Every finding on record at Signature Healthcare of Terre Haute

Based on record review, and interview, a facility staff member failed to follow a resident's plan-of-care intervention requiring the use of a gait belt for transfers, which resulted in a resident fall with fracture that required a hospital visit and follow-up care for 1 of 3 residents reviewed for accidents (Resident C). The deficient practice was corrected by 5/11/26 after the facility implemented a systemic plan and was therefore Past Noncompliance. Findings include: During an interview on 5/20/26 at 1:09 p.m., Resident C indicated he fell during a transfer when CNA 2 snatched him up by the back of his pants, real quick. She did not use a gait belt as other staff had done. He lost his balance and fell to the floor, landing on his left side. He indicated he had no use of that arm afterward and was in pain. The resident's clinical record was reviewed on 5/20/26 at 11:25 a.m. Diagnoses included hemiparesis (neurological condition caused by brain damage that causes partial weakness or loss of strength on one side of the body) affecting left non-dominant side, need for assistance with personal care, and pain in left ankle and joints of left foot. An annual Minimum Data Set (MDS) assessment, dated 3/17/26, indicated Resident C was cognitively intact and required substantial/maximum assistance with toileting, dressing, transferring, and personal hygiene. He used a manual wheelchair for mobility and was frequently incontinent of bowel and bladder. A current health care plan, created on 2/28/26 and edited on 3/19/26, indicated Resident C was at risk for injury related to falls due to left eye blindness, left-side hemiplegia related to a stroke, left foot drop, weakness, incontinence, and a history of falls. An intervention, dated 3/31/26, indicated staff were to use a gait belt with all transfers. The clinical record lacked a valid progress note regarding the fall on 5/1/26. A late entry note, dated 5/2/26 at 6:17 a.m., indicated a progress note, dated 5/1/26 at 6:15 p.m., as invalid. A nursing progress note, dated 5/2/26 at 4:39 p.m., indicated Resident C was on fall follow-up and reported left shoulder pain rated at five of ten. Staff noted no swelling. They notified the medical provider, who gave an order for an X-ray of the left should and arm. A nursing progress note, dated 5/3/26 at 1:19 p.m., included that the resident's left shoulder Xray had showed an acute left distal clavicle fracture. The medical provider ordered staff to send Resident C to the emergency department at an acute care hospital for further evaluation. The resident left the facility at 1:57 p.m. An Interdisciplinary Team progress note, dated 5/4/26 at 9:17 a.m., included Resident C lost his balance while transferring to the restroom with staff. An intervention was added to the resident's care plan for the assistance of two staff while transferring to the restroom. During a telephone interview on 5/21/26 at 11:11 a.m., CNA 2 indicated she did not use a gait belt when transferring Resident C. She indicated she lifted him by placing one arm under his right arm and grabbing the back of his pants with her other hand. His knees buckled, and he fell to the floor. She acknowledged she was aware of care sheets but could not say whether Resident C's care sheet included the use of a gait belt. She had not reviewed it. She indicated she would need to complete re-education regarding proper transfers before returning to work. During an interview on 5/21/26 at 11:00 a.m., the Corporate Nurse Consultant indicated Resident C had an intervention to use a gait belt during transfers on his care plan and on the care guides that were updated daily. CNA 2 should have used a gait belt when transferring Resident C. CNA 2 was receiving re-education prior to returning to work. The facility re-educated staff and audited all care plans for accuracy following the fall. The facility had no specific gait belt or transfer policy but expected staff to follow each resident's care plan. A current facility policy, revised 1/31/25, titled, Falls, provided by the Corporate Nurse Consultant on 5/21/26 at 11:29 a.m., included the following: Policy Statement The intent of this policy is to ensure the facility provides an environment that is as free from accident hazards, as possible, over which the facility has control to prevent avoidable falls.Guideline:.2. A Comprehensive Care Plan will be implemented based on the resident's risk for falls with an individual goal and interventions specific to each resident to attempt to reduce the risk of avoidable falls, to the extent possible. This deficient practice was corrected by 5/11/26 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included review of all resident care plans, staff education, and auditing of three resident transfers, two times per week for two weeks, then weekly, to ensure safety interventions are in place. All falls since the last clinical meeting will be reviewed during clinical meetings to ensure care plan interventions were in place at the time of the fall. The Quality Assurance and Performance Improvement (QAPI) meetings will be held weekly for four weeks to monitor audits and continued education. The deficient practice was corrected by 5/15/26 after the facility implemented a systemic plan and was therefore Past Noncompliance. This deficient practice was corrected on 5/11/26 before the survey, and therefore past noncompliant. The facility reviewed falls for current residents to ensure care plan interventions were in place; audited care guides for fall interventions, and re-educated staff including return demonstrations for safe transfers was completed. This citation relates to Intake 3016193. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

A. Based on record review and interview, the facility failed to notify responsible party of changes of condition and physician notifications for 1 of 32 residents reviewed for notification (Resident Q). B. Based on record review and interview, the facility failed to ensure a physician was notified when medications were unavailable to administer as ordered for 1 of 5 residents reviewed for unnecessary medications (Resident L). Findings include:A. On 3/02/26 at 12:47 p.m., during a phone interview Resident Q's daughter indicated she and her sister were durable power of attorney (POA) with healthcare and neither of them had been notified of changes in their mother's condition, medication changes, or of an incident when the resident had fallen in her room. On 3/3/26 at 10:00 a.m., the medical record of Resident Q was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease with late onset (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A care plan, dated 10/11/22, indicated Resident Q had impaired cognition related to diagnosis of dementia as evidenced by short term and long term memory impairments and needs for daily cues and reminders. Interventions included, but were not limited to, discuss concerns about confusion, disease process, and nursing home placement with responsible party. Review of the medical record indicated on 9/25/25 diagnostic testing results were reviewed. The record lacked documentation of notification to the responsible party. A quarterly Minimum Data Set (MDS) assessment, dated 12/29/25, indicated the resident had severe cognitive impairment and required assistance with daily care needs. On 11/29/25, STAT (immediate) labs were ordered related to change in condition and increased complaints of pain. The record indicated the lab was unable to send a technician to the facility to draw blood. The record lacked notification to the physician indicating the labs could not be obtained and/or notification that the resident refused to go to the hospital for labs. In addition, the record lacked documentation of notification of the responsible party. On 1/20/26, the medical record indicated a medication change had been ordered. The record lacked documentation of notification of the responsible party. On 1/22/26, the medical record indicated STAT labs were ordered. The record lacked documentation of notification of the responsible party. On 1/30/26, the medical record indicated new orders were obtained. The record lacked documentation of notification of the responsible party. On 2/10/26, the medical record indicated the resident fell in her room next to her bed. The nurse documented the resident was her own person and the resident was notified. The record lacked documentation of notification of the responsible party. On 2/10/26, diagnostic lab testing report was obtained. The record lacked documentation of notification of the responsible party. On 2/11/26, the record indicated orders were obtained for lab diagnostic testing and discontinuation of medication. The record lacked documentation of notification of the responsible party. On 2/17/26, the medical record indicated abnormal lab tests were returned, and the resident was notified of the report. The record lacked documentation of notification of the responsible party. On 3/3/26 at 1:00 p.m., during an interview, the Social Services Director indicated the resident's family had not complained about notifications. On 3/6/26 at 8:50 a.m., during an interview, Registered Nurse (RN) 9 indicated she would notify the responsible party of any changes in a resident's condition including labs and medication changes. She indicated if a resident was cognitively impaired she would not consider them their own person and would notify the responsible party of changes. On 3/6/26 at 9:00 a.m., during an interview RN 8 indicated she would notify the family or responsible party of any changes in condition within the day. She indicated if the resident was cognitively impaired she would notify the responsible party of any changes including labs and medication changes. On 3/6/26 at 10:10 a.m., during an interview, the Director of Nursing (DON) indicated if there was a change in condition and the resident was cognitively impaired the family or responsible party should be notified. On 3/6/26 at 2:00 p.m., the Administrator provided a document titled, Notification of Change if Condition, dated7/7/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Guidelines.2. Documentation of notification or notification attempts should be recorded in the resident electronic medical record. 3. The resident and or representative (if applicable), and medical provider should be notified of a change in condition. B. Resident L's record was reviewed on 3/3/26 at 2:47 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems) and personal history of other venous thrombosis and embolism (indicates a past occurrence of blood clots in veins, excluding, or in addition to, standard deep vein thrombosis (DVT) or pulmonary embolism [blood clot in your lung that creates blockage]). Facility census information indicated that the resident was admitted to the facility on [DATE]. A significant change in status Minimum Data Set (MDS) assessment, dated 2/9/26, indicated the resident was cognitively intact and received anti-coagulant (blood thinner) and antibiotic medications. The resident also received oxygen therapy. A care plan, dated 2/26/26, indicated the resident had impaired gas exchange related to COPD. Interventions included but were not limited to, medications/nebulizers/puffers as ordered, and notify doctor of changes as needed. A care plan, dated 2/21/26, indicated the resident had a diagnosis of HTN (hypertension- elevated blood pressure), CAD (coronary artery disease – plaque build up that reduces blood flow) and history of MI (myocardial infarction- heart attack). Interventions included but were not limited to, administer anti-coagulants as ordered. A physician order, dated 2/13/26, indicated to administer azithromycin (antibiotic medication) 250 milligrams (mg), 2 tablets by mouth in the evening for 1 day, then administer 1 tablet by mouth for 4 days for COPD. Review of February 2026 MAR (Medication Administration Record) indicated on 2/13/26 the 500 mg dose of azithromycin was unavailable and not stocked in cart. The record lacked documentation that the nurse administered the antibiotic on 2/13/26. The record lacked documentation that the resident ever received the 500 mg dose of azithromycin as ordered. Resident L's record lacked documentation of the physician being notified of the azithromycin medication being unavailable and therefore was not administered. A physician order, dated 1/30/26, indicated to administer Xarelto (blood thinner medication) 20 mg, one tablet by mouth daily for personal history of other venous thrombosis or embolism. Review of February 2026 MAR indicated on 2/18/26 and 2/27/26 the 20 mg dose of Xarelto was unavailable to administer. The record lacked documentation that the nurse administered the blood thinner on 2/18 or 2/27/26. Resident L's record lacked documentation of the physician being notified of the Xarelto medication being unavailable and therefore was not administered. During an interview on 3/4/26 at 11:02 a.m., the Clinical Consultant indicated azithromycin was available in the EDK (emergency drug kit). She was unaware if the azithromycin was empty on 2/13/26 in the EDK and if that was why the nurse didn't administer the medication. The physician should have been notified that the medications were not available and if he or she would want to substitute the medication for something else or wait for the dose to come in from the pharmacy. During an interview, on 3/4/26 at 11:48 a.m., the Clinical Consultant indicated the nurse should have administered the 500 mg of azithromycin as soon as it came in from the pharmacy. She was unable to provide documentation that the antibiotic was administered as ordered by the physician or that the physician was notified that the medication was never given. On 3/4/26 at 11:49 a.m., the Clinical Consultant provided a document, dated 01/23, titled, Non-Controlled Medication Orders, and indicated it was the current policy being used by the facility. The policy indicated, .4. The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available. This citation relates to Intake 2740716. 410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)

Based on record review and interview, the facility failed to ensure critical abnormal lab results were reported to the physician in a timely manner for 1 of 2 residents reviewed for labs (Resident D) and failed to obtain STAT (immediate) labs for 1 of 2 residents reviewed for labs (Resident Q). Findings include:1. On 3/5/26 at 1:00 p.m., the medical record of Resident D was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and hypertension (high blood pressure). The most recent quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was cognitively impaired and required maximum assistance from the staff for daily care needs. The most recent hospital stay was on 6/28/25. The resident was sent to the emergency department, related to critical lab of low hemoglobin (it indicates how well your blood carries oxygen throughout the body. Low levels usually indicate anemia). The resident returned to the facility after the hemoglobin level had adjusted to non-critical levels. On 7/3/25 blood was drawn for diagnostic labs. At 2:30 p.m., the critical lab values were reported to the facility. The record lacked documentation of notification to the physician of critical abnormal labs. On 3/6/26 at 10:10 a.m., during an interview the Director of Nursing (DON) indicated if there was a change in a resident's condition or abnormal labs it should be reported to the physician. On 3/6/26 at 2:00 p.m., the Administrator provided a document titled, Notification of Change if Condition, dated7/7/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Guidelines.2. Documentation of notification or notification attempts should be recorded in the resident electronic medical record. 3. The resident and or representative (if applicable), and medical provider should be notified of a change in condition. 2. On 3/3/26 at 10:00 a.m., the medical record of Resident Q was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease with late onset (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A care plan, dated 10/11/22, indicated Resident Q had impaired cognition related to diagnosis of dementia as evidenced by short term and long term memory impairments and needs for daily cues and reminders. Interventions included, but were not limited to, discuss concerns about confusion, disease process, and nursing home placement with responsible party. A quarterly Minimum Data Set (MDS) assessment, dated 12/29/25, indicated the resident had severe cognitive impairment and required assistance with daily care needs. On 11/29/25, STAT (immediate) labs were ordered related to change in condition and increased complaints of pain. The record indicated the lab was unable to send a technician to the facility to draw blood. The record lacked notification to the physician indicating the labs could not be obtained and/or notification that the resident refused to go to the hospital for labs. In addition, the record lacked documentation of notification of the responsible party. On 1/22/26, the medical record indicated STAT labs were ordered. The record lacked documentation of notification of the physician that the labs were not obtained. On 3/6/26 at 8:50 a.m., during an interview, Registered Nurse (RN) 9 indicated she would notify the responsible party of any changes in a resident's condition including labs and medication changes. She indicated if a resident was cognitively impaired she would not consider them their own person and would notify the responsible party of changes. On 3/6/26 at 9:00 a.m., during an interview RN 8 indicated she would notify the family or responsible party of any changes in condition within the day. She indicated if the resident was cognitively impaired she would notify the responsible party of any changes including labs and medication changes. On 3/6/26 at 10:10 a.m., during an interview, the Director of Nursing (DON) indicated the Nurse Practitioner (NP) was notified of Resident Q's refusal to go to the hospital to have labs drawn. She indicated if the facility had an order to draw labs the facility nurse would draw them. The DON acknowledged the facility had obtained an order to draw blood for diagnostic testing. The order did not specify the lab technician was the assigned person to obtain lab specimen. Documentation of the NP's notification was not provided. On 3/6/26 at 2:00 p.m., the Administrator provided a document titled, Notification of Change if Condition, dated7/7/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Guidelines.2. Documentation of notification or notification attempts should be recorded in the resident electronic medical record. 3. The resident and or representative (if applicable), and medical provider should be notified of a change in condition. This citation relates to Intake 2691760. 410 Indiana Administrative Code (IAC) 16.2-3.1-49(f)(2).

Based on interview, observation, and record review, the facility failed to ensure a resident's preference for his meals was met for 1 of 32 residents reviewed for food and food preferences (Resident J). Findings include:During the initial pool interview, on 3/2/26 at 3:30 p.m., Resident J indicated he had requested more food with his meals, but they had not been giving him bigger portions. He had requested this quite a while back, but they still just gave him the regular small amounts. He got hungry in between his meals. During the lunch meal observation, on 3/5/26 at 12:06 p.m., Resident J's lunch tray was observed. Double portions were not observed, in the resident's meal tray, when compared to a regular portion meal tray. Observation of the resident's meal ticket lacked documentation that double portions were to be served. At the same time, the Dietary Manager observed the order as written in the resident's diet orders. She indicated she needed to check the resident's diet orders as they presented in the kitchen. Resident J's record was reviewed on 3/5/26 at 1:50 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a progressive, long-term lung disease that makes it hard to breathe by limiting airflow) and unspecified dementia (a diagnosis for significant memory, thinking, and functional decline where doctors cannot yet determine the specific cause or there is not enough information to classify it). A quarterly Minimum Data Set (MDS) assessment, dated 1/23/26, indicated the resident had moderate cognitive deficit and required set-up assistance with eating. A care plan, dated 7/9/24, indicated the resident was at risk of malnutrition. Interventions included, but were not limited to, meals as ordered by the physician. A physician's order, dated 1/26/26, indicated to provide the resident a regular diet with double portions, per the resident's request. During an interview, on 3/5/26 at 1:31 p.m., the Dietary Manager indicated the resident's meal ticket indicated 4 HLF which meant 4 halves. She indicated that meant the resident received double portions. Regular portion lunch tickets all indicated 2 HLF which meant two halves. At the same time, she provided a copy of the resident's new meal ticket, which she had updated after the conversation on 3/5/26 at 12:06 p.m. The updated meal ticket now indicated Double Portion, at the bottom of the ticket. She indicated the meal that was provided at today's lunch meal was a resident choice meal. The tickets for the resident choice meals did not include any special deviation in portion sizes. All were served as regular portions. During an interview, on 3/6/26 at 9:33 a.m., [NAME] 10 indicated she did not know what the 2 HLF and 4 HLF meant on the lunch tickets. If a resident was to get double portions, it would be written on the meal ticket. During an interview, on 3/6/26 at 9:40 a.m., [NAME] 11 indicated she did not know what 2 HLF and 4 HLF stood for on lunch tickets. During an interview, on 3/6/26 at 10:56 a.m., the Registered Dietician indicated there was an issue with the meal tickets not being clear when indicating the portion sizes and when a special resident choice meal was prepared. The resident's meal ticket did not indicate double portions. On 3/6/26 at 11:00 a.m., the Administrator provided a document, with a revised date of 1/31/25, titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .All residents will be treated in a manner and in an environment that promotes.enhancement of quality of life.the stakeholders will respect the resident's individuality and value their input.through self-determination. This citation relates to intake 2713018. 410 Indiana Administrative Code (IAC) 16.2-3.1-20(a)

Based on record review and interview, the facility failed to development and implement a baseline care plan for 1 of 3 residents reviewed for admission. (Resident B)Findings include:A clinical record review for Resident B was completed on 12/9/25 at 10:29 a.m. Diagnoses included chronic obstructive respiratory disease (COPD), need for assistance with personal care, diabetes mellitus II, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and history of stroke. The resident admitted to the facility on [DATE] at 3:51 a.m., following an acute care hospital stay. The clinical record lacked a nursing admission assessment and development of a baseline care plan until the afternoon on 3/17/25. During an interview on 12/10/25 at 9:46 a.m., the Director of Nursing (DON) indicated she had not found documentation regarding Resident B's admission in the clinical record. The resident's baseline care plan was not completed in a timely manner. There had been no documented physical assessment, skin assessment, baseline care plan or catheter assessment. The staff should document an admission assessment and baseline care plan in the clinical record.A current facility policy, revised 9/15/23, titled, Baseline Care Plan Policy, provided by the Corporate Nurse Consultant on 12/10/25 at 11:21 a.m., included the following: Policy Statement A Baseline Care plan is developed and implemented to promote continuity of care and communication among facility stakeholders to increase resident safety and safeguard against adverse events that are most likely to occur right after admission. Guidelines: 1. The Baseline Care Plan will be developed and implemented within 48 hours of a resident's admission .This citation is in regard to Intake 2641934.

Based on record review and interview, the facility failed to ensure a newly admitted resident had quality of care when staff failed to complete a nursing admission assessment, wound assessments, and admission orders for two respiratory medications and a urinary catheter for 1 of 3 residents reviewed for admission. (Resident B) Findings include: A clinical record review for Resident B was completed on 12/9/25 at 10:29 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), need for assistance with personal care, diabetes mellitus II, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and history of stroke. The resident admitted to the facility on [DATE] at 3:51 a.m., following an acute care hospital stay. The clinical record lacked a nursing admission assessment including vital signs, skin assessment, and catheter assessment. A review of the resident's progress notes lacked nursing documentation regarding the resident's arrival to the facility. The record lacked a nursing progress note being entered until 3/16/25 at 5:02 p.m. A review of the resident's vital signs record lacked documentation of a blood pressure, heart rate, or oxygen saturation level until 3/17/25, two days following admission. A review of the resident's medication orders lacked the following medications as being ordered on admission: albuterol-ipratropium (a common prescription rescue medication used to treat or prevent wheezing and difficulty breathing caused by lung conditions like asthma and COPD) inhalation aerosol, 1 puff four times a day as needed; and budesonide (a steroid medication to treat asthma and COPD) 0.5 mg (milligram) per 2 ml (milliliter) inhalation suspension, four times a day as needed. These medications were not ordered until 3/17/25 in the afternoon. A review of the resident's electronic treatment administration record lacked orders for catheter care until 3/19/25. A Skin and Wound progress note, dated 3/17/25, indicated the resident was being evaluated as a new admission to the facility for a skin/wound assessment. The reported included, Skin and wound assessment completed. Pt is noted to have multiple pressure injuries and arterial ulcers of 2nd and 4th R [right] foot, 2nd toe L [left] foot, PI [pressure injury] of L buttock, coccyx, and L gluteal fold, L and R heels. A progress note, dated 3/19/25 at 6:46 a.m., indicated the resident was sent to an acute care hospital due to shortness of breath, wheezing, congested lung sounds, and cough with elevated blood pressure and heart rate. He was admitted to the hospital with shortness of breath. During an interview on 12/10/25 at 9:46 a.m., the Director of Nursing (DON) indicated she had not found documentation regarding Resident B's admission in the clinical record. There had been no documented physical assessment, skin assessment, catheter assessment or baseline care plan completed. The staff should document arrival and a nursing admission assessment in the clinical record. A current facility policy, revised 10/31/25, titled, Admissions to the Facility, provided by the Corporate Nurse Consultant on 12/10/25 at 11:21 a.m., included the following: .Procedure: 1. Prior to or at the time of admission, the resident's Physician must provide the facility with information needed for immediate care of he resident, including orders cover, but not limited to, the following: routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. This citation relates to Intake 2641934. 3.1-37(a)

Based on interview and record review, the facility failed to promptly revise the comprehensive care plan to reflect changes in regard to a resident's access to smoking for 1 of 4 residents reviewed for resident rights (Resident B). Findings include:Resident B's clinical record was reviewed on 11/5/25 at 10:44 a.m. Diagnoses included nicotine dependence and major depressive disorder. His smoking status on his profile page included current everyday smoker. A current health care plan, dated 5/19/22 and edited 10/9/25, indicated the resident chose to smoke and was a risk for injury related to smoking. The resident had been evaluated and was deemed a safe smoker. Interventions included, but was not limited to, the following: resident must be at dining room door to enter courtyard on time in order to participate in supervised smoking breaks; resident will be allowed two cigarettes, or 15 minutes per smoking pass; resident will smoke in designated area in courtyard of southwest of building; smoking/tobacco material will be made available to resident by facility staff at designated smoke breaks; staff members supervising smokers must light cigarettes for resident; and smoking assessment completed at this time and resident has been deemed as a safe smoker.During an interview on 11/5/25 at 1:46 p.m., Resident B indicated he was no longer allowed to go out at smoke breaks. He indicated he had hit another resident in the nose and was told he could no longer participate in smoke breaks.During an interview on 11/5/25 at 2:10 p.m., the Administrator indicated Resident B lost his smoking privileges after hitting another resident. She had spoken to him multiple times regarding his behaviors during smoke breaks. They had reviewed the Smoking Agreement with the resident multiple times due to his crowding behaviors, and on 8/31/25, he became physical and he lost his privilege to smoke. His care plan was not updated or the indication on his profile of him being an everyday smoker. This should have been done following the revocation of his smoking privileges.No specific facility policy regarding care planning provided. The facility followed CMS guidelines.This citation was in regard to intake 2655657.3.1-35(b)

Based on record review and interview, the facility failed to ensure informed consent was obtained for psychotropic medications for 5 of 5 residents reviewed for unnecessary medications (Resident 8, 11, 5, 99, and 103). The deficient practice was corrected on 9/9/25, prior to the start of the survey, and was therefore past noncompliance. Findings include:1. Resident 8's record was reviewed on 9/18/25 at 11:48 a.m. Census information indicated the resident was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 8/20/25, indicated the resident had a moderate cognitive impairment and received an antipsychotic (treats psychosis), antianxiety (treats anxiety), anticonvulsant (treats seizures and can be used as mood stabilizers), and antidepressant (treats depression) medication during the look-back period. Diagnoses on the resident's profile included, but were not limited to, anxiety disorder unspecified, major depressive disorder recurrent and mild, and bipolar disorder (extreme shifts in mood, energy, thinking, and behavior, ranging from periods of high energy to periods of low mood) unspecified. A physician's order, dated 6/21/25 and discontinued on 9/6/25, indicated alprazolam (antianxiety) 1 milligram (mg) by mouth daily for anxiety. A physician's order, dated 6/24/25, indicated bupropion (antidepressant) sustained release 150 mg by mouth once daily for bipolar disorder. A physician's order, dated 6/24/25, indicated Rexulti (antipsychotic) 2 mg daily for bipolar disorder. A physician's order, dated 6/25/25, indicated doxepin (antidepressant) 50 mg by mouth daily for depression. A physician's order, dated 6/25/25, indicated lamotrigine (anticonvulsant that can be used as a mood stabilizer) 200 mg daily for bipolar disorder. A physician's order, dated 9/6/25, indicated alprazolam 0.25 mg by mouth three times daily for anxiety. A consent for the use of psychotropic medications, dated 8/11/25, indicated informed consent was obtained from the resident for the use of bupropion and alprazolam. The consent lacked documentation an informed consent was obtained for Rexulti, doxepin, or lamotrigine. A consent for the use of psychotropic medications, dated 9/9/25, indicated informed consent was obtained from the resident for the use of Rexulti, doxepin, and lamotrigine. The resident's electronic record lacked documentation an informed consent, for the use of psychotropic medications, was obtained from the resident, or the resident's representative, prior to 8/11/25. 2. Resident 11's record was reviewed on 9/19/25 at 10:51 a.m. A 5-day Minimum Data Set (MDS) assessment, dated 8/27/25, indicated the resident was cognitively intact and received an antipsychotic (treats psychosis), antianxiety (treats anxiety), and antidepressant (treats depression) medication during the look-back period. Diagnoses on the resident's profile included, but were not limited to, anxiety disorder unspecified and depression unspecified. The resident's electronic record contained the following physician's orders for quetiapine (antipsychotic). -A physician's order, dated 4/24/25 and discontinued on 6/10/25, indicated quetiapine 100 milligrams (milligrams) by mouth daily for major depressive disorder and anxiety. -A physician's order, dated 6/10/25 and discontinued on 6/18/25, indicated quetiapine 25 mg by mouth daily for major depressive disorder and anxiety. -A physician's order, dated 6/18/25 and discontinued on 6/29/25, indicated quetiapine 25 mg by mouth daily for major depressive disorder and anxiety. -A physician's order, dated 7/17/25 and discontinued on 8/6/25, indicated quetiapine 25 mg by mouth once daily. -A physician's order, dated 8/22/25, indicated quetiapine 25 mg by mouth once daily. The resident's electronic record contained the following physician's orders for buspirone (antianxiety). -A physician's order, dated 4/24/25 and discontinued on 6/10/25, indicated buspirone 15 mg by mouth three times daily for anxiety. -A physician's order, dated 6/10/25 and discontinued on 6/29/25, indicated buspirone 15 mg by mouth three times daily for anxiety. -A physician's order, dated 7/17/25 and discontinued on 8/6/25, indicated buspirone 15 mg by mouth three times daily. -A physician's order, dated 8/22/25, indicated buspirone 15 mg by mouth once daily for anxiety. The resident's electronic record contained the following physician's orders for duloxetine (antidepressant). -A physician's order, dated 4/24/25 and discontinued on 6/10/25, indicated duloxetine 30 mg by mouth daily in the morning for depression. -A physician's order, dated 4/24/25 and discontinued on 6/10/25, indicated duloxetine 60 mg by mouth daily in the evening for depression. -A physician's order, dated 6/10/25 and discontinued on 6/26/25, indicated duloxetine 30 mg by mouth daily for depression. -A physician's order, dated 6/26/25 and discontinued 6/29/25, indicated duloxetine 30 mg by mouth daily for depression. -A physician's order, dated 7/17/25 and discontinued on 8/6/25, indicated duloxetine 30 mg by mouth daily for depression. -A physician's order, dated 8/22/25, indicated duloxetine 30 mg by mouth daily for depression. A consent for the use of psychotropic medication, dated 8/11/25, indicated informed consent was obtained from the resident for the use of buspirone. The consent lacked documentation informed consent was obtained for the use of quetiapine or duloxetine. A consent for the use of psychotropic medication, dated 9/9/25, indicated informed consent was obtained from the resident for the use of duloxetine, buspirone, and quetiapine. The resident's electronic record lacked documentation an informed consent, for the use of psychotropic medications, was obtained from the resident, or the resident's representative, prior to 8/11/25. During an interview, on 9/19/25 at 10:32 a.m., the Regional Clinical Consultant indicated there had been issues with the psychotropic medication consents. They got consents for all residents initially in August but then realized the consents did not include all of the required medications. They completed all required consents for psychotropic medications in September 2025. 3. On 9/19/25 at 10:16 a.m., the medical record of Resident 5 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but not limited to, depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). Physician orders, dated 12/13/24 and 4/17/25, indicated to administer amitriptyline one 100 mg (milligram) tablet by mouth for depression. The record lacked documentation of consent for psychotropic medication. 4. On 9/18/25 at 1:47 p.m., the medical record of Resident 99 was reviewed. The record indicated the resident had been admitted and discharged five times since first admission on [DATE]. The record indicated the most recent admission was on 7/6/25. admission diagnosis included but was not limited to, depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks), and dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A physician order, dated 9/5/25, indicated to administer quetiapine 150 mg (milligram) orally once a day for dementia. The record lacked documentation of consents for psychotropic medications from 2/12/25 to 8/8/25. 5. Resident 103's record was reviewed on 9/18/25 at 3:38 p.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia (occurs when a person's cognitive impairment is unclear), anxiety disorder (intense, persistent worry or feat that interferes with daily life), and unspecified psychosis not due to a substance or known physiological condition (a mental state characterized by a loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes). Census information indicated Resident 103 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 7/4/25, indicated the resident was cognitively intact and had received anti-psychotic (used to primarily reduce the symptoms of psychosis) and anti-depressant (used for depression symptoms) medications. A physician order, dated 6/30/25, indicated to administer olanzapine (anti-psychotic) 5milligrams (mg) orally twice a day. A physician order, dated 6/30/25, indicated to administer Zoloft (anti-depressant) 50 mg orally once a day. A physician order, dated 6/20/35 with a discontinue date of 9/5/25, indicated to administer Paxil (anti-depressant) 20 mg orally once a day. A consent for the use of psychotropic medications, dated 8/10/25, indicated informed consent was obtained from the resident for the use of olanzapine. The informed consent lacked documentation on the use of Paxil and Zoloft was obtained. The resident's electronic record lacked documentation the informed consent for the use of psychotropic medications was obtained from the resident, or the resident's representative, prior to 8/10/25. During an interview, on 9/19/25 at 11:41 a.m., the Regional Clinical Consultant indicated they had obtained consents for all residents initially in August but then realized the consents did not include all the required medications. The original consents that were completed in August only included anti-psychotic medications which did not meet the required guidelines of all psychotropic medications. They completed all required consents for psychotropic medications in September 2025. She indicated that the psychotropic medication consents should be completed on admission and with any new initiation of a new psychotropic medication. On 9/19/25 at 3:20 p.m., the Regional Clinical Consultant provided a document with a revised date of 2/23/25, titled, Psychotropic Medications Policy, and indicated it was the current policy being used by the facility. The policy indicated, .Psychotropic medications will be used appropriately for residents with mental illness and/or related disorders.These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic.1. The facility will make every effort to comply with state and federal regulations related to the use of psychotropic medications in the long-term care facility to include regular reviews for continued need.5. Resident and/or resident representative will have informed consent on the risks vs benefits of any psychotropic medication initiation or increase including any black box warnings. The deficient practice was corrected by 9/9/25 after the facility implemented a systemic plan that included the following actions: auditing resident records for antipsychotic medications, educating staff, and continued monitoring of resident antipsychotic medications to meet regulations. 3.1-3(n)(2)

Based on interview and record review, the facility failed to ensure the residents were informed of the contact information regarding how to file a complaint with the State (the government entity responsible for inspecting and certifying long-term care facilities to ensure they meet federal and state health and safety standards for resident care) for 1 of 1 Resident Council interview and 3 of 3 months of Resident Council meeting minutes reviewed. Findings include:On 9/22/25 at 11:18 a.m., the Resident Council meeting minutes for June, July, and August 2025 were reviewed. The minutes lacked documentation that the Resident Council members had been informed of where to locate the information on how to file a complaint with the State. During the Resident Council interview, on 9/22/25 at 2:23 p.m., the President of the Resident Council indicated she was not sure what the process was for contacting the State if she had a complaint. She could not remember ever discussing that topic at the Resident Council meetings. At the same time, Resident 76 indicated he had never been informed about how to contact the State if he had a complaint to file. On 9/22/25 at 2:30 p.m., the Activity Director indicated they had not covered how to file a complaint with the State in the resident council meetings. She just assumed that the members knew where the information was located. The Resident Council President's record was reviewed on 9/23/25 at 1:37 p.m. An annual Minimum Data Set (MDS) assessment, dated 7/7/25, indicated the resident had no cognitive deficit. Resident 76's record was reviewed on 9/23/25 at 1:47 p.m. An admission MDS assessment, dated 7/2/25, indicated the resident had no cognitive deficit. On 9/23/25 at 8:45 a.m., the Regional Clinical Consultant indicated that she was unable to find a specific policy related to the topics that were supposed to be discussed during the Resident Council meetings. The facility would follow the State regulations. 3.1-4(j)(3)(A)

Based on record review and interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessment for 4 of 27 residents MDS assessments reviewed (Residents 14, 15, 16, and 145). Findings include: 1. Resident 14's record was reviewed on 9/18/25 at 8:28 a.m. The profile indicated the resident's diagnoses included, but were not limited to, neuromuscular dysfunction of bladder (occurs when damage to the brain, spinal cord, or nerves disrupts the signals between bladder and the brain, leading to problems with bladder control) and urinary retention (difficulty urinating and completely emptying the bladder). A quarterly Minimum Data Set (MDS) assessment, dated 6/12/25, indicated the resident had an indwelling catheter and was always incontinent of urine. A quarterly MDS assessment, dated 6/24/25, indicated the resident had an indwelling catheter and was always incontinent of urine. A quarterly MDS assessment, dated 8/22/25, indicated the resident had severe cognitive impairment, had an indwelling catheter, and was always incontinent of urine. A physician's order, dated 8/7/25, indicated to anchor a Foley catheter size 16 Fr (French) (diameter of catheter tubing) 10cc (cubic centimeter) balloon to straight drainage. During an interview, on 9/18/25 at 2:34 p.m., the MDS Coordinator indicated if a resident had an indwelling catheter the MDS assessment should be marked as not rated. She was unsure why the assessments were marked as always incontinent. She indicated sometimes staff would mark them incontinent if a catheter was leaking. The record lacked any documentation of the resident having a catheter that leaked urine. During an interview, on 9/18/25 at 3:22 p.m., the Regional Clinical Consultant indicated the MDS assessments were not coded correctly for Resident 14, and the resident had not had any leaking from her indwelling catheter. She further indicated the MDS assessments would need to be amended since they were not coded correctly. Section H of the CMS (Centers for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, indicated, .H0300: Urinary incontinence .Coding Instructions .9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. 2. Resident 15's record was reviewed on 9/22/25 at 9:31 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a progressive brain disorder and the most common form of dementia, characterized by a gradual decline in memory and thinking skills that eventually affects daily life) and gastrostomy status (refers to medical diagnosis indicating the presence of a gastrostomy tube which is surgically created opening into the stomach for feeding). A significant change in status Minimum Data Set (MDS) assessment, dated 5/28/25, indicated the resident was severely cognitively impaired and was marked no for a terminal prognosis. A quarterly MDS assessment, dated 8/28/25, indicated the resident was marked no for a terminal prognosis. A physician order, dated 5/21/25, indicated to admit Resident 15 to hospice care. Review of a statement from the hospice agency, dated 5/28/25 indicated the hospice physician had certified the patient's prognosis was less than 6 months or less if the disease runs its normal course. The statement indicated the hospice nurse had received verbal consent from the physician on 5/22/25 at 10:00 a.m. and was signed by the physician on 5/28/25 electronically. Review of a statement from the hospice agency, dated 8/6/25 indicated the hospice physician had certified the patient's prognosis was less than 6 months or less if the disease runs its normal course. The statement indicated the physician electronically signed it on 8/6/25. During an interview, on 9/22/25 at 10:00 a.m., the Regional Clinical Consultant indicated the MDS assessments were not coded correctly and should have been marked as yes, because the resident had a terminal prognosis and was on hospice services. Section J of the CMS (Centers for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, indicated, .J1400: Prognosis.Does the resident have a condition or chronic illness that may result in a life expectancy of less than 6 months? .1.Yes. 3. Resident 16's record was reviewed on 9/23/25 at 11:32 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 8/26/25, indicated the resident had a diagnosis of Schizophrenia (a chronic brain disorder that affects how a person thinks, feels, and behaves, often involving hallucinations, delusions, and disorganized thinking). The option to code a diagnosis of psychotic disorder, other than schizophrenia, was not indicated. Diagnoses on the resident's profile included, but were not limited to, psychotic disorder (a state where a person loses contact with reality) with delusions due to a known physiological condition. The profile lacked documentation the resident had a diagnosis of Schizophrenia. A psychiatric progress note, dated 10/16/24, indicated the resident had a diagnosis of psychotic disorder but lacked documentation of a Schizophrenia diagnosis. During an interview, on 9/23/25 at 2:07 p.m., the Regional Clinical Consultant indicated the resident did not have a diagnosis of schizophrenia, and the MDS assessment was coded incorrectly. The facility used the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) manual for coding guidance. The CMS RAI Version 3.0 Manual, last revised in October 2024, indicated, .Section I: Active Diagnoses.Active Diagnoses in the Last 7 Days. ACTIVE DIAGNOSES Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. 4. On 9/23/2025 10:24 AM reviewed the medical record of Resident 145. The resident was admitted to the facility on [DATE]. admission diagnosis included but was not limited to, osteomyelitis (infection in the bone), non-pressure chronic ulcer of other part of left foot (a persistent, non-healing open sore that is caused by an underlying medical condition), and open wound of left great toe with damaged toenail. A physician order, dated 9/15/25, indicated to cleanse wound with wound cleanser, pat dry, apply betadine to area on left great toe, and cover with small border gauze daily and as needed for soilage and dislodgement once a day. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was mildly cognitively impaired and required assistance from the staff for care needs. The MDS indicated the resident had a dressing to foot. The MDS lacked documentation of a non-pressure wound. On 9/18/25 at 3:22 p.m., the Director of Nursing (DNS) provided a document titled, Resident Assessment, dated 9/15/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Guideline.7. If data is conflicting, appears in error or requires further clarification, Minimum Data Set Coordinator (MDSC) will verify with the resident, resident representative, licensed and non-licensed staff, and or physician to ensure data is accurate.15. The Assessment Coordinator will be responsible for ensuring that all required resident assessments are completed and submitted in accordance with current federal and state guidelines outlined in the RAI manual.

A. Based on observation, record review, and interview, the facility failed to ensure interventions were initiated after falls for 1 of 2 residents reviewed for falls (Resident 16). B. Based on observation, interview, and record review, the facility failed to ensure safe transport residents on the facility bus for 4 of 4 residents reviewed for accidents (Residents 132, 76, 145, and 65). Findings include:A. On 9/22/25 at 11:53 a.m., Resident 16 was observed lying in bed. The resident had a bariatric (wide) bed with borders on the mattress and the head and the foot with a gap in the middle of the mattress. There were non-skid strips on the floor at the head and foot of the bed, however there were no non-skid strips in the center area, where the gap in the mattress borders was located. A body pillow was on a table. On 9/22/25 at 11:58 a.m., the Regional Clinical Consultant observed Resident 16's room. At the same time, the Regional Clinical Consultant acknowledged the non-skid strips were missing in the middle area of the bed where the mattress border gapped. The resident's body pillow was on the table, but sometimes he refused it. Resident 16's record was reviewed on 9/22/25 at 10:42 a.m. Diagnoses on the resident's profile included, but were not limited to, blindness in right eye, mild cognitive impairment of unknown etiology, and fracture of the neck of an unspecified femur (thigh bone). A quarterly Minimum Data Set (MDS) assessment, dated 8/26/25, indicated the resident was cognitively intact and required substantial/maximal assistance from staff for transfers. A fall event, dated 4/15/25, indicated the resident fell out of bed, and the fall was unwitnessed. The area to select a new intervention to prevent further falls was left blank. A progress note, dated 4/15/25, indicated the resident had on and off confusion and was talking like drunk. The resident fell out of bed and appeared to be confused. The resident refused to be sent to the hospital and said he was faking all of his confusion. The note lacked documentation of a root cause analysis or new intervention put in place to prevent further falls. A fall event, dated 4/17/25, indicated the resident fell out of bed, and the fall was unwitnessed. The area to select a new intervention to prevent further falls was left blank. A progress note, dated 4/17/25, indicated the resident had an unwitnessed fall with no physical injuries. The resident was observed to be confused, disoriented, and combative with staff with a continued decline in status. The resident's altered mental status persisted but he continued to refuse hospitalization. The note lacked documentation of a root cause analysis or new intervention put in place to prevent further falls. A fall event, dated 5/8/25, indicated the resident fell out of bed, and the fall was unwitnessed. The area to select a new intervention to prevent further falls was left blank. A progress note, dated 5/8/25, indicated the resident was found on the floor on the right side of the bed. The fall was unwitnessed. The resident appeared to be at his baseline level of confusion and thought he was getting off the truck. The note lacked documentation of a root cause analysis or an intervention to prevent further falls. A progress note, dated 5/9/25, indicated the resident had continuously climbed out of bed. The resident's bed was moved against the wall. An interdisciplinary team (IDT) note, dated 5/9/25, indicated the resident had a witnessed fall out of bed on 5/8/25, and experienced baseline confusion. The intervention was to place the resident's bed against the wall. The note did not address the prior documentation which indicated the fall was unwitnessed. A fall event, dated 5/14/25, indicated the resident fell out of bed, and the fall was unwitnessed. The resident complained of right hip pain and was sent to the emergency room (ER). The area to select a new intervention to prevent further falls was left blank. A progress note, dated 5/14/25, indicated the staff heard the resident yelling from his room. The staff found the resident on the floor next to his bed. The resident's right leg was rotated outward, 911 was called, and the resident was transported to the hospital for further evaluation. An IDT note, dated 5/20/25, indicated the resident had a recent fall on 5/14/25. The resident was found on the floor after attempting a self-transfer. The resident was sent to the ER for further evaluation of injuries. Non-skid strips were placed on the floor. Census information indicated the resident was hospitalized from [DATE] to 5/22/25. A fall event, dated 6/22/25, indicated the resident fell out of bed, and the fall was unwitnessed. The area to select a new intervention to prevent further falls was left blank. An IDT note, dated 6/23/25, indicated the resident had a recent fall when he attempted to get out of bed. The resident turned himself around in bed and fell off the side. A bariatric bed was provided to give the resident more room in bed. A fall IDT note, dated 6/26/25, indicated a Certified Nurse Aide (CNA) walked past the resident's door, and the resident slid off the bed into a sitting position. The root cause was the resident needed to use the restroom and failed to use the call light. The immediate intervention was to educate the resident on the use of the call light and educate the CNA on to monitor closely. The note lacked documentation of the efficacy of the education considering the resident's prior noted confusion. The resident's events lacked documentation of a fall event which corresponded to a fall on 6/26/25. An IDT note, dated 6/27/25, indicated the resident had a prior fall in which he sat on the edge of the bed and slid off onto the floor. The staff witnessed the fall, and he did not hit his head. The intervention was to encourage the resident to get out of bed and sit in a chair if he wanted to sit up. A fall event, dated 8/11/25, indicated the resident slid out of bed, and the fall was witnessed. The new intervention was a fall mat next to the bed. A progress note, dated 8/11/25, indicated the resident slid off the end of the bed and sat on buttocks on the floor. The note indicated they requested bed to be fixed, unable, switched out a diff [different] bed. A fall event, dated 8/24/25, indicated the resident fell out of bed, and the fall was witnessed. The intervention was to move the resident's urinal closer to his reach. A progress note, dated 8/24/25, indicated the resident rolled to the right side of the bed and attempted to get his urinal that was hung on the trash can. The resident rolled too far and slid down the bed. It was too late for staff to catch him. The resident landed on his buttocks and hit his right knee on the wheelchair which caused a small cut to the right knee. The call light was placed within reach, and the resident was reeducated to hit the call light for help if he needed assistance. The note lacked documentation of why the resident would hit the call light if staff was already in the room or the efficacy of education considering the resident's prior noted confusion. An IDT note, dated 8/25/25, indicated the resident had a fall when he leaned out of bed to reach the urinal hanging on the trash can. The urinal was moved within reach. A new intervention was enablers to assist with bed mobility. An IDT note, dated 8/29/25, indicated the IDT reviewed the resident's fall interventions and resolved those which were no longer appropriate. The current interventions were reviewed by the IDT. A fall event, dated 9/13/25, indicated the resident was found on the floor next to his bed. The intervention was to get the resident up in the wheelchair when agitated. A progress note, dated 9/13/25, indicated the resident was found sitting on the floor with his legs extended out and the incontinence brief halfway down his legs. The resident stated, I was fishing. An IDT note, dated 9/15/25, indicated the resident had a fall when he believed he was fishing and rolled out of bed. The root cause was the resident being unaware of his boundaries in bed. The intervention was to place a body pillow on the right side of the bed to assist with bed boundaries. Progress notes, dated 9/15/25 to 9/22/25, lacked documentation the resident refused the body pillow. A current care plan indicated the resident was at risk for fall related injury related to right eye blindness, left eye low vision, balance issues, medications, and poor judgement. Interventions included, but were not limited to, body pillow to the right side of the bed to assist with bed boundaries, bed mobility devices as needed/ordered, resident prefers the urinal within reach, encourage the resident to get out of bed and sit in the chair if wanting to sit up, bariatric bed with bolsters, non-skid strips to the floor, bed against the wall on the left side per the resident's preference, call light within reach, and keep the resident's personal items within reach and instruct the resident where items are related to poor vision initiated on 12/24/23. During an interview, on 9/22/25 at 1:52 p.m., the Regional Clinical Consultant indicated there was no IDT note or interventions put in place for the resident's falls on 4/15/25 and 4/17/25 They completed a fall audit in August 2025, after they discovered issues with the fall program. The resident's fall interventions needed to be re-evaluated, and it was possible he did not need the non-skid strips anymore. The resident refused the body pillow at times, but the refusals should have been documented. On 9/22/25 at 2:22 p.m., the Regional Clinical Consultant provided a document titled, Falls, last revised on 1/31/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: The intent of this policy is to ensure the facility provides an environment that is as free from accident hazards as possible, over which the facility has control to prevent avoidable falls. Guideline.2. A Comprehensive Care Plan will be implemented based on the resident's risk for falls with an individual goal and interventions specific to each resident to attempt to reduce the risk of avoidable falls, to the extent possible. The care plan will be reviewed following each fall.3. Care Plan goals and interventions will be revised as applicable, with each review.5. Falls may be reviewed at the facility Quality Assurance/Performance Improvement [QAPI] Committee. B. During a random observation, on 9/16/25 at 12:45 p.m., the facility bus was observed backing out of the south parking area at an accelerated rate. When the bus had pulled from the parking area, it accelerated down the facility driveway quickly. During a random observation, on 9/19/25 at 12:23 p.m., the facility bus was observed backing out of the south parking area at an accelerated rate. When the bus had pulled from the parking area, it accelerated down the facility driveway quickly. During a random observation, on 9/22/25 at 12:16 p.m., the facility bus was observed to fail to stop at the stop sign at the end of the facility driveway onto the municipal street. a. During an interview, on 9/22/25 at 2:09 p.m., Resident 132 indicated that the facility bus driver had made her feel unsafe at times when she was on the bus. She would sometimes feel that she was jolted back and forth when the driver took off and/or stopped. She had never been hurt when on the bus but had felt unsafe at times. Resident 132's record was reviewed on 9/23/25 at 1:37 p.m. An annual Minimum Data Set (MDS) assessment, dated 7/7/25, indicated the resident had no cognitive deficit and used a motorized wheelchair for ambulation (the act of moving from place to place, either independently or with the use of assistive devices like wheelchairs, walkers, or canes). b. During an interview, on 9/22/25 at 2:11 p.m., Resident 76 indicated the bus driver would sometimes take corners so sharp that he had been tossed back and forth when on the bus. He had never been injured as a result but had not always felt safe. Resident 76's record was reviewed on 9/23/25 at 1:47 p.m. An admission Minimum Data Set (MDS) assessment, dated 7/2/25, indicated the resident had no cognitive deficit and used a manual wheelchair for ambulation (the act of moving from place to place, either independently or with the use of assistive devices like wheelchairs, walkers, or canes). c. On 9/17/25 at 2:16 p.m., during initial observation and interview Resident 145 indicated he would not ride with the bus driver because he drove too fast and he was afraid of getting hurt. On 8/17/25 at 3:00 p.m., the medical record of Resident 145 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but were not limited to, lack of coordination, abnormalities of gait and mobility. A quarterly Minimum Data Set (MDS) assessment, dated 8/19/25, indicated the resident required assistance with daily care needs and was mildly cognitively impaired. d. On 9/17/25 at 2:00 p.m., during an interview Resident 65 indicated he was afraid while riding in the facility transfer bus. He indicated the bus driver drove too fast and once when he was being transported he was afraid he was going to fall out of his wheelchair. He indicated he put out his arm to prevent another resident from falling over at the same time. On 9/17/25 at 3:30 p.m., the medical record of Resident 65 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but were not limited to, acquired absence of right leg below knee, and acquired absence of left leg below knee. A care plan, dated 9/2/25, indicated the resident was at risk for falls and fall related injuries. Interventions included but were not limited to provide a reacher, and call light within reach. The care plan lacked documentation of fall prevention when in wheelchair related to balance issues due to amputation of bilateral lower legs. A quarterly Minimum Data Set (MDS) assessment, dated 8/14/24, indicated the resident was dependent upon the staff for transfers and mobility assistance and was cognitively intact. On 9/23/25 at 1:00 p.m., during an interview the Administrator indicated the facility bus driver should be utilizing safe driving practices at all times when transporting residents. On 9/23/25 at 1:47 p.m., the Director of Nursing (DON) provided a document, titled, Transportation Policy, dated 1/31/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy.3. Any staff using facility owned motor vehicle, first must meet criteria for safe driving. 3.1-45(a) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the physician was notified of high blood sugars for 1 of 5 residents reviewed for unnecessary medications (Resident 6). Findings include:On 9/17/25 at 11:04 a.m., during an initial observation and interview, Resident 6 indicated he had elevated blood sugar (BS) levels due to infections and repeated urinary tract infections. On 9/22/25 at 2:30 p.m., during an interview, the Director of Nursing (DNS) indicated prior to 8/24/25 the parameter for notification for Resident 6 was to notify the physician of a BS over 400. She provided a copy of the physician order, dated 10/30/23, indicating to notify the physician of BS over 400. The DON acknowledged the order had not been brought forward under the physician's orders. The DON acknowledged a BS reading above 400 or a BS reading of HI should be reported to the physician immediately. The article, Diabetes, dated 5/15/24, was retrieved on 9/22/25 from the Centers of Disease Control (CDC) website at https://www.cdc.gov/diabetes/diabetes-testing/monitoring-blood-sugar.html. The guidance included: .The following recommended ranges are for most people with diabetes who aren't pregnant. Your target range may be different based on your age, health status and diabetes management plan.Before meals: 80 to 130 mg/dL.After meals (1-2 hours later): Below 180 mg/dL. On 9/22/25 at 10:00 a.m., the medical record of Resident 6 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included, but was not limited to, cerebral infarction (when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), paraplegia (paralysis that occurs in the lower half of the body), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). Review of the resident's glucose blood sugar (BS) levels indicated on 7/23/25 the BS was 506, on 8/2/25 the BS was 401, on 8/19/25 the BS was 406, 8/24/25 BS was 442, and on 9/14/25 the BS was recorded as HI (an indication the reading was above the maximum readings of the glucometer device). The record indicated the resident's BS varied daily and were most often greater than 200. The physician progress notes on 4/7/25, 5/19/25, 6/4/25, 6/16/25, 7/28/25, and 7/21/25 lacked documentation that the physician reviewed or addressed the elevated BS levels of Resident 6. A physician order, dated 8/24/25, indicated to administer Humalog KwikPen Insulin (insulin lispro) insulin pen administer subcutaneous (under the skin) four times a day; 100 unit/mL (milliliter) per sliding scale. If Blood Sugar was 400 to 449, give 12 Units. If Blood Sugar was 450 to 499, give 14 Units. If Blood Sugar was 500 to 549, give 16 Units. If Blood Sugar was 550 to 599, give 18 Units. If Blood Sugar was greater than 600, call MD. A care plan, dated 8/31/25, indicated Resident 6 had a diagnosis of diabetes and was at risk for unstable blood glucose. Interventions included but were not limited to, notify Medical Doctor with significant changes in signs and symptoms. Observe for/report signs and symptoms of hyperglycemia (elevated blood sugar): increased thirst, headaches, blurred vision, increased urination, fatigue, weight loss, blood sugars greater than 180. A physician order, dated 9/19/25, indicated to administer insulin Aspart U-100 insulin pen administer subcutaneous four times a day; 100 unit/mL (3 mL) per sliding scale. If Blood Sugar was 400 to 449, give 12 Units. If Blood Sugar was 450 to 499, give 14 Units. If Blood Sugar was 500 to 549, give 16 Units. If Blood Sugar was 550 to 599, give 18 Units. If Blood Sugar was greater than 600, call MD. On 9/22/25 at 11:25 a.m., during an interview, the facility Medical Director indicated the staff should notify him of BS levels above 400 and the facility was working to improve communication with the physician and the facility. He indicated he did not recall if he was notified of elevated BS levels of Resident 6 and it may have been that the staff did not document calling him and reporting the elevated levels. On 9/22/25 at 2:00 p.m., during an interview, the Medical Director indicated he reviewed his notes, and he did not receive a call regarding the resident's elevated BS levels and he had reviewed the resident's blood sugars on 9/22/25 and would make medication adjustments. On 9/23/25 at 2:15 p.m., during an interview Registered Nurse (RN) 21 indicated, if a BS is over 400 she would notify the physician immediately. She indicated the glucose monitor will reach a level of 600. If the BS is over 600 the glucose monitor will indicate a reading of HI. On 9/22/25 at 3:04 p.m., the DON provided a document, titled, Notification of Change of Condition, dated 9/13/23, and indicated it was the policy currently being used by the facility. The policy indicated, .The facility must inform, consult with the resident's physician.b. A significant change in the resident's physical, mental, or psychosocial status. c. A need to alter treatment significantly. 3.1-5(a)

Based on record review and interview, the facility failed to monitor for side effects for residents who received antipsychotic medications for 3 of 5 residents reviewed for unnecessary medications (Resident 8, 5, and 99). The deficient practice was corrected on 8/8/25, prior to the start of the survey, and was therefore past noncompliance Findings include: 1. Resident 8's record was reviewed on 9/18/25 at 11:48 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, bipolar disorder (mental health condition causing extreme shifts in mood, energy, and activity levels, characterized by periods of mania and depression) unspecified. A quarterly Minimum Data Set (MDS) assessment, dated 8/20/25, indicated the resident had a moderate cognitive impairment and received an antipsychotic (treats psychosis) medication during the look-back period. An admission observation, dated 2/22/25, indicated the resident had not received an antipsychotic medication, and an Abnormal Involuntary Movement Scale (AIMS) was not completed. A physician's order, dated 2/22/25 and discontinued on 4/9/25, indicated to administer Rexulti (antipsychotic) 2 milligrams (mg) by mouth daily. A care plan, initiated on 2/26/25, indicated the resident was at risk for side effects related to psychotropic medications used to treat bipolar disorder. Interventions included, but were not limited to, observe for any drug related signs or symptoms such as abnormal involuntary movements. A physician's order, dated 4/9/25 and discontinued on 4/23/25, indicated to administer Rexulti 2 mg by mouth daily. A physician's order, dated 4/23/25 and discontinued on 6/18/25, indicated to administer Rexulti 2 mg by mouth daily for bipolar disorder. A physician's order, dated 6/24/25, indicated to administer Rexulti 2 mg by mouth daily for bipolar disorder. An AIMS, dated 8/8/25, indicated the resident did not have abnormal movements. The resident's record lacked documentation an AIMS was completed prior to 8/8/25. During an interview, on 9/19/25 at 10:32 a.m., the Regional Clinical Consultant indicated AIMS should have been completed for residents on antipsychotic medications at admission, with changes/new orders, and every six months. Resident 8's was missed at admission when the admitting nurse did not know Rexulti was an antipsychotic medication. When they completed an audit on antipsychotic medications in August 2025, they realized the AIMS had not been completed and it was rectified at that time. 2. On 9/19/25 at 10:16a.m., the medical record of Resident 5 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but not limited to, depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A physician order, dated 12/13/24 and 4/17/25, indicated to administer amitriptyline 100 mg (milligram) tablet orally for depression once a day. A care plan, dated 10/28/25, indicated psychotropic drug use. Interventions included, but were not limited to, observe for any drug related signs and symptoms such as hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decrease in appetite, and abnormal involuntary movements. An Abnormal Involuntary Movement Scale (AIMS) assessment was completed on 8/8/25. The record lacked documentation of AIMS assessment prior to 8/8/25. During an interview, on 9/19/25 at 10:32 a.m., the Regional Clinical Consultant indicated AIMS should have been completed for residents on antipsychotic medications at admission, with changes/new orders, and every six months. When they completed an audit on antipsychotic medications in August 2025, they realized the AIMS had not been completed and it was rectified at that time. 3. On 9/18/25 at 1:47 p.m., the medical record of Resident 99 was reviewed. The record indicated the resident had been admitted and discharged five times since first admission on [DATE]. The record indicated the most recent admission was on 7/6/25. admission diagnosis included, but was not limited to, depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks), and dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A physician order, dated 7/24/25, indicated to administer quetiapine 150 milligrams (mg) orally once a day for dementia. A care plan, dated 7/24/25, indicated psychotropic drug use. Interventions included, but not limited to, observe for any drug related signs and symptoms such as hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL decline, decrease in appetite, and abnormal involuntary movements. An Abnormal Involuntary Movement Scale (AIMS) assessment was completed on 2/12/25. The record lacked documentation of AIMS assessment after most recent admission. During an interview, on 9/19/25 at 10:32 a.m., the Regional Clinical Consultant indicated AIMS should have been completed for residents on antipsychotic medications at admission, with changes/new orders, and every six months. When they completed an audit on antipsychotic medications in August 2025, they realized the AIMS had not been completed and it was rectified at that time. On 9/19/25 at 3:20 p.m., the Director of Nursing (DON) provided a document titled, Monitoring for Tardive Dyskinesia, dated 10/24/24, and indicated it was the policy currently being used by the facility. The policy indicated, .The facility will maintain an ongoing process to monitor residents receiving psychotropic medications for adverse consequences.Residents will be monitored on an ongoing basis, at regular intervals and with any change in condition or medication. The deficient practice was corrected by 8/8/25 after the facility implemented a systemic plan that included the following actions: auditing resident records for antipsychotic medications, educating staff, and continued monitoring of resident antipsychotic medications. 3.1-3(w)

Based on record review and interview, the facility failed to ensure pharmacy review of resident medications were completed quarterly and failed to ensure the physician was notified of recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident 5). Findings include:On 9/19/25 at 10:16 a.m., the medical record of Resident 5 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included, but not limited to, depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). On 5/12/25 a pharmacy recommendation suggested the following labs for medication monitoring: Magnesium level. The medical record lacked documentation of a magnesium level lab being completed or notification to the Physician. On 9/19/25 at 9:45 a.m., during an interview, the Director of Nursing (DON) indicated the lab recommendation for magnesium level had not been completed. Physician orders, dated 12/13/24 and 4/17/25, indicated to administer amitriptyline tablet; 100 mg (milligrams) orally for depression. On 5/15/25 a recommendation was entered by the mental health provider indicating, to consider a trial GDR (gradual dose reduction) of amitriptyline to 75 mg every evening. The medical record lacked documentation of physician notification. On 9/23/25 at 1:47 p.m., the DON provided a document titled, Medication Monitoring, Medication Regimen and Reporting, dated 01/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures.2. The consultant Pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medication each resident receives are clinically indicated.8.Recommendations should be acted upon within 30 calendar days or per facility protocols. 3.1-25(h)

Based on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 3 of 6 residents (Resident 26, 3, and 152) observed during the medication pass. There were 27 opportunities for error observed with 3 medication errors, resulting in a medication error rate of 11.1 percent. Findings include:1. On 9/18/25 at 9:24 a.m., Registered Nurse (RN) 7 prepared and administered medication to Resident 26. The medication included propranolol (treats high blood pressure) 10 milligrams (mg) 1 tablet by mouth. Resident 26's record was reviewed on 9/22/25 at 10:04 a.m. Diagnoses on the resident's profile included, but were not limited to, essential, primary hypertension (high blood pressure). A physician's order, dated 8/28/25 and discontinued on 9/15/25, indicated propranolol 20 mg, give 1 tablet by mouth twice daily for coronary artery disease. A physician's order, dated 9/15/25, indicated propranolol 10 mg, give 2 tablets by mouth twice daily coronary artery disease. On 9/19/25 at 10:25 a.m., the Regional Clinical Consultant provided a document titled, Medication Administration General Guidelines, dated January 2025, and indicated it was the policy currently being used by the facility. The policy indicated, .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber.If necessary, the nurse contacts the prescriber for clarification. 2. On 9/19/25 at 11:13 a.m., Registered Nurse (RN) 15 checked Resident 3's accu check, and it was 254 milligrams (mg)/deciliter (dL). RN 15 administered insulin lispro (rapid acting insulin) 6 units (u) via insulin pen subcutaneously (SQ). The insulin pen was not primed prior to the administration. Staff obtained and served Resident 3's lunch tray on 9/19/25 at 11:53 a.m., 40 minutes after the rapid acting insulin was administered. Resident 3's record was reviewed on 9/22/25 at 10:21 a.m. Diagnoses on the resident's profile included, but were not limited to, type two diabetes mellitus without complications. A physician's order, dated 8/11/25, indicated insulin lispro before meals and at bedtime per sliding scale (scaled dosing based on the accu check results). The sliding scale indicated if the resident's accu check was between 250 mg/dL and 299 mg/dL, administer 6 u of insulin lispro. 3. On 9/19/25 at 11:30 a.m., RN 15 checked Resident 152's accu check, and it was 196. RN 15 administered insulin lispro 8 u via insulin pen SQ. The insulin pen was not primed prior to the administration. Staff obtained and served Resident 152's lunch tray on 9/19/25 at 11:52 a.m., 22 minutes after the rapid acting insulin was administered. Resident 152's record was reviewed on 9/22/25 at 10:25 a.m. Diagnoses on the resident's profile included, but were not limited to, type two diabetes mellitus without complications. A physician's order, dated 9/10/25, indicated insulin lispro, administer 7 u SQ before meals for diabetes mellitus. A physician's order, dated 9/10/25, indicated insulin lispro before meals and at bedtime per sliding scale. The sliding scale indicated if the resident's accu check was between 150 mg/dL and 199 mg/dL, administer 1 u of insulin lispro. During an interview, on 9/19/25 at 11:37 a.m., RN 15 indicated she did not think she had to prime insulin pens before administration of insulin. During an interview, on 9/19/25 at 3:25 p.m., the Regional Clinical Consultant indicated meals should have been served within 15 minutes of the administration of rapid acting insulin. The insulin lispro pen was required to be primed before each insulin administration. On 9/19/25 at 3:25 p.m., the Regional Clinical Consultant provided a document titled, Instructions For Use Insulin Lispro Kwikpen, last revised July 2023, and indicated it was the policy currently being used by the facility. The policy indicated, .Preparing your Pen.Priming your Pen: Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window.You should see insulin in the tip of the Needle. On 9/23/25 at 2:45 p.m., the Regional Clinical Consultant provided a document titled, Insulin Lispro: Package Insert/Prescribing Info, last revised on 12/15/24. The policy indicated, .Insulin Lispro starts acting fast. Inject Insulin Lispro 15 minutes before or right after you eat a meal. 3.1-48(c)(1)

A. Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during direct patient care services for 3 of 3 random resident observations. (Residents 1,102, and 8). B. Based on observation, record review, and interview, the facility failed to ensure a urinary catheter (a flexible tube inserted into the bladder to drain urine) tubing was kept off the floor for 1 of 2 reviewed for catheter use (Resident 14). Findings include:A1. On 9/23/25 at 11:57 a.m., observed Registered Nurse (RN) 10 washing her hands. The RN turned off the faucet with her bare hand and then dried her hands on a paper towel. The nurse then donned (put on) gloves and picked up the glucometer device from the resident's dresser. On 9/23/25 at 11:59 a.m., observed RN 10 lay glucometer device (a small, portable device that measures the amount of glucose (sugar) in your blood) on the bed of Resident 1. After completing the procedure, she laid the glucometer on the resident's dresser. On 9/23/25 at 11:59 a.m., RN 10 changed her gloves, picked up the glucometer, and placed it on the bed of Resident 102. The RN obtained the blood glucose reading and returned the glucose monitor to the medication cart. On 9/23/25 at 12:05 p.m., during an interview RN 10 indicated she did not ever place a barrier between the resident's bed, table or dresser and she indicated she cleaned the glucometer with an alcohol wipe after she was finished with both glucose tests. She opened the medication cart drawer and indicated she had bleach wipes to use sometimes, but she usually used the alcohol wipes to clean the glucometer device. RN 10 acknowledged she did not sanitize the glucometer between residents, and she placed the glucometer on the residents' beds without a barrier. On 9/23/25 at 12:10 p.m., during an interview the DON indicated she had an issue with RN 10 prior to this, and she had been educated before regarding glucometers and infection control. She indicated there were no residents currently on the South hall with infectious disease. She acknowledged the staff were to disinfect glucometers between residents with approved bleach wipes only and the staff should follow all infection control practices. On 9/23/25 at 12:15 p.m., the medical record of Resident 1 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but not limited to, osteomyelitis (an infection in the bone), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A physician order, dated 7/1/25, indicated administer insulin lispro solution; 100 unit/mL (milliliter) per sliding scale, before meals. A2. On 9/23/25 at 12:30 p.m., the medical record of Resident 102 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but not limited to, congestive heart failure(CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A physician order, dated 8/21/25, indicated to administer Lispro insulin pen; 100 unit/mL; amt: per sliding scale before meals and at bedtime. A3. On 9/19/25 at 11:08 a.m., Registered Nurse (RN) 15 was observed completing Resident 3's accu check (blood sugar level). RN 15 applied gloves and placed the glucometer (checks blood sugar) and supplies on a barrier on the resident's bedside table. RN 15 used both gloved hands and cleaned the resident's fingertip. RN 15 then obtained a glucometer strip from the communal container of strips and placed it in the glucometer. RN 15 did not change gloves or perform hand hygiene after touching the resident, before touching a communal item. After obtaining the resident's accu check, RN 15 placed the glucometer strips back into the medication cart without cleaning it. During an interview, on 9/23/25 at 1:48 p.m., the Regional Nurse Consultant indicated staff should not have touched the glucometer strip container with the same gloves they touched the resident with. On 9/23/25 at 1:47 p.m., the Regional Nurse Consultant provided an undated document titled, Cleaning and Disinfecting Procedures for the Meter, and indicated it was the policy currently being used by the facility. The policy indicated, .The.Meter should be cleaned and disinfected between each patient.The following products have been approved for cleaning and disinfecting the.Meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach.Medline Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol.Clorox Healthcare Bleach Germicidal and Disinfectant Wipes.Medline Micro-Kill Bleach Germicidal Wipes. On 9/23/25 at 2:07 p.m., the Regional Nurse Consultant provided a document titled, Glucometer Cleaning and Disinfecting, last revised on 1/24/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose Statement: To minimize the risk of transmitting blood-borne pathogens, cleaning and disinfection procedure should be performed.Guidelines: 1. Licensed staff will follow the manufacturer guidelines and recommendations for the cleaning and disinfection of the glucose monitor. On 9/23/25 at 3:00 p.m., the Regional Nurse Consultant provided a document titled, Finger Stick Blood Glucose Monitoring Competency, dated 7/19/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Performs hand hygiene and dons gloves.Selects appropriate finger and cleans with alcohol swab; allows to air dry. Uses lancet to puncture side of fingertip.Ensures adequate blood sample is applied to strip for accurate reading. Applies gauze to site with gentle pressure to stop bleeding. Reads and records results.Disposes of used supplies and sharps in proper containers. Clean/disinfect glucometer per guidelines. Performs hand hygiene and removes gloves. B. On 9/17/25 at 10:30 a.m., Resident 14 was resting in bed and her Foley catheter (indwelling catheter, inserted into the bladder to drain urine) tubing was in contact with the floor mat that was located on the floor next to her bed. On 9/17/25 at 11:39 a.m., Resident 14 was asleep in bed, and her catheter tubing was in contact with the floor. On 9/17/25 at 1:33 p.m., Resident 14 was resting in bed, and her catheter tubing was in contact with her floor mat next to her bed. On 9/18/25 at 8:35 a.m., Resident 14 was asleep in bed, and her catheter tubing was in contact with her floor mat next to her bed. On 9/18/25 at 1:13 p.m., Resident 14 was asleep in bed, and her catheter tubing was contact with the floor underneath her bed. Resident 14's record was reviewed on 9/18/25 at 8:28 a.m. The profile indicated the resident's diagnoses included, but were not limited to, neuromuscular dysfunction of bladder (occurs when damage to the brain, spinal cord, or nerves disrupts the signals between bladder and the brain, leading to problems with bladder control) and urinary retention (difficulty urinating and completely emptying the bladder). A quarterly Minimum Data Set (MDS) assessment, dated 8/22/25, indicated the resident had severe cognitive impairment and had an indwelling catheter. A physician's order, dated 8/7/25, indicated to anchor a Foley catheter size 16 Fr (French) (diameter of catheter tubing) 10cc (cubic centimeter) balloon to straight drainage. A physician's order, dated 6/22/25, indicated change catheter if leaking, blockage, or dislodgement occurs as needed. A physician's order, dated 6126/25, indicated Foley catheter care every shift. A physician's order, dated 6/12/25, indicated urinary output every shift. During an interview, on 9/18/25 at 2:33 p.m., Qualified Medication Aide (QMA) 8 indicated the catheter tubing should not touch the floor, floor mat, and/or any other surface. During an interview, on 9/18/25 at 2:39 p.m., Regional Clinical Consultant indicated catheter tubing should not touch the floor. On 12/15/23 at 10:50 a.m., the DON provided a document, with a date of 1/31/25, titled, Foley Catheter Use, and indicated it was the current policy being used by the facility. The policy indicated, .To ensure that the use of indwelling urinary Foley catheters is medically justified, managed safely, and aligned with CMS requirements to minimize complications, maintain resident dignity, prevent infections 3.1-18(b)(1) 3.1-18(l)

Based on observation and interview, a facility dietary staff member failed to don gloves prior to handling sandwich bread during preparation of sandwiches during an initial tour of the kitchen. This deficient practice had the potential to affect 10 of 10 residents consuming the prepared sandwiches. Findings include: An observation of the facility's kitchen was completed on 8/4/25 at 10:10 a.m., accompanied by the Dietary Manager. Dietary Aide 2 was observed standing at a preparation table with bread laid out in a row. He held one piece of bread in a bare hand and had a knife with peanut butter in the other. He began to spread peanut butter onto the piece of bread. Dietary Aide 2 indicated he was preparing peanut butter and jelly sandwiches for lunch service and for snacks during the day. He indicated he should be wearing gloves and not touching food with his bare hands. He began to don gloves, when he was stopped by the Dietary Manager and asked to perform hand hygiene prior to donning the gloves.During an interview on 8/6/25 at 11:03 a.m., the Dietary Manager indicated the kitchen staff usually prepared around 10 peanut butter and jelly sandwiches a day for use as snacks and/or meals. They were usually all consumed throughout the day. Dietary Aide 2 should have been using gloves to touch food after washing hands and applying the gloves. The sandwiches he had been preparing during the observation were discarded.A current facility policy, revised 9/2017, titled, Food: Preparation, provided by the Corporate Nurse Consultant on 8/6/25 at 9:15 a.m., included the following: Policy Statement All foods are prepared in accordance with the FDA Food Code .Procedures 1. All staff will practice proper hand washing techniques and glove use This citation relates to Complaint 1385466.3.1-21(i)(3)

Based on record review and interview, the facility staff failed to administer scheduled doses of comfort medication per physician order without nursing assessment and physician notification for 1 of 8 resident reviewed for quality of care (Resident B). The deficient practice was corrected by 6/5/25 prior to the start of the survey and was therefore Past Noncompliance. Findings include: During a telephone interview on 6/12/25 at 3:20 p.m., Resident B's family member indicated the staff were not able to explain needs or symptoms that would be managed with the hospice ordered medications. They appeared confused about the administration of the medications and when they were to be given. The residents breathing would become rapid at times and he would begin to move his shoulders and grunt as if he were uncomfortable. When the medications were given, he seemed more comfortable and seemed to breath easier. One Qualified Medication aide (QMA) had entered the room and attempted to administer his medications, but indicated he was clenching his teeth and she was not able to administer the dose. She felt he looked calm and comfortable so she indicated she would skip it. We agreed only because we were relying on the staff to know what was best. It was very uncomfortable to watch him seem to struggle occasionally. The clinical record for Resident B was completed on 6/12/25 at 9:52 a.m. Diagnoses included dementia, chronic obstructive pulmonary disease, atrial fibrillation, heart disease and anxiety disorder. A nursing progress note, dated 5/19/25 at 7:13 p.m., indicated the resident had increased pain and agitation. The physician was notified for palliative treatment and changed the order for morphine (to treat pain and shortness of breath) from as needed to scheduled every four hours. A physician's order, dated 5/19/25, indicated to administer morphine concentrate 20 mg (milligram) per 1 ml (milliliter), 0.25 ml/5 mg, every four hours for pain and agitation. The medication was scheduled to be provided at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. QMA 2 failed to administer the ordered medication on the following dates and with explanations: a. On 5/20/25 at 12:00 p.m., the note indicated the resident had no pain and was sleeping. b. On 5/20/25 at 4:00 p.m., the note indicated the resident had no pain. c. On 5/21/25 at 4:00 p.m., the note indicated the resident was sleeping, had no pain, and had no agitation. d. On 5/22/25 at 12:00 p.m., the note indicated the resident had no agitation or pain. e. On 5/27/25 at 12:00 p.m., the note indicated the resident was sleeping. During an interview on 6/12/25 at 4:08 p.m., QMA 2 indicated Resident B's family was present when she came into the room to administer his morphine. She observed he was not in any distress and decided to hold the medication. She asked the family if they needed anything and if he seemed comfortable then left the room. She felt there was no issue and he did not need that dose. She held the scheduled medication because she observed no grimacing or signs and symptoms of pain. She indicated if the medication had been for high blood pressure or something like that, she would have administered the medication even without outward signs of need. QMA 4 failed to administer the ordered medication on the following dates with explanations: a. On 5/26/25 at 12:00 a.m., the note indicated unable to arouse resident. b. On 5/26/25 at 4:00 a.m., the note indicated unable to arouse resident. During an interview on 6/12/25 at 4:31 p.m., QMA 4 indicated she had put the dropper into the resident's mouth, and he clenched his teeth tightly making it difficult to administer. The family were at bedside and indicated they thought he may not have needed or wanted it at the time. QMA 4 indicated she held the dose. The clinical record lacked progress notes indicating completed assessments to hold the scheduled morphine or documentation of physician notification. During an interview on 6/12/25 at 4:34 p.m., the DON indicated QMA's and nurses should not skip doses of scheduled medications unless they contact the physician. A current facility policy, revised 1/31/25, titled, Physicians Orders, provided by the Nurse Consultant on 6/12/25 at 5:17 p.m., included the following: Policy Statement It is the standard of this facility that physician orders are followed Guideline: .2. Licensed Nurses and Medication Aides are expected to follow physician's orders. The deficient practice was corrected by 6/5/25 after the facility implemented a systemic plan that included re-education of nursing staff. On 6/12/25 at 4:28 p.m., the Nurse Consultant provided two documents of completed inservices. The In-Service Sign in Sheet, dated 5/30/25, indicated the training provided as assessments, notifying the physician for out of range vitals, documentation, fall prevention, and QMA scope of practice. The In-Service Sign in Sheet, dated 6/5/25, indicated the training provided as out of range vitals required physician be made aware and noted by nurse, and QMA's may not hold medications without nurse assessment and physician notification. QMA 2 and QMA 4 had signed each inservice record sheet. This citation relates to Complaint IN00460686. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure resident specific interventions were implemented for a dementia resident who was known to have behaviors upon admitting to the facility and intrusive wandering for 1 of 6 residents reviewed for dementia care (Resident J). This deficient practice resulted in harm when Resident J wandered into Resident F's room unsupervised and then exited with three circular bruises on the right lower arm and scratches with fresh blood on them. Resident F was found on the ground of her room with skin tears, and was diagnosed at the hospital with a non-displaced acute distal right clavicle fracture, and a subdural hematoma with mild midline shift. Findings include: A confidential interview during the survey indicated that local police responded to a nearby hospital to speak with Resident F who was being treated for injuries that occurred at the nursing home. The resident died on [DATE]. There was concern that the deceased resident had been beaten by Resident J. Resident J's record was reviewed on [DATE] at 2:30 p.m. Diagnoses on Resident J's profile included, early onset Alzheimer's disease (a progressive disease that destroys memory and other mental functions), and anxiety disorder (stress that was out of proportion to the impact of the event, inability to set aside a worry, and restlessness). On [DATE] at 9:35 a.m., Resident J was observed in an activity/dining room on the secured memory care unit, at a table with a peer, and their seating was spaced apart. The resident was calm and looking around. On [DATE] at 9:35 a.m., an observation of the secured memory care unit with the Nurse Consultant was completed. Resident J's room was at the end of a hallway near the outside exit doors, four resident rooms down from the nurse's desk. Resident F's room was observed to be directly next door on the same side of the hallway. The nurse's desk was located in the middle where the 3 separate hallways intersected on the 900 hallway. The Nurse Consultant indicated that a couch had previously been in an alcove in front of the nurse's desk on the hallway leading towards the exit into the main part of the facility, where QMA 5 who was in charge of the 900 hallways on [DATE] had been sitting while she charted and would not have been able to view Residents J and F's rooms at the end of the hallway. During a continuous observation of the 900 hallways, on [DATE] from 11:05 a.m. to 11:25 a.m., Resident J was observed walking swiftly towards the exit door upon entry of a visitor to the unit. The resident was observed to turn and follow the visitor to the nurse's desk, where she watched but did not engage the four unidentified staff members standing and sitting around the desk. At 11:17 a.m., Resident J was persuaded to enter the dining/activity room and sit at the end of a long table where peers were sitting during an activity, the resident actively watched activity around her, but maintained a flat affect and did not engage with those around her. Review of documentation from the skilled nursing home Resident J had transferred from on [DATE], indicated Resident J had initiated two prior resident-to-resident altercations by hitting other residents in the four months prior to admission to the current skilled nursing home. The most recent incident occurred on [DATE]. Physician's orders dated [DATE], included: a. Admit to a gated community due to Alzheimer's dementia. b. Resident may see psychiatrist as needed. The resident record lacked a physician's order to monitor target behaviors of wandering, cursing, yelling, until [DATE]. A progress note, dated [DATE] at 12:16 a.m., indicated Resident J had been admitted on the day shift of [DATE]. On the evening shift the resident had been exit seeking and walked fast in the halls. The resident attempted to exit with someone else's family member, but staff assisted, and Resident J was returned from outside the door area to the hall. The resident came back willingly but at times when staff talked to the resident, she got verbally aggressive and called staff curse words. Resident J spit at staff and attempted to throw things at them several times. She targeted resident rooms with stop signs on them and ripped the signs down and threw them on the floor. This behavior caused an issue with another resident (Resident F). Resident J was verbally aggressive toward others, and the administration was notified of the resident to be on 15-minute checks. Staff were educated that one staff member was to be up alternating to have eyes on Resident J to detour her from other residents' rooms and to decrease the risk of resident to resident incident. A 48-Hour Baseline Care Plan, dated [DATE], indicated a history of impaired daily decision making, dementia, Alzheimer's disease, short or long-term memory loss were not triggered. Interventions related to Alzheimer's or dementia were not added to the baseline care plan. A care plan for Resident J, dated [DATE], indicated the resident was placed in the locked unit as a least restrictive approach to protect the resident and assure her health and safety. Approaches included encouraging the family to place familiar objects, and pictures in the resident room for cueing, encouraging the resident to participate in activities, and to provide access and visitation by family, resident representative, and/or other individuals. Staff were to be alert to psychosocial needs and conduct ongoing periodic review for the continued need for placement on the unit. The care plan lacked documentation of individualized interventions for Resident J and did not mention the history of altercations with staff or another resident. A care plan for Resident J, dated [DATE], indicated the resident was at risk for injury or adverse outcomes related to wandering behaviors. Approaches included encouraging the resident's representative / family to visit as needed, encourage the resident to participate in activities of interest / choice, observe the resident's wandering patterns and escort her away from other residents or other resident rooms as needed, and observe for signs of increasing fatigue and offer rest periods. The care plan lacked documentation of individualized interventions for Resident J and did not mention the history of altercations with staff or another resident. The resident record lacked documentation of the care plans having been updated with behaviors to include exit seeking, physical and verbally combative behaviors, or the resident having been placed on 15-minute checks An admission MDS assessment, completed on [DATE], assessed Resident J as usually having the ability to make herself understood and to usually understand others. A BIMS score ,d+[DATE] indicated moderately impaired cognition. The resident had no signs or symptoms of delirium, behaviors, or rejection of care, but did displayed wandering behaviors daily. The resident was independent with bed mobility and required supervision with transfers and ambulation. The resident had no skin conditions to include pressure wounds, skin tears, or bruises. The MDS lacked documentation of behaviors. An event entered into the electronic medical record (EMR) by Licensed Practical Nurse (LPN) 6, on [DATE] at 3:40 a.m., indicated Resident J had new or worsening behaviors including wandering into other residents' rooms, not able to sleep, and hitting staff at times. LPN 6 indicated the resident wandered frequently and aimlessly, and at times when redirected she hit at staff. Psychiatric services had seen the resident. Interventions to alleviate behaviors included 15-minute checks, and a SBAR (situation, background, assessment and recommendation) had been sent to the physician requesting an order for psychiatric medication and medication to help the resident sleep. An event entered by LPN 6 on [DATE] at 4:19 a.m., indicated the resident had 3 circular dark purple bruises on the right arm, each measuring 1-centimeter (cm) by (x) 1 cm x 0 cm with scratches. At the time of the bruises occurrence the resident was wandering into another resident's (Resident F's) room. A possible contributing factor was combative/resistive behavior. A progress note, dated [DATE] at 4:13 a.m., indicated Resident J was observed leaving Resident F's room. Resident J had new bruises, three approximate 1 cm x 1 cm circular bruises on the right lower arm, and scratches as well that had fresh blood on them. Administration was notified, and the resident was placed on 15-minute checks. A progress note, dated [DATE] at 2:25 p.m., indicated Resident J was sent by ambulance to an in-house Geri-psychiatric (Geri-psych) hospital for admission. A progress note, dated [DATE] at 5:36 p.m., indicated Resident J returned from Geri-psych for readmission to the facility. A progress note, dated [DATE] at 4:45 p.m., indicated Resident J was seen by a visiting psychiatric group for a routine psychiatric follow up with no new concerns or orders. On [DATE] at 1:15 p.m., the Nurse Consultant indicated psychiatric services had seen Resident J in the facility on [DATE] for an initial visit, the facility had not yet received documentation of the visit. A confidential interview during the survey process indicated Resident F's family member had come through the locked memory care unit doors for a visit, and when she would not let Resident J out, Resident J became violent with her and staff had to intervene. Resident F's family member had reported Resident J having been found in Resident F's room at least 6 different times prior to the incident on [DATE]. On [DATE], CNA 8 had reported having seen Resident J walk out of Resident F's room holding her arm, with fresh scratches on her arm. When police arrived at the facility on [DATE], QMA 5 indicated staff thought there had been a resident to resident altercation between Residents F and J, causing Resident F to fall. During an interview on [DATE] at 2:03 p.m. Certified Nursing Assistant (CNA) 7 indicated, on the night of [DATE] she had been at the nurse's station and had seen Resident J walking around/pacing. Five minutes later CNA 8 had jumped up and said she had heard Resident F say ouch. As both CNAs walked into Resident F's room, Resident J walked out. Resident F was observed sitting on the floor in the doorway of the bathroom next to a footboard of a bed. During an interview on [DATE] at 11:26 a.m., the Nurse Consultant indicated, on [DATE] staff had been doing rounds and Resident J was pacing, they were on opposite ends of the hallway. The CNAs had their eyes off Resident J for approximately 3 minutes while they changed another resident. The CNAs then sat down to chart at the nurse's station and heard someone say ouch. Resident J was witnessed exiting Resident F's room, who was witnessed on the floor in her room. The CNAs denied hearing any indication of a fall. During an interview on [DATE] at 2:10 p.m., CNA 8 indicated, on [DATE], she had been doing bed checks with CNA 7, when she heard Resident F say ouch. She observed Resident J exit Resident F's room frowning and holding her right arm, and Resident F was observed sitting on the floor in front of the bathroom door. Resident J was to be watched and staff were to keep eyes on her, but the CNAs had been providing care in another resident room for about 1 minute and then went to the nurse's station to chart. During an interview on [DATE] at 12:51 p.m. the Administrator (ADM) and Nurse Consultant indicated after Resident F left the faciity on [DATE] an investigation was initiated, Resident J was placed on one on one (1:1), interviews were conducted with staff, and a policeman came in response to the family member's call. A facility State Reportable Incident report was sent on [DATE] in response to the fall with injury for Resident F. Resident J had been on 1:1, and after the fall became aggressive, more than her routine pacing, and was sent to Geri-psych. Resident J had not been viewed by staff as being escalated the night of the incident, but after being put on 1:1 her behaviors escalated. On the night shift of the incident on [DATE], two staff CNAs had been caring for another resident at the end of the hallway, and QMA 5 was sitting at the nurse's desk. Staff thought they heard a help, saw Resident J leave Resident F's room, and staff entered the resident's room to find Resident F on the floor. The Nurse Consultant indicated staff found a smear of blood on the foot board of the roommate's bed and 2 small drops of blood on the floor at the end of the bed to indicate where Resident F had fallen, and the policeman had requested to view the crime scene. During an interview on [DATE] at 3:10 p.m., LPN 6 indicated on [DATE] she had been working on the 700 and 800 hallways, and covering the 2 secured hallways, each of which had a Qualified Medication Aide (QMA). LPN 6 indicated she had been summoned to the 900 hallways by QMA 5 who reported a fall. LPN 6 had observed Resident F on the floor in the doorway to the hallway, sitting on her buttocks with her legs outstretched, which was within ,d+[DATE] feet of the bathroom. Resident F had skin tears on both lower shins, her leg looked abnormal, she had skin tears and scratches on the right forearm, there was slight penny sized bleeding on the floor, and she complained of pain in her right shoulder, so they did not move it. 911 was called and Resident F was transported to the hospital for evaluation and treatment. CNA 7 indicated, she had seen Resident J come out of Resident F's room. Resident J had been assessed and found with purple/blue bruising and fresh scratches with blood on the forearm. When asked what had happened Resident F indicated her and pointed to Resident J. The Administrator (ADM) was notified, and she told LPN 6 to put Resident J on 15-minute checks. LPN 6 instructed the CNAs to keep an eye on Resident J and assure she was not wandering in other residents' rooms. LPN 6 indicated, in the past Resident J had been monitored related to wandering, taking down other residents' stop signs, and hitting at staff, but she thought that might have ended. During an interview on [DATE] at 7:48 a.m., QMA 5 indicated, on [DATE], she had worked the night shift passing medications from 6:00 p.m. to 6:00 a.m. QMA 5 had given Resident F her evening medications on [DATE] at 7:30 p.m. and had not seen the resident after she was helped to bed by the CNAs. QMA 5 had been sitting on a couch charting, where she did not have a view of Residents F and J's rooms. CNA 7 had come and told her someone was on the floor, and she went and found LPN 6 before going to Resident F's room. Upon entering Resident F's room, the resident was observed on the floor near the end of the roommate's bed, sitting up, facing the doorway. Resident J had been seen exiting Resident F's room. Resident J had a history of aggression, would smack, kick, etc. toward staff, and her behavior got worse at night. QMA 5 indicated staff had been made aware that Resident J could be violent to staff with care, redirection, and did not like to be told what to do. QMA 5 indicated the Director of Nursing was aware of Resident J's behaviors, but to her knowledge she was not aware of Resident J having been placed on 1:1 monitoring related to her known behaviors. Resident J was known to enter other residents' rooms and take their stuff, and she frequently wandered into all other residents' rooms on the unit. QMA 5 indicated the CNAs had been able to see all 3 of the 900 hallways from the nurse's station. CNA 8 had heard Resident F say ouch, and being as her room was approximately 100 feet from the nurse's station it had to have been at a high volume. QMA 5 indicated she had not seen Resident J in bed asleep, but had seen the CNA's take her to her room, and they said she had been asleep. Staff did not see Resident J go into Resident F's room. During an interview on [DATE] at 8:19 a.m., CNA 7 indicated, she had worked [DATE] from 6:00 p.m. to 6:00 a.m. and made resident rounds every 30 minutes to 1 hour. Resident J had been observed around 12:00 a.m. and 12:30 a.m., walking in the hallways. Resident J was known to wander, and did not sit or lay in bed for long. Resident J used to be a housekeeper and would wander in and out of other residents' rooms, made other residents' beds, would take their bedding to the laundry room, and would pick up cups. CNA 7 indicated Resident J was violent towards staff, was unpredictable going from pleasant to violent, and staff were still learning her behaviors. CNA 7 indicated recently upon redirection from getting into another resident's bed, Resident J tried to backhand her. On [DATE], she saw Resident J come out of Resident F's room. Resident J seemed calm, walked to the nurse's station and sat down, and showed the CNA that she had scratches on her left arm. Resident J denied knowing what had happened to Resident F. CNA 7 indicated, her bosses knew Resident J was being violent towards staff, and staff had been told that if an incident was resident to staff, the staff were on their own. CNA 7 indicated she had reported the backhand incident to the DON a few days before [DATE], and was told the facility would send the resident for psychiatric help. Staff initially thought Resident J might have been involved in Resident F's fall because she could be mean but later thought due to Resident J's calm demeanor at the time, she was most likely not involved. CNA 7 indicated she had not known Resident J had been put onto 15-minute checks prior to [DATE]. If a resident was on 15-minute checks, staff would document seeing the resident every 15 minutes. Increased Monitoring - 15 minute check reports for Resident J, dated [DATE] - [DATE], were unavailable at the time of the survey exit. Handwritten copies of the reports were received via e-mail from the Nurse Consultant on [DATE] at 12:10 a.m. During the exit conference on [DATE] at 4:43 p.m., the Nurse Consultant indicated it was the right of all residents on the memory care unit to wander where they wanted, any time they wanted, and that included allowing Resident J to wander into other residents' rooms during the night on the unit. That was the purpose of a secured memory care wing. A behavior management policy was requested but not provided during the survey process. This citation relates to Complaint IN00458972. 3XXX,d+[DATE](a)

Based on interview, and record review, the facility failed to timely report an allegation of suspected resident-to-resident abuse for 1 of 7 residents reviewed for resident abuse (Resident F). Findings include: A facility reportable incident (FRI), dated [DATE] at 11:51 a.m., indicated Resident F was attempting to ambulate in her room in the memory care and fell . Resident F complained of right shoulder and bilateral lower extremities pain. The resident was transported by ambulance to the emergency room (ER) where she was diagnosed with a non-displaced acute distal right clavicle fracture, diffuse osteopenia, and a subdural hematoma with mild midline shift. A confidential concern during the survey indicated that local police responded to a nearby hospital to speak with Resident F who was being treated for injuries that occurred at the nursing home. The resident died on [DATE]. There was concern that the deceased resident had been beaten by another resident. A concern from a local hospital employee, dated [DATE], indicated Resident F had been brought into the ER for an unwitnessed fall via emergency medical services (EMS). She had been admitted to the hospital for injuries and uncontrolled pain associated with this event. A physician's note indicated that the resident presented to the hospital with a suspected unwitnessed fall and was taking Eliquis (a blood thinner). The Hospitalist Nurse Practitioner (NP) talked with the resident who maintained that a nurse at the nursing home twisted her arm behind her back, causing her to fall. The resident reiterated the recollection of events multiple times. The NP noted the resident had a clavicle fracture, brain bleed (subdural hematoma), scattered bruises, and skin tears from the event. Resident F's family made the decision not to have the resident return to the facility. A confidential interview during the survey process indicated, on [DATE], CNA 8 had reported having seen Resident J walk out of Resident F's room holding her arm, with fresh scratches on her arm. When police arrived at the facility on [DATE], QMA 5 indicated, staff thought there had been a resident-to-resident altercation between Residents F and J, causing Resident F to fall. During an interview on [DATE] at 2:03 p.m. Certified Nursing Assistant (CNA) 7 indicated, on the night of [DATE] she had been at the nurse's station and had seen Resident J walking around/pacing. Five minutes later CNA 8 had jumped up and said she had heard Resident F say ouch. As both CNAs walked into Resident F's room, Resident J walked out. Resident F was observed sitting on the floor in the doorway of the bathroom next to a footboard of a bed. During an interview on [DATE] at 11:26 a.m., the Nurse Consultant indicated, on [DATE], staff had been doing rounds and Resident J was pacing, they were on opposite ends of the hallway. The CNAs had their eyes off Resident J for approximately 3 minutes while they changed another resident. The CNAs then sat down to chart at the nurse's station and heard someone say ouch. Resident J was witnessed exiting Resident F's room, who was witnessed on the floor in her room. The CNAs denied hearing any indication of a fall. During an interview on [DATE] at 2:10 p.m., CNA 8 indicated, on [DATE], she had been doing bed checks with CNA 7, when she heard Resident F say ouch. She observed Resident J exit Resident F's room frowning and holding her right arm, and Resident F was observed sitting on the floor in front of the bathroom door. Resident J was to be watched, and staff were to keep eyes on her, but the CNAs had been providing care in another resident room for about 1 minute and then went to the nurse's station to chart. During an interview on [DATE] at 3:10 p.m., LPN 6 indicated, on [DATE], she had been summoned to the 900 hallways by QMA 5 who reported a fall. LPN 6 had observed Resident F on the floor in the doorway to the hallway, sitting on her buttocks with her legs outstretched, which was within ,d+[DATE] feet of the bathroom. Resident F had skin tears on both lower shins, her leg looked abnormal, she had skin tears and scratches on the right forearm, there was slight penny sized bleeding on the floor, and she complained of pain in her right shoulder, so they did not move it. 911 was called and Resident F was transported to the hospital for evaluation and treatment. CNA 7 indicated she had seen Resident J come out of Resident F's room. Resident J had been assessed and found with purple/blue bruising and fresh scratches with blood on the forearm. When asked what had happened, Resident F indicated her and pointed to Resident J. The Administrator (ADM) was notified, and she told LPN 6 to put Resident J on 15-minute checks. LPN 6 instructed the CNAs to keep an eye on Resident J and assure she was not wandering in other residents' rooms. LPN 6 indicated in the past Resident J had been monitored related to wandering, taking down other residents' stop signs, and hitting at staff, but she thought that might have ended. During an interview on [DATE] at 7:48 a.m., QMA 5 indicated, on [DATE], she had given Resident F her evening medications on [DATE] between 7:30 p.m.and 8:00 p.m. and had not seen the resident after she was helped to bed by the CNAs. QMA 5 had been sitting on a couch charting, where she did not have a view of Residents F and J's rooms. CNA 7 had come and told her someone was on the floor, and she went and found LPN 6 before going to Resident F's room. Upon entering Resident F's room, the resident was observed on the floor near the end of the roommate's bed, sitting up, facing the doorway. Resident J had been seen exiting Resident F's room. Resident J had a history of aggression, would smack, kick, etc. toward staff, and her behavior got worse at night. CNA 8 had heard Resident F say ouch, and being as her room was approximately 100 feet from the nurse's station it had to have been at a high volume. QMA 5 indicated she had not seen Resident J in bed asleep, but had seen the CNA's take her to her room, and they said she had been asleep. Staff did not see Resident J go into Resident F's room. During an interview on [DATE] at 8:19 a.m., CNA 7 indicated she had worked [DATE] from 6:00 p.m. to 6:00 a.m. and made resident rounds every 30 minutes to 1 hour. She had last checked Resident F about 15 minutes before she was found on the floor, and at the time the resident had been sitting in bed awake with the television (TV) off. CNA 7 indicated that she had then sat down at the nurse's station to chart. Resident J had been observed around 12:00 a.m. and 12:30 a.m., walking in the hallways. Resident J was known to wander, and did not sit or lay in bed for long. Resident J used to be a housekeeper and would wander in and out of other residents' rooms, made other residents' beds, would take their bedding to the laundry room, and would pick up cups. CNA 7 indicated Resident J was violent towards staff, was unpredictable going from pleasant to violent, and staff were still learning her behaviors. CNA 7 indicated recently upon redirection from getting into another resident's bed, Resident J tried to backhand her. On [DATE], she had seen Resident J come out of Resident F's room. Resident J seemed calm, walked to the nurse's station and sat down, and showed the CNA that she had scratches on her left arm. Resident J denied knowing what had happened to Resident F. CNA 7 indicated she had reported the backhand incident to the DON a few days before [DATE], and was told the facility would send the resident for psychiatric help. Staff initially thought Resident J might have been involved in Resident F's fall because she could be mean but later thought due to Resident J's calm demeanor at the time, she was most likely not involved. CNA 7 indicated she had not known Resident J had been put onto 15-minute checks prior to [DATE]. If a resident was on 15-minute checks, staff would document seeing the resident every 15 minutes. A confidential interview held during the survey process indicated Resident F's family had called the police in response to events that happened on [DATE]. A staff member heard a scream coming from Resident F's room where she was found on the floor injured, and Resident J was observed leaving Resident F's room while holding her own arm. At the hospital Resident F made statements about a staff member holding her arm behind her back causing the accident. The press had then found out about the incident and details had been aired in a local newspaper and on-line formats. A police detective had notified staff he and the Attorney General's office would be setting up times to interview staff. During an interview on [DATE] at 12:51 p.m. the Administrator (ADM) and Nurse Consultant indicated a family member had reported the fall and subsequent death of Resident F to the media. The family member had also posted videos of Resident F taken while she was in the hospital with details of how she fell , her injuries, and death on a major social platform. On [DATE] Resident F was sent to the ER for evaluation and treatment after a fall. The fall incident was State reported by the facility on [DATE] after a hospital report was obtained showing the resident had a broken clavicle and subdural hematoma. The Nurse Consultant indicated that an investigation was initiated on [DATE] after the family member had called and spoken to the Director of Nursing (DON). The family member indicated that she had called the police after being told by someone at the hospital that an EMT reported to them CNA 7 told the EMT's Resident J had potentially caused Resident F's fall. The Nurse Consultant indicated Resident F's fall had initially been a two-part investigation, resident to resident abuse, and fall with injury. After the DON had spoken with the family member on [DATE] around 8:00 a.m. to 9:00 a.m., the family member seemed to be on the same page of no abuse, so it was not reported. When interviewed, CNA 7 denied making that remark to the EMT of Resident J potentially causing the accident. During an interview on [DATE] at 12:51 p.m. the Administrator (ADM) and Nurse Consultant indicated after Resident F left the faciity on [DATE] an investigation was initiated, Resident J was placed on one on one (1:1), interviews were conducted with staff, and a policeman came in response to the family member's call. A facility State Reportable Incident report was sent on [DATE] in response to the fall with injury. Staff found a smear of blood on the foot board of the roommate's bed and 2 small drops of blood on the floor at the end of the bed to indicate where the resident had fallen, and the policeman had requested to view the crime scene. The Interdisciplinary team (IDT), Quality Assurance (QA), Quality Assurance and Performance Improvement (QAPI) teams all met to discuss Resident F's fall, and did not believe the incident was a resident-to-resident altercation. A facility decision was made at that time to not report resident-to-resident abuse. The Nurse Consultant indicated, if they had thought the fall was related to an altercation, they would have reported the incident within 2 hours, but this was not the situation. During an interview on [DATE] at 12:51 p.m. the Nurse Consultant indicated a family member had called the DON on [DATE] around 8:00 a.m. to 9:00 a.m. and indicated she had called the police in response to hearing in the ER of a potential resident to resident interaction, and Resident F kept saying someone had pulled on her arm causing her to fall. The family member had also thought the gash on the front of Resident F's left shin happened during the altercation. A policeman had come into the facility on [DATE] around 9:30 a.m., looked at the scene, and left. The situation had not been State reported as abuse after the family member called, but it was state reported on [DATE] in reaction to the fall with injury. The Nurse Consultant indicated the facility was unable to get a response in calls to the EMTs, had not attempted to speak with anyone at the hospital, and had not attempted to speak with the family member after the resident had discharged to the hospital. The Nurse Consultant indicated that the incident had not been reported as abuse due to the family member having seemed to be on the same page of the incident being an accident by the end of the phone conversation with the DON on [DATE]. A detective was now interviewing night staff that were present on [DATE], he had asked for the facility attorney information to speak with legal counsel (who had asked for the facility soft file), as it was the process. The Nurse Consultant indicated the police were following up the situation as a whole; circumstances related to the fall incident, Resident F's hospitalization , and Resident F's death at the hospital. The Nurse Consultant indicated at no time had the police indicated they thought the situation was abuse or a suspicious death. The Nurse Consultant and the ADM indicated at no time since the police, a detective, the family, hospital, EMT's, and media were involved, had any further investigation been completed as the facility felt a thorough investigation had already been completed. On [DATE] at 12:10 a.m., the Nurse Consultant provided a local newspaper article, dated [DATE]. The article indicated, A death investigation is underway involving a resident at a [name of city] long-term rehabilitation facility, authorities have confirmed On [DATE] at 12:10 a.m., the Nurse Consultant provided a local television station newscast and on-line blog, dated [DATE], indicated, A death investigation is underway in [name of city]. On [DATE], the [name of city] police department responded to [a local hospital] to speak with a patient who was being treated for injuries believed to have occurred at a local long term rehabilitation facility. While the investigation was underway, the victim passed away Review of documentation from the skilled nursing home Resident J had transferred from on [DATE], indicated Resident J had initiated 2 prior resident-to-resident altercations by hitting other residents in the 4 months prior to admission to the current skilled nursing home, the most recent incident had occurred on [DATE]. A progress note, dated [DATE] at 12:16 a.m., indicated Resident J had been admitted on the day shift of [DATE]. On the evening shift the resident had been exit seeking and walked fast in the halls. The resident attempted to exit with someone else's family member, but staff assisted, and Resident J was returned from outside the door area to the hall. The resident came back willingly but at times when staff talked to the resident, she got verbally aggressive and called staff curse words. Resident J spit at staff and attempted to throw things at them several times. She targeted resident rooms with stop signs on them and ripped the signs down and threw them on the floor. This behavior caused an issue with another resident (Resident F). Resident J was verbally aggressive toward others, and the administration was notified of the resident to be on 15-minute checks. Staff were educated that 1 staff member was to be up alternating to have eyes on Resident J to detour her from other residents' rooms to decrease resident to resident risk of incident. An event entered into the electronic medical record (EMR) by Licensed Practical Nurse (LPN) 6, on [DATE] at 3:40 a.m., indicated Resident J had new or worsening behaviors including wandering into other residents' rooms, not able to sleep, and hitting staff at times. LPN 6 indicated the resident wandered frequently and aimlessly, and at times when redirected she hit at staff. Psychiatric services had seen the resident. Interventions to alleviate behaviors included 15-minute checks, and a SBAR (situation, background, assessment and recommendation) had been sent to the physician requesting an order for psychiatric medication and medication to help the resident sleep. An Abuse, Neglect and Misappropriation of Property policy, dated [DATE], indicated, Allegation of Abuse. This means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred, or plausibly might have occurred .All alleged violations involving abuse, neglect .are reported immediately, but no later than 2 hours after the allegation is made . Cross reference tag F744. This citation relates to Complaint IN00458972. 3XXX,d+[DATE](a)

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident residing on the same locked unit for 2 of 3 residents reviewed for abuse (Residents B and C) resulting in an Immediate Jeopardy when the facility failed to keep the residents separated and prevent further abuse. The immediate jeopardy began on 9/22/24 when a cognitive impaired resident (Resident B) was observed by staff touching another cognitively impaired resident (Resident C) in the genital region in the common area after breakfast. Later that same day, Residents B and C were found together in bed with Resident B's hand was on Resident C's bare stomach and legs intertwined. In the afternoon, Residents B and C were observed in another resident's room with Resident B's pants down without a brief and his back turned towards the door and his hands on Resident C's shoulders. The Administrator (ADM) was notified of the immediate jeopardy at 4:45 p.m. on 9/25/24. The immediate jeopardy was removed on 9/27/24 at 4:37 p.m., 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: During an interview, on 9/24/24 at 10:29 a.m., the Director of Nursing (DON) indicated she had an incident that she was trying to input into the Indiana Department of Health (IDOH) facility reported incident record (FRI) system about Resident B and Resident C. Resident B was going around and leading Resident C by the hand. Resident C had on a gold belt buckle that Resident B kept trying to touch the buckle. Certified Nursing Aide (CNA) 5 and CNA 6, thought Resident B was being inappropriate with Resident C and Resident B was touching Resident C's private area. DON contacted the Administrator (ADM), Social Services (SS), and the behavioral health services. The behavioral health services staff called back and changed Resident B's medication order for Xanax (medication used to treat anxiety and panic disorders) and increased the medication from 0.25 milligram (mg) twice daily (BID) to 0.5 mg BID. The DON indicated, she had requested the CNAs to write statements and neither CNA wrote a statement. On 9/22/24, a Qualified Medication Aide (QMA) and two CNAs worked on the 500 locked unit. The QMA had told the DON that she did not see anything. CNA 5 told the DON Resident B kept touching Resident C at the belt buckle and taking Resident C's hand and walking around the unit. The DON told CNA 5 to separate Resident B and Resident C, and she went back to the 500 locked unit and watched the residents for about 15 minutes. She had asked the three staff members on the locked unit to write statements about the incident. The DON indicated Resident B kept leading Resident C around the unit hand in hand. CNA 6 kept telling CNA 5 that Resident B kept touching Resident C's private area. The DON indicated she had requested CNA 5 to stay with Resident B. There were other residents and residents' family members on the 500 locked unit, but no one had said anything to the DON about Resident B or Resident C. On 9/24/24 at 11:44 a.m., CNA 9, observed working on the 500 hall locked unit, indicated the night shift staff had reported to the day shift staff to keep Resident B and Resident C separated, because there was sexual tension, like Resident B rubbing on Resident C. Resident B was on 15-minutes checks and staff were to keep them separated, because Resident B was rubbing all over Resident C. Resident B nor Resident C had any care plan interventions besides keeping them separated. Resident B had the 15-minute checks, but no other interventions other than to keep the residents separated. On 9/24/24 at 12:47 p.m., Resident C was observed being fed lunch by CNA 9. Resident C was wearing clothes and nonskid socks. After Resident C was finished eating his lunch, he stood up out of the wheelchair, unassisted, and walked around the dining room area. CNA 9 directed Resident C to sit back down in his wheelchair. Resident C sat down in a regular chair at the dining room table by himself. On 9/24/24 at 12:52 p.m. Resident B was observed to eat his lunch at a dining table, unassisted by staff. Then Resident B stood up from the dining room chair and went over and sat in a recliner in the television area by himself. The DON, on 9/24/24 at 12:59 p.m., indicated Resident B was touching people and was put on 15-minute checks, on 9/22/24, and staff would continue the 15-minute checks to ensure Resident B's medication adjustment was working and until psychiatric services came, on 9/26/24, to assess Resident B. During an anonymous interview during the survey, Anonymous 1 indicated Resident B kept trying to get close to Resident C. In the morning after breakfast on 9/22/24, Anonymous 1 observed Resident B and Resident C sitting in recliners next to each other in the television area. Resident B put his hand inside Resident C's pants under his brief and rubbed Resident C's genitals. Anonymous 1 asked Resident B to remove his hand from Resident C's pants. Resident C was assisted to his room, by another staff member to get dressed. In the afternoon, Resident C was observed lying flat on his roommate's bed with Resident B lying on his side, next to Resident C with Resident B's hand on Resident C's bare stomach with the residents' legs intertwined. Anonymous 1 asked Resident B to remove his hand from Resident C's stomach and Resident B was escorted out of Resident C's room. About 5:50 to 6:00 p.m. on 9/22/24, Anonymous 1 assisted Resident C to the bathroom and the DON came into the bathroom and assessed Resident C's bottom. No one asked Anonymous 1 to write a statement about the incident and Anonymous 1 was told by another staff member on the 500 locked unit that the DON had told them not to document about the incident in the residents' medical records. During an anonymous interview during the survey, Anonymous 2 indicated, after breakfast on the morning of 9/22/24, Resident B and Resident C were sitting next to each other in recliners in the television area. Resident B had his hand in the slit of Resident C's boxer pants and was rubbing Resident C's thigh. Another staff member asked Resident B to stop touching Resident C. Resident C was moved from the recliner in the television room, because he was easier to remove from the situation. Resident C was assisted by Anonymous 2 to his room to get dressed. Anonymous 2 then went and told the DON about the incident with Resident B and Resident C. Resident B was put on 15-minute checks by the DON. The DON instructed staff to keep the two residents separated. There was no additional staff called to watch Resident B, so staff tried to keep Resident B within their sight, while providing care to the other residents. But Resident B kept going back to Resident C, touching him and grabbing Resident C's hand to walk with him. Anonymous 2 indicated Anonymous 2 had found the two residents laying in Resident C's roommate's bed with Resident C laying on his back and Resident B laying on his side next to Resident C with Resident B's hand on Resident C's bare stomach. At about 2:00 p.m., Anonymous 2 indicated, they observed the two residents in another resident's room with Resident B standing in the room with his back to the door, without a brief and his pants were down to his ankles and his hands were on Resident C's shoulders. Resident C was taken out of the room by another staff member and Resident B was taken by Anonymous 2 to his room to put on a brief. At about 4:00 p.m., Resident B had his hand down Resident C's pants, while the residents were sitting in recliners in the television area. Staff tried to keep Resident C by the nurses' desk. Anonymous 2 indicated they saw the two residents in another resident's room, laying on the bed together with Resident B's arm around Resident C, but no hands were observed on any genitals. Later in the afternoon on 9/22/24, Resident C was observed having a hard time sitting down. Anonymous 2 informed the DON that it was painful for Resident C to sit down. The DON and another staff member assessed Resident C. Resident C had no problem earlier in the day sitting down but had a problem sitting down toward the end of the shift, 6:00 a.m. to 6:00 p.m. Anonymous 2 indicated they were not asked to write a statement about the incidents, and the DON had told them not to chart the incident in the residents' medical records. During an anonymous interview during the survey, Anonymous 3 indicated, on 9/22/24, in the morning after breakfast, Resident B and Resident C were observed seated next to each other in recliners and Resident B had his hand down Resident C's pants. Anonymous 3 went over and told Resident B that he could not have his hand down Resident C's pants. Resident B's hand was assisted out of Resident C's pants by staff. Resident B said, okay. Both residents got up from the recliners and Resident B held Resident C's hand and they walked around the unit, hand in hand. Resident C followed along with Resident B, hand in hand or they walked beside each other. At about 9:00 a.m. on 9/22/24, Anonymous 3 went to the DON and told the DON they had found Resident B had his hand down Resident C's pants. DON told Anonymous 3 to put Resident B on 15 minutes checks. The DON came back to the unit later and observed Resident B and Resident C hand in hand and the DON told Resident B that he could not be holding Resident C's hand. Resident B let go of Resident C's hand. The two residents walked around the unit together, but not holding hands any longer. Resident B did not normally hold hands with any of the residents and was quiet, not causing any problems on the unit. Resident C went along with Resident B and did not normally get up and down as much until Resident B guided Resident C to walk together. Resident C liked to sit in a recliner in the television room area throughout the day. Resident B would not leave Resident C alone and kept coaxing Resident C to go walk around the unit. When it was time to eat lunch, the residents were seated at different tables. After lunch, Resident B slept most of the afternoon on the couch in the television room area and Resident C was up and down and wandering around the unit. After lunch, Resident C had a difficult time of sitting down, almost like he was scared or fearful to sit down. Resident C had peripheral vision problems and was always super careful when sitting down. Resident C, by the afternoon, was very tired from all the walking and roaming around the unit. The DON did a skin assessment on Resident C in the bathroom and did not find any skin issues. The DON had asked the staff to not document on the incident in the Residents' medical records and to keep it quiet. During an anonymous interview during the survey, Anonymous 4 indicated, on 9/22/24, there was a situation where Resident B sexually abused Resident C. The staff reported it to the nurse who reported it to the DON who came in on her day off and did a rectal exam on Resident C. Since the DON did not see any skin impairment on Resident C, the DON told the staff not to document the abuse. On 9/25/24 12:06 p.m., Social Services Assistant (SSA) indicated she did not personally know Resident B nor Resident C. She was home on Sunday, when she got a call from the DON. The DON requested SSA call psychiatric services for a medication review for Resident B. The psychiatric services on-call physician increased Resident B's Xanax medication to 0.5 mg twice daily (BID). Resident B did not have any behavior monitoring but had the behaviors of exit seeking and bowel movements and urinating in the hallways. She did not understand what happened on 9/22/24, the DON was trying to tell the SSA about Resident C's pants and a shiny belt buckle. SSA indicated she was at home and was confused about the situation. Resident B was wanting to touch shiny things such as a shiny belt buckle and shiny name tags. SSA indicated she was doing psychosocial follow ups for Resident B and Resident C and was documenting the follow ups in the residents' electronic medical records in the progress notes. SSA indicated she was following up for the behavior of a shiny buckle. SSA also was following up on Resident C, since he was the resident being touched. This morning, on 9/25/24, she had visited with Resident C's wife when she came to the facility. Resident C's wife indicated Resident C was tearful until his wife gave him a stuffed animal that seemed to cheer him up. SSA indicated, she needed to add a care plan intervention for Resident B about inappropriately touching other residents and add a care plan intervention for Resident C's tearfulness. Staff were making sure Resident B and Resident C were staying separated. The Corporate Social Services Director (SSD) indicated Resident B should have a care plan with interventions for touching others inappropriately with an intervention to separate the residents immediately, change rooms, and 15-minute checks for Resident B and psychosocial follow ups for Resident C. The SSD indicated the Interdisciplinary (IDT) team should have met Monday morning, 9/23/24, to discuss the incident and put care plan interventions to keep Resident B from touching other residents and an intervention to keep Resident C safe. SSA indicated, she had just now, on Resident B's electronic medical record, put in a new care plan intervention for Resident B to separate residents immediately for the care plan of resident makes sexually inappropriate advances towards female staff and other residents. On 9/25/24 at 1:25 p.m., DON provided a copy of the Indiana Department of Health (IDOH) facility reported incident record (FRI) about Resident B and Resident C and indicated she had spoken to the IDT on Monday, 9/23/24, about the incident but did not document the IDT meeting. She had 15-minute checks continue for Resident B. The DON, on 9/25/24 at 2:50 p.m., indicated she had contacted the three staff working on 9/22/24 from 6:00 a.m. to 6:00 p.m. shift on the 500-hall locked unit to get witness statements, but she had not gotten any responses. QMA 7 never came to the DON and told her there was any inappropriate touching between the Resident B and Resident C. CNA 5 came to her, on 9/22/24, and told her Resident B was touching inappropriately Resident C and that was the only staff member who had spoken to her about the inappropriate touching. CNA 5 had come to her about Resident B's inappropriate touching at least three times from 10 a.m. to 2 p.m. The DON had gone back to the 500-hall locked unit at least 3 times, on 9/22/24, and she had not seen any inappropriate touching. During an interview, on 9/26/24 at 8:05 a.m., CNA 6 indicated, on 9/25/24 at 9:30 p.m., the Administrator in Training (AIT) texted and asked if CNA 6 was able to send the statement over to the facility. The AIT indicated, We can transcribe a verbal statement of the incident over the phone. CNA 6 could call the AIT or the DON, and they would create the statement and CNA 6 texted, she would feel much more comfortable, providing a handwritten statement, written and signed by herself. She was willing to come in earlier and provide a written statement. CNA 6 indicated, they had handwritten the incident statement of three pages, written on lined paper, that they were providing to the facility, dated 9/25/24, which indicated, on the day of 9/22/24, they had worked on the 500 men's unit from 6 a.m. to 6 p.m. After breakfast at approximately between the times of 8 a.m. and 9 a.m., CNA 6 was sitting at the nurses' station charting. CNA 5 was also sitting at the nurses' station charting, when QMA 7 came to the nurses' station and indicated, come look at Resident B and Resident C. Resident B and Resident C were sitting in recliners next to each other facing the wall/television and Resident B's hand in and down Resident C's pants and brief, rubbing Resident C's genitals. At that time, CNA 6 assisted Resident C from the recliner and relocated him to another recliner. At the same time, CNA 5 redirected Resident B. QMA 7, CNA 5, and CNA 6, discussed what the best plan of action was moving forward. They all agreed/decided, to notify the DON and let her make the decision. CNA 5 offered to go find the DON and inform her of the situation/incident. CNA 5 then left the locked 500 unit and came back to the unit approximately 10 to 15 minutes later, and said, The DON said to not document the incident because it was a State offense, but to keep a close eye on Resident C. Throughout the shift, staff kept a close eye on Resident C. During our rounds and answering call lights, we lost track of both Resident B and Resident C. When we found both gentlemen, which was after lunch time, between 4:00 p.m. and 5:00 p.m., we found Resident B and Resident C laying perpendicularly in Resident C's roommate's bed. Resident B had his legs intertwined with Resident C's legs. Resident B's head was nuzzled into Resident C's neck region. Resident B also had his left hand was resting on Resident C's bare belly button region with Resident C's shirt slightly raised, but his brief/pants were not disturbed. Concerning the second incident, QMA 7, offered and spoke with the DON. CNA 6 was not informed of any further instructions pertaining to this incident. At approximately between 5:00 p.m. to 6:00 p.m. on 9/22/24, the DON came to the locked unit and had noticed how slowly Resident C was at sitting down in a chair. DON requested Resident C be taken to his private bathroom. CNA 6 indicated to the DON that Resident C had sat down like that since the first day he was admitted to the facility. The DON made the remark that they needed to make sure we do not actually have a reportable. Resident C was assisted from the chair and into his private restroom. Resident C's brief was removed, and his pants were pulled down. The DON walked into the bathroom and assessed Resident C's buttocks and genital region. The DON cleaned Resident C, then removed her gloves and exited the bathroom. Resident C was assisted on putting on a new brief and pulling up his pants. CNA 6 indicated, CNA 5 found Resident B and Resident C in another resident's room. CNA 5 called for CNA 6 to assist Resident C out of the room with CNA 5 telling CNA 6 that Resident B's pants had been pulled down and his brief was off. CNA 5 had taken Resident B to his room to get a new brief put on him. CNA 6 observed Resident C standing by the television in another resident's room and Resident C was escorted back to the dining room area and CNA 6 had tried to get Resident C to sit down, but Resident C was reluctant to sit down and walked around the dining room area. CNA 6 gathered their belongings and clocked out at 6:09 p.m. on 9/22/24 and was never asked to provide a written statement to the facility. The first time CNA 6 was asked to provide a statement to the facility about the incident between Resident B and Resident C was on 9/25/24. On 9/26/24 at 12:40 p.m. the Administrator provided a typed statement from QMA 7, dated 9/26/24, indicated QMA 7 observed Residents B and C walking down the hall and noticed Resident B had his hands down Resident's C pants. QMA 7 assisted Resident B with getting his hand out of Resident C's pants and was redirected and separated. The DON was notified, and fifteen-minute checks were implemented. Residents were not observed in bed together. QMA 7 indicated that nothing more was reported to her the rest of the day. QMA 7 indicated she did not believe that Resident B and C were able to get into a bed by themselves without help. On 9/26/24 at 6:24 p.m. the Administrator provided a copy of a handwritten statement from QMA 7 dated 9/25/24. QMA 7 indicated Residents B and C were never alone in a room by themselves at all. On 9/26/24 at 6:24 p.m. the Administrator provided a handwritten statement from CNA 5, dated 9/25/24. The statement indicated it was written by the DON and was a telephone statement from CNA 5. CNA 5 indicated he was told by CNA 6 around breakfast of that Resident B's hands were in Resident C's pants. Both CNAs went and separated the residents. After breakfast Resident B had his hand in Resident C's pants while sitting in the recliners by the television. CNA 5 reported to QMA 7 and the DON. The statement indicated that the DON had Resident B stay with CNA 5 and place the resident on fifteen- minute checks. After lunch Resident B went in a room and CNA 5 saw Resident B's pants and brief down with Resident C in the same room dressed. On 9/24/24 at 1:05 p.m., the DON provided copies of the fifteen-minute monitoring for Resident B dated 9/22/24. The document was blank from 12:00 a.m. until 10:00 a.m. Starting at 10:00 a.m. until 6:00 p.m., in every fifteen-minute slot were initials for the location the resident was found and initials for the staff member recording the fifteen-minute check. The document lacked documentation of what Resident B was doing or if Resident B was with another resident. On 9/26/24 at 12:40 p.m., the Administrator provided copies of the fifteen-minute monitoring for Resident B dated 9/22/24. This document differed from the document with the same date provided on 9/24/24. The document was blank from 12:00 a.m. until 10:30 a.m. Starting at 10:30 a.m. until 6:00 p.m. in every fifteen-minute slot were initials for the location the resident was found and the initials for the staff member recording the fifteen-minute check. The recorded initials for the locations and staff member were different than the record provided on 9/24/24. The document lacked documentation of what Resident B was doing or if Resident B was with another resident. Starting at 6:15 p.m. until 11:00 p.m. the fifteen-minute slots indicated what the resident was doing but lacked staff initials and if Resident B was with another resident. The monitoring tool was blank from 11:00 p.m. on 9/22/24 until 6:00 a.m. on 9/23/24. a. Resident B's record was reviewed, on 9/24/24 at 10:01 a.m. Diagnoses included, but not limited to, unspecified dementia, unspecified severity without behavioral disturbance (chronic condition that causes a gradual decline in cognitive abilities, such as thinking, reasoning, and remembering, that interferes with daily life) and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 7/24/24, indicated Resident B had a severe cognitive impairment, no impairments in upper extremity nor lower extremities, without mobility devices usage, supervision or touching assistance for eating, partial to moderate assistance for oral hygiene, substantial to maximal assistance for toileting hygiene and bathing, with partial to moderate assistance for upper and lower dressing and personal hygiene, and supervision or touching assistance with helper provided verbal cues or touching/steadying as resident completed activity of sit to stand, chair/bed-to-chair transfers, and toilet transfers. A care plan, started on 11/8/23, indicated Resident B had behavioral care plan for refusing care, such as showers and personal hygiene. Resident makes sexually inappropriate advances towards female staff and other residents with interventions included, but were not limited to, approach resident in a calm and unhurried manner to deliver provide services; explain care process prior to delivery of care as needed; offer choices in hands-on care and contact; resident chooses to sleep on couch and chooses to stay up late; and resident exercises right to decline treatment and services. A nursing progress note written by the DON, dated 9/22/24 at 10:30 a.m., indicated Resident B was wandering in the unit, following residents and reaching out to staff and residents for shiny items such as name badges and belt buckles. When the DON spoke to the resident about keeping his hands to himself, Resident B was naming all kinds of body parts to the DON. The DON had the unit staff keep redirecting and had a staff CNA stay with resident to redirect. A nursing progress note written by the DON, dated 9/22/24 at 10:57 a.m., indicated staff noted to the DON that Resident B was following another resident and holding his hand and leading resident to different areas on the unit. Staff continued to redirect and separate the residents. Resident B was put on 15-minute checks to redirect from other residents and to engage in other activities. Resident B was toileted and redirected to the bathroom with assistance of staff. The resident was redirected from urinating in the unit hallway corner. On 9/26/24 at 12:40 p.m., the Administrator provided Resident B's Point of Care History for September 2024. The Point of Care History indicated on 9/21/24 Resident B needed limited assistance getting dressed and on 9/22/24 Resident B only needed supervision to get dressed. The Point of Care History indicated on 9/21/24 Resident B was independent with movement in bed in the morning and limited assistance at night. On 9/22/24, Resident B was independent with movement in bed in the morning and needed supervision at night. A Social Services progress note, written by the SSA, dated 9/23/24 at 2:08 p.m., indicated Social Services follow up. Resident had been asleep on the couch in the residents' common area intermittently though out the day so far. Staff reported resident had been pleasant and had healthy appetite, with no signs or symptoms of psychosocial distress at this time. A Social Services progress note, written by the SSA, dated 9/24/24 at 1:56 p.m., indicated Social Services follow up. Resident has been sitting in a chair intermittently though out the shift. Staff reported resident has had pleasant mood with no signs or symptoms of psychosocial distress at this time. A nursing progress note, dated 9/24/24 at 7:47 p.m., indicated Resident B was observed standing in other resident's room while they were resting. Resident B was redirected to the day room, took all medications, and continued 15-minute checks. A Social Services progress note, written by the SSA, dated 9/25/24 at 10:36 a.m., indicated Social Services follow up. Resident was currently sitting in the residents' common area. SSA sat with resident a while. Resident B declined to speak the SSA. The resident preferred to sit and observe. No signs or symptoms of psychosocial distress at this time. Resident B's care plans and medical record lacked documentation of interventions for when Resident B made sexually inappropriate advances towards female staff and other residents and lacked documentation Resident B's family was notified of the incident on 9/22/24. No written statements were provided from Occupational Therapy or Physical Therapy for Resident B. b. Resident C's record was reviewed on 9/24/24 at 11:12 a.m. The resident was admitted to the facility, on 9/6/24, with diagnoses included, but not limited to, vascular dementia (brain condition that affects thinking, memory, and behavior, and is caused by damaged blood vessels in the brain) and anxiety. A care plan, dated 9/6/24, indicated the resident had a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of activities of daily living (ADL) cares with interventions included, but not limited to, be alert for changes or declines in ability to participate in ADL cares. Notify Nurse if noting any changes in abilities, encourage resident to participate if they are able, and provide frequent encouragement, along with prompting and assistance. A Brief Interview for Mental Status assessment, dated 9/9/24, indicated the resident had a severe cognitive impairment. On 9/26/24 at 12:40 p.m., the Administrator provided Resident B's Point of Care History for September 2024. The Point of Care History indicated on 9/21/24 Resident C needed limited assistance with dressing. On 9/22/24 Resident C needed supervision one time and was totally dependent the second time with dressing. The Point of Care History indicated on 9/21/24 Resident C needed limited assistance one time and extensive assistance the second time with bed mobility. On 9/22/24 Resident C needed supervision one time and extensive assistance the second time with bed mobility. A Social Services progress note, written by the SSA, on 9/24/24 at 2:01 p.m., indicated SSA follow up. Resident C had visit with his wife today. Wife reported the resident was tearful briefly during the visit but cheered up when the wife brought out a stuffed [NAME] toy. Staff reported resident has had a pleasant mood with no signs or symptoms of psychosocial distress at this time. A written statement by the Registered Occupational Therapist (OTR), dated 9/26/24 and provided by the Administrator on 9/26/24 at 12:40 p.m., indicated Resident C needed partial or moderate assistance with verbal and/or tactile cueing for all activities of daily living. A written statement by the Physical Therapist (PT), dated 9/26/24 and provided by the Administrator on 9/26/24 at 12:40 p.m., indicated Resident C had been able to walk with PT on 9/25/24. Resident C needed verbal or visual cueing to start but was able to do task after cueing. The statement indicated that Resident C .was at a good level of following verbal cues yesterday as compared to the previous therapy sessions A written statement dated 9/27/24 and signed by the ADM was provided by the ADM on 9/27/24 at 4:25 p.m. The statement indicated the DON notified the ADM by phone on 9/22/24 at 11:08 a.m. that two CNAs reported potential resident to resident interactions on the 500 hall between two cognitively impaired residents. The DON asked the staff to do 15-minute checks and would assess the residents. The DON was working as the nurse that day and would enter the incident into the Indiana Department of Health report system. Cross reference F609 and F610. On 9/24/24 at 9:35 a.m., the ADM provided and identified a document as a current facility policy, titled Abuse, Neglect and Misappropriation of Property, dated 9/15/23. The policy indicated, .Policy Statement .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse .Sexual abuse is defined as non-consensual sexual contact of any type with a resident The immediate jeopardy that began on 9/22/24 was removed on 9/27/24 at 4:37 p.m., when the facility ensured a systemic plan to include education, assessment, and monitoring for all cognitively impaired residents to prevent resident to resident abuse. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Complaint IN00443846. 3.1-27(a)(1)

Based on record review and interview, the facility failed to provide personalized care and interventions for a resident (Resident F) with the diagnoses of schizophrenia (serious mental health condition that affects how people think, feel and behave) and behaviors for 1 of 5 residents reviewed for behavior management which resulted in Resident F having resident to resident altercations with 4 cognitively impaired residents residing on the same locked unit (Residents B, G, H, and J). Findings include: During the survey a document titled, All About Me, undated, was observed in Resident F's room. The document described the resident's likes and dislikes, such as her favorite hobbies, food, movies, snacks, etc. Her dislikes included when people touched her without letting her know and when people tried to make her eat when she didn't want to eat. The clinical record for Resident F was reviewed on 7/30/24 at 1:43 p.m. Resident F was [AGE] years old and resided in the facility's secured behavioral unit. Diagnoses included, but were not limited to, schizophrenia, behaviors, cerebral palsy, mild cognitive impairment, developmental disorder of speech and language, blindness in the left eye, and normal vision in the right eye. A quarterly Minimum Data Set (MDS) assessment, dated 7/6/24, indicated the resident had a moderate cognitive impairment with no behaviors noted during the 7-day look back assessment period. An Indiana Department of Health (IDOH) facility reported incident record (FRI), dated 6/17/24 at 9:01 p.m., submitted by the facility indicated Resident F made physical contact with Resident B. Both residents resided on a secure unit. Resident B had diagnoses, including but not limited to, severe dementia, frontotemporal neurocognitive disorder, and Alzheimer's disease. Both residents were assessed and there were no injuries. Resident F's electronic record lacked additional documentation of interventions implemented to prevent further events after the incident reported 6/17/24. The facility's investigation of the event lacked documentation of interventions implemented to prevent further events. An IDOH FRI report, dated 6/29/24 at 6:10 p.m., submitted by the facility indicated Resident F tossed a two handled cup into the air. The cup landed on Resident G's left shoulder. Resident G tossed the cup back to Resident F and the cup struck Resident F above the eyebrow causing a laceration on Resident F's left temple. Resident G had diagnoses, including but not limited to, vascular dementia, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left dominant side, and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Resident F's electronic record lacked additional documentation of interventions implemented to prevent further events after the incident reported on 6/29/24. The facility's investigation of the event lacked documentation of interventions implemented to prevent further events. An IDOH FRI report, dated 7/6/24 at 6:50 p.m., submitted by the facility indicated Resident B was walking into the dining room and Resident F reached out and touched Resident B's legs. Staff tried to intervene and redirect residents from touching each other. Resident B fell to the ground. The residents were immediately separated and redirected by staff. Resident B had diagnoses, including but not limited to, severe dementia, frontotemporal neurocognitive disorder, and Alzheimer's disease. Both residents were assessed and there were no injuries. Resident F's electronic record lacked additional documentation of interventions implemented to prevent further events after the incident reported on 7/6/24. The facility's investigation of the event lacked documentation of interventions implemented to prevent further events. An IDOH FRI report, dated 7/8/24 at 4:30 p.m., submitted by the facility indicated Resident G was sitting in a chair in the day room. Resident F came over to Resident G and began raising fists up and down hitting Resident G's chair and arms. Resident G had diagnoses, including but not limited to, vascular dementia, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left dominant side, and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A behavioral care plan, dated 7/9/24, indicated Resident F was involved in a resident-to-resident altercation with the interventions of head-to-toe assessment, report to regulatory entities, and separate residents immediately with the target goal, dated 8/2/24, of the resident would not have any adverse effects from the incident. The plan lacked documentation of interventions to prevent further events. Resident F's electronic record lacked additional documentation of interventions implemented to prevent further events after the incident reported on 7/9/24. The facility's investigation of the event lacked documentation of interventions implemented to prevent further events. A behavioral care plan, dated 7/11/23 and revised on 7/17/24, indicated the resident was at risk and active behavior problems, such as: smacking self, accusatory actions, attention seeking, physical aggression such as biting/grabbing at others, disrobing in public spaces, urinating on the floor, sitting/lying on the floor, refusal of care, such as medications, showers and meals, and yelling out. Interventions on the care plan, included but were not limited to, assist resident away from other residents, observe for triggers of inappropriate behaviors and alter environment as needed, and observe for unmet needs such as toileting, rest, food, fluids, companionship, etc. The long-term care plan goal, target dated 8/7/24, indicated the resident's behaviors will not result in disruption of others environment. An IDOH FRI report, dated 7/18/24 at 3:15 p.m., submitted by the facility indicated Resident F pushed her hand against Resident J's shoulder causing Resident J to fall to the floor on her left side. Resident J's diagnoses, included but were not limited to, dementia, cognitive communication deficit, hearing loss, and seizures. Both residents were assessed and had no injury. Resident F's electronic record lacked additional documentation of interventions implemented to prevent further events after the incident reported on 7/18/29/24. The facility's investigation of the event lacked documentation of interventions implemented to prevent further events. An IDOH FRI report, dated 7/20/24 at 7:23 p.m., submitted by the facility indicated Resident F tossed a dinner tray at Resident G. Resident G was assessed with a 1.5 centimeter (cm) by 1.5 cm pink area above the right eyebrow. Resident G had diagnoses, including but not limited to, vascular dementia, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left dominant side, and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A behavioral care plan, dated 7/20/24, indicated Resident F was involved in a resident-to-resident altercation with the interventions of notify family, notify physician, and separate residents immediately with the target goal, dated 8/2/24, of the resident would not have any adverse effects from the incident. The care plan lacked documentation of interventions implemented to prevent further events after the incident reported on 7/20/24. Resident F's electronic record lacked additional documentation of interventions implemented to prevent further events after the incident reported on 7/20/24. The facility's investigation of the event lacked documentation of interventions implemented to prevent further events. An IDOH FRI report, dated 7/26/24 at 11:57 p.m., submitted by the facility indicated Resident F went to Resident H's room, as Resident H was asleep in bed. Resident F began to hit Resident H with an open hand waking Resident H. Staff removed Resident F from Resident H's room and another staff stayed in the room with Resident H. Resident H had diagnoses, including but not limited to, vascular dementia, Parkinson's disease, cognitive communication deficit, and depression. Both residents were assessed and had no injuries. Resident F's electronic record lacked additional documentation of interventions implemented to prevent further events after the incident reported on 7/26/24. The facility's investigation of the event lacked documentation of interventions implemented to prevent further events. Resident F's electronic medical record lacked documentation to implement person-centered, individualized care to prevent Resident F from physically making contact with or throwing items at other residents. On 7/29/24 at 11:18 a.m., Qualified Medication Aide (QMA) indicated staff tried to redirect Resident F if she went into another resident's room or got too close to another resident. On 7/30/24 at 8:57 a.m., the Director of Nursing (DON) indicated Resident F had multiple behaviors and the staff's immediate intervention for Resident F was to get the residents separated, check them out from head to toe, and notify the physician, Administrator (ADM), and family of the incident. They tell the family there was an altercation with another resident and the facility was investigating. Resident F was [AGE] years old and was inappropriate for the facility. She was diagnosed with dementia (a group of thinking and social symptoms that interfered with daily functioning), but the DON did not believe Resident F had dementia, but the resident did have an intellectual cognitive disability deficit. Staff tried to keep her away from the other residents with diversional activities, but she was harming the older female residents on the unit. On 7/31/24 at 9:34 a.m., ADM provided documentation of Resident F's 30-day Notice of Transfer or Discharge, dated 7/30/24, and indicated she had mailed the 30-day Notice of Transfer or Discharge to the resident's mother. The notice indicated the reason for the transfer or discharge was due to the safety of the individuals in the facility were endangered. The ADM indicated she and the Social Services Director (SSD) had a care plan meeting with Resident F's mother a couple of weeks ago and told her that Resident F was not appropriate for the facility, due to her interactions with the other residents and she was younger and stronger than the other residents. The ADM, on 7/26/24 at 10:45 a.m., provided and identified a document as a current facility policy titled, Abuse, Neglect, and Misappropriation of Property, dated 5/27/16 and revised on 9/15/23. The policy indicated, .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The organization will include screening, training, prevention, identification, investigation, protection, and reporting to provide protection for the health, welfare, and rights of each resident in the facility This citation relates to Complaint IN00438294. 3.1-43(a)(1)

A. Based on observation, interview, and record review, the facility failed to prevent pressure ulcers for 1 of 6 residents reviewed for pressure ulcers resulting in immediate jeopardy when the resident developed a stage 3 pressure ulcer to the sacrum, a deep tissue injury to the left lateral ankle, and an unstageable to the right thigh (Resident 135). B. Based on observation, interview, and record review, the facility failed to appropriately treat pressure ulcers as ordered for 1 of 6 residents reviewed for pressure ulcers resulting in immediate jeopardy when the stage 3 sacral pressure ulcer worsened to a stage 4, the deep tissue injury to a left lateral ankle worsened to a stage 4, and the unstageable to the right anterior thigh worsened to a stage 3 (Resident 135). C. Based on record review and interview, the facility failed to ensure skin assessments were completed as ordered for a resident with a stage 3 pressure ulcer for 1 of 6 residents reviewed for skin assessments (Resident 21). The immediate jeopardy began on 8/11/23 when Resident 135 developed a stage 3 pressure ulcer to the sacrum. Interventions to prevent pressure ulcers and interventions to assist healing of the pressure ulcer were not initiated until September. Additional wounds to the resident's left lateral ankle and right anterior thigh developed in November. Interventions ordered to prevent pressure and promote healing were not observed during the survey. Treatment and dressing changes of all wounds were observed to not match the physician orders and the physician orders did not match the wound doctor's treatment plan. The wounds were observed to have a strong odor and after the observation the resident was started on antibiotics for a wound infection. The Executive Director (ED), the Director of Nursing, the [NAME] President of Operations, and the Corporate Clinical Support were notified of the immediate jeopardy at 4:18 p.m. on 12/15/23. The immediate jeopardy was removed on 12/16/23, 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: A. On 12/11/23 at 12:30 p.m., Resident 135 was observed awake lying on her back in bed with the head of bed slightly elevated. The resident's left leg was severely contracted (shortening of muscles, tendons, and/or tissues causing deformity) with loss of range of motion greater than two thirds range and zero degree of extension at a 90-degree angle over the top of the right upper thigh. The resident's left leg was observed to lay against her right thigh. Off-loading pressure devices were not on her feet at the time of the observation. Resident 135 indicated she allowed the staff to turn and reposition her. On 12/15/23 at 8:45 a.m., the resident was lying in bed on her back with a thin pillow between the contracted left leg and lower right leg. Offloading anti pressure foam boots were on the chair next to her bed. The left foot was laying on the mattress, the left ankle was on top of the pillow. On 12/18/23 at 9:42 a.m., resident was observed laying on her back in the bed. The contracted left leg was laying on top of the right upper thigh. There was no pillow between the leg to prevent skin to skin contact. An off-loading boot was partially on the left foot and no off-loading boot was on the right foot. On 12/14/23 at 2:30 p.m., medical record review. Diagnoses included but are not limited to pressure ulcer of sacral region (a shield-shaped bony structure that is located at the base of the spine and that is connected to the pelvis), Chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems), degenerative disease of nervous system, dysphagia (difficulty swallowing), unspecified protein-calorie malnutrition (condition that happens when your diet does not contain the right amount of nutrients), type 2 diabetes mellitus, and diabetic neuropathy (a type of nerve damage that can occur if you have diabetes). An admission Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident admitted to the facility with intact skin and no pressure wounds during the assessment period were identified and she was at risk for skin breakdown. The brief interview for mental status (BIMS) indicated a score of 13 and resident was cognitively intact and able to make own decisions. 1. A physician order, dated 7/18/23, indicated to apply adhesive foam dressing to coccyx scar for protection and change dressing 3 times a week on Monday, Wednesday, and Friday. Physician orders, dated 8/11/2023, indicated daily and as needed (PRN) to cleanse coccyx with normal saline (NS), pat dry, apply a thin layer of Medi Honey (honey) gel 80 % topically, and cover with sacral foam border daily. On 8/21/23 the wound care notes indicated the resident had a sacral pressure ulcer stage 3 (full thickness tissue loss) which measured 2 cm (centimeters) by (x) 2.5 cm by (x) 0.1 cm. Wound care notes from Wound Care Physician, on 8/21/23, indicated the following recommendations for Resident 135. Off-Load wound, limit sitting to 30 minutes, utilize a low air loss mattress. On 8/28/23 the Wound Care Physician ordered a low air loss mattress, to off load pressure points, and limit sitting to 30 minutes. The medical record lacked documentation of the order until a physician order was entered on 9/6/23. The order indicated resident may use low loss air mattress to aid with wound healing to wound on coccyx with setting per resident weight. A care plan, dated 9/25/2023, for Skin Integrity indicated Resident 135 had the potential for alterations in skin integrity. Interventions included but were not limited to administer treatment as ordered, encourage resident to consume at least 75% of meals and snacks, observe skin during routine caregiving for acute changes, utilize a pressure reducing mattress, provide pressure redistribution products for the bed and chair, and use a draw sheet for turning and repositioning me to decrease the probability of getting shear or friction injuries. The facility failed to create a care plan when the wound to coccyx was identified on 8/21/23. An initial care plan indicating the resident was at risk was created on 9/25/23. On 12/11/23 a care plan was created for a stage 3 pressure ulcer to the coccyx. On 12/11/23 the sacral wound, stage 3, measured, 5.5 cm x 4 cm x 0.3 cm with muscle and bone exposed. During a phone interview on 12/15/23 at 12:21 p.m., the Wound Care Physician, the physician overseeing the wound care of the resident, indicated the sacral wound was a stage 4 (full thickness tissue loss with bone and/or muscle visible). She reviewed the wound on Monday and indicated 30% of muscle and bone in the wound bed but had not updated it in her notes. She had not been consulted regarding a diagnosis of unavoidable wounds and she did not write unavoidable on her wound orders. She acknowledged the resident was a challenge to maintain offloading and prevention of wounds. 2. A care plan, dated 11/2/23 and edited on 12/11/23, indicated Resident 135 had a stage 4 (full thickness tissue loss with bone, muscle, and/or tendon visible) pressure ulcer to left lateral ankle. As of 11/6/23, interventions included: administer analgesics per physician order, assess and record the condition of the skin surrounding the pressure ulcer, observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever), and perform a weekly skin assessment, measurement, and observation of the pressure ulcer. A care plan, dated 11/2/23, indicated Resident 135 had an unstageable (slough/eschar) pressure ulcer to the left lateral ankle. As of 11/06/2023, interventions included: assess and record the condition of the skin surrounding the pressure ulcer, observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever), use a pressure reducing cushion to chair and pressure reducing mattress, perform treatment per physician order, notify physician if treatment was not effective, and conduct weekly skin assessment, measurement, and observation of the pressure ulcer. On 11/6/23 the medical record indicated the resident had an unstageable pressure wound on the left lateral ankle which measured 3 cm x 3 cm. A care plan, dated 11/2/23 and edited 12/11/23, indicated Resident 135 had a stage 4 pressure ulcer to left lateral ankle. As of 11/06/23 interventions included access and record the condition of the skin surrounding the pressure ulcer, and observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever). On 12/11/23 the left ankle measured stage 4, 8 cm x 2 cm x 0.2 cm. 3. On 11/6/23 the medical record indicated the resident had an unstageable pressure wound to the left heel which measured 3 cm x 4.5 cm. On 12/11/23 the wound on the left heel measured 1.5 cm x 2.3 cm. 4. On 11/20/23 the record indicated the resident had an unstageable pressure wound to the right inner thigh which measured 1 cm x 2 cm. A care plan, dated 11/21/2023 and edited 12/11/2023, indicated Resident 135 had a stage 3 pressure ulcer to right anterior thigh. Interventions included assess and record the condition of the skin surrounding the pressure ulcer, observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever), observe for and report signs of pain related to pressure ulcer. Wound care notes from Wound Care Physician on 11/27/23 recommended to utilize an off loading boot due to patient's leg contracted and lying on top of the other leg. On 12/4/23 the pressure wound to the right inner thigh which stage 3 measured 5 cm x 3 cm x 0.1 cm. On 12/16/23 at 2:58 p.m., the Administrator provided a document, titled, Pressure Ulcer Prevention, dated 5/27/16, and indicated it was the policy currently being used by the facility. The policy indicated, .Preventing pressure injuries .turn and reposition with care .offload heels in bed On 12/16/23 at 3:34 p.m., the DON provided a document, titled, Pressure Ulcer Care and Treatment, dated 5/27/26, and indicated it was the policy currently being used by the facility. The policy indicated, .Pressure ulcer care .Initiate care plan or revise .report any changes to the pressure ulcer tot eh physician ie. (appearance, odor, depth, etc) .Wound/Skin Treatment .In the event of multiple wounds, each wound is considered a separate treatment B. On 12/11/23 at 12:30 p.m., Resident 135 was observed awake lying on her back in bed with the head of bed slightly elevated. The resident's left leg was severely contracted (shortening of muscles, tendons, and/or tissues causing deformity) with loss of range of motion greater than two thirds range and zero degree of extension at a 90-degree angle over the top of the right upper thigh. The resident's left leg was observed to lay against her right thigh. Off-loading pressure devices were not on her feet at the time of the observation. Resident 135 indicated she allowed the staff to turn and reposition her. During a wound treatment observation on 12/14/23 at 11:45 a.m., Licensed Practical Nurse (LPN) 14 prepared to complete the ordered wound care treatment to the resident. The previous dressings had been removed and nurse requested assistance from Registered Nurse (RN) 15 to turn and reposition the resident. LPN 14 prepared supplies, Kerlex gauze, calcium alginate dressing, border dressings and gauze to clean wounds. She placed all items on paper towel on the over bed table. LPN 14 donned gloves and asked the nurse assisting her to obtain an additional set of gloves for her and placed them on the table. RN 15 lifted the residents severely contracted left leg. A very strong foul odor was noted. LPN 14 applied three sprays of wound cleanser to a gauze pad and cleaned the wound on the right anterior thigh. She patted the wound dry, turned and stepped into the hall with contaminated gloves on, next to the treatment cart in the hall. LPN 14 was not observed to change gloves or wash her hands. She returned and applied calcium alginate dressing to the entire wound area including some of the surrounding excoriated area. She picked up a clean gauze border dressing and covered the wound. The nurse failed to apply skin prep (a protective dressing that forms a protective interface to prepare intact skin for attachment sites, tapes, films, and adhesive dressings. It also protects skin from incontinence, wound drainage, ostomy effluent, adhesive trauma, tape stripping, and friction) to the area around the wound. LPN 14 sanitized hands with hand sanitizer, and donned clean gloves and cleansed the left anterior ankle with gauze moistened with wound cleanser. LPN 14 picked up the calcium alginate dressing and applied it to the wound area. The nurse failed to apply skin prep to the surrounding tissue. LPN 14 did not change her gloves. LPN 14 cleansed the area to the left medial heel with gauze moistened with wound cleanser, she picked up a dry gauze and patted the wound area dry. Skin prep was not applied to the skin surrounding the wound. LPN 14 picked up the tube of Santyl ointment and squeezed out a thumb nail size amount of Santyl ointment onto her gloved index finger and applied the Santyl ointment directly into wound bed with her finger. Skin prep was not applied to the skin surrounding the wound. LPN 14 picked up the gauze dressing wrap and wrapped both wounds and secured with tape. LPN 14 sanitized her hands with hand sanitizer and donned clean gloves. RN 15 turned the resident to her left side and pulled her brief down past her buttocks. A small amount of bowel movement (BM) was noted just below the sacrum area. This was not cleaned prior to beginning the wound care to the sacrum. LPN 14 minimally cleaned the wound on the sacrum with moistened gauze. She picked up the tube of Santyl and applied a thumb nail size amount of ointment onto the second finger of the gloved hand and applied the Santyl ointment to part of the sacral wound bed with her finger. She picked up calcium alginate dressing and applied it to the wound bed and covered it with a border dressing. LPN 14 did not change her gloves, she failed to apply the calcium alginate to the undermining (tunneling) area of the wound as ordered and failed to apply Skin prep to the skin surrounding the wound. A very strong foul odor was noted during the cleaning of the wounds. LPN 14 indicated she did not apply wound cleanser by spraying directly to the wound bed because it hurt the resident. The nurse failed to apply skin prep to skin surrounding the wound. The dressing was within 3 centimeters (cm) of the BM within the rectal area. LPN 14 failed to change gloves to prevent contamination of the clean dressings and failed to maintain the integrity of the Santyl ointment by dispensing and touching the ointment without using an applicator. During an interview on 12/14/23 at 12:00 p.m., with Registered Nurse (RN) 13, Licensed Practical Nurse (LPN) 14, and a Regional Nurse, LPN 14 indicated that during the dressing change procedure she used 4 pairs of gloves and indicated she treated the one wound on the heel and another wound on the inner leg as one wound and did not need to change gloves between wounds. RN 13 indicated the wounds could be treated as one wound if the physicians order indicated it to be one and Santyl did not have to be applied with an applicator. LPN 14 indicated she was unaware the resident had a BM and the aide had just been in and cleaned the resident beforehand. LPN 14 indicated she used a different finger from the same glove each time she applied Santyl to glove. She indicated she did not touch the clean dressings with contaminated gloves. During a phone interview on 12/15/23 at 12:21 p.m., the Wound Care Physician, the physician overseeing the wound care of the resident, indicated she expected the nurse completing the treatment to wash the wounds with wound cleanser by spraying or irrigating the wound. The Santyl was to be applied to the entire wound bed with an applicator and should not be applied with a gloved finger. Touching the tube with the hand would contaminate the medication. However, she did not order Santyl for the wound to the coccyx. On her last visit she changed the order and discontinued the Santyl. She ordered calcium alginate with silver to the wound bed. The physician indicated the nurse should not apply Santyl with calcium alginate with silver to the wound, this would cause an adverse reaction between the two treatments within the wound. The sacral wound was a stage four. She reviewed the wound on Monday and indicated 30% of muscle and bone in the wound bed but had not updated it in her notes. She had not been consulted regarding a diagnosis of unavoidable wounds and she did not write unavoidable on her wound orders. She acknowledged the resident was a challenge to maintain offloading and prevention of wounds. During an interview on 12/15/23 at 2:00 p.m., RN 15 indicated she had completed an observation note on 12/13/23 at 8:56 a.m., titled, Pressure Ulcer Letter of Unavoidability. The document observation details indicated, Despite routine preventative care such as turning and proper positioning, application of pressure reduction or relief devices, good skin care and maintaining adequate nutrition and hydration this resident is at high risk for skin breakdown. She had not consulted with the Wound Care Physician overseeing the resident's wound treatments. She had a phone conversation with the Medical Director. The medical record lacked documentation of this conversation and she verified she had not documented their discussion. During an interview on 12/15/23 at 2:00 p.m., RN 15 indicated she had noticed the wound did smell a bit while assisting with the wound care on 12/14/23. She had not notified the Wound Care Physician or the Medical Director about the wound odor and was waiting until the Medical Director saw the resident as scheduled. On 12/15/23 at 8:45 a.m., the resident was lying in bed on her back with a thin pillow between the contracted left leg and lower right leg. Offloading anti pressure foam boots were on the chair next to her bed. The left foot was laying on the mattress, the left ankle was on top of the pillow. The Medical Director visited the resident on 12/15/23 at 8:51 p.m. and determined the wound was infected and ordered an antibiotic to be administered orally then changed the order to be administered through intravenous (vein) (IV). A culture of the wound was not ordered. On 12/16/23 at 2:43 p.m., the Director of Nursing (DON) indicated the LPN 14 was aware of the new orders at the time of the wound care physician visit. She was the only nurse who entered the orders into the medical record and the orders were given the same day as the visit. On 12/18/23 at 9:42 a.m., resident was observed laying on her back in the bed. The contracted left leg was laying on top of the right upper thigh. There was no pillow between the leg to prevent skin to skin contact. An off-loading boot was partially on the left foot and no off-loading boot was on the right foot. On 12/14/23 at 2:30 p.m., the resident's medical record review. Diagnoses included but are not limited to pressure ulcer of sacral region (a shield-shaped bony structure that is located at the base of the spine and that is connected to the pelvis), Chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems), degenerative disease of nervous system, dysphagia (difficulty swallowing), unspecified protein-calorie malnutrition (condition that happens when your diet does not contain the right amount of nutrients), type 2 diabetes mellitus, and diabetic neuropathy (a type of nerve damage that can occur if you have diabetes). An admission Minimum Data Set (MDS) assessment, dated 7/21/23, indicated the resident admitted to the facility with intact skin and no pressure wounds during the assessment period were identified and she was at risk for skin breakdown. The brief interview for mental status (BIMS) indicated a score of 13 and resident was cognitively intact and able to make own decisions. 1. On 8/21/23 the wound care notes indicated the resident had a sacral wound stage 3 which measured 2 cm (centimeters) by (x) 2.5 cm by (x) 0.1 cm. On 8/28/23 the sacral wound, stage 3, measured 3 cm x 2.2 cm x 0.1 cm. On 9/4/23 the sacral wound, stage 3, measured 3 cm x 3 cm x 0.1 cm. On 9/11/23 the sacral wound, stage 3, measured 3 cm x 3.5 cm x 0.1 cm. On 9/18/23 the sacral wound, stage 3, measured 3 cm x 3 cm x 0.1 cm. On 9/25/23 the sacral wound, stage 3, measured 3.5 cm x 2.5 cm x 0.1 cm. On 10/2/23 the sacral wound, stage 3, measured 2.2 cm x 2.2 cm x 0.1 cm. On 10/9/23 the sacral wound, stage 3, measured 2.8 cm x 2.8 cm x 0.1 cm. On 10/16/23 the sacral wound, stage 3, measured 2.8 cm x 3 cm x 0.1 cm. On 10/23/23 the sacral wound, stage 3, measured 3.2 cm x 3.1 cm x 0.1 cm. On 11/6/23 the sacral wound, stage 3, measured 6 cm x 7 cm x 0.7 cm. On 11/20/23 the sacral wound, stage 3, measured 5 cm x 5 cm x 0.5 cm. On 11/27/23 the sacral wound, stage 3, measured 6 cm x 5.5 cm x 0.3 cm. On 12/4/23 the sacral wound, stage 3, measured 6 cm x 4.5 cm x 0.3 cm. Physician order, dated 12/4/23, indicated daily and as needed (PRN) due to soilage to cleanse wound to coccyx/sacral area with wound cleanser, pat dry, apply skin prep to peri wound, apply nickel thick Santyl (collagenase clostridium histo) 250 unit/gram ointment to necrotic tissue, apply calcium alginate, and cover with a gauze island. On 12/11/23 the sacral wound, stage 3, measured 5.5 cm x 4 cm x 0.3 cm with muscle and bone exposed. On 12/11/23 the Wound Care physician ordered to stop Santyl and to cleanse sacrum pressure wound with wound cleanser, apply skin prep to surrounding tissue, apply calcium alginate with silver to the wound bed, and cover with gauze island dressing daily for 23 days. This order was not entered into the medical record until 12/15/23. 2. On 11/6/23 the medical record indicated the resident had an unstageable pressure wound on the left lateral ankle which measured 3 cm x 3 cm. Physician order, dated 11/6/23, indicated to monitor and observe the DTI (deep tissue injury) to left lateral ankle every shift for signs and symptoms (s/s) of infection every shift. On 11/20/23 the wound on the left ankle measured 7 cm x 2 cm. Physician order, dated 11/21/23, indicated daily and PRN due to soilage to cleanse left lateral ankle (measuring 7 cm x 2 cm) with wound cleanser, pat dry, apply skin prep to peri wound, apply Santyl nickel thick, apply calcium alginate, and cover with gauze island and offloading boot daily. On 11/27/23 the wound on the left ankle measured 6.5 cm x 3 cm x 0.4 cm. On 12/4/23 the wound on the left ankle measured stage 4, 6 cm x 3.5 x 0.3 cm. On 12/11/23 the left ankle measured stage 4, 8 cm x 2 cm x 0.2 cm. 3. On 11/6/23 the medical record indicated the resident had an unstageable (full thickness pressure injury where depth is obscured by eschar and/or slough) pressure wound to the left heel which measured 3 cm x 4.5 cm. Physician order, dated 11/6/23, indicated to monitor and observe, DTI to left medial heel every shift for s/s of infection every shift for signs and symptoms (s/s) of infection every shift. Physician order, dated 11/13/23, indicated to cleanse left medial heel with wound cleanser, pat dry, apply skin prep, and offloading boot daily and PRN. On 11/20/23 the wound on the left heel measured 1.5 cm x 2.5 cm. On 11/27/23 the wound on the left heel measured 1.3 cm x 2.5 cm. On 11/27/2023, the Wound Care Physician ordered to stop skin prep, apply Santyl with calcium alginate and wrap in Kerlex. Order was not entered into the medical record. On 12/4/23 the wound on the left heel measured 1.5 cm x 2.4 cm. On 12/11/23 the wound on the left heel measured 1.5 cm x 2.3 cm. 4. On 11/20/23 the record indicated she had an unstageable pressure wound to the right inner thigh which measured 1 cm x 2 cm. Physician order, dated 11/21/23, indicated to cleanse wound to right anterior thigh (measuring 1cm x 2 cm) with wound cleanser, pat dry, apply skin prep to peri wound, apply Santyl nickel thick cover with calcium alginate, and a gauze island daily and PRN. Physician order, dated 11/21/23, indicated to monitor and observe wound to right anterior thigh, every shift for s/s of infection every shift for signs and symptoms (s/s) of infection every shift. On 11/27/23 the pressure wound to the right inner thigh measured 2 cm x 2 cm x 0.1 cm. On 12/4/23 the pressure wound to the right inner thigh which stage 3 measured 5 cm x 3 cm x 0.1 cm. On 12/16/23 at 2:58 p.m., the Administrator provided a document, titled, Pressure Ulcer Prevention, dated 5/27/16, and indicated it was the policy currently being used by the facility. The policy indicated, .Preventing pressure injuries .turn and reposition with care .offload heels in bed On 12/16/23 at 3:34 p.m., the DON provided a document, titled, Pressure Ulcer Care and Treatment, dated 5/27/26, and indicated it was the policy currently being used by the facility. The policy indicated, .Pressure ulcer care .Initiate care plan or revise .report any changes to the pressure ulcer to the physician ie. (appearance, odor, depth, etc) .Wound/Skin Treatment .In the event of multiple wounds, each wound is considered a separate treatment On 12/16/23 at 3:34 p.m., the DON provided an undated document, titled, Gloves and indicated it was the policy currently being used by the facility. The policy indicated, .outside of gloves are contaminated The immediate jeopardy that began on 8/11/23 was removed on 12/16/23 when the facility conducted a skin sweep of all residents, ensured residents with pressure ulcers had skin assessments and physician orders that matched the wound doctor's recommendations, educated all nursing staff on pressure ulcer prevention and care, and created an auditing system. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. 34525 C. Resident 21's record was reviewed on 12/14/23 at 8:51 a.m. The profile indicated the resident's diagnoses included, but were not limited to stage 3 pressure ulcer of right buttock, unspecified protein-calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food), peripheral vascular disease (the reduced circulation of blood to a body part due to a narrowed or blocked blood vessel), and type 2 diabetes mellitus with diabetic peripheral angiopathy (a common complication that arises from chronic diabetes causing a narrowing in the arteries and an undersupply of blood and oxygen to different organs and can lead to damage in the long term). An annual Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive deficit, was at risk for the development of pressure ulcers, and had an unhealed stage 3 pressure ulcer. A skin integrity care plan, dated 3/25/19 and updated on 12/12/23, indicated the resident was at risk for alteration in skin integrity. Interventions included, but were not limited to, weekly skin assessment. A physician's order, dated 8/8/23, indicated weekly skin assessment. Document 0 for no skin impairment, 1 for any new skin area identified, and 2 for an existing skin impairment. Once a day on Mondays. Special Instructions: Open appropriate event for newly identified skin issues. The October 2023 TAR (Treatment Administration Record) lacked documentation of skin assessments having been completed as ordered on 10/9/23 and 10/16/23. The record lacked documentation of the reason the treatment had not been completed as ordered. The November 2023 TAR lacked documentation of a skin assessment having been completed as ordered on 11/20/23. The record indicated the night shift nurse had left the day shift nurse to complete charting. During an interview, on 12/14/23 at 10:00 a.m., the Director of Nursing (DON) indicated the nursing staff were expected to complete all skin assessments as ordered by the physician. On 12/14/23 at 10:00 a.m., the DON provided a document, with a revision date of 9/15/23, titled, Skin Integrity, and indicated it was the policy currently being used by the facility. The policy indicated, . Policy Statements: The facility will ensure that based on the comprehensive assessment of a resident: 1. A resident receives care, consistent with professional standards of practice .Procedures: .3 .ongoing observation of skin integrity by licensed nursing staff .5 .document all impaired skin integrity .in the EMR (electronic medical record) on an ongoing basis 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident was assessed when there was a significant decline which resulted in a delay in treatment before being transferred to an acute care setting due to unresponsiveness with diagnosis of acute respiratory distress and sepsis for 1 of 5 residents reviewed for quality of resident care (Resident C). The isolated deficiency that compromised the resident's ability to maintain their highest practicable physical well-being (harm) was corrected on May 02, 2023 prior to the start of the survey and was therefore Past Noncompliance. Findings include: Resident C's closed clinical record was reviewed on June 08, 2023 at 11:00 a.m. Resident C's diagnoses included but were not limited to cerebral infarction, sepsis severe with septic shock (12-09-2022), acute kidney failure, cognitive communication deficit, and dementia. The admission Minimum Data Set assessment, dated February 07, 2023, indicated Resident C's speech was clear. When communicating he usually understood, and others usually understood him. His cognitive skills for daily decision making were severely impaired. He required limited to extensive assistance from nursing staff for activities of daily living. Current March 2023, open ended, physician orders and Face Sheet documentation indicated Resident C was a Full Code [if the person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive]. Red alert (abnormal and require attention) vitals were documented for Resident C on March 12, 2023 at 6:32 p.m. The vitals documented indicated, an oxygen saturation of 89 percent (normal between 95 and 100 percent), heart rate of 121 (above normal), and blood pressure of 154/118 (high blood pressure). Red alert oxygen saturation was documented for Resident C on March 13, 2023 at 10:00 a.m. The oxygen saturation documentation indicated 79 percent (88 percent or lower is considered to be dangerously low). Resident C's clinical record lacked documentation of notes from March 08, 2023 to March 13, 2023 at 4:40 p.m. A progress note, dated March 13, 2023 at 4:40 p.m., indicated Resident C was found with altered mental status unresponsive and had a decreased oxygen saturation level 79 percent. Resident C was transferred to an acute care emergency room . During an interview on June 08, 2023 at 1:50 p.m., the Director of Nursing indicated no documentation during the time period of March 08 through March 13, 2023 at 4:40 p.m. was available. No documentation of further assessment or response to assessed change in physical health was documented. Hospital emergency room records, dated March 13, 2023 at 5:07 p.m., indicated initial vitals assessment of blood pressure 120/88, pulse 140, respirations 27, and oxygen saturation of 75 percent on room air, then 85 percent on 4 liters of oxygen, then 90 percent on NRB (Non-rebreather mask - a facial mask to assist in the delivery of oxygen therapy that allows for the delivery of higher concentration of oxygen by not permitting air from the surrounding environment to be inhaled) with 12 liters of oxygen. An initial physical assessment of hypoxic with increased WOB [insufficient amounts of oxygen with increased effort to breath]. Lactic acid was measured at 3.7 (normal below 2, severe 4 or higher). Resident C was diagnosed with sepsis (a life threatening condition that arises when the body's response to infection causes injury to its own tissue and organs). Resident C health status was documented as Critical care condition. Resident C was started on IV antibiotics and transferred to the hospital's intensive care unit. The Past Noncompliance of isolated actual harm began on March 12, 2023. The deficient practice was removed and corrected by May 02, 2023 after the facility implemented a systemic plan that include the following actions: -All residents residing in the facility had a nursing assessment for a change of condition completed and a full set of vital signs taken which included: temperature, pulse, respirations, blood pressure and oxygen saturation to assess for any type of change in condition. Any residents assessed as having a change of condition had a physician notification. -All administrative and nursing staff were educated resident change of condition and notification of change of condition. -On going monitoring of residents' clinical record documentation to ensure identification and prompt response to changes in condition. -Weekly QAPI (Quality Assurance and Performance Improvement) committee meetings to ensure continued substantial compliance of prompt response to changes in residents' health status. This Federal tag relates to Complaint IN00410070. 3.1-37(a)

Based on interview and record review, the facility failed to ensure thorough assessment of a resident with a change of condition and failed to timely send the resident with a change of condition out to the hospital for 1 of 3 residents reviewed for emergency transfers due to change of condition (Resident O). The immediate jeopardy began on [DATE] when at 7:30 a.m. Certified Nurse's Aide (CNA) 10 observed Resident O to have not touched her breakfast tray, her face was red in color, she was struggling to breathe, not talking, grabbing at the air, and her eyes were rolling up. Licensed Practical Nurse (LPN) 11 was notified but indicated she did not assess due to Resident O having had tests for a possible urinary tract infection (UTI) earlier in the morning. CNA 9 observed the resident to still be red in color, struggling to breathe, not talking, and eyes rolling up. LPN 11 was again notified, but indicated she was unable to get vital signs due to the resident moving too much. No other assessment or actions were taken for the resident's change of condition. Around 11:20 a.m., CNA 10 found the resident to still be in distress. CNA 10 went to find LPN 12 from another unit to assess the resident. LPN 12 was unable to obtain vital signs and attempted to call the doctor and family. At 11:32 a.m., the nurse received a text message from the family to send the resident to the emergency room (ER). Emergency Medical Services (EMS) was called at 11:40 a.m. After EMS arrived, the resident was sent to the hospital, intubated, admitted to the hospital with diagnoses of septic shock and hypoxia, and ultimately died within 24 hours. The Executive Director (ED), [NAME] President of Clinical Operations (VPCO), and Regional Clinical Risk Manager (RCRM) were notified of the immediate jeopardy on [DATE] at 2:28 p.m. The immediate jeopardy was removed on [DATE], 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: During a confidential interview, on [DATE] at 10:07 a.m., indicated Resident O was in distress since breakfast time, she did not eat her breakfast on the morning of [DATE]. Resident O was not attended to until lunch time by the nursing staff and the resident was placed on a ventilator as soon as she arrived at the emergency room . Resident was found to be septic (infected with microorganisms, especially harmful bacteria). Resident O later died in the hospital on [DATE]. On [DATE] at 8:45 a.m., Resident O's medical record was reviewed, her diagnosis included, but were not limited to, septic shock (a life-threatening condition caused by a severe localized or system wide infection that requires immediate medical attention), sepsis with acute hypoxic respiratory failure (severe inflammatory responses induced by sepsis lead to acute pulmonary edema), acute kidney injury (a condition in which the kidneys suddenly can't filter waste from the blood), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Census information indicated emergent discharge on [DATE] with no return. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident O was cognitively intact, exhibited no behaviors, and no rejection of care. The resident required a one person assist with transfers, dressing, and eating, she further required an assistance of 2 for toileting. A care plan, dated [DATE] and revised on [DATE], indicated the resident, relative, or representative expressed wish to remain in the facility for long term care. Interventions included, but were not limited to, staff were to provide services according to plan of care in an effort to enhance optimum wellbeing. A care plan, dated [DATE] and revised on [DATE], indicated the resident was at risk for respiratory distress related to diagnosis COPD (chronic obstructive pulmonary disease), Saddle of Pulmonary Artery (a rare type of acute pulmonary embolism that can lead to sudden hemodynamic collapse and death). Resident required HOB (head of bed) elevated to alleviate/prevent SOB (shortness of breath) while lying flat related to COPD. Interventions included, but were not limited to, notify MD (medical doctor) with significant changes, and observe for/report SOB, respiratory distress, confusion, decreased level of consciousness, and decreased oxygen levels. A review of a Situation, Background, Assessment, and Recommendation (SBAR) communication form, dated [DATE] at 11:30 a.m., indicated the resident was disorientated and had increased respirations. The form indicated LPN 12 was unable to obtain blood pressure, pulse, and pulse oximetry reading. The resident had a respiration rate of 24 and temperature of 97.9 F (Fahrenheit). Resident was a full code status (if a person's heart stopped beating and or the stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of progress note, dated 4//,d+[DATE] at 12:02 p.m., indicated the resident was very out of it upon being assessed, grabbing at things that were not there, and only reacting to sternal rub. An ambulance arrived at the facility at 11:58 a.m. and took the resident. The family did not answer the phone but did reply to a text message and asked staff to send the resident to the hospital. During an interview, on [DATE] at 9:46 a.m., [NAME] President of Clinical Operations (VPCO) indicated LPN 12 attempted to obtain vitals on Resident O, but her blood pressure was reading too low to obtain on the machine. She further indicated the nurse attempted to reach the doctor and the resident's family due to her change of condition. When LPN 12 was unable to reach the family by telephone, she proceeded to text them. The family received a text message from LPN 12 on [DATE] at 11:27 a.m. The text message indicated, Yr [sic] mom is very out of it -- confused grabbing at things that aren't there. At 11:31 a.m. the text message from family to LPN 12 indicated, Then she needs to be sent to ER, call ambulance. At 11:32 a.m. LPN 12 texted, I will. The VPCO indicated during their investigation, LPN 12 was asked to assess Resident O by CNA 9 on [DATE]. LPN 12 indicated she had agreed with CNA 9 that the resident had a change of condition. LPN 12 attempted to call the family members with no answer. The nurse then proceeded to text a family member and at that time the family member agreed to the transfer to the hospital. The VPCO indicated it was not in their facility policy for a staff member to text representatives in regard to a resident/family member's condition. During an interview, on [DATE] at 10:40 a.m., CNA 9 indicated she was working the 200 hall on [DATE] but went over to the 100 hall to help CNA10 pass her breakfast trays. The CNA 9 went into Resident O's room and noted that she had not eaten her breakfast. CNA 9 noted the resident's face was red, she was struggling to breathe, not talking, her eyes were rolling up, and she was grabbing at the air. CNA 9 notified the other CNA 10 that was working along with the agency nurse, LPN 11, that worked the 100 hall on [DATE]. CNA 9 indicated LPN 11 did not listen to them and indicated the resident probably had a urinary tract infection and lab tests were sent that morning. Later on, that morning, the resident was noted to still be in distress, CNA 9 got LPN 12 from the 200 hall to assist. CNA 9 never saw any oxygen being placed on the resident. During an interview, on [DATE] at 10:49 a.m., CNA 10 indicated on [DATE] at 07:30 a.m., she went into Resident O's room and noted resident to be red in the face, struggling to breathe, and her eyes were rolling back in her head. She went to tell the agency nurse, LPN 11, who did not listen to her on several occasions. CNA 10 indicated agency LPN 11 went into the resident's room, but LPN 11 was unable to obtain vitals because the resident was moving too much. LPN 11 did not return to the room and no oxygen was placed on the resident. The CNA notified LPN 12 to assess the resident. CNA 10 indicated it was well after 11 o'clock before the resident left the facility to go to the hospital. During an interview, on [DATE] at 9:41 a.m., LPN 2 indicated if a resident had a change in condition, she would assess the resident and obtain vitals. She would notify the physician and follow orders. If it were an emergency, she would not have to wait for the physician to order the transfer to the hospital. During an interview, on [DATE] at 10:38 a.m., Unit Manager 4 indicated nursing staff may call 911 in the case of an emergency without a physician order. A review of the patient care record from the local Fire Department, dated [DATE] at 6:34 p.m., indicated that 911 was called at 11:40 a.m., and EMS was dispatched to the facility at 11:43 a.m. EMS arrived on scene at 11:49 a.m. Resident O was found to be unresponsive with a blood pressure of ,d+[DATE], pulse 50, respiration rate 6 and SP02 (oxygen saturation) was 40% on room air upon EMS assessment. At 12:03 p.m. a non-re-breather mask (device used in medicine to assist in the delivery of oxygen therapy) was placed on resident at 15 lpm (liters per minute). The resident's extremities were noted to be mottled (usually a temporary condition that occurs when blood flow to tiny vessels under your skin is disrupted) and cool to the touch. Her neurological assessment indicated the resident was unresponsive with a blank stare. She had a Glasgow Coma Scale/Score (GCS) of 5. A score of 5 is considered as someone being comatose (state of deep unconsciousness for a prolonged or indefinite period). A review of physician progress note, dated [DATE] at 12:19 p.m., indicated when Resident O arrived at the hospital emergency room she was cyanotic (blue), pale, minimal respirations, thready radial pulse, not responsive to verbal stimuli, she was then sedated and intubated (insert a tube down into the trachea for ventilation). A review of hospital discharge summary, dated [DATE] at 8:26 a.m., indicated Resident O had expired at the hospital on [DATE] at 3:38 a.m. Discharge diagnoses included, but were not limited to, Septic Shock (a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in the cellular level), Sepsis with acute hypoxic respiratory failure (condition when you don't have enough oxygen in the tissues in your body), acute kidney injury (a condition in which the kidneys suddenly can't filter waste from the blood), and urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, and urethra). Resident O's lab results indicated a White Blood Count (measures the number of white cells in your blood) 32.7 (critical high level), Hemoglobin (protein in your red blood cells) 18.2 (high), Potassium (essential mineral that is needed by all tissue in the body) 5.6 (high), Blood Urea Nitrogen (measures the amount of urea nitrogen that's in your blood) 126 (critical high level). On [DATE] at 2:18 p.m., the VPCO provided an undated document, titled, Change in Condition: When to report to the MD/NP/PA, and indicated it was the policy currently being used by the facility. The policy indicated, .Sudden change in level of consciousness or responsiveness, immediate notification The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility provided education to all Department Heads on resident change of condition and notification of change of condition. Educated all nursing staff on resident change of condition, following up on resident change of condition when notified by others, and notifying the physician immediately of a resident change of condition. Educated all non-licensed nursing staff on immediately notifying nursing staff of any change of condition of a resident to allow the nursing staff to assess the resident and notify the physician immediately. Educated all non-nursing staff on resident change of condition and notification of resident change of condition. Provided a schedule of daily audits of progress notes, event notes, and vital signs of residents for documentation of change in condition and to ensure physician notification by the nurse. Provided a schedule of daily interviews with non-licensed nursing staff on the awareness of any resident with a change of condition and subsequent reporting of such. Provided a schedule of daily interviews with licensed nursing staff regarding the awareness of any resident with a change of condition and immediate notification to the charge nurse. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag related to Compliant IN00407412. 3XXX,d+[DATE](a)

A. Based on interview and record review, the facility failed to ensure a resident's hospice (specialized care for the terminally ill) choice was honored for 2 of 2 residents reviewed for hospice choice which resulted in psychosocial harm when an actively dying resident (Resident B) was moved to an Air BnB (temporary vacation rentals) in order to maintain care with their choice of hospice after being given 8 days' notice of the facility ending the hospice contract and expired 8 days later (Residents B and C). B. Based on observation, record review, and interview, the facility failed to honor resident and family choice regarding pharmacy services for 1 of 4 residents reviewed for choices (Resident 109) and failed to ensure resident preference with shaving and showers were followed for 1 of 4 residents reviewed for choices (Resident 31). Findings include: A1. During an interview, on [DATE] at 1:35 p.m., an anonymous interviewee indicated a few weeks ago a hospice contract was terminated by the facility. At the time of the contract termination, Resident B was actively dying. The resident had chosen their hospice, and the family did not want to change companies. The family moved the resident to an Air BnB, where she expired, in order to maintain services from the hospice provider. During an interview, on [DATE] at 2:20 p.m., the Director of Nursing (DON) indicated any vendors had to be affiliated with the facility before residents were able to choose them as a hospice company. The hospice's contract was terminated on [DATE]. At the time of the contract termination, Resident B received hospice services from the company. The resident's family took her to an Air BnB and continued hospice services with the same company. The resident's family was given three options to choose from after the contract termination date of [DATE], they could choose another hospice company, accept palliative care from facility staff, or choose another facility. During an interview, on [DATE] at 2:36 p.m., Resident B's family member indicated they spent 12 to 14 hours each day at the facility helping to provide care to Resident B. The resident was admitted to the facility in 2019, and elected hospice care in [DATE]. The resident chose the hospice company herself, as she was able to make the choice at that time. The facility staff attempted to get her to choose a different company and even attempted to encourage the resident into a different choice. In [DATE], the family member received a call and was notified the facility wanted to have an immediate care conference. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Chief Executive Officer (CEO), and Social Services Director (SSD) were present at the meeting. During the meeting, they were told the facility was no longer working with the hospice company. The facility presented the family member with options to choose a different hospice company or utilize the facility's palliative care. The facility gave them seven or eight days to make the decision. The family member did not feel there was enough facility staff to provide sufficient palliative care. The family was not presented with the option to take the resident home, but that was what they decided to do. Resident B required total care, and there was no other family in town. The family member attempted to hire privately paid caregivers to come into the facility to provide additional care to the resident, but they were told by facility staff this was not allowed. They even wanted to hire the caregivers for one day in order to attend a family funeral. Since this was not acceptable to the facility, the family member was unable to attend the family funeral. Ultimately, since the family member did not live locally, they rented an Air BnB, hired privately paid caregivers, kept the hospice company the resident had chosen for herself, and discharged the resident to the Air BnB. The resident expired eight days later, at the Air BnB, under the care of the resident's chosen hospice service. During an interview, on [DATE] at 2:59 p.m., the Regional [NAME] President (RVP) indicated the facility was able to terminate the hospice company's contract immediately if they were found to be fraudulent in some way. The facility gave the residents 30 days to go to another facility contracted with the hospice company, choose another hospice company, or outlive the contract. They worked with their attorney throughout the contract termination. He did not recall being asked about Resident B's family member hiring privately paid caregivers but indicated they could be hired if a family wished as long as they were not being charged to the resident's insurance. The staff had not thought Resident B would live the 30 days that it took the contract to be terminated. They thought Resident B would have expired before the end of the contract, but she had not. During an interview, on [DATE] at 3:38 p.m., the DON indicated they gave the hospice company a 30-day extension before the contract was terminated. However, residents and resident representatives were not notified of the impending contract termination at that time. Resident B's family member was notified of the impending contract termination on [DATE], and this gave them eight or nine days to decide what to do. The 30 days were up on [DATE], and the contract was terminated. Resident B was actively dying on [DATE]. He had not thought Resident B would have lived past [DATE], but she had. The residents and resident representatives were not provided a written notice of the contract termination. They were notified verbally about eight days before the termination of the contract. Resident B's record was reviewed on [DATE] at 1:27 p.m. A significant change Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had a moderate cognitive impairment, had a disease or chronic condition which may result in a life expectancy of less than six months, and received hospice care while a resident. Census information indicated the resident was admitted to the facility on [DATE], elected hospice services on [DATE], and discharged from the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated [DATE], indicated the resident requested to cancel the positron emission tomography (PET) scan (a test used to diagnose various conditions such as cancer, heart disease, and brain disorders) scheduled for [DATE], and requested a referral to the hospice company she chose. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated [DATE], indicated the resident received hospice care for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, coordinate care with hospice. A nurse's note, dated [DATE] at 6:03 p.m., indicated the resident's family member requested the hospice company be called for more pain medication. Hospice was called, and a message was left for the on-call nurse. A nurse's note, dated [DATE] at 6:11 p.m., indicated the hospice nurse returned the phone call and would come into visit the resident. A nurse's note, dated [DATE], indicated the hospice nurse was at the facility, and the resident's pain medication orders were changed. A nurse's note, dated [DATE], indicated the resident was being reviewed related to a fall on [DATE], and had experienced a significant physical decline related to the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff was to offer more frequent activities of daily living (ADL) (activities related to personal care) assistance, and the resident was moved closer to the nurse's station. An activities note, dated [DATE], indicated the resident had a supportive family throughout her decline in condition. The resident had previously attended resident council meetings but was no longer strong enough to do so. A nurse's note, dated [DATE], indicated a call was placed to the hospice company to request nausea medication. A nurse's note, dated [DATE], indicated the resident's daughter requested the resident be turned every two hours related to the resident's decline in her ability to do this independently. An interdisciplinary team (IDT) note, dated [DATE], indicated the resident was reviewed for falls. The resident continued to experience a physical and mental decline related to the cancer diagnosis. A nurse's note, dated [DATE], indicated the resident's family member was concerned the resident might have thrush (a fungal infection that can grow in the mouth) and was more confused. The resident's family member requested hospice be called. A call was placed to the hospice company. A nurse's note, dated [DATE], indicated the hospice nurse contacted the facility with new orders. A social services note, dated [DATE] at 1:25 p.m., indicated the social worker was notified the resident would discharge that day with continued hospice services. A nurse's note, dated [DATE] at 5:44 p.m., indicated the resident left the facility and hospice medications were sent. During an interview, on [DATE] at 11:12 a.m., the RVP indicated there was no facility policy on how residents and resident representatives should have been notified of changes in contracts or service provisions. It was handled differently depending on the contract. Each contract had a different time frame of how long from the time of the dispute to the time of actual contract termination would have been. The hospice company's contract was terminated due to, Federal violations and ethical violations. There was a 30-day waiting time before it was actually terminated. They were not required to give a written notice to the residents and resident representatives. Normally, they would have sent out a letter to, Welcome, residents and resident representatives to their new service provider, and this also would have served as notification of the termination of the previous service provider. This was not done in the case of the hospice contract termination, however, because very few residents were affected by the change. A2. Resident C's record was reviewed on [DATE] at 2:23 p.m. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had a severe cognitive impairment, had a disease or chronic condition which may result in a life expectancy of less than six months, and received hospice care while a resident. Census information indicated the resident admitted to the facility on [DATE], elected hospice services on [DATE], and discharged from the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, last revised [DATE], indicated the resident received hospice services related to ischemic heart disease. Interventions included but were not limited to coordinate care with hospice. A nurse's note, dated [DATE], indicated the resident was transferred to another skilled nursing facility. The note lacked documentation of why the resident transferred to another facility. During an interview, on [DATE] at 2:20 p.m., the Director of Nursing (DON) indicated a hospice company had to be affiliated with the facility before a resident was able to use them as their provider. This hospice's contract was terminated on [DATE]. Two residents were on their service at the time it was terminated. After [DATE], residents and their families were given three options, choose another hospice company, utilize palliative care provided by the facility, or move to another facility that was contracted with the hospice company. During an interview, on [DATE] at 3:38 p.m., the DON indicated they gave a 30-day contract extension to the hospice company in an attempt to get everything settled, and the extension ended on [DATE]. The day he was informed the 30-day contract extension would be the official end of business with the hospice company was [DATE]. The residents ended up having eight or nine days to decide what they wanted to do. At this time, they were able to choose another hospice company, receive palliative care provided by the facility, or discharge to another facility contracted with the hospice company. There was no written notification of their intent to terminate the hospice contract provided to residents or their family members. They were verbally notified about eight days before the change went into effect. During an interview, on [DATE] at 2:54 p.m., the DON indicated Resident C transferred to another facility four days after they gave the hospice company the notice their contract would be terminated. They had not yet notified the residents and families, but Resident C had a family member who worked for the hospice company and decided to transfer. The facility the resident transferred to was also closer to where his family lived. An anonymous interview during the survey indicated Resident C transferred to the other facility early on in the contract dispute. The facility also questioned the resident's eligibility for hospice, and the hospice company felt that the physician should have been the one to determine eligibility. There ended up being an opening at the other facility, so the family decided to take it as they wanted the resident to remain on service with the hospice company. During an interview, on [DATE] at 11:12 a.m., the Regional [NAME] President (RVP) indicated there was no facility policy regarding how residents and families should have been notified of contract changes or changes in service providers. It was different depending on the contracted service. It would also have depended on how long the wait time was before the actual termination occurred. It was usually a 30-day wait time before the termination took place, but they were not required to give a written notice. Normally, they would have sent out a letter to welcome residents and families to their new provider, which would also have served as notification the previous provider was no longer providing service. In this case, however, there were not very many residents affected and this was not done. On [DATE] at 2:00 p.m., the Chief Executive Officer (CEO) provided a document titled, Hospice Program, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY STATEMENT: Facility contracts for hospice services for residents who wish to participate in such programs. GUIDELINE: 1. Facility has entered into a contractual arrangement for hospice services with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so .4. Hospice services are provided under contractual arrangement. Complete details outlining the responsibilities of the facility and hospice agency are contained in this agreement. A copy of this agreement is on file in the business office and hospice agency On [DATE] at 12:24 p.m , the DON provided a document titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility .GUIDELINE: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .d. Participate in decisions and care planning B1. During a family interview, on [DATE] at 12:36 p.m., Resident 109's husband indicated when his wife was admitted to the facility he requested that he continue to use an outside pharmacy to fill his wife's prescription medications, as he was able to get them at a lesser cost than if he were to use the facility's contracted pharmacy. Initially he was told that this was acceptable, but later the facility indicated to him that he had no choice but to use the facility's contracted pharmacy. This increased the cost of the medication significantly. He was paying privately for her facility stay, at that time. Resident 109's record was reviewed on [DATE] at 2:55 p.m. The record indicated the resident had been admitted to the facility's Memory Care Unit on [DATE]. The profile indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the census section of the resident's record indicated the resident was a private pay stay from admission on [DATE] until becoming Medicaid eligible, effective on [DATE]. During an interview, on [DATE] at 11:16 a.m., the Facility Liaison indicated all of the residents were required to use the facility's contracted pharmacy. She was unsure if the facility had a specific policy regarding the requirement for using the contracted pharmacy or if the resident was private pay. During an interview, on [DATE] at 11:24 a.m., the Regional [NAME] President (RVP) indicated the Centers for Medicare and Medicaid Services (CMS) required that any pharmacy that did not have twenty-four hour, seven day a week (,d+[DATE]) availability could not be used in a facility. The pharmacy that the resident's husband had chosen to use was not available ,d+[DATE]. The resident's husband had been instructed about the CMS requirement. The company was not required to do business with any other pharmacy. He indicated a resident or family should not be able to dictate company policy, just because they did not agree with the policy. The family or resident always had the choice to find another facility placement. At the same time, the VP indicated the facility did not use bottled medications because it was felt that medication distribution and count verification could not be done safely and within infection control standards, since the medication would have to be removed from the bottles to count and distribute. On [DATE] at 3:40 p.m., the Chief Executive Officer (CEO) provided a document, with a revision date of [DATE], titled, Resident Handbook & Admission Documents, and indicated it was the policy currently being used by the facility. The policy indicated, .B. Personal Services .Pharmacy .You may choose an alternate pharmacy that complies with our uniform medication distribution system, procedures On [DATE] at 3:40 p.m., the CEO provided a document, with a revision dated of [DATE], titled, Admission Paperwork, and indicated it was the policy currently being used by the facility. The policy indicated, .3. Resident .Further agrees and understands: .f. Certain items that Resident .may request are not included in the Facility's daily rate, and Resident will pay Facility separately and in addition to the daily rate for those items (e.g .medications) On [DATE] at 12:24 p.m., the CEO provided a document, with a revised date of [DATE], titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .When providing care and services, the stakeholders will respect the resident's individuality and value their input .through self-determination .Guideline: 1. Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .c. Choose .and participate in decisions pertaining to the treatment plan; d. Participate in decisions B2. During an interview, on [DATE] at 2:10 p.m., Resident U was observed with a full facial beard seated in a wheelchair in his room watching television. Resident U indicated he was scheduled for two showers a week but had not gotten showers very often and would like at least two showers a week. Resident U indicated staff were not shaving him either. He would like to be shaven with a goatee, not the full facial beard that he had. On [DATE] at 10:30 a.m., Resident U was observed in his room, unshaven with a full beard. On [DATE] at 11:48 a.m., Resident U was observed seated in a wheelchair in his room, unshaven with a full beard. On [DATE] at 12:20 p.m., Resident U was observed unshaven with a full beard, seated in a wheelchair in his room eating lunch. On [DATE] at 10:19 a.m., Resident U was observed unshaven with a full beard, seated in a wheelchair in his room. Resident U indicated Certified Nursing Assistant (CNA) 22 assisted him with his showers and he had not had a shower since last Monday, [DATE], over a week ago. He would like to have two showers a week and be shaved to have a goatee not a full beard. Resident U's record was reviewed, on [DATE] at 9:22 a.m. An annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact and required limited assistance of one staff for personal hygiene and bathing. A psychosocial well-being care plan, initiated on [DATE] and revised on [DATE], indicated Resident U was at risk for violation of resident's right to choose his bathing preference. Interventions on the care plan included but were not limited, per resident or responsible parties' choice, Resident U preferred showers on Wednesdays and Saturdays in the evening. On [DATE] at 9:43 a.m., the Director of Nursing (DON) provided C.N.A. Skin Care Alert shower sheets from [DATE] to [DATE] for Resident U. The DON indicated the CNAs were to complete a shower sheet every time a resident was showered, and staff were to document on the shower sheet, if the resident's nails were trimmed, hair shampooed, resident shaved, and was the resident's skin clear. The C.N.A Skin Care Alert shower sheets indicated Resident U had received a shower every Monday and Thursday from [DATE] to [DATE], but none of the shower sheets indicated Resident U had not been shaven. CNA 22 had documented on the shower sheets; she had given Resident U a shower on [DATE] and [DATE]. On [DATE] at 12:24 p.m., the DON provided and identified a document as a current facility policy, titled Increasing Resident Independence, dated [DATE]. The policy indicated, .Policy Statement .The facility will promote an atmosphere of respect for human dignity in the provision of healthcare and services provide by the facility. Healthcare providers are to encourage resident's independence to increase resident self-esteem and self-confidence .Direct healthcare providers will assist, support and encourage the resident to maintain good standards of personal hygiene and grooming which include: .Bathing .Teeth Care (Oral Care) .Hair Care .Nail care .Proper Toileting .Elimination/Reduction of Body Odors This Federal tag relates to Complaints IN 644, IN 963, and IN 533. 3.,d+[DATE](u)(3)

Based on observation, record review, and interview, the facility failed to ensure gastrostomy tube (g-tube) (a tube inserted directly into the stomach through the abdomen for nutrition) feedings and water flushes were administered as ordered resulting in harm when the resident had [CONDITION(S)] (high sodium levels) and dehydration which resulted in hospitalization for 1 of 1 resident reviewed for tube feeding (Residents 30). Findings include: During a random observation, on 7/21/21 at 10:00 a.m., Resident 30 was lying in bed with her eyes closed. A g-tube pump was observed next to the resident's bed and was not connected to the resident or infusing at this time. Resident 30's record was reviewed on 7/22/21 at 9:31 a.m. A dietician note, dated 3/11/21 at 1:58 p.m., indicated the resident body mass index (BMI) was 30.7. The resident received her primary nutrition and hydration via g-tube. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . for 14 hours and water flushes at 50 ml/hr for 14 hours. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. 4/1/21: 960 ml. b. 4/7/21: 220 ml. c. 4/10/21: 640 ml. d. 4/11/21: 720 ml. e. 4/16/21: 770 ml. f. 4/20/21: 640 ml. g. 4/23/21: 880 ml. h. 4/24/21: 720 ml. A MAR, dated April 2021, indicated to document total water flush given per shift in mls (Runs at 50 ml/hr.), 700 ml daily total. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. 4/1/21: 250 ml. b. 4/7/21: 150 ml. c. 4/8/21: 500 ml. d. 4/10/21: 400 ml. e. 4/14/21: 640 ml. f. 4/16/21: 480 ml. g. 4/2/21: 480 ml. h. 4/23/21: 550 ml. A care plan, dated 4/5/19, indicated the resident had a feeding tube. Interventions included, but were not limited to, administer tube feeding formula and flushes as ordered by physician, dietician to observed adequacy of tube feeding formula and flushes quarterly and as needed with any change of status. A progress note, dated 4/22/21, indicated the resident had a critical lab for sodium level of 167. New order received to administer a bolus of 0.9% normal saline, then run 100 ml/hr. until Saturday. A progress note, dated 4/24/21, indicated the resident's sodium level was 168 and a new order was received to send resident to the emergency room . A facility census indicated the resident was on a medical leave of absence from 4/24/21 to 4/30/21. A hospital admitting history and physical, dated 4/24/21, indicated the resident presented from a nursing home because of increased confusion and less responsiveness. The residents BMI was 28.9 and considered to be overweight. The assessment plan indicated [CONDITION(S)] likely due to dehydration. During an interview, on 7/26/21 at 11:57 a.m., the Registered Dietician (RD) indicated she calculated monthly averages for nutritional intake by mouth verses enteral feeding. She had found a discrepancy with the amounts for enteral feeding that included, but was not limited to, the resident receiving less than feedings and flushes than ordered. There were days the resident had received over the daily amount, under the daily amount, and times where the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She had not seen a change in this concern following it being addressed. She was unsure why the resident became dehydrated. On 7/26/21 at 1:49 p.m., the Director of Nursing (DON) provided a document titled, and last reviewed 6/5/18, Gastrostomy Feeding, and indicated it was the policy currently being used by the facility. The policy indicated, .Guideline Steps .19. Documentation: a. Record and report amount and type of feeding, method of infusion, resident's response to tube feeding, patency of tube, condition of skin at tube site. b. Record volume of formula and any water in the medical record. c. Report type of feeding, status of feeding tube, resident tolerance, and adverse outcomes. On 7/27/21 at 2:18 p.m., the Director of Nursing (DON) provided a document last reviewed 6/22/18, and titled, General Medication Orders, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement: the purpose of this procedure is to establish uniform guidelines in the receiving and recording medication orders. Guideline: .Recording Orders: .7. Commercial Dietary Supplements: When recording orders for commercial dietary supplements, specify the type, the amount and frequency. 3.1-44(a)(2)

Based of observation, record review, and interview, the facility failed to ensure issues were identified in which quality assessment and assurance activities were necessary as evidenced by the severity and number of deficiencies cited and to ensure active quality assessment and performance improvement (QAPI) plans were implemented to prevent deficiencies from re-occurring which resulted in harm when during this recertification and complaint survey, dated 7/20/21 to 7/28/21, 3 of 18 deficiencies were cited at harm level (F684, F690, and F693). Findings include: On 7/27/21 at 1:20 p.m., the Director of Nursing (DON) provided a document, dated 10/2/19, titled, Quality Assurance/Performance Improvement (QAPI) Program, and indicated it was the Quality Assurance/Performance Improvement (QAPI) plan currently being used by the facility. The plan indicated, .Purpose Statement: To provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all service provided by the facility. Policy Statement: It is the intent of this facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate, and improve the quality and appropriateness of resident care. QAPI supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improving the organization's overall performance During this recertification and complaint survey, dated 7/20/21 to 7/28/21, three deficiencies were cited at harm level-F684, F690, and F693. The facility also received fifteen additional deficiencies-F561, F563, F622, F623, F625, F641, F655, F656, F657, F677, F685, F692, F755, F761, and F812. The facility's Quality Assurance Performance Improvement (QAPI) Committee did not identify, develop, and implement appropriate measures to prevent deficiencies as follows: 1. Non-Pressure Skin Conditions: The facility failed to provide nursing services and treatments for a non-pressure diabetic wound with [CONDITION(S)] (an infection in the bone caused by bacteria or fungi) that resulted in harm when the resident developed 2 infections in the wound, [MEDICATION(S)]-resistant enterococcus (vre) (a type of bacteria called enterococci that have developed resistance to many antibiotics, particularly [MEDICATION(S)]) and extended spectrum beta-lactamase (esbl) (enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that doctors use to treat infections) requiring hospitalization and intravenous antibiotics for 1 of 1 resident reviewed for non-pressure skin conditions (Resident 59). Resident 59 developed antibiotic resistant infections in a diabetic wound with chronic [CONDITION(S)] after the facility failed to provide treatments as ordered by the physician. A review of deficiencies cited from a complaint survey, dated March 1, 2, and 3, 2021, indicated F684 was cited when the facility failed to ensure physician's treatment orders were in place for a resident's surgical wound upon admission to the facility. The facility lacked documentation that a QAPI plan had been developed to monitor the following of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Cross reference F684. 2. Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure a suprapubic catheter (a tube inserted through the lower abdomen, into the bladder, to drain urine) was re-inserted timely when it was pulled out resulting in harm when a resident was hospitalized with a urinary tract infection (UTI) for 1 of 2 residents reviewed for urinary catheters (Resident 107). The facility failed to ensure urinary catheter tubing was not in contact with the floor (Resident 107) and to ensure Foley catheter (a tube inserted through the urethra, into the bladder, to drain urine) bags were not in contact with the floor (Resident 106) for 2 of 2 residents reviewed for catheters. Two random observations were made of a resident, with a suprapubic catheter and a history of UTI's, with the catheter tubing being in contact with the floor. The resident's record documented a Certified Nurse Aide (CNA) on the night shift of 7/12/21, discovered the catheter tubing was dislodged and notified the nurse. The tubing was reported to have become dislodged on the shift prior to being identified, but the record lacked documentation of when the catheter had actually become dislodged. The night shift nurse had attempted to re-insert the catheter, but the stoma had closed. It was the next shift when the resident was sent out to the emergency room to address the issue. The resident was diagnosed with a UTI and high blood potassium and admitted to the hospital. The facility lacked documentation that they had identified, developed, or implemented an action plan to address the concerns related indwelling catheter tubing/bags being in contact with the floor or tubing becoming dislodged. Cross reference F690 3. Tube Feeding Management/Restore Feeding Skills: The facility failed to ensure gastrostomy tube (g-tube) (a tube inserted directly into the stomach through the abdomen for nutrition) feedings and water flushes were administered as ordered resulting in harm when the resident had [CONDITION(S)] (high sodium levels) and dehydration which resulted in hospitalization for 1 of 1 resident reviewed for tube feeding (Residents 30). physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility lacked documentation that they had identified, developed, or implemented and action plan to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Cross reference F693 4. Care Plan Timing and Revision: The facility failed to ensure care plan meetings were conducted for 7 of 30 residents reviewed for care plans (Residents 137, 81, 30, 25, 103, 118, and 36). Seven residents were identified whose records lacked documentation that care plan meetings had been held in a timely manner. QAPI Meeting minutes, dated 4/7/21 and again on 5/26/21, indicated under new business, that care plan meetings were to occur timely thru 6/19/21. QAPI Meeting minutes, dated 6/28/21, indicated under old business, care plan meetings were to occur timely. Cross reference F657 During the entrance conference interview with the Executive Director (ED), on 7/20/21 at 9:55 a.m., the ED indicated the QAPI Committee consisted of the ED, Director of Nursing (DON), Medical Director, Dietician, all Unit Managers, and all other department heads. The Committee meets monthly and more often, if needed. All members were encouraged to bring concerns to the meetings, so resolutions could be discussed and/or action plans developed. During an interview, on 7/23/21 at 10:09 a.m., the DON indicated she and the ED had both been at the facility for less than a year. Since they began working together, they had met several times, and discussed areas of concern they had identified. They had both identified that care plan meetings were not being completed since the previous Social Services Director (SSD) had left the position. The Quality Assurance and Performance Improvement (QAPI) Committee had developed a QAPI plan to address the concern in March 2021. 3.1-52(b)(2)

Based on record review and interview, the facility failed to ensure a resident who transferred to the hospital was able to return to the facility, which resulted in harm when the resident unable to be discharged from the emergency room , she did not receive her [MEDICAL CONDITION] medications while at the hospital, after an 8 day hospital stay had manic behaviors resulting being escorted out of the hospital by police officers and sent to jail, then was admitted to a different hospital, and eventually placed in a facility hours away from family for 1 of 3 residents reviewed for residents permitted to return to the facility (Resident B). Findings include: Resident B's record was reviewed, on 11/17/20 at 9:43 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/2/20, indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. A care plan, revised 7/13/20, indicated the resident received an antidepressant medication related to major [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. A care plan, revised 7/13/20, indicated the resident had a [DIAGNOSES REDACTED]. Interventions included, but were not limited to, administer medications as ordered. A fall incident report, dated 8/11/20 at 1:40 p.m., indicated the resident had a fall. The report indicated the resident's physician and family were notified on 8/12/20. A Notice of Transfer or Discharge, dated 8/11/20, indicated the resident was transferred to another health facility, a local hospital. The transfer or discharge was necessary to meet the resident's welfare and resident's needs cannot be met in the facility. An appeal rights indicated the facility must attach the following documents to this Notice of Transfer or Discharge: Attach State Form Notice of Transfer or Discharge Request for Hearing. The notice of transfer or discharge request for hearing, dated 8/11/20, indicated the resident received a notice of transfer or discharge from the health facility informing her that she was going to be transferred or discharged from the facility and the resident hereby requested a hearing on the facility's decision to transfer or discharge her from the health facility. An untitled document, dated 8/11/20 and untimed, indicated the resident had a fall and 911 was called for emergency medical service assistance due to the resident's complaints of pain in her lower back and hip area. The resident was sent to the emergency department (ER) for assessments and treatment. While picking up the resident's rollator walker, the Administrator noticed smoking contraband that had fallen out of a pouch that had been attached to the walker. During the inspection 3 full and half cigarettes, and one lighter were found inside the pouch. Due to the findings the Administrator, Social Services Director (SSD)4, SSD 8, and Registered Nurse (RN) Unit Manager 9 conducted a thorough search of the resident's room. During the search of the resident's property many other items were found that violated the smoking policy and safety related restrictions. These found items included: 1. Large Styrofoam cup filled with Vodka (alcohol). 2. Cigarette lighters. 3. Rolled aluminum foiled with a chard end that smelled of marijuana or tobacco. 4. A razor knife. 5. A steak knife. 6. A 7-up can that was fashioned as confiscating device with a screw one top. The inside smelled of marijuana. 7. An empty cigarette with tobacco residue. 8. A shot glass. 9. A screwdriver. 10. 3 prescription medication bottles that contained Abreva cream ([MEDICAL CONDITION] drug), [MEDICATION NAME] (antibiotic) eye drops and [MEDICATION NAME] (Nonsteroidal anti-[MEDICAL CONDITION] drug) solution. 11. 4 packages of [MEDICATION NAME] powder (stool softener). 12. Smoke bomb (fire work). Due to the findings the facility elected as an operation to discharge the resident from the facility immediately. The Administrator notified the hospital the resident was transferred to, Sate Ombudsman, the son, the local Health Department, and the facility legal and compliance teams to make them aware of the findings and decision. On 8/18/20 it was reported to the Administrator from the hospital the resident had attempted to elope from the hospital and resulted in an altercation with security staff and was sent to the local county jail as a result. Later in the day of 8/18/20 another local hospital called to verify the facility would not accept the resident back to the facility and the facility declined. The facility had done everything possible to support the resident and her family in finding placement and meeting all needs. At this time, the facility would not be accepting the resident back at any time. A discharge MDS assessment, dated 8/11/20, indicated there was no active discharge planning already occurring for the resident to return to the community. A review of the resident's clinical record lacked documented evidence that indicated discharge planning had been completed. A hospital history and physical document, dated 8/11/20, indicated the resident had been transferred to ER with complaint of back and head pain. The document indicated the resident was unable to be transferred back to the long-term nursing home facility due to an immediate termination and was placed on a hold in the emergency department due to the resident trying to leave. Per behavioral health at the hospital, the resident was no threat to self or others, and had no acute [MEDICAL CONDITION] and had not met admission criteria for [MEDICAL CONDITION]. Active scheduled inpatient medications indicated none reported. A hospital discharge note dated 8/18/20. indicated the resident was admitted to the hospital after being discharged from a skilled nursing facility for having cannabis and other barbiturate paraphernalia in her room. The resident had a mild acute kidney injury and fall and was given intravenously hydration and improved. Efforts were made to place the resident in another facility, however because of behavioral issues it was very difficult. On 8/18/20 the resident had an altercation with security, police were called and allegedly the resident assaulted a police officer and was subsequently arrested and escorted out of the hospital. The resident was deemed to have left against medical advice. A Findings of Fact, Conclusions of Law and Recommended Order, dated 9/24/20, indicated, .Following the untimely discharge from the Facility, Resident (initials) failed to get her medications for her mental health conditions for a period of days which had a detrimental affect sending her into a [MEDICAL CONDITION] manic phase which required police intervention, a trip to (County name) Jail until it was determined that Resident (initials) would be more appropriately placed on a psychiatric ward at (name off second hospital) (second hospital name) was also inappropriate placement for Resident (initials) as it was determined that due to her co-ocurring Alzheimer's [DIAGNOSES REDACTED].and eventually released upon her being stabilized to the only skilled nursing facility that had agreed to accept her The new skilled facility was approximately two and a half hours away. The Administrative Law Judge recommended the following order: The discharge request of the long-term care facility as to Resident B should be denied and the resident should be allowed to return to the long-term care facility from her current placement. During an interview, on 11/19/20 at 8:49 a.m., the Corporate Care Consultant indicated the resident was transferred to the hospital on [DATE] due to a fall. After the transfer the Administrator and other staff found contraband items in the resident's room. The facility felt it was unsafe for the resident to return to the facility and the hospital was notified shortly after the resident transferred there that the resident would not be able to return to the facility. No 30-day notice was provided to the resident and resident's representative and she could not find where a discharge summary had been completed. She could not find documentation in the resident's clinical record of completed documentation of the discharge by a physician. She was unsure if there had been any correspondence of the resident returning to the facility, and from her understanding the resident had not qualified to be readmitted to the facility. During an interview, on 11/19/20 at 2:50 p.m., Resident B's son indicated he was the resident's POA. His mother had been transferred to a hospital after a fall on 8/11/20. The facility had done a search of his mother's room after she was transferred and indicated they had found items she should not have in her room and they immediately discharged her. He never received any written documentation of this, nor was his mother provided with a 30-day notice of the discharge. The facility had not helped find another place for the resident to reside and did not let his mother return to the facility during the appeal process of the discharge. He indicated she had not received her medications during her stay at the hospital and had been placed in a posy (enclosed) bed which scared her. He felt between not receiving her [MEDICAL CONDITION] medications and being kicked out of her home (at the long-term care facility) she became manic from her [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The resident had not assaulted a police officer and was unsure why that had been said. From the county jail the resident was sent to another hospital. He was not sure why the hospital had not given her medications to her but felt if she had not been uprooted from her home none of this would have happened. The facility she was currently at was across the state and hours away. It had sent a request for admission back to the facility that discharged her without notice, but within minutes the facility denied the request for readmission. On 11/18/20 at 10:53 a.m., the Corporate Care Consultant provided a document titled, Transfer/Discharge Notice, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: Statement: The appropriate notice will be provided if it is necessary to transfer or discharge a resident(s) from a facility .Guideline: 1. Before the transfer or discharge occurs, the facility will notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. a. The facility's notice will include an explanation of the right to appeal the transfer to the State as well as the name, address, and phone number of the State Long-Term Care Ombudsman .b. The facility may not transfer or discharge a resident while an appeal is pending. 2. Contents of the notice include: a. Reason for transfer or discharge: b. Effective date of transfer or discharge; c. Statement of resident's appeal rights; d. Name, address and telephone number of the Office of the State Long-Term Care Ombudsman .f. If resident has a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individual with a mental disorder 4. The reasons for the transfer or discharge will be documented in the resident's medical record. 5. The notice will be provided at least 30 days prior to the transfer .Documentation: 1. Documentation of transfers includes: a. The reason for transfer or discharge .2. documentation of resident transfers or discharges in the medical record will be made by the following: a. The resident's physician when transfer or discharge is necessary, and b. A physician when transfer or discharge is necessary. 3. Information provided to the receiving facility should include: a. Contact information of the practitioner responsible for the care of the resident. b. Representative information including contact information. c. Advanced directive information. d. Special instructions for ongoing care. e. Comprehensive Care Plan goals. f. Any other applicable information, including discharge summary, as applicable, to ensure a safe and effective transfer .7. Documentation of the transfer/discharge may be completed by a physician extender This Federal tag relates to Complaint IN 593. 3.1-12(a)(26)

Based on observation, record review, and interview, the facility failed to ensure smoking materials were secured and adequate monitoring and supervision were provided for 3 of 9 residents (Residents B, C, and D) reviewed for safe smoking. This resulted in Resident B smoking in bed with oxygen in place, igniting a fire to Resident B's face and bed and causing a second degree burn (a partial thickness burn that affects the lower layer of the skin and can cause pain, redness, and swelling) to the nose and additional unspecified degree [MEDICAL CONDITION] the head, face, and neck. The Immediate Jeopardy began on 5/18/20, when Resident B attempted to smoke a cigarette in her room. This ignited the resident's oxygen resulting in a fire to the resident's face and bed. Resident B sustained second [MEDICAL CONDITION] her nose and an unspecified degree of burn to the head, face, and neck. Resident B was sent to the local hospital and then transferred by critical care ambulance to a burn unit at a specialty hospital. The Administrator, Director of Nursing, and Corporate Nurse Consultant were notified of the Immediate Jeopardy at 5:14 p.m. on 5/19/20. The immediate jeopardy was removed on 5/19/20, but noncompliance remained at a lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B's record was reviewed on 5/19/20 at 12:03 p.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 3/24/20, indicated the resident was cognitively intact and received oxygen therapy. A current face sheet, as of 5/19/20, indicated the resident was a current, every day smoker. A smoking assessment, dated 6/12/19, indicated the resident was able to smoke safely and did not require supervision. Smoking materials were to be kept at the nurses' station or a designated location, and oxygen was to be removed prior to smoking. A physician's orders [REDACTED]. A document titled, SMOKING, was signed by the resident and facility staff on 6/12/19. The document indicated smoking was prohibited inside the facility and on the property, all smoking materials were to be kept secured by facility staff and were not to be kept in the resident's possession, a care plan would be developed to include smoking materials to be secured in a locked box and immediately secured upon the resident's return to the facility from smoking, violation of the policy should be reported immediately to the Administrator and would result in discharge from the facility. A care plan, dated 6/13/19, and last revised 5/19/20, indicated the resident was a smoker and was at risk for safety concerns related to desire to smoke and was designated as a safe smoker. Interventions, dated 6/13/19, included, but were not limited to, resident observed every shift for safety, obtain physician's orders [REDACTED]. to the facility staff following smoke breaks. A physician's orders [REDACTED]. Smoking assessments, dated 11/20/19, 1/13/20, 1/22/20, and 2/22/20, indicated the resident was able to smoke safely and did not require supervision. Smoking materials were to be kept at the nurses' station or a designated location, and oxygen was to be removed prior to smoking. A nursing note, dated 5/18/20, indicated at approximately 5:00 a.m., the fire alarm sounded and the resident cried out for help. The resident was found sitting on the floor in the doorway of her room, with noticeable smoke coming from the room. The resident had blackened areas on her face around her lips and up to her nose. The resident admitted she had been smoking and reported difficulty breathing. The resident was removed from the area, and another staff member retrieved a fire extinguisher and put out the fire in the resident's room. The fire department and emergency medical services (EMS) arrived within minutes, and the resident was immediately transported to the hospital. All other residents were evacuated from the hallway to the dining room. The resident was last seen prior to the incident by a Certified Nursing Assistant (CNA) at 4:35 a.m., with nothing unusual noted. During the investigation, smoking materials were found in the resident's room. The fire was observed to be contained to the resident's bed. An emergency room (ER) report, dated 5/18/20, indicated the resident had an endotracheal (ET) tube (a breathing tube inserted through the windpipe to deliver oxygen to the lungs) placed. The assessment indicated the resident had second [MEDICAL CONDITION] the nose and an unspecified degree of [MEDICAL CONDITION] the head, eyes, ears, nose, and throat. There was soot present on both cheeks and nasal hair singeing. A preliminary report from the ER, dated 5/18/20, indicated the resident needed to be transferred to a burn center. The resident was transferred by critical care ambulance to another hospital. On 5/19/20 at 10:57 a.m., Resident B's room, prior to her hospital admission, was observed. The room was in the process of being repaired. A magnet on the door frame indicated no smoking related to oxygen in use. During an interview, on 5/19/20 at 3:30 p.m., Resident B was observed back from the hospital and lying in bed, with red scabbed areas around her nose and mouth. At the same time, Resident B indicated the night before the fire, she went out to smoke with her roommate and had not turned her smoking materials back in. She kept the cigarettes and lighter in her pocket. No staff was at the front desk, and no staff members asked her for her smoking materials. Sometime through the night, she woke up and lit a cigarette, which started a fire. She rolled out of bed, into the hallway, and yelled for help. Resident B indicated she had pain at a nine on a pain scale of one to ten. 2. Resident C's record was reviewed on 5/19/20 at 12:34 p.m. [DIAGNOSES REDACTED]. to think, feel, and behave clearly) unspecified, and nicotine dependence unspecified uncomplicated. An annual Minimum Data Set (MDS) assessment, dated 5/1/20, indicated the resident was cognitively intact. A smoking assessment, dated 5/15/19, indicated the resident was able to smoke safely and did not require supervision. Smoking materials were to be kept at the nurses' station or a designated location. A care plan, dated 5/15/19, and last reviewed on 5/18/20, indicated the resident smoked and was at risk for safety concerns related to the desire to smoke and was designated as a safe smoker. Interventions included, but were not limited to, obtain a physician's orders [REDACTED]. A document titled, SMOKING, was signed by the resident and facility staff on 5/16/19. The document indicated smoking was prohibited inside the facility and on the property, all smoking materials were to be kept secured by facility staff and were not to be kept in the resident's possession, a care plan would be developed to include smoking materials to be secured in a locked box and immediately secured upon the resident's return to the facility from smoking, violation of the policy should be reported immediately to the Administrator and would result in discharge from the facility. Smoking assessments, dated 7/20/19, 11/06/19, and 1/20/20, indicated the resident was able to smoke safely and did not require supervision. Smoking materials were to be kept at the nurses' station or a designated location. A physician's orders [REDACTED]. Smoking assessments, dated 2/20/20, 5/01/20, and 5/18/20, indicated the resident was able to smoke safely and did not require supervision. Smoking materials were to be kept at the nurses' station or a designated location. A document titled, SMOKING, was signed by the resident and facility staff on 5/18/20. The document indicated smoking was prohibited inside the facility and on the property, all smoking materials were to be kept secured by facility staff and were not to be kept in the resident's possession, a care plan would be developed to include smoking materials to be secured in a locked box and immediately secured upon the resident's return to the facility from smoking, violation of the policy should be reported immediately to the Administrator and would result in discharge from the facility. On 5/19/20 at 2:43 p.m., Resident C was observed to sign out on the LOA log, retrieve her smoking materials, and go out to smoke independently. During an interview, on 5/19/20 at 11:08 a.m., Resident C indicated Resident B was her roommate. Resident C was out of the room when the fire occurred. She has smoked since she admitted to the facility. They used to be able to keep their smoking materials, cigarettes and lighters, with them in their rooms, but now they have to turn everything into the front desk. This all changed yesterday after the fire. Until yesterday, she was not aware she should not have kept her cigarettes and lighter with her. No staff had ever said anything to her about it. During an interview, on 5/19/20 at 11:53 a.m., Resident C indicated the night before the fire, she and Resident B went out to smoke. They kept their smoking materials, as usual, and returned to their room. She had never kept her smoking materials locked up prior to this incident, and had not been offered a place to lock them up. 3. Resident D's record was reviewed on 5/19/20 at 4:28 p.m. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 3/16/20, indicated the resident was cognitively intact and received oxygen therapy. A physician's orders [REDACTED]. An undated physician's orders [REDACTED]. A care plan, dated 2/28/20, and last reviewed on 5/18/20, indicated the resident smoked and was at risk for safety concerns related to the desire to smoke, and the resident was designated as an impaired smoker related to the failure to smoke in designated areas. Interventions included, but were not limited to, obtain physician's orders [REDACTED]. A document titled, SMOKING, was signed by the resident and facility staff on 3/26/20. The document indicated smoking was prohibited inside the facility and on the property, all smoking materials were to be kept secured by facility staff and were not to be kept in the resident's possession, a care plan would be developed to include smoking materials to be secured in a locked box and immediately secured upon the resident's return to the facility from smoking, violation of the policy should be reported immediately to the Administrator and would result in discharge from the facility. A smoking assessment, dated 3/26/20, indicated the resident was able to smoke safely and did not require supervision. Smoking materials were to be kept at the nurses' station or a designated location. A smoking assessment, dated 5/18/20, indicated the resident was able to smoke safely and did not require supervision. Smoking materials were to be kept at the nurses' station or a designated location. During an interview, on 5/19/20, at 2:37 p.m., Resident D indicated he had smoked since he was admitted to the facility. He smoked independently. There had been a fire a day ago because another resident smoked in her room, and after that a new policy was started where the residents were not allowed to keep their smoking materials in their rooms. Prior to the incident, he kept one pack of cigarettes and a lighter in his room with him. He kept any extra cigarette packs at the front desk. He had lived at the facility for about three months, and when he was admitted he was told it was fine to keep his smoking materials in his room. He was never offered a lockbox or anywhere secure to keep the smoking materials in his room. He kept them in the drawer of his dresser. During an interview, on 5/19/20 at 10:59 a.m., Licensed Practical Nurse (LPN) 5 indicated she was working the hall Resident B was on prior to her hospital admission. She was not sure which residents on the hall smoked, because she had not worked the hall very many times. Smoking materials were supposed to be kept at the front desk with the receptionist during the day and at the south nurses' station at night. She was not sure if that was a new policy. She was not sure what happened during the fire incident. During an interview, on 5/19/20 at 11:21 a.m., Hospitality Aide 6 indicated she was familiar with Residents B and C. Prior to yesterday, Resident C always had her lighter and cigarettes with her and had not turned them into the front desk. The residents were supposed to give smoking materials to the receptionist during the day and the south unit nurse at night after they were done smoking, but this was not always done. She was not sure if this was a new policy. Some residents had kept smoking materials with them since she started working at the facility about a month ago. She was not aware Resident B smoked. During an interview, on 5/19/20 at 11:25 a.m., Certified Nursing Assistant (CNA) 7 indicated she had worked at the facility for about a week and a half. She was aware Residents B and C smoked and normally kept their smoking materials in their room, and was told during her training this was acceptable. During an interview, on 5/19/20 at 12:45 p.m., Receptionist 4 indicated all residents were supposed to turn in their smoking materials to her after they were done smoking during the day and to the south unit nurse at night; however, they had not always done this. Residents B and C often kept their smoking materials with them. When residents kept their smoking materials, she was supposed to report it to the Administrator. As of 5/18/20, residents turned in their smoking materials after they were done smoking. During an interview, on 5/19/20, at 2:45 p.m., a tackle box was observed to contain resident smoking supplies at the front desk. At the same time, Receptionist 9 indicated all smoking materials were kept in the tackle box. When the receptionist went home, the tackle box was taken to the south unit. During an interview, on 5/19/20 at 3:05 p.m., the Administrator indicated she received a call from the facility between 5:10 a.m., and 5:15 a.m., on 5/18/20, and was notified there had been a fire. She instructed staff to evacuate the residents on the unit to the dining room. Fire alarms sounded at 5:09 a.m., and the fire department arrived at the facility at 5:14 a.m. Staff extinguished the fire to Resident B's bed with a fire extinguisher. Resident B returned to the facility today. Resident B lit a cigarette during the night on 5/18/20, which ignited her oxygen, causing a fire. The resident made it out to the hallway and was provided assistance. The resident had not smoked in the building prior to this incident. All smokers were required to sign an agreement that smoking materials would be turned in after they smoked. The staff were doing weekly room sweeps to ensure smoking materials are not in the residents' rooms. This was being done occasionally prior to the incident, but not weekly. She was not aware Residents B, C, and D had not typically turned in their smoking materials prior to the incident. This should have been reported to her by the receptionist. Since the incident, the receptionist was to stop residents and request their smoking materials back after they were done smoking. This had not happened consistently before 5/18/20. Regardless of whether or not residents were assessed as safe smokers, they were not to keep smoking materials in their rooms. At the same time, the Director of Nursing (DON) indicated there were currently eight residents who smoked independently, not including Resident B. Resident B planned to not smoke anymore since her return to the facility. On 5/19/20 at 2:55 p.m., the DON provided a document titled, SMOKING, and indicated it was the policy currently being used by the facility. The policy indicated, Provided to Residents and Families Upon Admission .Smoking is prohibited inside the Nursing Facility and on .property. A licensed nurse will complete a Safe Smoking Evaluation at the time of admission, quarterly thereafter and with any change of condition, a licensed nurse will contact your primary care physician upon admission/readmission to request an order for [REDACTED].are to be secured by facility staff. Smoking materials are prohibited to be kept in the Resident's possession. A licensed nurse will develop a Care Plan with Interventions which will include keeping all smoking materials secured in a locked box. Your Smoking materials will be available to you when you go LOA. Materials must be secured immediately upon your return to the facility. Violation of this Smoking Notice will be reported immediately to the Administrator. The violation will result in discharge from the facility. The Immediate Jeopardy that began on 5/18/20 was removed on 5/19/20 when the facility completed staff education on the facility smoking policies and practices, identifying all resident smokers, checking BIMS levels, and conducting reassessments using the Safe Smoking Assessment, updating the care plans, conducting room sweeps for smoking materials, and re-educating smoking residents on the smoking policy and storage of smoking materials. The Immediate Jeopardy was removed on 5/19/20, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because of the need to further monitor staff and residents for compliance to the smoking policies and procedures This Federal tag relates to Complaint IN 995. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from significant medication errors for 1 of 7 residents reviewed for significant medication errors when Resident B did not receive doses of medications to treat high blood pressure, heart rhythm, and chest pain resulting in a high blood pressure that the facility failed to notify the physician of and follow up on. The resident was found unresponsive the following morning and expired (Resident B). The Immediate Jeopardy began on [DATE], when scheduled daily doses of [MEDICATION NAME] (medication to treat high blood pressure, and chest pain) and magnesium (a mineral that helps keep blood pressure normal and heart rhythm steady) for a resident with a magnesium deficiency and hypertension were not given from [DATE] through [DATE]. The medications were not pulled from the Emergency Drug Kit or ordered from the pharmacy. The resident had elevated blood pressure. The physician was not notified of the missed doses of medications or the elevated blood pressure and the following morning the resident was found unresponsive and expired. The Administrator, Director of Nursing (DON), Director of Clinical Operations, and Regional Vice President were notified of the Immediate Jeopardy at 1:53 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy Findings include: On [DATE] at 9:49 a.m., Resident B's closed clinical record was reviewed. The resident's [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B had moderate cognitive impairment. A 14 day MDS assessment, dated [DATE], indicated Resident B had severe cognitive impairment. A care plan that addressed the resident's medical conditions had not been done. During an interview on [DATE] at 1:20 p.m., the DON indicated it should have been completed seven days after the first comprehensive assessment completed on [DATE]. Physician's orders on the [DATE], recapitulation, included, but were not limited to: Full code; [MEDICATION NAME] tablet 25 milligrams (mg) orally for secondary hypertension, once a day with an order date of [DATE]; and magnesium 200 mg for magnesium deficiency once a day with an order date of [DATE]. A physician's progress note, dated [DATE], included but was not limited to: . 3. [MEDICAL CONDITION], unspecified type Notes: Patient stable. Continue current tx (treatment) and monitor. 4. Other secondary hypertension Notes: BP (blood pressure) stable at present. BP today ,[DATE]. Will continue same tx and monitor The electronic Medication Administration Record [REDACTED]. Both of the entries were created by Qualified Medication Aide (QMA) 4. The medications were documented as given on [DATE] and [DATE]. Documentation on a form titled, Delivery Manifest Report Details ., provided by the Medical Records nurse on [DATE] at 1:16 p.m., included but was not limited to, [MEDICATION NAME] 25 mg tab 30 and [MED] 400 mg [CONDITION] 15 delivered to the facility for Resident B on [DATE]. The Director of Nursing (DON) was interviewed on [DATE] at 1:20 p.m., and indicated there was no evidence of the medications being sent to the facility at any other time. The resident's Medication Disposition Record, (a record utilized to document what unused medications were returned to the pharmacy after a resident's discharge) provided by medical records on [DATE] at 2:00 p.m., did not include the medications MG oxide or [MEDICATION NAME] as returned to the pharmacy. The record lacked documentation of how the resident would have received magnesium or [MEDICATION NAME] tablets on [DATE] and [DATE]. Documentation of the resident's vital signs included daily blood pressures. The average daily readings for [DATE] ranged from ,[DATE] millimeters of [MED] (mmHg) to ,[DATE] mmHg. On [DATE] at 6:55 a.m., her blood pressure was ,[DATE] mmHg. On [DATE] at 8:54 a.m. her blood pressure was ,[DATE] mmHg. On [DATE] at 11:56 a.m. her was blood pressure was ,[DATE] mmHg. No physician orders to check daily blood pressure or to call for elevated blood pressure was found. No documentation of physician notifications were found for [DATE] or [DATE]. Documentation in the resident's electronic clinical record's progress note, dated [DATE] at 8:00 a.m., included but was not limited to, .at 7:10 this am. was alerted by CNA (certified nursing assistant) that a nurse was needed in res (resident) room. Upon entering room res was leaying (sic) on her back in bed. There was nopulse (sic) or resp. (respirations) Res a full code so CPR (cardiopulmonary resuscitation) was started. At 7:15 Paramedics arrived at facility and took over code. CPR was cont (continued) for 26 mins (minutes) paramedic call (sic) (hospital name) and talked with DR (name) and let him know the situation and that all efforts to attempt res had failed. Dr gave the ok to call time of death at 7:36 a.m Documentation on the resident's Death Certificate listed the cause of death as ischemic and hypertensive cardiovascular disease. During an observation and interview on [DATE] at 11:00 a.m., with Licensed Practical Nurse (LPN) 2, the Emergency Drug Kit in the South Unit's locked medication room was observed. The locked tackle-like box was opened, and a sheet containing the list of available medications was reviewed. The list included [MEDICATION NAME] 25 mg tablet - quantity 10. The LPN indicated QMAs were not allowed to utilize the EDKs, but were to notify a nurse of a missing medication, who would then obtain the medication for the QMA to administer. During an interview on [DATE] at 1:24 p.m., QMA 4 indicated QMA's do not use the EDK. If a medication was not available she would reorder the medication, tell the nurse she didn't have it, and mark the medication as unavailable. If the nurse had brought her the medication the entry would have been amended to show the medication was given. During an interview on [DATE] at 3:18 p.m., the Director of Nursing (DON) indicated [MEDICATION NAME] 25 mg had not been taken from the EDK and there was no evidence of the [MEDICATION NAME] 25 mg or the magnesium 200 mg being reordered from the pharmacy. The daily blood pressure checks had been a nursing measure implemented for residents who received antihypertensive medications. The Medical Director was interviewed on [DATE] at 1:32 p.m., and indicated he did not believe the missed doses of the medications caused the resident's death. A facility's current policy titled, Emergency Pharmacy Service and Emergency kits (E-Kits), dated 2007, provided by the Medical Records Nurse on [DATE] at 9:27 a.m., included but was not limited to, .5. Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency kit or from the provider pharmacy A facility's current policy titled, Medication Orders Non-Controlled Medication orders, dated 2007, provided by the Medical Records Nurse on [DATE] at 1:24 p.m., included but was not limited to, .4. The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility completed an audit of all Medication and treatment administration records for the last 7 days and contacted the physicians regarding any medications identified as not available. Medication carts were audited to ensure the availability of all medications and treatments. A vitals out of range report was completed and physicians notified of any findings. Medication administrations were observed to ensure competency of nursing staff with no significant medication errors identified. Education was provided to all licensed nursing staff regarding significant medications, vital sign parameters set in MatrixCare (electronic clinical record) and Qualified Medication Aides to alert nursing staff of unavailable medications. Education was provided to licensed nurses on the emergency drug kit policy, retrieving medications for the QMAs, and to notify the physicians when medications were not available. Nursing management started running daily progress reports to review entries, compare daily vital signs out of range notifications and to ensure physicians were notified timely. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy for continued medication administration observations, monitoring of vital signs out of range and physicians notifications, adherence to the EDK and Medication Orders Non-Controlled Medication Orders policies, physician notifications of unavailable medications, and in-service training to ensure all staff have received training on the policies and procedures. This Federal tag relates to Complaint IN [AGE]2. 3XXX,[DATE](c)(2)

Based on record review and interview, the facility failed to ensure a prescribed medication was obtained and administered to prevent significant medication errors. This resulted in an untreated blood sugar of 300 and the resident was discharged from the facility without receipt of medication prescribed for management of diabetes for 1 of 5 residents reviewed for medication errors (Resident B). Finding includes: Resident B's record was reviewed on 9/18/15 at 9:45 a.m. The record indicated Resident B was admitted to the facility on [DATE] at 7:00 p.m. An admission nursing note, dated 8/25/15, indicated Resident B was alert and oriented to person, place, and time, but had some difficulty with short term memory. The admission note indicated, .orders verified per (name of physician) [DIAGNOSES REDACTED]. Hospital discharge orders, dated 8/25/15 at 4:30 p.m., indicated, .34 UNITS [MEDICATION NAME] R U-500 PTS (patient's) OWN MED (medication) TAKES IN AM AND AT LUNCH. [MEDICATION NAME] R U-500 25 UNITS AT SUPPER. [MEDICATION NAME] R U-500 SLIDE SCALE IS BS (blood sugar) > (greater than) 150 SUBTRACT 100 FROM BS THEN DIVIDE THAT BY 20 TO GET DOSE, IF BS< (less than) 70 TAKE 7 UNITS OFF SCHEDULED DOSE The Medication Administration Record [REDACTED]due to MD (Medical Doctor). The MAR indicated [REDACTED]. The MAR indicated [REDACTED] 1. Sliding scale dose not required at 7:00 a.m. The MAR indicated [REDACTED]. 2. At 8:00 a.m., the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. 3. At 11:30 a.m., the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. 4. At 12:00 p.m., the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. 5. At 3:00 p.m., the MAR indicated [REDACTED]. The record indicated the blood sugar was 300 (high). 6. At 5:00 p.m., 25 units was not given and was coded, HELD SEE NURSES NOTES. The record did not indicate the resident's blood sugar level. A nurses' note, dated 8/26/15 at 10:00 a.m., indicated Resident B's blood sugar was 133. A nurses' note, dated 8/26/15 at 12:00 p.m., indicated Resident B's blood sugar was 300 and indicated the endocrinologist (diabetes specialist) was contacted at 10:45 a.m. regarding changing the prescribed insulin. The noted indicated the endocrinologist did not want the insulin changed due to irregularity of the resident's blood sugars. The record did not indicate the facility administered the prescribed [MEDICATION NAME] R U-500. The nurses' note indicated the primary care physician was notified at 12:28 p.m. and order was received to send the resident to a facility that could give the prescribed insulin. A nurses' note, dated 8//26/15 at 3:00 p.m., indicated the primary care physician ordered [MEDICATION NAME] 10 units subcutaneously (under the skin) stat (immediately). The record indicated the resident refused the alternate insulin. A nurses' note, dated 8/26/15 at 6:00 p.m., and identified as a Late entry, indicated, .Unit Manager called (name of physician) et (and) received order to discharge resident to (name of hospital). A physician order, dated 8/26/15 at 6:00 p.m., indicated Resident B was to be discharged from facility and sent to the hospital emergency room . A nurses' note, dated 8/26/15 at 6:35 p.m., indicated an order to send Resident B to the hospital emergency department due to unable to accept resident and administer [MEDICATION NAME] R U-500. During an interview on 9/17/15 at 2:25 p.m., the Director of Nursing (DON) indicated the Marketing and Admissions Director accepted Resident B to the facility. The DON indicated the Marketing and Admissions Director was unaware the facility was unwilling to administer [MEDICATION NAME] R U-500 insulin and indicated Resident B refused alternative insulin not prescribed by his endocrinologist. The DON indicated the facility was not able to provide the recommended medication and transferred the resident to the hospital. The DON indicated the facility did not have a written policy regarding refusal of care to residents receiving [MEDICATION NAME] R U-500 insulin. During an interview on 9/18/15 at 11:15 a.m., LPN #1 indicated Resident B was transferred to the hospital emergency department because the facility could not give him the prescribed insulin and the resident refused an alternate insulin. During a confidential interview on 9/18/15 at 12:07 p.m., the caller indicated hospital emergency department staff indicated Resident B would not be admitted to the hospital, and the resident left without being assessed by medical staff. The caller indicated the resident did not return to the nursing facility because he had been discharged and indicated the resident was staying in the home of a friend. 3.1-48(c)(2)

Based on observations, interview, and record review, the facility failed to monitor skin and ensure interventions to prevent a stage II pressure sore and failed to ensure updated care plans and interventions to promote healing of pressure wounds for 2 of 3 sampled residents reviewed for pressure ulcers (Resident A and Resident B). Findings include: 1. Resident A was observed on 02/12/13 at 11:05 a.m., receiving treatment to a dark purple, stage II, pressure ulcer on her right ear. According to a Weekly Pressure Ulcer Report, dated 02/12/13, the wound on the ear measured 0.5 cm (centimeters) x (by) 0.4 cm x < (less than) 0.1 cm (depth). During observations on the 300 hall on 02/13/13 at 11:30 a.m., hearts were observed on door frames of some resident rooms. CNA #1 indicated the heart represented the resident had pressure areas or was at risk for pressure areas. Resident A's door frame was missing a heart to show she had pressure areas. Resident A's clinical record was reviewed on 02/12/13 at 10:10 a.m. The record indicated the resident had [DIAGNOSES REDACTED]. Resident A's most recent admission Minimum Data Set (MDS) assessment, dated 11/30/12, indicated the resident was severely cognitively impaired and was at risk for pressure ulcers. The Resident Weekly Skin Check Sheets, dated 01/07/13, 01/14/13, 01/21/13, and 01/28/13, indicated no open areas. Shower Body Assessment Tools, used by the CNA's for any open, reddened, bruised areas or tears/cuts, dated 01/01/13, 01/04/13, 01/08/13, 01/11/13, 01/15/13, 01/18/13, 01/22/13, 01/25/13, 01/29/13 indicated, "ok" (no areas). Resident A's Weekly Pressure Ulcer Report, dated 01/31/13, indicated the wound on the right ear measured 0.8 cm (centimeters) x (by) 0.6 cm x < (less than) 0.1 cm (depth). Resident A's Weekly Pressure Ulcer Report, dated 02/12/13, indicated the wound on the right ear was dark purple in color and measured 0.5 cm x 0.4 cm x < 0.1 cm (depth). A care plan for altered skin integrity, dated 01/31/13, developed after pressure ulcers were identified, lacked interventions for a heart on the door frame to alert staff of the resident's pressure risk and lacked interventions specific to reducing pressure to the right lower extremity and left heel. During an interview on 02/13/13 at 11:45 a.m., LPN #2 indicated Resident A's daughter found the pressure area on the right ear after accompanying the resident to a medical appointment on 01/31/13. The record indicated the facility did not identify the pressure ulcers prior to 01/31/13. The LPN indicated Resident A should have been turned and repositioned every 2 hours. She indicated the facility did not have a system to ensure/document the resident was repositioned every 2 hours. During an interview on 02/13/13 at 11:48 a.m., LPN #2 indicated a heart on the door frame indicated the resident was at risk for or had a pressure ulcer. She indicated she did not know why Resident A's door frame lacked a heart signifying pressure risk/presence. During an interview on 02/13/13 at 4 p.m., the Director of Nursing (DON) indicated a stage II pressure ulcer was identified on Resident A's right ear on 1/31/13 and indicated it was caused by the resident's oxygen tubing. 2. During observations on 02/13/13 at 11:20 a.m., LPN #1 was observed providing wound care to a stage II pressure ulcer on Resident B's right lower buttocks. Review of Resident B's clinical record, on 02/12/13 at 2:30 p.m., indicated the resident had [DIAGNOSES REDACTED]. Resident B's most recent MDS assessment, dated 12/10/12, indicated the resident was at risk for pressure ulcers. Resident B's Weekly Pressure Ulcer Report indicated the right lower buttock pressure ulcer was found on 11/06/12 and measured 0.6 cm x 0.6 cm x < 0.1 cm. A Weekly Pressure Ulcer Report, dated 02/13/13, indicated, the pressure ulcer increased in size and measured 1.6 cm x 1.1 cm x < 0.1 cm. Resident B's care plan for ulcer pain, dated 11/06/12, indicated interventions which included, but were not limited to, documentation of treatment on the Treatment Administration Record (TAR) and treatment as ordered by the physician. A physician order [REDACTED]." The TAR dated November 2012, indicated the physician ordered treatments were not completed on 11/10/12, 11/12/12, 11/19/12, 11/28/12, and 11/30/12. . This federal deficiency is related to Complaint IN 529 and Complaint IN 562. 3.1-40(a)(1) 3.1-40(a)(2)