/23/12 at 10:15 a.m., with the Laboratory Supervisor, from the laboratory where the facility's labs are ordered to be done, the Supervisor indicated the laboratory had not received an order by fax or telephone for a PT/INR for 7/24/12. During an interview with the Wound Nurse on 8/23/12 at 11:05 a.m., she indicated she had not done any other assessment or measurement of the bruises since 8/12/12. During an interview on 8/23/12 at 11:25 a.m., the DON indicated when they receive an order for [REDACTED]. During an interview on 8/23/12 at 3:20 p.m., the DON indicated the nurses on the floor were responsible for monitoring bruising and they know they are responsible to measure and monitor bruising. She stated "I do not know why they did not monitor for bruises before 8/12/12 or do follow-up assessments on the bruising," During an observation with the Wound Nurse on 8/23/12 at 4:15 p.m., Resident #A's bruises were assessed with [REDACTED]. - right elbow, 7.4 cm X 11.5 cm - right anterior upper arm, 12 cm X 4 cm - right posterior upper arm, 3 cm X 4.4 cm - right forearm, 4.4 cm X 3.4 cm - left wrist, 2 cm X 1 cm - left forearm, 1 cm X 0.7 cm - left upper arm, 5.0 cm X 4 cm - left posterior upper arm, 5.5 cm X 2.8 cm - right shin, 1 cm X 1 cm - left posterior upper arm, 3 cm X 2 cm - left posterior upper arm, 1 cm X 0.5 cm - left upper medial arm, 6 cm X 3 cm - right foot/toe, 5.5 cm X 1.4 cm - left knee, 1.5 cm X 1 cm - left medial back, 4.7 cm X 2 cm - left medial back, 2 cm X 1 cm - left lower back, 2.5 cm X 1 cm - left lower back, 2 cm X 1 cm During an interview with the Wound Nurse on 8/23/12 at 5:00 p.m., she indicated the bruises were fading and were not nearly as dark purple as they were on 8/12/12. A document titled "[MEDICATION NAME]/[MEDICATION NAME]" provided by the Administrator on 8/23/12 at 8:30 a.m., dated 7/20/11, and indicated by the Administrator to be the most current policy, included: "Purpose: To ensure that residents taking [MEDICATION NAME]/[MEDICATION NAME] do not experience a drug to drug, or drug to food adverse reaction. Procedure: Before receiving [MEDICATION NAME]/[MEDICATION NAME] the resident must have a PT/INR lab test, once the resident's PT/ INR are stable, a PT/INR will be drawn as per the physician's orders [REDACTED]. and the physician's response in the nurse's notes." The immediate jeopardy that began on 7/24/12 was removed on 8/24/12 when the facility inserviced the CNAs and nurses on adverse effects of [MEDICATION NAME] including bleeding and bruising, residents on [MEDICATION NAME] were indicated on the CNAs assignment sheet, the nursing staff were instructed to document skin assessments twice a week on all residents on [MEDICATION NAME], and the PT/INR monitoring tool is to be documented on the Treatment Administration Record when applicable. Any new orders received in the evening, nights or on the weekend were to be documented on the 24 hour report then go on the lab sheet. The nurses were inserviced on the lab tracking log and to monitor the physician orders [REDACTED]. Nurses and CNAs were interviewed on their knowledge of the adverse effects of [MEDICATION NAME] and CNAs also demonstrated understanding of the effects and risks of [MEDICATION NAME], also how to monitor the effects and when to report significant changes. The interdisciplinary team will review physician orders [REDACTED]. This federal tag relates to complaint IN 311. 3.1-48(a)(3)