Every finding on record at Silver Oaks Health Campus

Based on observation, interview, and record review, the facility failed to ensure call light accessibility for a resident with a history of frequent falls for 1 of 17 residents reviewed for accommodation of needs. (Resident 61)Findings include:On 05/08/2026 at 2:20 P.M., during an observation, the resident was seated in his recliner with his eyes closed. The recliner control was next to him, but the call light was on the floor behind the wheelchair, approximately six feet away.On 05/08/2026 at 2:52 P.M., during another observation, the resident remained seated in the recliner with his eyes closed, and the call light continued to be located on the floor behind the wheelchair, six feet away. On 05/08/2026 at 2:54 P.M., during an observation and interview, RN 5 observed the call light on the floor behind the wheelchair and stated it should be positioned within the resident's reach. She acknowledged she had recently been in the room to obtain the resident's vital signs but had not noticed the call light was not accessible.On 05/11/2026 at 9:09 A.M., an observation showed the resident seated in his recliner with the call light hanging from the nightstand, approximately four feet away.On 05/11/2026 at 9:34 A.M., during an observation and interview, the Director of Nursing (DON) observed the call light on the nightstand and confirmed it should have been placed close enough for the resident to reach. A clinical record review, completed on 05/08/2026 at 10:30 A.M., revealed an Annual Minimum Data Set (MDS) assessment, dated 04/10/2026, indicating the resident was moderately cognitively impaired. Diagnoses included, but were not limited to, heart failure(a chronic, serious condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen, often causing fluid to build up in the lungs and legs), and the resident had experienced two or more falls without injury since the previous assessment. The resident required staff assistance for transfers between the chair and bed.An Interdisciplinary Team (IDT) note, dated 05/07/2026 at 10:05 A.M., indicated the resident had been observed on the floor by his recliner on 05/07/2026. The resident had an abrasion to his left forehead. The root cause of the fall was determined to be the resident climbed over the arm of his recliner. The facility's current policy, Guidelines for Answering Call Lights, with a reviewed date of 12/10/2025, provided by the DON on 05/11/2026, states, .The purpose of this policy is to respond to the resident's requests and needs . Ensure the call light is plugged in securely to the outlet and in reach of the resident .410 IAC (Indiana Administrative Code) 16.2-3.1-3(v)(1)

Based on record review and interview, the facility failed to notify the physician of residents' change in condition for 2 of 17 residents reviewed for notification of change. (Residents 76 and 5)Findings include:1.The clinical record for Resident 76 was reviewed on 05/08/2026 at 1:18 P.M. An admission Minimum Data Set (MDS) assessment, dated 04/27/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, femur fracture and heart failure (a chronic, serious condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen, often causing fluid to build up in the lungs and legs). A current open-ended physician's order, with a start date of 04/22/2026, indicated the resident was to be weighed daily for congestive heart failure. The resident had the following weight gain with no indication the physician was notified: - On 05/05/2026 the resident weighed 305.7 pounds and on 05/06/2026 the resident weighed 310 pounds. A 4.3-pound weight gain in 24 hours, and -On 05/08/2026 the resident weighed 316.4 pounds and on 05/10/2026 the resident weighed 328.6 pounds. A 12.2-pound weight gain in 48 hours. During an interview, on 05/12/2026 at 10:28 A.M., Licensed Practical Nurse (LPN) 3 indicated when a resident was ordered to have daily weights, the resident's weight would be obtained in the morning and put into the clinical record. The Electronic Medication Administration Record (EMAR) would prompt the user if the physician was notified. The staff would notify the physician by sending them a message. During an interview, on 05/12/2026 at 10:41 A.M., the Director of Nursing (DON) indicated if a resident was to be weighed daily, the resident's weight would be documented in the EMAR or under the vitals report. Resident 76 didn't have a specific order to notify the physician of weight gain but, as a nurse, she would have notified the physician of the resident's weight gain. 2. The clinical record for Resident 5 was reviewed on 05/07/2026 at 3:04 P.M. A Quarterly MDS assessment, dated 03/18/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, heart failure (a chronic and serious condition in which the heart muscle cannot pump sufficient blood to meet the body's oxygen needs, often resulting in fluid accumulation in the lungs and lower extremities). A current open-ended physician's order, initiated on 11/03/2023, indicated the resident was to be weighed daily for management of congestive heart failure. The order further required nursing staff to notify the provider of a three-pound weight gain within one day or a five pound weight gain within seven days. Record review revealed the following weight gain for Resident 5 with no indication the physician was notified: On 05/03/2026, the resident weighed 241.3 pounds and on 05/04/2026, the resident weighed 251.4 pounds, reflecting a 10.1 pound weight gain in 24 hours. During an interview, on 05/12/2026 at 11:41 A.M., RN 2 stated the resident was weighed each morning using the mechanical scale when the resident was assisted out of bed. The resident should have been reweighed to verify the significant weight change and the physician should have been notified of the 10 pound increase. RN 2 confirmed the EMAR includes a designated section to document provider notification. There was no documentation to indicate the physician was notified on 05/04/2026. The current facility policy titled Physician–Provider Notification Guidelines, with a reviewed date of 12/08/2025, was provided by the Administrator on 05/12/2026 at 11:03 A.M. The policy indicated, .The purpose of this policy is to ensure the resident's physician or practitioner (including NP, PA, or clinical nurse specialist) is aware of all diagnostic testing results or any change in condition in a timely manner to allow evaluation and implementation of appropriate interventions for care. 410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(3)

Based on observation, record review, and interview, the facility failed to ensure proper infection control practices were followed for the maintenance and positioning of an indwelling urinary catheter drainage bag for 1 of 4 residents reviewed for Urinary Tract Infections. (Resident 5) Findings include:On 05/06/2026 at 12:58 P.M., Resident 5 was observed sitting in her wheelchair in her room. The resident's urinary catheter drainage bag was hanging beneath the wheelchair, with approximately two inches of the bag directly touching the floor. On 05/07/2026 at 10:56 A.M., the resident was observed being transported down the 100 Hall while seated in her wheelchair. Approximately six inches of the urinary drainage bag was dragging directly on the floor during transport. On 05/07/2026 at 11:17 A.M., the resident was observed in a common area attending a Resident Council meeting. Her urinary catheter drainage bag was hanging beneath the wheelchair with an estimated six inches touching the floor. During an observation and interview, on 05/07/2026 at 11:34 A.M., the Activities Director (AD) was transporting the resident in her wheelchair from the common area to the dining room. The resident's urinary catheter drainage bag slipped from its secured position, fell to the floor, and the AD inadvertently stepped on the bag before stopping. The AD then picked up the drainage bag with their bare hands and reattached it beneath the wheelchair. She stated that nursing staff should be notified whenever a drainage bag was observed touching the floor. After the AD repositioned the drainage bag under the resident's wheelchair, the bag continued to hang with approximately two inches of the bag was dragging on the floor as the AD continued the resident's transport. During an interview, on 05/07/2026 at 11:38 A.M., Registered Nurse (RN) 2 indicated a resident's urinary catheter drainage bag should not be touching the floor. The RN repositioned the resident's catheter bag to prevent it from contacting the floor. The resident's clinical record was reviewed on 05/07/2026 at 3:04 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/18/2026, indicated Resident 5 as moderately cognitively impaired. The resident's diagnosis included, but was not limited to, obstructive uropathy (a structural or functional blockage of urine flow, leading to urine backflow, potential kidney swelling (hydronephrosis), and kidney damage). The resident required total assistance for toileting hygiene and transfers. The March 2026 Electronic Medication Administration Record (EMAR) documented that the resident was receiving Cipro (an antibiotic used for UTIs) 500 milligrams (mg), one tablet twice daily for seven days beginning 03/30/2026, for treatment of a UTI. The current facility policy titled Patient with a Foley Catheter, with a revision date of 08/05/2022, was provided by the Administrator on 05/11/2026 at 9:57 A.M. The policy indicated: .Do not let catheter tubing to touch floor (prevent infection) . 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on record review and interview, the facility failed to document residents' meal consumption for 3 of 3 residents reviewed for nutrition. (Residents 4, 76 and 7)Findings include:1. The clinical record for Resident 4 was reviewed on 05/08/2026 at 10:27 A.M. An admission Minimum Data Set (MDS) assessment, dated 03/04/2026, indicated the resident was severely cognitively impaired. The resident's diagnosis included, but was not limited to, malnutrition (a serious condition resulting from an imbalance between the nutrients the body needs and what it consumes). The resident had a gastrostomy tube (a surgically inserted device that delivers nutrition, fluids, and medication directly into the stomach, bypassing the mouth and throat). A Registered Dietician Progress Note, dated 05/08/2026, included a recommendation to discontinue the resident's tube feedings. The resident was to continue with a fortified diet and a nutritional pudding cup supplement three times a day. If the resident's weights and intakes were to decline, they may need to reconsider the tube feedings.The Meal Consumption Record was reviewed and indicated the resident's clinical record lacked documented meal intake values for the following dates and times:- On 04/16/2026 at dinner, - On 04/18/2026 at breakfast and lunch, - On 04/22/2026 at breakfast and lunch,- On 04/27/2026 at lunch, - On 05/02/2026 at breakfast and lunch, - On 05/03/2026 at breakfast and lunch, - On 05/06/2026 at breakfast and lunch, and- On 05/08/2026 at breakfast and lunch.2. The clinical record for Resident 76 was reviewed on 05/08/2026 at 1:18 P.M. An admission MDS assessment, dated 04/27/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, femur fracture and heart failure (a chronic, serious condition where the heart muscle cannot pump enough blood to meet the body's needs for oxygen, often causing fluid to build up in the lungs and legs). The Meal Consumption Record was reviewed for Resident 76 and indicated the resident's clinical record lacked documented meal intake values the following dates and times:- On 04/22/2026 at breakfast and lunch, - On 04/23/2026 at lunch, - 04/25/2026 at breakfast and lunch, - On 04/27/2026 at lunch,- On 04/30/2026 at lunch, and - 05/06/2026 at lunch and dinner. 3. The clinical record for Resident 7 was reviewed on 05/08/2026 at 2:41 P.M. A Quarterly MDS assessment, dated 04/18/2026, indicated the resident was cognitively intact. The resident's diagnosis included, but was not limited to, heart failure. The Meal Consumption Record was reviewed for Resident 7 and indicated the resident's clinical record lacked documented meal intake values for the following dates and times:- On 04/15/2026 at lunch, - On 04/20/2026 at breakfast and lunch, - On 04/29/2026 at breakfast, lunch, and dinner, - On 04/30/2026 at dinner, - On 05/01/2026 at breakfast and lunch, - On 05/02/2026 at breakfast and lunch, and- On 05/03/2026 at breakfast and lunch. During an interview, on 05/12/2026 at 1:22 P.M., Certified Nurse Aide (CNA) 4 indicated all resident meals should be documented in the clinical record after each meal. If the resident was out of the facility or refused a meal it would also be documented to reflect that in their record. During an interview, on 05/12/2026, the Administrator indicated they did not have a policy for documenting resident meal consumptions. 410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)(1)

Based on interview, observation, and record review, the facility failed to maintain complete and accurate clinical records related to the care and monitoring of a resident with an indwelling urinary catheter and failed to ensure accurate documentation of medication/treatment administration for 2 of 18 sampled residents. (Residents 27 and 6)Findings include:1. On 05/07/2026 at 1:46 P.M., during an interview and observation, Resident 27 indicated she had a suprapubic catheter (a thin, flexible tube surgically inserted through a small incision in the lower abdomen directly into the bladder to drain urine) and pointed to the catheter drainage tubing extending from beneath her shirt. The tubing was connected to a drainage bag hanging beneath her wheelchair. The resident reported she had recently completed antibiotic treatment for a urinary tract infection (UTI). A Quarterly Minimum Data Set (MDS), dated [DATE], indicating the resident was cognitively intact. The resident's diagnoses included, but were not limited to, reduced kidney function and neurogenic bladder (nerve damage causing loss of bladder control). The resident had an indwelling urinary catheter. The resident's current physician's orders included an open-ended order, with a start date of 08/04/2025, to irrigate the suprapubic catheter with 250 mL of normal saline every Monday, Wednesday, and Friday. The clinical record contained no additional physician's orders related to catheter care or monitoring, including orders related to insertion site assessment, catheter change frequency, or cleansing and dressing changes. Review of the Vitals section of the Electronic Health Record (EHR) did indicate the Certified Nurse Aides (CNAs) documented urinary output each shift when emptying the drainage bag; however, no routine documentation existed for nursing assessments or catheter care. During an interview, on 05/11/2026 at 1:59 P.M., Registered Nurse (RN) 2 indicated he was familiar with the resident and confirmed the resident had a suprapubic catheter and experienced UTIs a couple times per year. RN 3 indicated typically, the Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) would contain the physician's orders for catheter management, including catheter change frequency, monitoring the insertion site each shift for signs of infection or complications, and cleansing the insertion site and replacing the drain sponge each shift and It should be documented. During an interview, on 05/12/2026 at 10:50 A.M., the Director of Nursing (DON) indicated residents' indwelling catheter care and monitoring should be documented in the resident's EMAR/ETAR. During an interview, on 05/12/2026 at 2:28 P.M., the Administrator indicated the facility did not have a policy regarding clinical record documentation or requirements for accurate and complete resident records. 2.The clinical record for Resident 6 was reviewed on 05/08/2026 at 9:21 A.M. A Quarterly MDS assessment, dated 04/22/2026, indicated the resident was moderately cognitively impaired. The resident's diagnosis included, but was not limited to, depression (a serious, common medical illness causing persistent sadness, loss of interest, and physical symptoms that interfere with daily life for two weeks or more). A physician's order, dated 12/15/2025 through 05/06/2026, indicated the resident was to receive sertraline (an antidepressant medication) 50 milligrams. The staff were to administer 1.5 tablets once a day. A current open-ended physician's order, with a start date of 05/06/2026, indicated the resident was to receive sertraline 25 mg. The staff were to administer 25 mg along with 50 mg to equal 75 mg. The resident's record lacked a specific physician's order for the 50 mg of sertraline. During an observation and interview, on 05/12/2026 at 9:12 A.M., RN 2 indicated if a resident had to take two doses of a medication that were different strengths, he was unsure if it was two different physician orders but believed it should have been. He opened the medication cart and displayed the resident's sertraline package for 05/13/2026. The package contained two different tablets and indicated one was a 25 mg tablet, and one was a 50 mg tablet. During an interview, on 05/12/2026 at 9:19 A.M., the Director of Nursing indicated if a resident had two different doses of sertraline, then there should have been two separate physician orders so the nurse would document they were giving both doses. The resident should have had an order for the 50 mg tablet. The current facility policy titled, Medication Orders, with a revision date of 11/2018, was provided by the Administrator on 05/12/2026 at 9:55 A.M. The policy indicated, .Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)

Based on interview and record review, the facility failed to follow appropriate medication administration guidelines for 1 of 3 residents reviewed for significant medication errors. (Resident D) Findings include:During an interview, on 02/09/2026 at 11:08 A.M., a family member indicated they were visiting Resident D on January 10, 2026, when a staff member came into the resident's room to test the resident's blood related to insulin use. The resident was not diabetic and had never been on insulin. The test was intended for a resident in a nearby room. The family member stopped the staff member from testing the resident's blood. The family member indicated seven days later they were notified the resident had received the wrong resident's medications. During an interview, on 02/09/2026 at 1:04 P.M., Qualified Medication Aide (QMA) 2 indicated on the night of 01/17/2026, she was administering medications from the 200 Hall medication cart for the first time. Resident D and Resident E resided in rooms near one another. She had two cups of pills, one with two medications, and one with three medications. After administering medications to Resident D, she went back to the medication cart and realized she had administered the wrong medications. She had given Resident D Resident E's medications. She informed the Director of Nursing and the Administrator right away. They contacted the Nurse Practitioner and monitored the resident for 24 hours. The resident had no negative reactions. They monitored the resident's blood sugar. The other medication was a seizure medication, and the resident showed no signs of an adverse reaction to the seizure medication. They were Resident E's 9:00 P.M. medications. During an interview, on 02/10/2026 at 10:31 A.M., the Director of Nursing (DON) indicated on January 17, 2026, QMA 2 said she was distracted by another resident talking to her while at the medication cart and she accidentally gave the wrong medication to a resident. The clinical record for Resident D was reviewed on 02/09/2026 at 9:16 A.M. An admission Minimum Data Set (MDS), dated [DATE], indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, osteoporosis (reduced bone mass), and dementia (a decline in mental abilities). The January 2026 Electronic Medication Administration Record (EMAR) for Resident D indicated the resident was to receive the following medications during the 9:00 P.M. medication pass: -Atorvastatin (a cholesterol medication) 20 milligrams (mg), at bedtime, with a start date of 01/04/2026, and a discontinued date of 01/20/2026,-Donepezil (a dementia medication) 5 mg, at bedtime, with a start date of 01/03/2026, and a discontinued date of 01/20/2026, and-Zetia (a cholesterol medication)10 mg, at bedtime, with a start date of 01/04/2026, and a discontinued date of 01/20/2026. The January 2026 EMAR for Resident E indicated the resident was to receive the following medications during the 9:00 P.M. medication pass: -Keppra (a seizure medication) 500 mg, twice a day, with a start date of 12/29/2025, and a discontinued dated of 01/20/2026, once between 6:00 A.M. and 10:00 A.M., and once between 6:00 P.M. and 10:00 P.M., and-Metformin (a diabetic medication) 1000 mg, twice a day, with a start date of 12/29/2025, and a discontinued dated of 01/20/2026, once between 6:00 A.M. and 10:00 A.M., and once between 6:00 P.M. and 10:00 P.M. The current MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy, with a revised date of 11/2018, was provided by the DON on 02/10/2026 at 10:57 A.M. The policy indicated, .FIVE RIGHTS.Right resident, right drug, right dose, right route [sic] and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. The past noncompliance was corrected prior to the start of the survey after the facility implemented a systemic plan that included the following actions: on 01/23/26, after the facility assessed the residents, provided education to all staff related to medication administration, and an ongoing monitoring audit was put in place for staff administering medications. This citation relates to intake 2728012. 3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to store medications appropriately for 1 of 1 resident reviewed for self-administering medications. (Resident 19) Findings include: During an observation, on 04/09/25 at 11:32 A.M., the top of Resident 19's nightstand by the door contained a bottle of nasal spray and two inhalers that were out in plain sight. During an observation, on 04/11/25 at 10:42 A.M., the top of the resident's nightstand by the door contained a bottle of nasal spray and two inhalers that were out in plain sight. During an observation, on 04/11/25 at 1:12 P.M., the top of the resident's nightstand by the door contained a bottle of nasal spray and two inhalers that were out in plain sight. During an observation, on 04/15/25 at 8:44 A.M., the top of the resident's nightstand by the door contained a bottle of nasal spray and two inhalers that were out in plain sight. During an interview, on 04/15/25 at 1:43 P.M., RN 8 indicated if a resident had medications at bedside, then they should have an assessment completed. During an interview, on 04/15/25 at 1:47 P.M., Corporate Clinical Support Nurse indicated if a resident had an assessment completed for medications at the bedside, then they didn't need to have a physician's order. During an interview, on 04/15/25 at 1:43 P.M., Corporate Clinical Support Nurse indicated the resident's self-administer assessment indicated the medications would be stored in the nursing cart and not in her room, so the medications should not have been in her room and per the facility policy there should be a physician's order to self-administer medications. During an observation, on 04/15/25 at 2:00 P.M., Cooperate Minimum Data Set (MDS) Support was in Resident 19's room. The following medications were observed on the resident's nightstand in plain sight: - albuterol inhaler, - ipratropium bromide (nasal spray), - debrox (ear wax cleaner), and - Advair (inhaler). The resident indicated she had not used the debrox for a few weeks. The clinical record for Resident 19 was reviewed on 04/11/25 at 1:28 P.M. A Significant Change MDS assessment, dated 03/27/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, primary adrenocortical, anemia, heart failure, hypertension, diabetes, osteoporosis, anxiety, and depression. The resident had the following physician's order's: - An open-ended physician's order, with a start date of 11/11/23 for Advair, 2 puffs twice a day, - An open-ended physician's order, with a start date of 11/11/23 for albuterol inhaler 2 puffs as needed every 6 hours, - A discontinued order, dated 11/11/23 through 01/21/25, for ipratropium bromide, 1 spray, once a day, and - A discontinued order, dated 08/20/24 through 08/23/24, for Debrox, 4 drops each ear for 3 days. A Self-Administration of Medication Assessment, dated 04/30/24, indicated the resident could self-administer the following medications and they would be stored in the medication cart: - Tylenol, - Tums, - eye drops, - inhalers, - ointments, and - medications set up by the facility and left at the bedside. The current facility policy, titled Guidelines for Self-Administration of Medications, was provided by the Director of Nursing (DON) on 04/15/25 at 2:18 P.M. The policy indicated, .To ensure the safe administration of medication for residents who request to self-medicate or when self-medication is a part of their plan .Results of the assessment will be presented to the physician for evaluation and an order for self-medication .The medication will be kept in a locked drawer in the residents' room . 3.1-11(a)

Based on record review, interview, and observation, the facility failed to follow physician's orders related to cardiac medication hold parameters and adequately assess and monitor a resident's skin impairment for 3 of 15 residents reviewed for Quality of Care. (Residents 10, 22, and 19) Findings include: 1. Resident 10's clinical record was reviewed on 04/10/25 at 2:27 PM. A Quarterly Minimum Data Set (MDS) assessment, dated 02/10/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, coronary artery disease, heart failure, and diabetes. A physician's order, with a start date of 09/24/24 and a discontinued date of 03/26/25, for amlodipine (a blood pressure medication), 10 milligrams (mg) once a day in the evening between 6:00 P.M. and 10:00 P.M. The medication was to be held if the systolic blood pressure (SBP) was below 110. The Vitals Reports for December 2024, and January, February, and March of 2025 were reviewed. The reports indicated the resident lack blood pressure assessments on the following dates when receiving the medication: - On 12/04/24 through 12/31/24, no blood pressure assessment was documented for the resident's amlodipine medication administration. - On 01/04/25 through 3/25/25, there was no documented blood pressure assessment for the resident's amlodipine medication administration. A physician's order, with a start date of 09/24/24 and a discontinued date of 03/26/25, for carvedilol (a blood pressure medication), 25 mg twice a day between 6:00 A.M. and 10:00 A.M., and between 6:00 P.M. and 10:00 P.M. The medication was to be held if the SBP was below 110. The December 2024, and January, February, and March 2025 Electronic Medication Administration Record (EMAR) lacked documented blood pressures for the medication administration. The Vitals Reports for December 2024, and January, February, and March of 2025 were reviewed. The reports indicated the resident lack blood pressure assessments on the following dates when receiving the medication: - On 12/04/24 through 12/27/24, there were no documented blood pressure assessment for the resident's carvedilol medication administration between 6:00 A.M. and 10:00 A.M. - On 12/29/24 and 12/30/24, there were no documented blood pressure assessments for the resident carvedilol medication administration between 6:00 A.M. and 10:00 A.M. 38769 2. The clinical record for Resident 22 was reviewed on 04/10/25 at 2:26 P.M. An Admission Minimum Data Set assessment, dated 02/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, multiple fractures of the ribs, anemia, atrial fibrillation, hypertension, diabetes, cerebrovascular accident, and malnutrition. A physician's order, dated 02/14/25 through 03/25/25, indicated the staff were to administer metoprolol (a blood pressure medication) 25 mg once a day from 6:00 A.M. to 10:00 A.M. The staff were to hold the medication if the systolic blood pressure was less than 100 or the heart rate was less than 50. A physician's order, dated 03/25/25 through 04/11/25, indicated the staff were to administer metoprolol 25 mg, twice a day from 6:00 A.M. to 10:00 A.M. and 6:00 P.M. to 10:00 P.M. A Progress Note, dated 03/25/25, indicated the resident was to start metoprolol 25 mg, twice a day and the medication was to be held if the systolic blood pressure was less than 100 or the heart rate was less than 50. The February and March 2025 EMAR lacked documented blood pressure or heart rates for the medication administration. The Vitals Report for February and March 2025 lacked documented heart rates or blood pressures for the following dates and times: - 02/14/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 02/22/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 02/24/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 02/28/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 03/04/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 03/05/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 03/13/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 03/20/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 03/21/25 from 6:00 A.M. to 10:00 A.M., no heart rate was documented, - 03/25/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 03/26/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 03/27/25 from 6:00 A.M. to 10:00 A.M., and 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 03/28/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 03/29/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 03/30/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 03/31/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 04/01/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 04/02/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 04/03/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 04/04/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 04/05/25 from 6:00 A.M. to 10:00 A.M., no heart rate or blood pressure was documented, - 04/06/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, - 04/07/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented, and - 04/09/25 from 6:00 P.M. to 10:00 P.M., no heart rate or blood pressure was documented. During an interview, on 04/16/25 at 12:57 P.M., RN 8 indicated if a resident had hold parameters on medications, he would obtain the vitals before administering the medication and would not administer the medication if vitals were outside the parameters. The current facility policy titled, Medication Orders, with a revised date of 11/18, was provided by the Director of Nursing on 04/16/25 at 1:40 P.M. The policy indicated, .Medications are administered only upon clear, complete, and signed order . 3. During an observation and interview, on 04/09/25 at 11:32 A.M., Resident 19 had an undated, pink foam bandage on her left lower arm that was covering the bandage. The resident indicated she had bumped it on her over bed table and a nurse had put a bandage on it. During an observation and interview, on 04/16/25 at 10:15 A.M., Resident 19 was sitting on her bed. The resident had a protective sleeve over her left lower arm. The resident pulled the sleeve down and there was a scabbed skin tear that was covered with wound closure strips (thin sticky bandages applied to skin to help wounds stay closed as they healed) on it. The resident indicated she had the sleeve on her arm to protect her from hitting it again. The clinical record lacked any documentation, or any orders related to the area to the left lower arm. During an interview, on 04/16/25 at 12:57 P.M., RN 8 indicated when a resident had a new skin concern that required more than Band-Aid then the wound nurse would be notified, and an order would be initiated. The resident would also have an assessment completed for the area. The skin impairment would be measured weekly. He wasn't sure what the resident had done to her arm. It looked like a skin tear, and someone placed wound closure strips on it. He would think the resident should have an order to monitor the area. During an interview, on 04/16/25 at 1:18 P.M., the Wound Nurse indicated if a resident had a skin impairment, she would be made aware and then start an appropriate treatment. The skin impairments would be assessed weekly. When a nurse found a new skin impairment, they should make a progress note and have an assessment completed. She was unaware of Resident 19 had skin impairments to her left lower arm. The staff should have made her aware of it. The current facility policy titled, Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, with a revised date of 04/09/25 was provided by the Corporate Clinical Support on 04/16/25 at 1:51 P.M. The policy indicated, .Skin Tear/Laceration .Complete Skin Tear/Laceration Incident in the Electronic Health Record by an RN/LPN [Licensed Practical Nurse] along with the template/assessment progress note. IDT [Interdisplinary Team] should review this timely and wound nurse or designee complete an assessment in wound management .Continue to monitor weekly in wound management . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to follow the current nursing standards of practice when providing Activities of Daily Living (ADL) care to residents with impaired mobility that were at risk for falls for 2 of 4 residents reviewed for accidents. (Residents 41 and 47) Findings include: 1. During an observation, on 04/16/25 at 9:38 A.M., Certified Nurse Aide (CNA) 4 was on the right side of Resident 41's bed. The resident was lying in the bed on her back. CNA 4 indicated to the resident that she was going to perform personal care. The resident's incontinent brief was removed, and care was provided. CNA 4 had the resident roll onto her left side, away from the CNA. The CNA rolled the resident and the resident held on to the corner of the nightstand on the left side of her bed with her right hand. The resident's body was approximately one foot from the edge of the bed. There were no other staff in the room and the resident's bed lacked side rails. CNA 4 stayed on the right side of the bed during the entire observation of care. The clinical record for Resident 41 was reviewed on 04/10/25 at 3:04 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/13/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, senile degeneration of the brain, hemiplegia and hemiparesis, weakness, unspecified fall, anemia, hypertension, neurogenic bladder, diabetes, Alzheimer's disease, anxiety, and depression. The resident had impairments to one side of their upper extremities and both lower extremities. The resident was dependent on staff for bed mobility and rolling left and right. An open-ended physician's order, with a start date of 03/26/25, indicated the resident required a mechanical lift for transfers. The resident's complete Plan of Care included, but was not limited to, the following: - A Care Plan that indicated the resident had a cerebrovascular accident with hemiparesis/hemiplegia and had a neurogenic bladder. The resident required staff assistance with ADLs, with a start date of 02/28/24, and revised on date of 02/25/25, and - A Care Plan that indicated the resident was at risk for falling related to incontinence, medications, history of falls, a need for staff assistance with ADL care, and weakness, with start date of 02/28/24, and a revised on date of 02/25/25. 2. During an observation, on 04/16/25 at 10:23 A.M., CNA 11 let Resident 47 know that she was going to provide care. The CNA was on the left side of the resident's bed and never left it. She removed the resident's incontinent brief and provided care for the resident. She turned the resident on her right side away from the CNA and provided care to the resident's backside. A portion of the resident's head was hanging off the right side of the bed. The resident's body core was approximately one foot from the edge of the bed. There were no side rails on the bed or other staff in the room. The clinical record for Resident 47 was reviewed on 04/11/25 at 9:39 A.M. An Annual MDS assessment, dated 01/31/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, other toxic encephalopathy, aphasia, cerebrovascular accident, seizure disorder, hemiplegia and hemiparesis, weakness, depression. The resident had impairments on both sides of the lower extremities. The resident was dependent on staff for bed mobility. A current, open-ended physician's order with a start date of 01/22/25 indicated the resident required a mechanical lift for all transfers. The resident's complete Plan of Care included, but was not limited to, the following: - A Care Plan that indicated the resident had a cerebrovascular accident with aphasia and hemiplegia/hemiparesis affecting the right side. The resident required staff assistance with ADL care, with a start date of 02/29/24 and revised on date of 04/10/25, - A Care Plan that indicated the resident was at risk for falling related to diagnoses, medications, incontinence, a need for staff assistance with ADL care, and weakness, with a start date of 02/29/24 and revised on date of 04/10/25, - A Care Plan that indicated the resident had an impairment in functional status related to diagnoses, medications, incontinence, a need for staff assistance with ADL care, and weakness, with a start date of 02/29/24 and revised on date of 04/10/25. A Progress Note, dated 02/18/25 at 6:19 P.M., indicated the resident was in the lobby with activities when the resident leaned forward in her chair and fell to the floor. During an interview, on 04/16/25 at 10:34 A.M., CNA 9 indicated when she was assisting a resident with care in bed by herself, she would turn the resident away from her. She would ensure the resident was closer to her so they wouldn't roll out of the bed. There had been no staff in-servicing recently on how to turn dependent residents in bed. During an interview, on 04/16/25 at 10:36 A.M., Qualified Medication Aide (QMA) 10 indicated if she was turning a dependent resident in bed by herself, she would pull the resident toward her to ensure they weren't close to the edge of the bed and then turn the resident away from her. Depending on the resident's level of care, she would sometimes get a second staff member to help. During an interview, on 04/16/25 at 10:39 A.M., the Director of Nursing (DON) indicated when providing care for dependent residents by themselves, the staff should use the draw sheet and pull the resident to them and then roll them away from them. She would hope the staff would keep their hand on the resident so they wouldn't roll out of bed. There was always a risk for anything. During an interview, on 04/17/25 at 11:00 A.M., QMA 13 indicated the resident was dependent on staff for all care. She was able to roll the resident in bed by herself but at times she needed help. The resident was not able to turn in the bed by herself. During an interview, on 04/16/25 at 12:47 P.M., the DON indicated she would expect the CNAs to follow that they learned in the CNA class. During an interview, on 04/16/25 at 1:01 P.M., the DON indicated there were no facility policies related to bed mobility for dependent residents, and they would just follow the individualized plan of care. The current Indiana Nurse Aide Curriculum-Procedure #55: Occupied Bed was reviewed on 04/16/25. The procedure indicated, .The caregiver will raise the side rail on far side of bed (if rail not in use, ensure there is a second caregiver on the opposite side of the bed to ensure that the resident does not roll over the side of bed). Assist resident to turn onto side moving away from you toward raised side rail (or second caregiver) . 3.1-45(a)(2)

Based on record review and interview, the facility failed to monitor and provide gastrostomy tube (g-tube) maintenance for 1 of 2 residents reviewed for tube feeding. (Resident 9) Findings include: Resident 9's clinical record was reviewed on 04/10/25 at 2:44 P.M. An Admission Minimum Data Set assessment, dated 03/04/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, Chronic Obstructive Pulmonary Disease (COPD), and ulcerative colitis. An Admission Assessment Observation Report indicated the resident was admitted to the facility on [DATE]. The Nutrition section of the assessment indicated the resident had a gastrostomy tube. The resident resided in the facility in December of 2024 until she was discharged back home in January of 2025. She was readmitted to the facility on [DATE] until 03/28/25, when she went to the hospital for a COPD exacerbation. The resident returned to the facility on [DATE] and remained there. During an interview, on 04/16/25 at 4:09 P.M., Licensed Practical Nurse 12 indicated she was familiar with the resident. The resident had admitted and discharged from the facility a few times in the last several months. The resident came to the facility with the g-tube. She did not ever receive enteral feeding or medications through the g-tube. When a resident had a g-tube, nursing staff would normally check for placement, monitor the insertion site for drainage and signs of infection, and flush the g-tube once a shift. The resident's current physician's orders included, but were not limited to, the following: - An open-ended order, with a start date of 04/06/25, to change the g-tube feed irrigation set daily, - An open-ended order, with a start date of 04/06/25, to flush the g-tube with 30 milliliters of water twice a day, and - An open-ended order, with a start date of 04/06/25, for g-tube site care twice a day. The resident's record lacked documentation of any physician's orders related to g-tube care from 02/26/25 through 03/28/25. During that time frame, there was no documentation that indicated the g-tube was monitored or flushed with any regularity and there was no care plan related to the g-tube. During an interview, on 04/17/25 at 10:31 A.M., the Director of Nursing indicated the facility did not have a policy for care of a resident with a g-tube, it would be resident specific and would follow the physician's orders. There should be a care plan related to the g-tube. 3.1-44(a)(2)

Based on observation and interview, the facility failed to store medications appropriately for 2 of 4 medication carts observed (100 Hall Medication Cart and 300 Hall Medication Cart). Finding Include: 1. During a continuous observation on 04/09/25 from 10:25 A.M. to 10:31 A.M., a box that contained one albuterol cartridge was sitting on top of the 100 Hall Medication Cart. A Certified Nurse Aide (CNA) and a housekeeper walked by the medication cart. At 10:31 A.M., RN 8 placed the box inside the 100 Hall Medication Cart. The 100 Hall Medication Cart was observed on 04/10/25 at 10:39 A.M., with RN 8. The second drawer contained the following: - one small white oval pill, and - one small white round pill. During an interview on 04/17/25 at 1:59 P.M., RN 8 indicated the box containing the albuterol vial should not have been sitting unattended on top of the medication cart and loose pills should not be in the drawers of the medication cart. 2. The 300 Hall Medication Cart was observed with Licensed Practical Nurse (LPN) 7 on 04/10/25 at 10:45 A.M. The following were observed in the top drawer: - A half full insulin pen belonging to Resident 46 with an opened date of 02/17/25, and - A full insulin pen belonging to Resident 5 that had no opened date. During an interview, on 04/10/25 at 10:47 A.M., LPN 7 indicated insulin pens should be dated when placed in the medication cart and were only good for 28 days. Resident 46 had not received any injections from that insulin pen, he had moved rooms, and his medications were in a different medication cart. The current facility policy titled, MEDICATION STORAGE IN THE FACILITY, was provided by the Director of Nursing (DON) on 04/17/25 at 2:08 P.M. The policy indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed facility personnel, pharmacy personnel, or facility personnel lawfully authorized to administer medications . 3.1-25(j) 3.1-25(o)

Based on record review, observation, and interview, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 1 of 4 observations of high-contact resident care activities. (Resident 9) Findings include: Resident 9's clinical record was reviewed on 04/10/25 at 2:44 P.M. An Admission Minimum Data Set assessment, dated 03/04/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, Chronic Obstructive Pulmonary Disease (COPD), and ulcerative colitis. The resident had a gastrostomy tube (g-tube). The resident's current physician's orders included, but were not limited to, an open-ended order, with a start date of 04/03/25, that indicated the resident was in EBP and staff were to wear a gown and gloves at minimum during high-contact care activities. During an observation, on 04/17/25 at 1:01 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Everyone must wear gloves and a gown when providing care, including device care or use of a feeding tube. RN 8 entered the resident's room and provided g-tube care without donning a gown. During an interview, on 04/17/25 at 1:10 P.M., RN 8 indicated the resident was in EBP, he should have worn a gown while working with the resident's g-tube. The current facility policy, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 04/01/24, was provided by the Director of Nursing on 04/17/25 at 1:51 P.M. The policy indicated, .EBP will be in place during high-contact care activities for residents with the following conditions .indwelling medical devices .feeding tubes .at minimum, staff shall wear gloves and gowns during high-contact care activities . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to prevent a fall during care that resulted in a fracture for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: During an observation on 09/09/24 at 2:31 P.M., Resident B was lying in bed with his call light in reach. The resident was lying on an air mattress and there were no side rails or grab bars on the bed. The resident's bed was located by the door. The resident's bathroom door was located on the far side of the room by the other resident's bed. The clinical record for the Resident was reviewed on 09/09/24 at 10:33 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/17/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, anemia, hypertension, and multiple sclerosis. The resident had impairments to the upper and lower extremities. The resident was dependent on staff assistance for all care. A Care Plan, with a start date of 10/04/21 and a revision date of 8/21/24, titled ADL (Activities of Daily Living), indicated the resident required two staff assistance with bed mobility. A Progress Note, dated 07/22/24 at 1:32 P.M., indicated after changing the resident's coccyx wound dressing at 7:30 A.M., the staff was walking around the resident's bed to assist with a full body lift sling. The resident rolled off the bed between the wall and the bed. The resident had a 7 cm (centimeter) x (by) 7 cm bruise noted to the right forearm and a 2 cm x 1 cm x 1 cm skin tear in the bruised area. First aid was applied, and new treatment orders were received from hospice. The family was notified. The resident had no complaints of pain or discomfort at that time and the resident's vital signs were within normal limits. An IDT (Interdisciplinary Team) Progress Note, dated 07/23/24 at 10:17 A.M., indicated the resident rolled off the bed to the floor space between the wall and the bed onto the left side of the body during a dressing change. There was a bruise noted to the right arm with a skin tear. The initial intervention, on 7/22/24, was to apply first aid. A new intervention, dated 7/30/24, was initiated to have two staff assistance during dressing changes. A Progress Note, dated 07/25/24 at 10:14 P.M., indicated the resident had discoloration and warmth noted to the right shin. The Hospice nurse was notified and was in the building to look at the resident. A new order was obtained to obtain an x-ray of the right leg. A Progress Note, dated 07/26/24 at 5:04 P.M., indicated the resident had an x-ray at approximately 3:10 P.M. At about 3:43 P.M., the results for the x-ray were received. The resident had an acute distal tibia/fibula (lower bones of the leg) fracture. The Hospice nurse was in the facility and the resident was sent to the local emergency room for splinting of the leg. A Progress Note, dated 07/26/24 at 8:44 P.M., indicated the resident returned to the facility. The resident was non-weight bearing to the bed and the leg should be supported when moving and rotating. The resident was to follow-up with an orthopedic surgeon for casting. A Radiology Report, dated 07/26/24 at 3:21 P.M., indicated the resident had a right ankle x-ray for pain and swelling. The results were .Distal tibia/fibula fractures with mild displacement . An ED (Emergency Department) Hospital Note, dated 07/26/24, indicated the resident present to the ED with concerns for a right leg injury. The resident fell out of bed on 07/22/24. Due to changes in color of the leg an x-ray was obtained, which showed a fracture. The resident was transferred to the ED for further evaluation and splinting. The radiology report of the right tibia/fibula result indicated the resident had fractures involving the distal shafts of the tibia and fibula. The assessment/plan was for the resident to be placed in a posterior leg splint and to follow up with orthopedic for casting. During an interview on 09/09/24 at 11:27 A.M., RN 2 indicated on 07/22/24, he and CNA (Certified Nurse Aide) 3 were in the resident's room changing a dressing to the coccyx. He had done the dressing change a thousand times. He inflated the resident's air mattress to the firm setting before the dressing change. He was on the resident's right side of the bed and CNA 3 was on the left side of the bed during the dressing change. After he finished, he was fastening the resident's brief when CNA 3 stepped away from the bed to get the resident's full body lift pad. He was walking around the end of the bed, while the resident was still lying on his left side, to go to the left side. As he was rounding the end of the bed the resident had rolled off the left side of the bed, like a log. He never saw the resident move or twitch. After the fall, the resident was assessed and noted to have a skin tear and bruise to the right arm. There were no other concerns at that time and the resident was transferred to his wheelchair. A few days after the fall the resident was noted to have a fracture to his right tibia/fibula. The resident required two staff assistance while in bed and required an air mattress. He believed the resident's air mattress wasn't as stable since he had it on firm. If the resident was turned to their side, then someone should stay on the side the resident was rolled to. During an interview on 09/09/24 at 11:47 A.M., CNA 3 indicated she was in the resident's room with RN 2 while he was changing the dressing for Resident B. The resident was lying on his left side while the RN completed the dressing change to his bottom. She moved away from the left side of the bed to go to the resident's bathroom (located on the far side of the room) to get his full body lift pad. While she was away from the bed the resident had rolled out. The resident required one to two staff assistance while in bed. She was able to complete care on him by herself while he was in bed, but other staff needed two people to complete the care. If she was rolling a resident in bed for care she would grab the draw sheet, scoot the resident toward her, and then roll the resident away from her. During an interview on 09/09/24 at 2:20 P.M., CNA 4 indicated if a resident was dependent on staff for all care while in bed she would take two staff in the room. There would be one person on each side. If she was providing care by herself, she would always roll the resident toward her and never away from her so they wouldn't fall out of bed. During an interview on 09/09/24 at 3:02 P.M., the DON (Director of Nursing) indicated that staff were providing care for Resident B. He was lying on his left side when the CNA left the bedside to grab the resident's chair. The RN went to walk around to get the full body lift pad. The air mattress was on the firm setting and then returned to the normal setting, causing the bed to deflate a little, which caused the resident to roll out of bed. The resident had obtained a skin tear and bruise to the right arm. No other injuries were observed at that time. On 07/25/24 the resident was noted to have warmth and redness to the right leg and hospice gave orders to obtain an x-ray. On 07/26/24 the results came back and showed the resident had a tibia/fibula fracture. The resident was sent to the local emergency room and was placed in a splint. The resident followed up with the orthopedic doctor on 08/02/24 and was placed in a cast. The facility didn't have a policy for turning residents in bed. Staff were trained in CNA class to turn residents' side to side. The type of care that was being provided would determine if the resident was turned towards staff or away from staff. The fall was caused by the air mattress deflating. During an interview on 09/09/24 at 3:45 P.M., RN 5 indicated Resident B had never had side rails or grab bars on his bed. If the resident did have them on the bed, he wouldn't have been able to grip them. The current facility policy titled, Fall Management Program Guidelines with a review date of 12/31/23 was provided by the DON on 09/09/24 at 1:37 P.M. The policy indicated, .to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures . The current facility policy titled, Turning and Repositioning with a review date of 12/31/23 was provided by the DON on 09/09/24 at 1:37 P.M. The policy indicated, .To identify residents who are unable to turn and reposition themselves or those requiring assistance to reposition while in bed and assist with turning and repositioning as needed to maintain skin integrity, decreased pain, and maintain proper body alignment .Proper turning techniques and body mechanics should be utilized to prevent injury to the resident and care giver . The current Indiana Nurse Aide Curriculum-Procedure #55: Occupied Bed was reviewed on 09/09/24. The procedure indicated, .The caregiver will raise the side rail on far side of bed (if rail not in use, ensure there is a second caregiver on the opposite side of the bed to ensure that the resident does not roll over the side of bed). Assist resident to turn onto side moving away from you toward raised side rail (or second caregiver) . The Past noncompliance began on 7/22/24. The deficient practice was corrected by 8/14/24 after the facility implemented a systemic plan that included the following actions: Nurses and aides were educated on turning a repositioning resident dependent on staff. Staff were educated on accident hazards related to air mattress, bed mobility, and falls. Return demonstration of proper rolling/turning/repositioning techniques. This citation relates to Complaint IN00439751. 3.1-45(a)(2)

Based on interview, observation, and record review, the facility failed to ensure a resident did not acquire a burn during care. This deficient practice resulted in Resident B sustaining a second-degree burn (a mild to moderate burn caused by heat, chemical, or light source and damages the outer and second layer of skin) on the left foot. (Resident B) Findings include: An Annual MDS (Minimum Data Set) assessment, dated 02/08/24, indicated Resident B was cognitively intact. The diagnoses included, but were not limited to, traumatic spinal cord dysfunction, quadriplegia, hypertension, and neurogenic bladder. The resident required extensive staff assistance with all ADL (Activities of Daily Living). The resident's clinical record lacked documentation of an order, or a care plan related to the staffs' use of a blow dryer to dry the resident's feet. A Progress Note, dated 04/02/2024 at 5:45 P.M., indicated the resident requested for CNA 2 to dry her feet with a blow dryer. CNA 2 dried the resident's feet and now there was redness observed to the resident's left foot. A cool rag was placed on the resident's foot and LPN 3 was monitoring the resident's condition. A Progress Note, dated 04/03/2024 at 12:49 P.M., indicated the resident had blisters present to the top of her left foot toe areas. A new order was entered by the NP to leave the blisters open to the air. A Progress Note, dated 04/04/2024 at 8:50 A.M., indicated the resident was seen by the NP (Nurse Practitioner) and presented with fluid filled blisters to the top of the left foot. The resident had requested for staff to blow dry her feet after her shower. After the CNA dried the resident's feet the resident had redness to her foot and later blisters appeared on her toes. A topical cream was ordered for the blisters. A Wound Center Note, dated 04/10/24, indicated the resident was being seen for second degree burns on the left 1st through 4th toes. During an interview on 04/30/24 at 10:10 A.M., Resident B indicated her shower days were Tuesday and Friday. She had been having her feet dried with the blow dryer for a long time, since it was recommended by her podiatrist. On 04/02/24, after her shower she had asked CNA (Certified Nurse Aide) 2 to dry her feet with the blow dryer. This was the first time CNA 2 had assisted her with her shower. The resident had looked down at her left foot and it was red. She had brought this to the attention of CNA 2. The CNA seemed to not be paying attention. The resident was unable to feel her feet. CNA 2 then informed LPN (Licensed Practical Nurse) 3 of the resident's red foot. The LPN advised the DON (Director of Nursing). Blisters had formed on the resident's toes later that evening. The resident went to the wound center for treatment for the blisters on the toes of the left foot. During an observation 04/30/24 at 10:35 A.M., RN 11 removed the gauze dressing from Resident B's left foot. Each of the resident's 5 toes had a dried opened blister. The toes were cleaned with normal saline, patted dry, coated with a liquid antiseptic, gauze was placed between each toe, and the entire foot was wrapped with gauze and secured with tape. During an interview on 05/06/24 at 10:45 A.M., CNA 4 indicated Resident B required total assistance with all ADLs. She received her showers on second shift on Tuesdays and Fridays. The CNAs were aware the resident wanted her feet dried with a blow dryer. During an interview on 05/06/24 at 11:03 A.M., CNA 2 indicated she had not assisted Resident B in the shower prior to the incident with the blow dryer and had not been trained on using a blow dryer on the resident's feet. The resident requested she use the blow dryer to dry her feet. Her foot wasn't red until she finished drying them. When she noticed the resident's foot was red, she notified LPN 3. During an interview on 05/06/24 at 2:01 P.M., LPN 3 indicated CNA 2 asked him to assess the foot of Resident B after her shower. The foot was more red than normal. He notified the DON of the situation, and she came to assess the left foot. He didn't think CNA 2 was aware the resident didn't have feeling in her feet. During an interview on 05/08/24 at 2:13 P.M., the NP indicated the resident had requested the CNA to blow dry her feet when she was finished with her shower. She gave an order to treat the burns at the time of the occurrence. She wasn't sure the CNA was aware the resident didn't have feeling in her feet. The current facility policy titled, Notification of Change in Condition with a revised date of 12/31/23, was provided by the Administrator on 05/08/24 at 3:23 P.M. The policy indicated, .To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician .when .An accident involving the resident which results in an injury and has the potential for requiring physician intervention . Brain and Spinal Cord Injury information at www.brainandspinalcord.org/quadriplegia .Related injuries. People with quadriplegia may experience an injury, such as a burn, without realizing it, since they have no sensation in their limbs. For this reason, it is important that your caregivers do not place a heating pad or electric blanket on you . Indiana_Nurse_Aide_Curriculum.pdf, Pages 22 through 29 .IV.Burns .Risk Factors .1 .paralysis .3.Heating appliances .BPrevention .1.know residents that are at risk .2.Check/report use of heating appliances . The Past noncompliance began on 04/02/24 and the deficient practice was corrected prior to the start of the survey. On 04/04/24, the facility implemented a systemic plan that included the following actions: The facility completed education on impaired sensation and the use of blow dryers for all staff members. This citation relates to complaints IN00431864 and IN00430897. 3.1-47(a)(7)

Based on record review and interview, the facility failed to provide bathing for 2 of 3 dependent residents reviewed for Activities of Daily Living. (Residents C and D) Findings include: 1. During an interview on 05/06/24 at 2:34 P.M., QMA (Qualified Medication Aide) 10 indicated residents were to be offered showers at least twice a week but could have more if requested. The showers were given on dayshift and evening shift. The bathing was to be documented in the electronic record and they were to fill out a skin sheet on each resident after bathing. The skin sheets were signed by the nurse and then given to the ADON (Assistant Director of Nursing). During an interview on 05/06/24 at 2:50 P.M., CNA Student (Certified Nurse Aide Student) 8 indicated If a resident refused a shower, she would offer to give them a bed bath and document the refusal of bathing or the type of bathing in the computer charting. The clinical record for Resident C was reviewed on 05/02/24 at 3:02 P.M. An Admission MDS (Minimum Data Set) assessment, dated 04/03/24, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, metabolic encephalopathy, hypertension, heart failure, diabetes, malnutrition, anxiety, and depression. The Point of Care History and the Shower Sheets indicated the resident had the following showers or complete bed baths since admission to the facility on [DATE]: - 04/03/24, shower, - 04/06/24, complete bed bath, - 04/13/24, shower, - 05/01/24, shower, - 05/04/24, refused, and - 05/05/24, complete bed bath. The resident had only received 6 of 20 scheduled showers or complete bed baths since admission. There was only one documented resident refusal of a scheduled shower or complete bed bath. 2. The clinical record for Resident D was reviewed on 05/06/24 at 9:38 A.M. An Admission MDS assessment, dated 03/04/24, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, metabolic encephalopathy, anemia, diabetes, and malnutrition. The Point of Care History and the Shower Sheets indicated the resident had the following showers/bathing from admission to the facility on [DATE] until discharge on [DATE]: - 02/28/24, shower, - 03/08/24, shower, - 03/11/24, shower, - 03/13/24, shower, - 03/18/24, shower, - 03/23/24, lack of documentation of a bathing, the skin sheet indicated the resident had no new skin concerns with no documentation of shower and the point of care history indicated no bathing occurred, and - 03/29/24, shower. The resident had 7 of 11 showers, complete bed baths, or refusals documented in the clinical health record. The current facility policy, titled Guidelines for Bathing Preference with a review date of 12/31/23, was provided by the Clinical Nurse Consultant on 05/08/24 at 2:51 P.M. The policy indicated, .Bathing shall occur at least twice a week unless resident preference states otherwise . The current facility policy, titled Nursing ADL [activities of daily living] Documentation Guidelines with a review date of 12/31/23, was provided by the Clinical Nurse Consultant on 05/08/24 at 2:51 P.M. The policy indicated, To document the type and amount of assistance provided to the resident for activities of daily living .Completion of ADL service will be validated through the use of the CARE ASSIST ADL reports .ADL services will be conducted and documented by the CNA each shift at the [point of care] or as reasonably possible after care . This citation relates to Complaint IN00432712. 3.1-38(a)(2)(A)

Based on interview, observation, and record review, the facility failed to hold a resident's blood pressure medication when vitals were outside of the physician's hold parameters for 1 of 16 residents reviewed for quality of care. (Resident E) Findings include: The clinical record for Resident E was reviewed on 05/02/24 at 10:10 A.M. An Admission Minimum Data Set assessment, dated 03/06/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, senile degeneration of the brain, anemia, diabetes, heart failure, and hypertension. A current physician's order, with a start date of 02/28/24, indicated the resident was to get metoprolol succinate (a blood pressure medication) extended release 24 hour tablet, 100 mg (milligrams), one time a day, for hypertension. The staff were to hold the medication if the resident's heart rate was less than 60. The March and April 2024 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident received the medication when the heart rate was less than 60 on the following dates: - On 03/05/24, the resident's heart rate was 55. - On 03/07/24, the resident's heart rate was 57. - On 03/08/24, the resident's heart rate was 52. - On 03/09/24, the resident's heart rate was 55. - On 03/10/24, the resident's heart rate was 56. - On 03/14/24, the resident's heart rate was 51. - On 03/16/24, the resident's heart rate was 55. - On 03/24/24, the resident's heart rate was 47. - On 03/26/24, the resident's heart rate was 55. - On 04/04/24, the resident's heart rate was 45. - On 04/10/24, the resident's heart rate was 53. - On 04/17/24, the resident's heart rate was 59. - On 04/22/24, the resident's heart rate was 51. - On 04/30/24, the resident's heart rate was 49. During an interview on 05/08/24 at 2:49 P.M., Licensure Practical Nurse (LPN) 5 indicated if a resident's medication had hold parameters for the heart rate, the heart rate should be obtained prior to the medication being given. If the heart rate was outside of the parameters, the medication shouldn't be administered, and the Nurse Practitioner should be notified. The current facility policy titled, Medication Administration-General Guidelines with a revised date of 11/18, was provided by the Clinical Nurse Consultant on 05/08/24 at 2:51 P.M. The policy indicated, .Medications are administered in accordance with the written orders of the prescriber . This citation relates to Complaint IN00433027. 3.1-40(a)(1) 3.1-40(a)(2) 3.1-37(a)

Based on observation, interview, and record review, the facility failed to follow a resident's diet order for 1 of 2 residents reviewed for therapeutic diets. (Resident C) Findings include: During a continuous observation and interviews on 04/29/24 from 12:16 P.M. through 12:29 P.M., the following was observed in the 600 Hall dining room: - At 12:16 P.M., Resident C was sitting at a dining room table, waiting for lunch, - At 12:20 P.M., Resident C was served a lunch plate that contained a slice of ham, cheddar hashbrowns, roasted carrots, and a piece of cake, RN 6 went and cut up the resident's ham into bite size squares. The resident's meal ticket sitting on the table in front of her indicated she was a mechanical soft diet, - At 12:25 P.M., RN 6 indicated the resident's diet orders were in the electronic record. When the resident had a new diet order it would get sent to the kitchen and printed on their meal ticket. The staff should follow the meal ticket. Resident C used to be on a mechanical soft diet, but it had recently changed but the kitchen hadn't updated her meal ticket, she confirmed the meal ticket indicated mechanical soft. She confirmed the resident order in the clinical record was started on 04/10/24 as a mechanical soft diet and indicated she should have been served a mechanical soft diet until the order changed. She would have to confirm with the Speech Therapist about the resident's diet, -At 12:27 P.M., the Speech Therapist indicated the resident was to be on a mechanical soft diet and should have been served a mechanical soft meal. She went and observed the resident and ordered a mechanical soft diet from the kitchen, -At 12:29 P.M., the Dietary Manager indicated the cook working in the 600 Hall kitchen had never worked down there before. The resident's all had meal trays that indicated what their diet was, and the kitchen and other staff should follow the diet order. The meal tickets would be updated if the order changed. The aides should be looking at the tickets when serving the meals to ensure the meal served is the correct diet. If the meal was incorrect, they would give it back to the cook to get the correct diet. The resident's diet order was reviewed on 04/29/24 at 12:25 P.M. The open ended, diet order with a start date of 04/10/24, indicated the resident was to be on a mechanical soft diet with extra gravy and no straws. An Admission MDS (Minimum Data Set) assessment, dated 04/03/24, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, metabolic encephalopathy, hypertension, heart failure, diabetes, malnutrition, anxiety, and depression. The resident had episodes coughing or choking during meals or when swallowing medications and had complaints of difficulty or pain with swallowing and had no natural teeth. The resident did not have any documented concerns related to coughing or choking after the admission assessment. The current facility policy titled, Resident Dining & Nutritional Preferences with an approval date of January 2024, was provided by the DON (Director of Nursing) on 05/06/24 at 2:41 P.M. The policy indicated, .The Dining Services and Clinical Nutrition Support teams have continued commitment to ensuring our residents have the best dining experience possible .The dietary order is included in the 48-hour baseline care plan .The individual resident's food plan meets his or her nutritional needs . 3.1-46(a)(2)

Based on observation, record review, and interview, the facility failed to follow physician orders related to a blood thinner for 1 of 6 resident reviewed for pharmacy services. (Resident 219) Findings include: During an observation on 05/01/24 at 2:20 P.M. Resident 219 was lying in his bed. His call light was in reach, and he said he was feeling good that day with no concerns. The resident had no visible bruises or bleeding. The clinical record for the resident was reviewed on 05/06/24 at 12:13 P.M. An Admission MDS (Minimum Data Set) assessment, dated 04/19/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, fracture, anemia, atrial fibrillation, and hypertension. The resident had received an anticoagulant while in the facility. A Progress Note, dated 04/24/24 at 4:01 P.M., indicated a new order was received to give Coumadin 7 mg daily and recheck the PT/INR (Prothrombin Time/International Normalized Ratio) on 04/26/24. A Progress Note, dated 04/26/24 at 12:57 P.M., indicated a new order was received to continue Coumadin 7 mg daily and recheck PT/INR on 04/29/24. A Progress Note, dated 04/29/24 at 12:55 P.M., indicated a new order was received to start Coumadin 2 mg on Sunday, Monday, Wednesday, and Friday. Give 3 mg on Tuesday, Thursday, and Saturday. A physician's order, dated 04/24/24 through 04/29/24, indicated the resident was to receive Warfarin (Coumadin), a 5 mg with the 2 mg tablet to equal 7 mg, once a day. A physician's order, dated 04/24/24 through 04/26/24, indicated the resident was to receive Warfarin, a 2 mg, with the 5 mg tablet to equal 7 mg, once a day. The April EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident lacked receiving the Coumadin dose 2 mg from 04/26/24 through 04/28/24. During an interview on 05/06/24 at 2:40 P.M., RN 6 indicated when a resident had orders for PT/INR's they were completed first thing in the morning. The night shift nurse would obtain the results and send them to the physician. The day shift nurse would then coordinate with the physician if the dose needed to be changed or remained the same. The nurse working the floor, or the physician could input the resident's orders. During an interview on 05/08/24 at 11:15 A.M., the DON (Director of Nursing) indicated she was unsure why the resident's 2 mg dose of Coumadin had discontinued on 04/26/24 when the order was to remain the same. The current facility policy titled, Medication Administration-General Guidelines with a revised date of 11/18 was provided by the DON on 05/08/24 at 9:55 A.M. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principals and only by persons legally authorized to do so . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident D) Findings include: During an observation on 02/13/24 at 2:50 P.M., RN 2 alerted Resident D of the need to observe his feet. The resident agreed and the resident's feet were observed with no concerns. After the resident was settled back into his chair he asked if she would like to look at his bottom. He indicated he had sores on his bottom that had been there for a while, they were sore, and he did not have them when he admitted to the facility. The resident's bottom was observed, there was no dressing in place and the following was observed: - a small open area to the coccyx the size of a pencil eraser, the wound bed was pink in color with no drainage, - a small area to the left buttock cheek the size of a pencil eraser, the wound bed was pink in color with no drainage, and - a small area to the right buttock cheek the size of a pencil eraser, the wound bed was pink in color with no drainage. During an interview on 02/13/24 at 2:54 P.M., RN 2 indicated the nurse had removed the dressing earlier in the day due to the resident having increased bowel movements. She had alerted her to replace it later when the resident's bowel movements were decreased. During an interview on 02/13/24 at 3:00 P.M., QMA (Qualified Medication Aide) 3 indicated she and the CNA (Certified Nurse Aide) that was working with her had never worked with the resident. They were unaware if the resident had wounds to his buttocks. The clinical record was reviewed on 02/13/24 at 1:15 P.M. An Admission MDS (Minimum Data Set) assessment, dated 02/01/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, hyponatremia, and respiratory failure. The resident was at risk for pressure ulcers and had no pressure ulcers at the time of admission. The resident was always incontinent of bowel and bladder. An Admission Observation and Data Collection record, dated 01/28/24, indicated the resident's Braden Scale for pressure ulcer predictability rated the resident as being at high risk. An Interdisciplinary Team (IDT) Progress Note, dated 01/29/23 at 3:07 P.M., indicated they had reviewed a bruising and wound event. The resident had scattered bruises to the bilateral upper extremities, a 3 cm (centimeters) x (by) 1 cm x 0.1 cm area on his spine, a 1 cm x 0.3 cm x 0.1 cm area on the slight left of the coccyx, and a 3 cm x 4 cm x 0.1 cm abscess on the anterior scrotum with yellow drainage. The bilateral feet had hardened, dark calluses at the sesamoid bone area on the bottom of the foot. The bilateral lower extremities were extremely dry. The resident and Nurse Practitioner were aware, and orders were in place. The resident would be monitored weekly on wound rounds. An open-ended physician's order, with a start date of 01/29/24, indicated the staff were to apply a foam dressing to the mid-spine and coccyx. The dressing was to be changed every 5 days and as needed for soilage. An open-ended physician's order, with a start date of 01/29/24, indicated the staff were to observe the dressing to the mid-spine and coccyx every shift, three times a day. The dressing may be peeled back so the area could be viewed to monitor for any open areas. A Progress Note, dated 02/04/24 at 5:24 A.M., indicated the resident's dressings had been changed to his scrotum, spine, and coccyx on Saturday night (02/03/24). A Point of Care History for skin problems for February 2024 indicated the resident had clear skin (without impairment) or a dressing on the following dates and times: - 02/13/24 at 7:53 A.M., the residents' skin was clear and signed by RN 4 and QMA 6, - 02/12/24 at 12:18 A.M., the resident had a dressing in place to the back and buttocks and signed by RN 5, - 02/12/24 at 7:28 A.M., the residents' skin was clear and signed by CNA 7, - 02/12/24 at 11:52 A.M., the residents' skin was clear and signed by QMA 8, - 02/10/24 at 11:46 A.M., the residents' skin was clear and signed by QMA 8, - 02/09/24 at 7:24 A.M., the resident skin was clear and signed by CNA 7, - 02/08/24 at 10:27 A.M., the residents' skin was clear and signed by QMA 6, - 02/07/24 at 12:26 P.M., the resident's skin was clear and signed by QMA 6, - 02/06/24 at 1:02 A.M., 7:03 A.M., and 11:23 P.M., the resident's skin was clear and signed by QMA 8 and CNA 7, - 02/05/24 at 12:36 A.M., 6:43 A.M., and 3:03 P.M., the resident's skin was clear and signed by CNA 9, CNA 7, and CNA 10, - 02/04/24 at 12:38 A.M., 7:53 A.M., and 3:49 P.M., the resident's skin was clear and signed by CNA 9, RN 11, and QMA 6, - 02/03/24 at 6:59 A.M., the resident's skin was clear and signed by CNA 7 - 02/02/24 at 6:55 A.M., 4:07 P.M., and 11:18 P.M., the resident's skin was clear and signed by CNA 7, QMA 6, and CNA 9, and - 02/01/24 at 6:55 A.M., the resident's skin was clear and signed by CNA 7. The clinical record lacked indication the resident had any pressure ulcers to the coccyx. During an interview on 02/13/24 at 3:05 P.M., Wound Care Nurse 12 indicated the resident came to the facility with an abscess to his scrotum, a bruise to the spine, and a bruise to the coccyx. When a resident was admitted to the facility, she would look through the hospital documentation and complete an assessment to determine if there were any skin issues. If a resident acquired a new skin issue while in the facility she would rely on the nurses and aides to let her know about it. The nurses would then open an event to monitor the area. The staff should be alerting her if the resident had any new reddened areas, non-blanchable areas, or any type of skin breakdown. During an observation and interview on 02/13/24 at 3:15 P.M., Resident D's coccyx was reviewed with Wound Care Nurse 12. She indicated the resident had a small Stage 2 to the sacrum that measure 0.5 cm x 0.5 cm with excoriation to the bilateral buttocks, the wounds did not have any drainage. The staff should have let her know of the resident's condition of his bottom before the areas were open as they were able to remove the dressing to look at the bottom. The areas were not there on admission. The current facility policy titled, GUIDELINES FOR WEEKLY SKIN OBSERVATION', with a review date of 12/31/23, was provided by Clinical Support on 02/13/24 at 4:05 P.M. The policy indicated, .To monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated .In addition to the Weekly Observation by the licensed nurse, the nurses assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified . This citation relates to Complaint IN00426993. 3.1-40(a)(2)

Based on observation and interview the facility failed to label and store and medications appropriately for 4 of 5 medication carts reviewed. (200 Hall Medication Cart, 600-1 Medication Cart, 600-2 Medication Cart, and 100 Hall Medication Cart) Findings include: 1. The 200 Hall Medication Cart was observed on 04/10/23 at 10:38 A.M., with LPN (Licensed Practical Nurse) 9 and contained the following: - a Humalog insulin vial with no opened date for Resident 102 that was 1/2 full. The Humalog vial had a received date from the pharmacy of 04/05/23. The LPN indicated the insulin pen should have had an opened date written on it, and it was good for 28 days. 2. The 600-1 Medication Cart was observed on 04/10/23 at 10:51 A.M., with LPN 11 and contained the following: - a bottle of Timolol Maleate 0.5% eye drops with no opened date for Resident 254 that was 1/2 full and - a Lispro insulin pen with no opened date for Resident 38 that was 3/4 full. The LPN indicated each bottle should have an opened date written on the bottle. An Expiration Date Table was provided by the DON (Director of Nursing) on 04/14/23 at 11:23 A.M. Timolol Maleate, 1 month after opening of foil .Lispro pen, 28 days . 3. The 600-2 Medication Cart was observed on 04/10/23 at 10:54 A.M., with RN 10 and contained the following: - a Humalog insulin vial with no opened date for Resident 16 that was 1/4 full and - a Novolog insulin pen with no name or date that was 1/2 full. The RN indicated the medications in the cart should be labeled with resident names and an opened date. An Expiration Date Table was provided by the DON (Director of Nursing) on 04/14/23 at 11:23 A.M.Novolog, 28 days . The current facility policy titled, MEDICATION STORAGE IN THE FACILITY was provided by the Administrator on 04/13/23 at 11:15 A.M. The policy indicated .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . 38769 4. During an observation on 04/10/23 at 1:42 P.M., an unattended medication cart on the 100 Hall had an unopened clonadine patch on the top of the cart that belonged to Resident 8. RN 2 walked to the cart from the area of the nurses station, retrieved the patch and took it to Resident 8's room. During an interview on 04/13/23 at 2:10 P.M., RN 2 indicated resident medications should absolutely not be left on the top of the medication unattended. The current facility policy, titled Medication Administration-General Guidelines, with a revision date of 11/2018, was provided by the Clinical Support Nurse 5 on 04/12/23 at 4:39 P.M. The policy indicated, .During administration of medications, the medication cart is kept closed and locked when out of sight of the facility mediction administration personnel. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . 3.1-25(m)

Based on record review and interview, the facility failed to accurately document a medication error in detail and the full assessment for a medication error in the resident's clinical record for 1 of 3 residents reviewed for accuracy of assessment. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/31/22 at 10:11 A.M. An Admission MDS (Minimum Data Set) assessment, dated 08/22/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, sepsis, cancer, anemia, hypertension, anxiety, depression, and respiratory failure. The resident required the extensive assistance of two physical staff for bed mobility. A Medication Error Event, dated 08/24/22, indicated the resident had received another resident's guaifenesin (cough medication) liquid. He had received the correct dose. No other information was documented. The medication event information was not completed. During an interview on 11/01/22 at 9:22 A.M., the DON (Director of Nursing) indicated RN 3 had come to her and said she had given Resident B another resident's cough medication, but it was the correct dose. The family and Nurse Practitioner were notified. The resident was assessed, and his vitals were obtained every shift for 72 hours after the event. When a medication error took place a medication error event form would be initiated, staff would notify the appropriate parties, monitor the resident for any change in condition, and monitor the resident's vital signs. Verbal education was provided to the nurse on identifying the correct resident before administration of medication. She did not document that the nurse was provided verbal education. She would document a written warning on the second occurrence. The residents medication error form documentation should have been completed. During an interview on 11/01/22 at 9:53 A.M., LPN (Licensed Practical Nurse) 4 indicated she was unaware of any medication errors with residents in the building. During an interview on 11/01/22 at 9:54 A.M., RN 3 indicated when administering a resident's medications she would ensure the five rights were being followed such as, right resident, right medication, right dose, right route, and right time. The current facility policy, titled Guidelines for Medication Error Reporting, with a review date of 10/01/21, was provided by the DON on 11/01/22 at 10:39 A.M. The policy indicated, .To identify medications given in error and expedite correction actions .Initiate the appropriate Event form. Monitor the resident closely for 72 hours or as directed .Document the following in the resident's clinical record: a. A description of the error (brief) b. Name of physician and time notified c. Physician's subsequent orders . This Federal tag relates to Complaint IN00392018 .

Based on observation, interview, and record review, the facility failed to ensure that residents, with impaired mobility, did not develop pressure wounds for 2 of 6 residents reviewed for pressure ulcers and to implement pressure ulcer interventions for 1 of 6 residents. This deficient practice resulted in residents developing unstageable pressure ulcers to the heels. (Residents 31, 26, and C) Findings include: 1. During an observation on 06/11/19 at 09:34 A.M., Resident 31 received a treatment to his right heel by LPN (Licensed Practical Nurse) 9. The resident's feet were elevated on a pillow. The resident indicated the staff had been putting his legs up on a pillow for about 2 weeks. The nurse indicated the current treatment to the heel was Skin Prep to keep the skin tough. The resident received Skin Prep to both heels. The resident was observed to have an irregular, dark red/black area on his right heel with some dry, peeling skin. The area was approximately 4 cm (centimeters) x (by) 2 cm. The nurse indicated the resident had broken his right hip and was not a candidate for surgery. The Clinical Record for Resident 31 was reviewed on 06/10/19 at 3:20 P.M. The resident was admitted to the facility on [DATE]. The Admission MDS (Minimum Data Set) assessment, dated 05/10/19, indicated the resident was cognitively intact. The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. [DIAGNOSES REDACTED]. Section M, Skin Conditions, indicated the resident was at risk for developing pressure ulcers and had no unhealed pressure ulcers. The resident had a pressure reducing device for his chair and bed. Wound Management documentation for Resident 31 was provided by Clinical Support 24 on 06/12/19 at 4:47 P.M. The document indicated the resident had a pressure ulcer wound on his right heel that was identified on 05/28/19 at 2:31 P.M. The wound was not present on admission to the facility. The wound measured 2 cm (centimeters) x 4 cm, was unstageable, and completely covered by eschar (dead) tissue. On 06/04/19 the wound measured 2 cm x 4 cm, was unstageable, and completely covered by eschar tissue. On 06/11/19 the wound measured 2 cm x 3 cm, was unstageable, and completely covered by eschar tissue. The complete Care Plan for Resident 31 was provided by Clinical Support 24 on 06/10/19. The Care Plan indicated the resident had an impairment in functional status in regards to bed mobility, transfers, and toileting, related to a [MEDICAL CONDITION]. The Skin Integrity Care Plan, with a start date of 05/06/19, indicated the resident was at risk for skin breakdown related to diagnoses, the need for staff to assist with ADLS (Activities of Daily Living), and weakness. Approach interventions, with a start date of 05/06/19, were listed as, Encourage and assist to turn and reposition for comfort and as needed, Conduct weekly skin assessment. Pay particular attention to bony prominences. The Resident has a pressure ulcer to right heel Care Plan, with a start date of 05/29/19, contained Approach interventions that included, but were not limited to, encourage and assist to turn and reposition every 2 hours, and float heels while in bed. Both were dated 05/30/19. An intervention, dated 05/29/19, included treatments per MD (Medical Doctor) order. The EMAR (Electronic Medication Administration Record) for Resident 31, for (MONTH) 2019, was provided by the DON (Director of Nursing) on 06/10/19 at 4:45 P.M. The record indicated the resident had an order for [REDACTED]. An order, with a start date of 05/28/19, indicated the resident was to receive a treatment of [REDACTED]. An order, with a start date of 05/30/19, indicated the resident was to receive a treatment of [REDACTED]. An order, with a start date of 05/30/19, indicated the resident was to be encouraged to turn and reposition every two hours. An order, with a start date of 05/30/19, indicated the resident was to have his heels floated while he was in bed. No order was noted in the (MONTH) EMAR or the Physician order [REDACTED].(protect an ulcer or open wound) boots. During an interview on 06/12/19 at 10:17 A.M., Resident 31 and his family member indicated he always slept on his back. The family member indicated the last time the resident had a spot on his heel it took her from (MONTH) to (MONTH) to get it healed. He now wore foam boots when he was in bed at the facility. When he first came here he was not wearing the boots. The staff started putting the boots on him after she told them he had a place on his heel. He always slept on his back here and at home ever since he had a stroke. The resident broke his hip and had it replace in (MONTH) of (YEAR). He broke the same hip again on (MONTH) 27, 2019. During an interview on 06/11/19 at 3:29 P.M., RN 7 indicated she found the wound on Resident 31's right heel one evening. On that unit, for new admits, the staff document daily weights for three days, unless ordered otherwise, and apply Skin Prep to the residents' heels twice a day for the first 30 days. She discovered the pressure area on his right heel when applying the skin prep. When a skin issue was identified the staff complete a Skin Event, measure the wound, and document the stage of the wound. Resident 31 developed this area after he was admitted . The weekly skin checks were completed by the nurse on duty. If an area was discovered, the wound nurse would measure and document on the wound weekly. The nurse on duty notified the wound nurse if there were detrimental changes in the wound. Once an area was identified, the nurse on duty monitored the wound at least daily or every shift and it would be documented under the specific event or in the EMAR if there was a treatment ordered. During an interview on 06/12/19 at 09:58 A.M., Clinical Support 24 indicated the Informed Refusal and Non-compliance Observation was put into place in (MONTH) of 2019 to document resident and families had acknowledged that the resident was non-compliant. Examples of areas of concern addressed in the observation included, but were not limited to, falls, skin integrity, and nutritional status. Resident and family education would be documented in the Progress Notes. The Progress Notes for Resident 31 were provided by Clinical Support 24 on 06/10/19 at 5:05 P.M. No notes were documented indicating the resident or the family had been educated regarding keeping the pressure off of the resident's heels and other bony prominences. No notes indicated the resident had refused care or treatments. During an interview on 06/12/19 at 3:57 P.M., Clinical Support 24 indicated all new residents had base pressure relief measures put in place that included a cushion in a wheelchair, and a pressure relieving mattress. Turning people every 2 hours was a standard procedure. For residents at risk, he would put in an order that would show up on the EMAR every shift to remind staff to turn the resident. The order reads, Encourage and assist in turning and repositioning every 2 hours. It was standard care. During an interview on 06/12/19 at 4:22 P.M., CNA 16, indicated for Resident 31 the staff helped him with transfers, toileting, showers, and dressing. At night they helped him to bed and made sure he had his C-pap on. During an interview on 06/13/19 at 10:41 A.M., CNA 17, indicated the CNA staff had papers they carried on them that told them what kind of care was needed for each resident on the hall that they were assigned. The paper contained information about individual care and who needed to be turned or sat up on the side of the bed. It was not always on the paper if a resident needed to be turned. Not all of the interventions were on the papers for each resident. She wished they were because it would help her and especially the newer CNAs. The older CNAs usually knew what the interventions were for all the residents. The new CNAs did not always know the interventions for the residents if someone was not physically there to tell them. It was nice for them to have something to refer to as a guide. The Assignment Sheet for the Certified Nursing Assistants record, with an updated date of 06/10/19, was provided by the Clinical Support Consultant on 06/10/19 at 4:27 P.M. The record indicated Resident 31 needed the assistance of two staff for transfers, ADLS, bathing, toileting, and hygiene. The resident used a wheel chair and was a fall risk. The resident was to wear .-Boots when in bed. The record did not indicate the resident was at risk for skin impairment, should be turned and repositioned, or that his heels should be floated. 2. During an observation and interview, on 06/11/19 at 09:34 A.M., with LPN 19 and LPN 20, Resident 26 received a treatment to his right and left heels. The wounds were cleansed with normal saline and [MEDICATION NAME] applied. The right heel was covered with an absorbent pad and gauze. The resident's pressure reducing boots were placed on his feet and a pillow was placed under his legs to allow his heels to float. LPN 19 indicated the current treatment to the left heel was cleanse heel with normal saline and apply [MEDICATION NAME] daily, wear pressure reducing boots, or use pillow to float his heels. The current treatment to the right heel was to cleanse the heel with normal saline and apply [MEDICATION NAME] and a dry dressing daily, wear pressure reducing boots, or use pillow to float his heels. The resident was observed to have a dark red/black area on his left heel with some dry, peeling skin. The area appeared to be 5 cm by 5 cm. The area on the right heel was dark red/black with some dry, peeling skin and appeared to be 6 cm by 7 cm. The nurse indicated the resident had broken his right hip. The Clinical Record for Resident 26 was reviewed on 06/10/19 at 11:46 A.M. The resident was admitted to the facility on [DATE]. A Significant Change MDS assessment, dated 05/28/19, indicated the resident was moderately cognitively impaired. [DIAGNOSES REDACTED]. The resident needed extensive assistance of two staff members for bed mobility. Section M, skin conditions, indicated the resident had two stage II pressure ulcers, one on the right and one on the left heel. The resident had a pressure reducing device on his bed and in his chair. Skin Integrity Event documentation for Resident 26 was provided by Clinical Support 24 on 06/12/19 at 4:47 P.M. The document indicated the resident had a stage II pressure ulcer (fluid filled blister) on his left heel measuring 1.5 cm by 1.5 cm. and a stage II pressure ulcer (fluid filled blister) on his right heel measuring 4 cm by 4 cm. The pressure ulcers were not present upon admission to the facility. Wound Management documentation for Resident 26 was provided by Clinical Support 24 on 06/12/19 at 10:33 A.M. The document indicated the following measurements: Left heel pressure ulcer measurements: - On 05/07/19, the wound was 3 cm by 5 cm. Stage II pressure ulcer. - On 05/14/19, the wound was 4 cm by 5 cm. Stage II pressure ulcer. - On 05/21/19, the wound was 3.5 cm by 4 cm. Unstageable pressure ulcer with dark hard covering (eschar). - On 05/28/19, the wound was 3.5 cm by 4 cm. Unstageable pressure ulcer with dark hard covering (eschar). - On 06/04/19, the wound was 5.8 cm by 5.8 cm. Unstageable pressure ulcer with dark hard covering (eschar). - On 06/11/19, the wound was 5.8 cm by 5.8 cm. Unstageable pressure ulcer with dark hard covering (eschar). Right heel pressure ulcer measurements: - On 05/07/19, the wound was 5 cm by 5 cm. Stage II pressure ulcer. - On 05/14/19, the wound was 6 cm by 8 cm by 0.1 cm, Unstageable pressure ulcer with dark hard covering (eschar). - On 05/21/19, the wound was 6 cm by 8 cm by 0.1 cm, Unstageable pressure ulcer with dark hard covering (eschar). - On 05/28/19, the wound was 5 cm by 7.5 cm by 0.1 cm, Unstageable pressure ulcer with dark hard covering (eschar). - On 06/04/19, the wound was 5.7 cm by 7.8 cm by 0.1 cm, Unstageable pressure ulcer with dark hard covering (eschar). - On 06/11/19, the wound was 6.7 cm by 7 cm by 0.1 cm, Unstageable pressure ulcer with dark hard covering (eschar). The Care Plan for Resident 26 was provided by Clinical Support 24 on 06/12/19. The Skin Integrity Care Plan, with a start date of 05/01/19, indicated the resident was at risk for skin breakdown related to diagnoses, the need for staff to assist with ADLS (Activities of Daily Living), and weakness. Approach interventions, with a start date of 05/01/19, were listed as, Encourage and assist to turn and reposition for comfort and as needed, Conduct weekly skin assessment. Pay particular attention to bony prominences. The Resident has a pressure ulcer to left heel Care Plan, with a start date of 05/07/19, indicated the interventions included, but were not limited to, Treatment per MD order. Notify MD if treatment is not effective dated 05/07/19, pressure relieving boot to foot, dated 05/08/19, and float heels while in bed, dated 05/08/19. The Resident has a pressure ulcer to right heel Care Plan, with a start date of 05/07/19, indicated the interventions included, but were not limited to, Treatment per MD order. Notify MD if treatment is not effective dated 05/07/19, pressure relieving boot to foot, dated 05/08/19, and float heels while in bed, dated 05/08/19. The Admission Observation and Data Collection, dated 04/30/19, indicated the resident lacked any skin impairments on his right or left heel. An order, with a start date of 04/30/19 and an end date of 05/07/19, indicated the resident was to receive a treatment of [REDACTED]. During an interview on 06/12/19 at 3:52 P.M., Clinical Support 24 indicated turning and repositioning every two hours and a pressure relieving mattress was standard practice of care for each resident in the facility. an order for [REDACTED]. During an interview on 06/13/19 at 11:18 A.M., LPN 19 indicated a resident with a [MEDICAL CONDITION] should be rolled in bed by two staff members and toes should be checked for sensation and movement. During an interview on 06/13/19 at 3:47 P.M., RN 7 indicated a resident with limited bed mobility and at risk for skin breakdown should have Skin Prep applied to their heels every shift, be monitored for fluid intake and nutrition, turned and reposition at least every 2 hour while in bed or in the chair. There should be a pressure relieving mattress on the bed and a pressure relieving cushion in the chair. The nursing staff should be off loading the resident's heels and monitor the skin on the back of their legs. 3. During an observation on 06/11/19 at 1:55 P.M., Resident C received treatment to his right and left heels by LPN 14 with assistance from CNA 18. CNA 18 removed the resident's pressure relieving boots and LPN 14 applied Skin Prep to the resident's heels. The right heel was noted to have a round, pencil eraser sized area of dry, flaky tissue. The skin around the wound was without redness or swelling, and there were no signs of infection. LPN 14 indicated the resident developed pressure areas to his right and left heels in (MONTH) of (YEAR), but the left heel had been healed for some time. The area on the right heel was almost healed; the dry skin seemed like it was about to fall off, but it kept hanging on. CNA 18 reapplied the resident's pressure relieving boots after the treatment was administered. The Clinical Record for Resident C was reviewed on 06/07/19 at 4:00 P.M. A Quarterly MDS assessment, dated 03/20/19, indicated the resident was severely cognitively impaired. The resident required extensive staff assistance with all ADLS, but only limited staff assistance with eating. [DIAGNOSES REDACTED]. The resident was at risk for pressures ulcers and had one unstageable pressure ulcer documented on the MDS assessment. The resident utilized a pressure reducing device for the bed, nutrition or hydration interventions to manage skin problems, pressure ulcer care, and the application of medications or ointments to areas other than the feet. Wound Management documentation for Resident C was provided by Clinical Support 24 on 06/13/19 at 5:28 P.M. The documents indicated the following: Resident C had a pressure ulcer on the left heel that was identified on 12/13/18 at 9:40 A.M. The wound was not present on admission to the facility. The wound measured 3 cm by 1 cm, and was an unstageable deep tissue injury. On 01/08/19, the wound on the left heel measured 2 cm by 1 cm, and was an unstageable deep tissue injury. On 01/15/19, the documentation of the wound on the left heel indicated the wound was healed. The resident had a stage two pressure ulcer (partial thickness loss of skin with exposed dermis) on the right heel that was identified on 12/13/19 at 8:34 A.M. The wound was not present on admission to the facility. The wound measured 2.5 cm by 2 cm, and had a light amount of clear, to amber colored, thin and watery drainage. On 12/24/18, the wound on the right on the right heel measured 3.3 cm by 3 cm, and was an unstageable deep tissue injury. On 01/01/19, the wound on the right on the right heel measured 3.3 cm by 3 cm, and was unstageable. On 01/15/19, the wound on the right on the right heel measured 1.4 cm by 1.5 cm, and was an unstageable deep tissue injury. On 02/05/19, the wound on the right on the right heel measured 0.9 cm by 0.8 cm, and was an unstageable deep tissue injury. On 03/05/19, the wound on the right on the right heel measured 0.7 cm by 0.7 cm, and was an unstageable deep tissue injury. On 03/27/19, the wound on the right on the right heel measured 0.7 cm by 0.7 cm, and was an unstageable deep tissue injury. On 04/23/19, the wound on the right on the right heel measured 0.5 cm by 0.5 cm, and was an unstageable deep tissue injury. On 05/14/19, the wound on the right on the right heel measured 0.5 cm by 0.5 cm, and was an unstageable deep tissue injury. On 06/11/19, the wound on the right on the right heel measured 0.4 cm by 0.4 cm, and was an unstageable deep tissue injury. A Progress Note, dated 12/13/18 at 11:44 A.M., indicated Clinical support in this day to assist wound care nurse with skin sweeps and assessed areas on resident. During assessment identified new pressure areas to this resident's right lateral heel, left heel, and penile shaft/foreskin .Current interventions: Pressure reducing redistribution mattress to bed, pressure reducing redistribution cushion to w/c (wheelchair), encourage to turn and reposition, incontinence care as needed, house barrier cream, float heels while in bed .Recommendations: Clinical support recommends to provide resident with low air loss mattress, pressure relieving boots, and (a) nutritional consult . A Progress Note, dated 12/13/18 at 1:22 P.M., indicated IDT (Interdisciplinary Team) met to discuss resident's new skin events noted on 12/13 .MD, hospice, and family aware .requested to provide resident with low air loss mattress, pressure relieving boots, and (a) nutritional consult. Care plan updated. Attendees include CS (Clinical Support), DHS (Director of Health Services), ADHS (Assistance Director of Health Services), UM (Unit Manager) . The Pressure Wound Care Plan was provided by Clinical Support 24 on 06/13/19 at 5:15 P.M. The Care Plan, with a start date of 12/12/18 indicated, .Resident has pressure wounds to right heel and left heel . Approaches listed included .-boots (pressure relieving boots) while in bed, with a start date of 06/13/19. There was no indication this approach had been included in the resident's Care Plan prior to 06/13/19. The Current physician orders [REDACTED].-boots on while in bed. There was no indication in the clinical record that pressure relieving boots were ordered prior to 03/27/19. The Treatment Administration History for 12/18/18 through 03/26/19 was reviewed for Resident C. There was no indication the resident was wearing pressure relieving boots during that time frame. During an interview on 06/13/19 at 4:13 P.M., Clinical Support 24 indicated he made a recommendation for pressure relieving boots for Resident C on 12/13/18. A physician's orders [REDACTED]. The Care plan did not reflect the approach of the pressure relieving boots until 06/13/19. On 06/13/19 at 4:35 P.M., Clinical Support 24 provided a Progress Note dated 02/14/19 at 12:15 P.M. that indicated the resident was wearing pressure relieving boots. There was no other documentation in Resident C's clinical record that indicated the resident was wearing the boots prior to 03/27/19. The current facility policy titled Guidelines for Pressure Prevention, with a revision date of 05/10/ , was provided by Clinical Support 24 on 06/13/19 at 5:20 P.M. the policy indicated, .To maintain good skin integrity and avoid development of pressure ulcers .Interventions may include .Apply Skin Prep .over bony prominences or reddened areas to reduce friction and provide barrier . 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview, observation, and record review, the facility failed to ensure interventions were in place to prevent a resident with a decline in cognition from being burned related to hot coffee for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a resident spilling coffee and receiving second [MEDICAL CONDITION] his left thigh. (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/22/19 at 3:37 p.m. The resident's [DIAGNOSES REDACTED]. The re-admission MDS (Minimum Data Set) assessment, dated 3/21/19, indicated the resident was alert and oriented. The resident required supervision and set up with dining. The resident required extensive assistance of one physical staff member for dressing, toileting, and locomotion. The discharge MDS assessment, dated 3/31/19, indicated the resident required extensive assistance of one physical staff member with dressing, toileting, and required supervision of meals. The admission MDS, dated [DATE], indicated the resident required supervision with meals, and required extensive assistance of one physical staff member with toileting. A Safety Care Plan, with a problem start date of 3/26/19, indicated Resident B had impaired cognition with associated short term memory impairment. The resident was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to dementia. The goal was for the resident to remain safe and not injure himself. The interventions included, but were not limited to, pay attention to basic needs, provide ADL (activity of daily living) care as required, and provide cues and supervision for decision making. A Care Plan for the resident demonstrated exit seeking behaviors, with a problem start date of 3/15/19, indicated the resident was to be evaluated for need of a secured unit, transfer if needed, and a Wanderguard placement (a device to alarm staff if the resident attempted to leave the building). An ADL Care Plan, with a problem start date of 3/15/19, indicated Resident B required staff assistance to complete ADL's tasks completely and safely. The goal was for the resident to have ADL needs met safely by staff. The interventions included, but were not limited to, observe for deterioration in ADL abilities and report as needed. A second ADL Care Plan, with a problem start date of 3/15/19, indicated Resident B had potential for decline in ADL's. The goal was for the resident to have been free of complication with ADL decline. The interventions included, but were not limited to, observe for decline and report as needed. The incident report, dated 4/1/19 at 1:15 p.m., indicated .On 3/31/19 resident in main dining room of unit accidentally spilled coffee on left side of lap area to left leg/thigh. Staff took resident to restroom and noted red, blistered areas to inner left thigh, top of left thigh, and outer areas along with redness. Full assessment completed by nurse. Nurse provided first aid treatment The Event report, dated 3/31/19 at 10:35 a.m., indicated, on 3/31/19 at 8:34 a.m., Resident B had spilled coffee on left inner thigh, left outer thigh, and hip. The physical observation by RN 2 indicated the following: - location 1 the top of the left thigh had a second degree/superficial partial thickness burn with blistered areas. (extends though the epidermis downward into the superficial into the dermal layer; dermal structures are intact. Characterized by large blister, [MEDICAL CONDITION], pain shiny surface) -location 2 the outer left thigh had a second degree/superficial partial thickness burn with large blistered area. -location 3 the inner left thigh area had a second degree/superficial partial thickness burn with a large blistered area, with redness of skin and scratched area. A Nursing Progress note, dated 3/31/19 at 10:40 a.m., indicated the resident spilled beverage that smelled like coffee, on left side of lap area to left leg. Coffee had been cooled down by staff adding water before serving. No complaints voiced at 8:15 a.m. and was sleepy. Resident then ate breakfast, took meds, and then spilled orange juice to same area. Staff then took resident to rest room and noted red, blistered areas to inner left thigh, top of left thigh and outer areas along with redness in which resident was scratching . An IDT note, dated 3/25/19 at 9:55 a.m., indicated the resident has severely impaired cognition with poor safety awareness. Resident was noncompliant with care. A Nursing note, dated 3/21/19, indicated Resident B voided (urinated) in a heater beside his bed. Will continue to monitor. Hospital admission history and physical report, dated 3/31/19 at 2:18 p.m., indicated the resident was brought to the emergency department due [MEDICAL CONDITION] his left thigh and increased confusion. The resident had sustained a small burn near the left groin with significant redness and a few blisters. The resident was unresponsive upon arrival to the emergency room . The resident's left thigh burn involved less than 4 percent of the body. Silver sulfadiene was ordered to be placed topically. The resident was admitted to the hospital for hepatic impairment (liver failure). Review of the nursing statement, dated 4/1/19, indicated, on 3/31/19, RN 2 observed Resident B up in the dining room for breakfast. The CRCA 4 notified her about 10:00 a.m. that Resident B had a red area with blisters on his left inner thigh. She assessed the resident and applied burn gel and a dressing to the burn. Review of the CRCA statement, dated 4/2/19, indicated, on 3/31/19, CRCA 4 assisted Resident B to get dressed for the day and helped him down to the dining room for breakfast. The resident was wheeled up to the dining room table where he normally eats with another resident. I poured (Resident B) a cup of coffee and gave it to him just as I always do when I bring him down to breakfast. As I was down the hall assisting another resident I heard the resident ( another resident sitting at the table with Resident B) yell out for me and as I returned to the dining room, he pointed to (Resident B's) coffee cup overturned and I noticed it was on his lap and on the floor. I immediately took (Resident B) back to his room, assisted in changing his clothes, and looked at his skin where the coffee was spilled and his skin was slightly pink. (Resident B) was not showing any signs of pain or discomfort, so I redressed him and returned him to the dining room table. He continued eating breakfast and then later spilled orange juice on the table as well therefore, I took him back to his room to change his clothing again and noticed that his leg was then redder and had visible blisters I immediately went and got my nurse to assess him. Review of the ST (Speech Therapy) note, dated 3/31/19, indicated she was completing a diet texture analysis at breakfast. Pt (patient) required constant cues to stay awake. He kept closing his eyes, dropping his toast, and spilled his orange juice once. ST had to feed pt intermittently due to pt dropping food. Towards the end of the session, pt was drinking his orange juice through a straw. He appeared to be awake enough to be safely drinking, but he started coughing and coughed for several minutes. Meal was discontinued at that time. ST reported aspiration event to nurse. Nurse verbalized understanding. Nurse reported that pt was up last night until after 1am (1:00 a.m.), causing lethargy. The five pictures related to Resident B'[MEDICAL CONDITION] observed, on 4/22/19 at 3:22 p.m. The pictures indicated [MEDICAL CONDITION] the resident's left thigh had multiple linear areas (lines like the crease in pants when sitting) of burn marks that stretched across the width of the residents inner, top, and outer area of the left thigh. The residents left groin area was red on the side of his left testicle and in the crease of the left leg area. The resident's inner left thigh had a large fluid (serum a fluid that seeps from the body tissue) filled blister, pink and yellow in color, that covered half of the width of his inner thigh. The resident's outer thigh had multiple small fluid filled blisters, pink and yellow in color. During an interview, on 4/23/19 at 8:42 a.m., CRCA 4 indicated Resident B was pushed up to the breakfast table at 7:05 a.m. The resident needed more assistance than his normal on that day. He was normally given a cup of coffee without a lid. It was not normal for this resident to spill his drinks. Another resident was sitting at the table with the resident. Three nurses were up at the nurses station. She had heard the cup hit the table and turned around to see what happened. As soon as she seen the coffee spilled at 7:10 a.m., she took the resident to his room and changed his clothing. When she changed his clothing she noticed a pink area on his left thigh. The CRCA did not tell the nurse about the resident's pink area to his thigh when she first changed him. She notified the nurse after the resident spilt his second drink (orange juice) and she had seen blisters on the resident's left thigh while she was changing the resident clothing a second time. She had not added cold water to the coffee prior to sitting the coffee directly in front of the resident. She did not know who monitored the coffee temperatures. The resident was sometimes alert and other times he was not. The resident seemed out of sorts for his normal behavior that day. He had not complained of any pain or discomfort after spilling the coffee. During an interview with RN 2, on 4/22/19 at 3:37 p.m., she indicated the coffee machine was broken on the day the resident was burned. The kitchen staff was brewing the coffee and bringing it to the dining area. The resident was burned in the morning she did not witness the event. No other resident was burned. During an interview with DM (Dietary Manager), on 4/22/19 at 3:43 p.m., he indicated he was aware the coffee machine was broken on the 600 hall dining area. The coffee that was brought to the 600 hall dining area came from the coffee liquid roast machine in the main dining area. Staff do not check the coffee temperature since the coffee liquid roast machine regulates the coffee temperatures. The company the supplied the machine came and checked the temperatures of the hot liquid after the resident was burned. The coffee temperatures were 194 degrees Fahrenheit. He knew the liquid roast machine on the 600 hall dining room was broken from (MONTH) 26 to (MONTH) 5 from the emails with the company. During an observation with the DM, on 4/22/19 at 3:48 p.m., the main dining area Coffee Liquid Roast machine was tested . The DM picked up a coffee cup and dispensed coffee directly from the machine. The coffee tested 169 degrees Fahrenheit. During an interview ,on 4/23/19 at 8:55 a.m. , ST (Speech Therapist) 3 indicated Resident B was more tired than normal on the morning of 3/31/19. The resident was shaky and having problems staying awake. The resident normally would stay awake. He had periods of confusion and the resident was having a bad day. She had reported that he was not his normal self. The nurse indicated she was aware he was not himself. The resident normally could feed himself. He had some cognition issues and swallowing so she was observing the resident during the breakfast session. Later during her session with the resident he was doing a little better around 8:30 a.m. to 9:00 a.m. During an interview, on 4/23/19 at 9:16 a.m., LPN (licensed Practical Nurse) 6 indicated she normally worked on the hall with Resident B. He was frequently tired and kept the staff busy. The Chemical and Beverage Service report, dated 4/2/19, indicated the Coffee Liquid Roast machine was leaking and heating. The comments indicated one of the coffee machines was leaking and not heating, and had burned someone. They rebuilt all of the water valves and the machine was ok now. The temperatures tested for all three coffee machines were found to be at 194 degrees. The normal range was 176 to 212 degrees Fahrenheit. This Federal tag relates to Complaint IN 998 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place when a cognitively impaired resident, exited the facility through the front door and was located off the property for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 01/9/18 at 6:00 P.M. when a cognitively impaired resident with a Wander guard, exited the facility through the front door. The resident walked off of the facility property at least one and a half miles before being picked up by a passerby and then taken to the resident's home. The Administrator, Consultant, and the Director of Nursing were notified of the Immediate Jeopardy at 3:30 P.M. on 2/28/18. The Immediate Jeopardy that began on 1/9/18 at 6:00 P.M. was removed on 1/10/18 at 2:30 P.M., when the facility completed staff education/inservices on the identification of elopement, reviewed the facility policy and procedures, the wander guard device was moved from the resident's ankle to the dominate wrist, and the Wander Guard vendor completed testing of the doors to ensure proper functioning. The correction date was prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident B was reviewed on 2/27/18 at 1:30 P.M. [DIAGNOSES REDACTED]. The Entry Tracking MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was admitted from community/private home. The discharge MDS, dated [DATE], indicated the resident was independent but required supervision for mobility and activities of daily living. A Progress Note, dated 1/6/18 at 8:00 P.M., indicated the resident was noted to be wandering in the halls, on the assisted living unit in the dining area, and trying to enter Legacy Lane doors. When the nurse approached her, the resident stated her name and that she was lost and trying to find her room. The resident walked back to her room. Wander guard was in place. An Observation Report, dated 1/6/18 at 9:29 P.M., indicated the resident was an elopement risk due to wandering and confusion. Prevention measures were to observe elopement attempts and exit seeking. A Progress Note, dated 1/9/18 at 8:00 P.M., indicated a head to toe assessment was completed upon return to the facility. An Observation Report, dated 1/9/18 at 9:09 P.M., indicated the resident was an elopement risk due to a history of exit seeking, voicing statements of leaving, and exhibiting periods of wandering toward an exit. Prevention measures were to observe elopement attempts, one on one supervision, and exit seeking alarm device in place. An Event Report, dated 1/9/18 at 9:47 P.M., indicated Resident B was not seen exiting the building and was off the property while wearing a wander alert device and was found by a family member. Mental status indicated periods of confusion. Exit seeking risk factors included being cognitively impaired with the ability to learn door codes and the resident had a risk agreement (Agreement for transfer if the resident's needs can not be met by the facility). The resident had a recent medication change of starting [MEDICATION NAME]. Interventions included, but were not limited to, a wander alert device, keeping hat/coat/purse or other exit reminders put away, engage in activities, one on one observation, photograph posted, and to monitor patterns and needs. A Progress Note, dated 1/9/18 at 11:34 P.M., indicated at approximately 6:00 P.M., the nurse assigned to the Assisted Living part of the facility alerted the health care staff Resident B was unable to be located. The resident had set off the wander guard alarm in the back service hallway. The nurse attempted to shut off the alarm and re-directed the resident down the 300 hall but did not assist the resident. The assisted living nurse instructed a CNA (Certified Nursing Aide) to see if the resident was in her room. The CNA was unable to locate the resident and a Code 100 (missing resident) was initiated. A search of the facility inside and outside was initiated. The resident's family was able to locate the resident at approximately 7:20 P.M., at a neighbor of the resident's previous home 2 miles away from the facility. The wander guard was placed on Resident B's left wrist. On 2/27/18 at 11:44 A.M., during an observation of the Director of Plant Operations testing the exit doors with a wander guard device in hand, the alarm sounded at each door. During an interview he indicated he checked the doors daily at different times. He indicated there had been an elopement about a month ago. He had completed the door checks prior to that elopement. On 2/27/18 at 11:58 A.M. during an interview with the CCS (Clinical Campus Support), ADHS (Assistant Director of Health Services), and the ED (Executive Director), the ADHS indicated on (MONTH) 9, (YEAR), an elopement had occurred. The CCS indicated Resident B had eloped. At approximately 6:00 P.M., the nurse on the AL (Assisted Living) unit encountered two residents, Resident B and Resident E. They told the nurse they were trying to find the front door to go home. The AL nurse redirected them back to the health center by pointing down the service corridor (back hall). As Resident B passed the exit door of the service corridor the alarm sounded. The AL nurse exited the nurses station and proceed down the service corridor to shut off the alarm, and when the CNA responded to the alarm, she was instructed to locate the residents. The ED indicated Resident B encountered a visitor in the front hallway, and appearing cognitive, inquired how to get out of the facility and was escorted by the visitor to the front door where she exited. Staff were unable to locate Resident B, so they announced the elopement overhead and started the process of looking inside the facility. When Resident B was not found the staff went outside the building. The search continued until the resident was found at a neighbor's house near her previous home. The ED indicated it was determined she walked out to Central Ave and hitched a ride. The driver was a person familiar with the resident's family and when the resident was unable to get into the home, she accompanied Resident B to the neighbors. The driver stayed with the resident while the neighbor contacted the family and the family member went to the house. During an observation of Central Avenue, on 2/28/18 at 4:30 P.M., a heavy traffic area, four lane road with a center turning lane, and a posted speed limit of 35 mph. The traffic pattern was heavy with multiple cars going in both directions. Across the street from the facility was a new construction site. The site contained a partially constructed open building, equipment, and building materials covered in plastic. The ED indicated the root cause was determined the original wander guard was placed on her ankle per manufacture recommendations and the alarm didn't sound when the resident exited the front entry door. The alarm vendor came in to check the alarm system; all doors were checked and a timer was replaced on the 100 hall exit door. The resident was returned to the facility and placed on one on one. Upon Resident B's return the wander guard was removed from the resident's ankle, the door tested , and it alarmed. The wander guard was then replaced on the residents dominate hand. The CCS indicated the resident was wearing jeans, shoes, and a quarter length sleeved heavy sweater. The ED indicated the resident was able to reach Central Ave in approximately 5 minutes or so and couldn't have been outside 10 minutes before obtaining a ride. The ADHS indicated the temperature was 37 degrees and cloudy. The CCS revealed Resident B had a BIMS (Brief Interview for Mental Status) of 7 indicating she was cognitively impaired. On 2/28/18 at 11:03 A.M., during an interview with Resident B's family member, he indicated she had the ankle bracelet on when she went out the door of the facility. She liked to walk and wanted to go home. She had walked one and a half miles to a local subdivision. While she was standing in the subdivision a person who was driving by noticed the resident holding her arms like she was cold and asked if she could help. The resident gave the driver her home address and she drove her there. When the resident was unable to get in the house, because she had no key, the driver walked with her to the neighbors. My family was out looking for her and saw a car in the driveway of the resident's house. She was wearing jeans and a shirt. The facility gave the reason for the elopement as the monitoring device on her leg didn't go off when she went out the front door. On 2/28/18 at 2:30 P.M., RN (Registered Nurse) 2 indicated she had worked on the TCS (Transitional Care Services unit) on 1/9/18, when the elopement occurred. I saw the resident that day down by her room. They posted pictures of new residents who were an elopement risk at all the nurses' stations. The nurse on the health center notified everyone by calling Code 100. I was assigned to the TCS unit to search for the resident. We searched inside first and then outside. On 2/28/18 at 2:44 P.M., during an interview, CNA 3 indicated the elopement occurred on 1/9/18, during the time for her break, as the residents had just finished the evening meal. She noticed Resident B and Resident E, as she was going into the back hallway (service corridor). I knew Resident B was an elopement risk, the two residents were just talking about what they were going to do. I was in the breakroom [ROOM NUMBER] to 15 minutes when someone ask me if I had seen (Resident B). I jumped up out of my chair and went to the hallway, where (RN 2) was and she had me look in the rooms. I was assigned the AL hall. We looked in all the rooms, and all the bathrooms but was unable to locate the resident. On 2/28/18 at 3:13 P.M. during an interview with LPN 4, she indicated she was behind the desk when a lady came to the desk and asked where the front door was. She thought the lady was a visitor at first. I looked over and we hadn't put the new resident's picture in the walking program binder, realized she was a new resident, and an elopement risk. I pointed her to the back hallway (service hall) and redirected her back to her room. Resident B walked by the exit door in the back hallway and the alarm went off as she went on down the hall toward the 300 Hall. I went to shut the alarm off. When I turned and looked down to turn the alarm off (approximately 30 seconds) the resident disappeared. A CNA came out of the dining area and I sent her (CNA 3) to see if the resident went to her room. I knew Resident B was looking for an exit because she wanted to know where the front door was. I went and looked in the resident's room and bathroom but the resident wasn't there. I then went to the nurses' station and the healthcare nurse called the code. It was very chilly and wet outside that evening, and with the construction covered in plastic across the street, I was worried she would go there and get hurt. The nurse from Legacy Lane and I went in a car looking for her. On 2/27/18 at 12:38 P.M., the Administrator provided a current copy of the document titled Guidelines: Elopement Risk Assessment and Prevention, dated 9/28/16. It included, but was not limited to the following, .These policies assist to define the mechanisms and procedures for monitoring and managing residents at risk for elopement and help to minimize the risk of a resident leaving a safe area without .appropriate supervision .Residents identified with significant risk factors .beyond the campus's environmental capabilities (unsecured facilities) should be evaluated for transfer to a more secure facility .Should a resident be found to have exited the doorway .the Elopement/Missing Resident Guidelines and Checklist should be initiated . On 2/27/18 at 12:38 P.M., the Administrator provided a current copy of the document titled Elopement/Missing Resident Guidelines and Checklist dated 3/20/17. It included, but was not limited to the following, .Door Alarm Sounding/Missing Resident .Two additional staff members to exit the alarming doorway and go in opposite directions around the building perimeter until they meet each other and return to the central area of the facility . The past noncompliance Immediate Jeopardy that began on 1/9/18 at 6:00 P.M. The Immediate Jeopardy was removed and deficient practice corrected by 1/10/18 at 2:30 P.M., after the facility implemented a systemic plan that included the following: all staff completed education/inservices on the identification of elopement, reviewed the facility policy and procedures, the wander guard device was moved from the resident's ankle to the dominate wrist, and the Wander Guard vendor completed testing of the doors to ensure proper functioning. All residents were audited for elopement risk. This Federal tag relates to Complaint IN 945. 3.1-45(a)

Based on observation, record review and interview, the facility failed to ensure 1 of 4 sampled residents (Resident B) received timely treatment for [REDACTED]. Findings include: 1a. Resident B's closed record was reviewed on 3/26/2015 at 12:31 p.m. [DIAGNOSES REDACTED]. Admission Minimum Data Set (MDS) assessment, dated 1/2/2015, indicated a Brief Interview for Mental Status (BIMS) score of 11; indicating the resident was cognitively intact. physician's orders [REDACTED]. Indication-DX (diagnosis): [MEDICAL CONDITIONS]." Resident B's March, 2015 Medication Administration Record [REDACTED].o. qid x 14 days. 3/5/2015 (to indicate the order date). Scheduled dose times indicated, "12 AM, 6 AM, 12 N, 6 PM." The MAR indicated [REDACTED]. The documentation for the 3/6/2015 scheduled doses at 12:00 a.m., 6:00 a.m., and 12:00 p.m. indicated circled initials, to indicate the medication was not administered. The MAR indicated [REDACTED] Nurse's Notes, dated 2/19/2015 at 4:00 p.m., indicated physician's orders [REDACTED]. The following Nurse's Notes, dated 3/4/2015 at 9:00 a.m., indicated, "Res (resident) c/o (complained of) diarrhea (with) foul odor. MD notified. N.O. (new order) 1) Stool spec (specimen) for C.diff. Dx (diagnosis) diarrhea." The following Nurse's Notes, dated 3/5/2015 at 4:00 p.m., indicated, "[MEDICAL CONDITION] results reviewed and [MEDICATION NAME] 250 mg (5 ml) po QID x 14 days ordered...." The following Nurse's Notes, dated 3/6/2015 at 9:00 a.m., indicated, "N.O. 1) [MEDICAL CONDITION] (sic) precautions." The following Nurse's Notes, dated 3/7/2015 at 10:00 a.m., indicated, "Pt (patient) c/o (complained of) not feeling well. B/P (blood pressure) 80/40, P (pulse) 57, Resp (respiratory rate per minute) 24...O2 (oxygen saturation) 80%." The following Nurse's Notes, dated 3/7/2015 at 10:55 a.m., indicated, "B/P 70/40, P 100, Resp 22, Pt on 6 L (liters) of oxygen unable to get O2 stat (sic). Send to ER (emergency room ) for eval (evaluation)." The following Nurse's Notes, dated 3/7/2015 at 11:00 a.m., indicated, "Ambulance here to transport pt to (hospital name) via stretcher." Infection Assessment and Review, dated 3/5/2015, indicated, "Type of Infection: [MEDICAL CONDITION]. Symptoms: diarrhea (with) foul odor. Treatment required: Yes. MD Orders: [MEDICATION NAME]. Vital Signs: Pulse: 96. B/P (blood pressure): 101/68. Respirations: 18. Temperature: 97.0 (degrees Fahrenheit).... Follow Up (on reverse): Date: 3/6/15. Time: 2 (a.m.) - 10 (p.m.). Assessment completed (check mark). VS (vital signs) (check mark) 97.6 (to indicate temperature in degrees Fahrenheit). Symptoms continue (check mark). Isolation continues (check mark). ABT/Tx (antibiotic/treatment) continues (check mark).... Date: 3/7/15. Time: 10 (p.m.) - 6 (a.m.). Assessment completed (check mark). VS (check mark) 98.4. Symptoms continue (check mark). ABT/Tx (check mark).... Date: 3/7/15. Time: 6 (a.m.) - 2 (p.m.). Transfer to hospital." Hospital History and Physical, dated 3/7/2015, indicated, "DATE OF SERVICE: 3/7/2015 at 16:57 p.m. HISTORY OF PRESENT ILLNESS: "...has been brought to the ER for evaluation for [MEDICAL CONDITION] (low blood pressure), hypoxemia (low oxygenation of blood) and altered mental status.... ASSESSMENT AND PLAN: 1. Recurrent severe [MEDICAL CONDITIONS] This is the likely source of patient's [MEDICAL CONDITION] (life-threatening blood infection) and septic shock (severe drop in blood pressure which can lead to organ and [MEDICAL CONDITION] and death)...." A copy of Resident B's Certificate of Death, dated 3/10/2015, indicated, "...3. Time of Death: 8:21 PM. 4. date of death : 3/8/2015.... Cause of Death: A. [MEDICAL CONDITION]. B. Septic Shock. C. [MEDICAL CONDITIONS]." The Director of Health Services (DHS) was interviewed on 3/26/15 at 2:58 p.m. She indicated Resident B began having loose stools on 3/4/2015 and was diagnosed with [REDACTED]. She indicated she discovered Resident B did not receive the first four doses of the ordered antibiotic between 3/5/2015 and 3/6/2015 after Resident B's death. The DHS indicated the medication was available in the EDK (Emergency Drug Kit) at the time it was ordered and stated, "So that was a med error." The current Medication Pass Procedures and Error Prevention Policy and Procedure was provided by the Assistant Director of Health Services (ADHS) on 3/27/2015 at 1:28 p.m. The procedure included, but was not limited to, "...Check emergency boxes first.... Responsibilities for administering medications ordered - withholding medications due to medication not being available is not acceptable - first check the EDK (Emergency Drug Kit) box...." Licensed Practical Nurse (LPN) #3 was interviewed on 3/27/2015 at 2:20 p.m. She indicated she worked day shift on 3/6/2015 and was assigned to Resident B's hall. LPN #3 indicated the third shift nurse giving her report that morning indicated Resident B had an order for [REDACTED].#3 indicated, "Most of the time, we go to the EDK. I was wrong in assuming we didn't have any ([MEDICATION NAME])." Registered Nurse (RN) #4, who was on duty 3/6/2015 during evening shift, was interviewed on 3/30/2015 at 1:45 p.m. RN #4 indicated a CNA (Certified Nurse Aide) on duty indicated to her, "(RN #4), this man (Resident B) isn't acting right." RN #3, who was on duty 3/6/2015 during evening shift, was interviewed on 3/30/2015 at 1:55 p.m. RN #3 indicated, "You could just tell he (Resident B) didn't feel well." CNA #2, who was on duty 3/7/2015 during day shift, was interviewed on 3/30/2015 at 2:14 p.m. CNA #2 indicated she recalled assisting Resident B with breakfast the morning of 3/7/2015 and the resident "would not eat." CNA #2 indicated she told nursing staff, "Something's not right (with Resident B)." b. Resident B's physician's orders [REDACTED]." The order did not include an indication (diagnosis) for the medication. January, 2015 Medication Administration Record [REDACTED]. The DHS was interviewed on 3/30/2015 at 2:08 p.m. She indicated, "I don't know why ([MEDICATION NAME]) wasn't started." The DHS indicated the medication was available in the Emergency Drug Kit (EDK) at the time it was ordered and that antibiotics should be started "immediately or the next day when pharmacy brings it." On 3/31/2015 at 1:50 p.m., the DHS indicated she could not find a documented physician's indication or [DIAGNOSES REDACTED]." A copy of the current Guidelines for Medication Orders Policy and Procedure was provided by the Director of Health Services (DHS) on 3/31/2015 at 9:55 a.m. The procedure included, but was not limited to, "...When recording medication orders specify: 1. The type, route, dosage, frequency, strength of the medication and reason for order (i.e. [MEDICATION NAME] 100mg po, TID for [MEDICAL CONDITION] disorder)...." 2. Resident D's clinical record was reviewed on 3/30/2015 at 2:00 p.m. [DIAGNOSES REDACTED]. March, 2015 Physican's Orders indicated, "Humalog 100 units/ml (milliliter) vial. Accu-CK (blood glucose testing) QID (6:00 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m.) w/ (with) SSI (sliding scale insulin): 70 - 140 = 0 units. 141 - 180 = 4 units. 181 - 220 = 6 units...." Registered Nurse (RN) #1 was observed during a routine medication pass beginning on 3/30/2015 at 11:07 a.m. RN #1 performed a scheduled blood glucose test on Resident D and indicated the result was "184 (mg/dl (milligrams per deciliter))." RN #1 was then observed drawing up 4 units of Humalog (100 units/ml) insulin and administering it to Resident D. Resident D's March, 2015 MAR indicated [REDACTED]"134 (mg/dl). Amount of Humalog insulin given per sliding scale indicated, "4 (units)." On 3/22/2015 at 11:00 a.m., Resident D's blood glucose result indicated, "142 (mg/dl). Amount of Humalog insulin given per sliding scale indicated, "2 (units)." On 3/28/2015 at 11:00 a.m., Resident D's blood glucose result indicated, "144 (mg/dl). Amount of Humalog insulin given per sliding scale indicated, "0 (units)." On 3/30/2015 at 11:00 a.m., Resident D's blood glucose result indicated, "184 (mg/dl). Amount of Humalog insulin given per sliding scale indicated, "4 (units)." On 3/31/2015 at 11:16 a.m., the ADHS indicated, "(Resident D) should have gotten six units (during observed medication pass on 3/30/2015)." This Federal tag relates to the Investigation of Complaint IN 553. 3.1-37(a)