Every finding on record at Spring Mill Health Campus

Based on record review and interview, the facility failed to ensure residents were administered insulin and accuchecks (blood sugar testing) were completed as ordered for 2 of 3 residents reviewed for medications and accuchecks. (Residents C and D)Findings include:1. Resident C's record was reviewed on 6/3/26 at 10:08 a.m. The diagnoses included, but were not limited to, diabetes mellitus.A Care Plan, dated 5/18/26, indicated a risk for complications related to diabetes mellitus. The interventions included, diabetic medication would be administered and blood sugars checked as ordered by the physician.A Physician's Order, dated 5/10/26 and discontinued on 5/24/26, indicated Glargine-yfgn (long acting insulin) 10 units was to be administered at bedtime.The Medication Administration Record (MAR), dated 5/2026, indicated the blood sugar on 5/12/26 at 9:00 p.m. was 124 and the insulin had not been given due to not required (marked with a code of 13). The blood sugar on 5/17/26 at 9:00 p.m. was 112 and the insulin had not been given (marked with a code of 9, see progress notes).There were no Nursing Progress Notes, dated 5/17/26, that indicated the reason the insulin was not administered.During an interview on 6/3/26, the RN Nurse Consultant indicated there had been no documented reasons for the insulin not being administered.A Physician's Order, dated 5/28/26, indicated 10 units of Glargine-yfgn insulin was to be administered every 12 hours for blood sugar levels of 150 and above.The blood sugar on 5/31/26 at 7:30 a.m. was 149 and the insulin had been administered.During an interview on 6/3/26 at 1:58 p.m., the Director of Nursing (DON) acknowledged the insulin had been given with a blood sugar result less than 150.A Physician's Order, dated 5/7/26, indicated an accucheck was to be completed before meals and at bedtime. The Physician was to be notified if the results were below 70 or above 350.The 9:00 p.m. blood sugar result on 5/21/26 was 362. There was was no documentation that indicated the Physician had been notified.The blood sugar result on 5/22/26 at 5:30 p.m. was 359.A Nurse's Progress Note, dated 5/22/26 at 8:25 p.m., indicated the Nurse Practitioner (NP) had been notified of the blood sugar of 359 and orders for Novolog insulin 10 units was to be given and Glargine-yfgn insulin was increased by five units at bedtime.The blood sugar at 8:30 p.m. on 5/22/26 was 379 and the insulin had been administered as ordered. There was no documentation that indicated the Physician/NP had been notified of the blood sugar of 379 at 8:30 p.m.The blood sugar result on 5/26/26 at 9:00 p.m. was 353. There was no documentation that indicated the Physician had been notified.During an interview on 6/3/26 at 2:10 p.m., the RN Nurse Consultant indicated there was no documentation that indicated the Physician had been notified of the blood sugars over 350. 2. Resident D's record was reviewed on 6/3/26 at 2:33 p.m. The diagnoses included, but were not limited to, diabetes mellitus.A Physician's Order, dated 3/9/26, indicated blood sugars were to be checked three times a day, before meals.The MARs, dated 5/2026 and 6/2026, lacked documentation the blood sugars had been checked as ordered.There was no documentation in the clinical record that indicated the blood sugars had been checked three times a day as ordered. During an interview on 6/3/26 at 2:49 a.m., the DON acknowledged the blood sugars were not checked as ordered.The undated facility guidelines for diabetes mellitus care, received from the DON as current on 6/3/26 at 2:47 p.m., indicated the Physician's Orders were to be followed.This citation relates to Intake 3011487.410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 3 residents observed during medication pass. Two errors were observed during 33 opportunities for errors during medication administration. This resulted in a medication error rate of 6.06%. (Resident G)Finding includes:During a morning medication pass observation on 6/3/26 at 7:45 a.m., RN 2 prepared Resident G's morning medications, which consisted of 13 different oral medications.RN 2 pulled the medication cards out of the medications cart. The cards which contained meloxicam (anti-inflammatory) 15 mg and Senna (laxative) 8.6 mg were placed on the top of the medication cart with the other medications cards. The medications were not removed from the cards and placed in the plastic medication cup to be given. RN 2 indicated the medications were ready to be administered and counted 11 oral medications in the medication cup.The morning medications were reviewed again and RN 1 acknowledged there should have been 13 oral medications in the medication cup and indicated the meloxicam and senna had not been placed in the medication cup.Resident G's record was reviewed on 6/3/26 at 10:00 a.m. The diagnoses included, but were not limited to, soft tissue disorder.The Physician's Orders, dated 3/4/26, indicated meloxicam 15 mg, 1 tablet was to be given daily and the Senna 8.6 mg, 1 tablet was to be given twice a day.A facility medication administration policy, dated 12/2025 and received from the DON as current, indicated medications were to be administered in accordance with the Prescriber's Orders.This citation relates to Intake 3011487.410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(1)

Based on observation, record review and interview, the facility failed to develop and implement a care plan related to the use of a Continuous Passive Motion (CPM) machine for 1 of 2 residents reviewed for rehab and restorative. (Resident 64) Finding includes:On 12/2/25 at 10:00 a.m., Resident 64 was observed seated in her room. There was a CPM machine on the floor next to her bed. The resident indicated she had a recent knee replacement and the machine was supposed to be used twice daily, but only therapy staff put the machine on her once a day when they were present. The resident's record was reviewed on 12/3/25 at 9:23 a.m. Diagnoses included, but were not limited to, encounter following orthopedic aftercare and presence of right artificial knee joint.The admission Minimum Data Set assessment, dated 11/25/25, indicated the resident was cognitively intact and needed set up assistance for toileting and bed mobility. There were no nursing care plans related to the CMP machine. The Physical Therapy (PT) Evaluation and Plan of Treatment, dated 11/20/25, indicated treatment approaches were therapeutic exercises, neuromuscular reeducation, gait training therapy, PT evaluation moderate complexity and therapeutic activities. There was no approaches or interventions related to the CPM machine. During an interview on 12/3/25 at 10:06 a.m., the Director of Nursing indicated the CPM machine was the responsibility of the therapy department and nursing had nothing to do with it. During an interview on 12/3/25 at 11:26 a.m., the PT Director indicated the CPM should be included on the Plan of Treatment. 3.1-35(b)(1)

Based on record review and interview, the facility failed to ensure a compression glove was in place per the physician's order, there was adequate monitoring of use of the compression glove and medications were available and administered as ordered for 1 of 1 resident reviewed for edema and for 1 of 21 records reviewed. (Resident 58)Finding includes:a. During an observation on 12/1/25 at 12:25 p.m., Resident 58 was observed sitting up in her wheelchair. Her right hand was observed with no compression glove on at the time.Resident 58's record was reviewed on 12/3/25 at 9:07 a.m. Diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage (brain bleed) and multiple sclerosis.A Physician's Order, dated 11/26/25, indicated compression glove for right hand and try to maintain a degree of elevation as well to reduce edema.The record lacked documentation of how often the compression glove was supposed to be on or when the compression glove was on or off.There was no care plan related to the compression glove.During an interview on 12/8/25 at 9:22 a.m., the Director of Nursing indicated she believed the resident's daughter had brought in the compression glove as they had not ordered it. There was no other documentation of when the compression glove was on or off.b. A Physician's Order, dated 11/20/25, indicated theophylline extended-release oral tablet 100 milligrams, 1 tablet twice daily.The November 2025 Medication Administration Record indicated the theophylline was not administered at 8:00 p.m. on 11/20/25, 11/21/25, 11/22/25, and 11/23/25 and at 8:00 a.m. on 11/21/25, 11/22/25, 11/23/25, and 11/24/25.During an interview on 12/9/25 at 11:54 p.m., the Director of Nursing indicated all of the doses were marked 9 - See Progress Notes and had no further information to provide.3.1-37(a)

Based on observation, record review and interview, the facility failed to obtain Physician Orders and coordinate care between departments related to the use of a Continuous Passive Motion (CPM) machine for 1 of 2 residents reviewed for rehab and restorative care. (Resident 64)Finding includes: On 12/2/25 at 10:00 a.m., Resident 64 was observed seated in her room. There was a CPM machine on the floor next to her bed. The resident indicated she had a recent knee replacement, and the machine was supposed to be used twice daily, but only therapy staff put the machine on her once a day when they were present. The resident's record was reviewed on 12/3/25 at 9:23 a.m. Diagnoses included, but were not limited to, encounter following orthopedic aftercare and presence of right artificial knee joint.The admission Minimum Data Set assessment, dated 11/25/25, indicated the resident was cognitively intact and needed set up assistance for toileting and bed mobility. There was no Physician's Order for the CPM machine or frequency of use. During an interview on 12/3/25 at 9:55 a.m., LPN 2 indicated the resident put the CPM machine on herself, she believed after therapy. The LPN indicated she was unable to find a Physician's Order related to the CPM machine. During an interview on 12/3/25 at 10:06 a.m., the Director of Nursing indicated the CPM machine was the responsibility of the therapy department and nursing had nothing to do with it. During an interview on 12/3/25 at 10:45 a.m., the Administrator indicated they did not have a Physician's Order for the CPM machine. During an interview on 12/3/25 at 11:26 a.m., the Physical Therapy Director indicated when therapy wasn't available, nursing staff should be putting the CPM machine on. She indicated PT put the machine on the resident twice daily when they were present. She was unable to locate documentation when the CPM machine was applied by therapy. 3.1-42(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident was assessed and treated for pain prior to wound care for 1 of 2 residents reviewed for pressure ulcers. (Resident 71)Finding includes: On 12/8/25 at 11:30 a.m., Resident 71's wound care was observed with the Wound Nurse and CNA 1. The resident was in bed, positioned on her left side and held in place by the CNA. The Wound Nurse removed the old dressing from her sacrum. Then she used normal saline and gauze to clean the wound bed. The resident said, ow, ow, the Wound Nurse apologized to her and continued to clean the wound. The resident again said, ow, ow, the CNA said she was sorry. The Wound Nurse completed the treatment with no additional complaint of pain from the resident. During an interview following the wound treatment observation, the Wound Nurse indicated the resident had prn (as needed) pain medication she could take if she started moaning. She indicated the resident wasn't complaining of pain and had not received anything. The resident's record was reviewed on 12/8/25 at 11:00 a.m. Diagnoses included, but were not limited to, diabetes mellitus, adult failure to thrive and spinal stenosis. The resident had a stage 3 pressure ulcer on her sacrum. The Brief Interview for Mental Status, dated 12/7/25, indicated the resident had moderate cognitive impairment. There were no Physician's Orders for any type of analgesic. A Care Plan, dated 12/4/25, indicated the resident was at risk for pain related to (blank). Intervention was to administer analgesia as per orders. During another interview on 12/8/25 at 2:13 p.m., the Wound Nurse indicated she did not recall the resident verbalizing signs of pain during the wound treatment or apologizing to her. She also indicated she had obtained an order for a prn pain medication. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure medication was labeled correctly, a bag of normal saline (NS) 0.9% was not expired, and a tube of zinc paste was stored to prevent cross-contamination for 1 of 4 medication carts and 1 of 2 medication rooms. (Healthcare 1)Finding includes:On [DATE] at 2:13 p.m. the Healthcare 1 Medication Cart and Medication Room was observed with QMA 1 and the Director of Nursing (DON). Inside the top drawer of the Medication Cart there was a used tube of zinc paste, stored openly with boxes of eye drops and other medications in the drawer. The tube of zinc was not labeled with a resident's name. QMA 1 indicated she was unsure who the zinc was used for.In the Medication Room refrigerator there was a 100 milliliter bag of NS 0.9% with an expiration date of [DATE] and a box of cath flo activase (blood clot busting agent for occluded central lines) without a label or resident's name. In the cabinet in the Medication Room, there was an opened box of Gas-X with no label and two mediplanners (Monday through Friday medication set ups), that contained medication, stored in a plastic bag without a resident's name.The DON at the time of the observation indicated it the Gas-X was probably medication someone had at the bedside and the mediplanner was someone's medications from home.A facility policy titled, Medication Storage, indicated .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels.14.5 Facility should ensure that infusion therapy labels include the medication name, volume, infusion rate, name and quantity of each additive, date of preparation, initials of compounder, date and time of administration, ancillary labeling and expiration date.3.1-25(j)3.1-25(o)3.1-25(r)

Based on observation, record review and interview, the facility failed to ensure resident records were accurate related to documentation of an air mattress in place and intravenous (IV) flushes for 2 of 21 records reviewed. (Residents 71 and 61)Findings include: 1. On 12/8/25 at 11:30 a.m., Resident 71's wound care was observed with the Wound Nurse and CNA 1. The resident was positioned in her bed, and she was on a standard mattress. The resident's record was reviewed on 12/8/25 at 11:00 a.m. Diagnoses included, but were not limited to, diabetes mellitus, adult failure to thrive and spinal stenosis. The resident had a stage 3 pressure ulcer on her sacrum. The Brief Interview for Mental Status, dated 12/7/25, indicated the resident had moderate cognitive impairment. A Physician's Order, dated 12/5/25, indicated an air mattress for the resident. The Treatment Administration Record for December 2025 indicated the air mattress was signed out as in place every shift from 12/5-12/8/25. During an interview on 12/8/25 at 2:13 p.m., the Administrator and Nurse Consultant indicated the resident had refused to get out of bed during the weekend to have the air mattress placed on the bed, it was being changed at that time. They were aware staff had been documenting the air mattress was in place incorrectly. 2. On 12/4/25 at 1:56 p.m., LPN 1 was observed passing medication to Resident 61. She prepared meropenem (an antibiotic medication) 1 gram (g) intravenous (IV). She primed the intravenous (IV) tubing, cleaned the right upper arm PICC lumen with an alcohol swab, flushed the PICC with 5 milliliters (ml) of normal saline, attached the IV tubing containing the meropenem, and started the IV infusion. On 12/4/25 at 2:45 p.m., LPN 1 was observed disconnecting the IV tubing after the medication had completed infusing. She flushed the PICC with 5 ml of normal saline and applied a cap to the lumen. Resident 61's record was reviewed on 12/4/25 at 3:25 p.m. Diagnoses included, but were not limited to, osteomyelitis, type two diabetes mellitus, and hypertension. A Physician's Order, dated 11/27/25, indicated meropenem 1 g three times a day intravenously for 31 days. A Physician's Order, dated 11/26/25, indicated sodium chloride 0.9% (normal saline) flush 10 milliliters (ml) intravenously every shift. There were no Physician's Orders to indicate the PICC was to be flushed with saline before and after the administration of the antibiotic medication. The Medication Administration Record (MAR), dated 11/2025 and 12/2025, indicated the meropenem had been administered as ordered. The normal saline 10 ml flushes were documented as given once on the day shift, once on the evening shift, and once on the night shift. There was lack of documentation to indicate the PICC was flushed with saline before and after the administration of the antibiotic medication. During an interview on 12/4/25 at 3:05 p.m., the Director of Nursing indicated LPN 1 had administered the medication and flushes correctly. The PICC was to be flushed before and after the IV antibiotic medication administration. 3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure prn (as needed) medications were administered with documentation for an indication for use for 1 of 3 residents reviewed for hospice. (Resident C) Finding includes: The closed record for Resident C was reviewed on [DATE] at 7:25 a.m. The resident expired in the facility on [DATE] while receiving hospice services. Diagnoses included, but were not limited to, stroke, dysphagia (difficulty swallowing), chronic kidney disease, quadriplegia, vascular dementia, and heart failure The Significant Change Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident cognitively impaired for daily decision making and received hospice care. A Care Plan, dated [DATE], indicated the resident was at risk for pain. The nursing approaches were to record and report any nonverbal signs of pain. A Physician's Order, dated [DATE], indicated Lorazepam (an antianxiety medication) Concentrate, 2 milligrams/milliliters (mg)/(ml), give 0.5 ml by mouth every 1 hour as needed for anxiety, restlessness, and insomnia. A Physician's Order, dated [DATE], indicated Morphine Sulfate (a narcotic medication) oral Solution 20 mg/ml, give 0.25 ml sublingually (under the tongue) every 1 hour as needed for pain or shortness of breath. The Medication Administration Record (MAR) for the months of 3/2025 and 4/2025 indicated the Lorazepam was administered on [DATE] at 11:29 a.m. and [DATE] at 9:06 a.m. The Morphine Sulfate was administered on [DATE] at 12:28 p.m., [DATE] at 9:57 a.m., [DATE] at 9:06 a.m., and 4/12 at 3:21 a.m. A Nurses' Note, dated [DATE] at 11:29 a.m., indicated the Lorazepam was administered as needed for anxiety, restlessness, and insomnia. The Hospice Nurse was in the facility and it was given to the nurse to administer the medication. A Nurses' Note, dated [DATE] at 12:28 p.m., indicated the Morphine Sulfate was administered as needed for pain or shortness of breath and the resident spit out the medication. A Nurses' Note, dated [DATE] at 9:57 a.m., indicated the Morphine Sulfate was administered as needed for pain or shortness of breath. A Nurses' Note, dated [DATE] at 9:06 a.m., indicated the Morphine Sulfate was administered as needed for pain or shortness of breath. The resident was restless. A Nurses' Note, dated [DATE] at 9:06 a.m., indicated the Lorazepam was administered as needed for anxiety, restlessness, and insomnia. The resident was restless. There was no documentation to indicate why the two medications were given at the same time. A Nurses' Note, dated [DATE] at 3:21 a.m., indicated the Morphine Sulfate was administered as needed for pain or shortness of breath. At 4:46 a.m., the nurse documented the Morphine was effective. A Nurses' Note, dated [DATE] at 4:53 a.m., indicated the nurse entered the resident's room, and noted the resident not breathing. The carotid and apical pulses were checked and her pupils were fixed and dilated. The Hospice Nurse was notified as well as the physician and family. There was no documentation of a specific indication for the use of the Lorazepam or the Morphine Sulfate prior to the administration of the medications. There was no documentation the resident had experienced any pain, anxiety, or restlessness prior to receiving the medications. During an interview on [DATE] at 12:00 p.m., the Director of Nursing had no additional information to provide. This citation relates to Complaint IN00459069. 3.1-48(a)(4)

Based on record review and interview, the facility failed to implement the admission policy, related to an Admission Agreement not explained and signed by a resident who had been admitted into the facility for 1 of 1 resident reviewed for Admission Agreement implementation. (Resident D) Finding includes: Resident D's record was reviewed on 2/18/25 at 10:53 a.m. The diagnoses included, but were not limited to, chronic respiratory failure. The Census History indicated the resident was admitted into the facility on [DATE]. A transfer/discharge to an acute care hospital occurred on 9/25/24 and a return re-admission occurred on 9/30/24. A transfer/discharge to an acute care hospital occurred on 10/2/24 with a return re-admission on 10/8/24. A transfer/discharge to an acute care hospital occurred on 11/14/24 with a return re-admission on 11/18/24. The resident was discharged to another facility on 1/16/25. A Quarterly Minimum Data Set assessment, dated 11/24/24, indicated an intact cognitive status. There was no signed Admission Agreement that included, but was not limited to, the consent for treatment, explanations of resident rights, characteristics and services of the facility, conditions for transfer discharges, bed hold policies, room changes, personal property, financial responsibilities, which included Medicare and Medicaid services, the daily basic rate and what was covered by the basic rate and what was not covered by the basic rate, physician services, grievance procedures, safe guarding personal property, and other terms of agreements. During an interview on 2/18/25 at 1:20 p.m., the Admission's Manager indicated the resident had not signed the Admission Agreement and she had not explained the items in the agreement to the resident. She indicated the resident seemed confused when he came back from dialysis and she did not feel comfortable going over the paperwork and having the resident sign the agreement since there was a lot of information in the Admission Agreement. No further information was provided when asked why the Admission Agreement had not been completed on the non-dialysis days. During the interview on 2/18/15 at 1:20 p.m., the Administrator indicated the Admission Agreement was to be completed for all admissions. 3.1-4(a)

Based on record review and interview, the facility failed to ensure a resident received blood sugar monitoring to determine if insulin was required (sliding scale) for 1 of 3 residents reviewed for unnecessary medications. (Resident B) Finding includes: Resident B's record was reviewed on 2/18/25 at 9 a.m. The diagnoses included, but were not limited to, stroke and diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 11/4/24, indicated a severely impaired cognitive status and received insulin in the past seven days. A Physician's Order, dated 11/13/24, indicated the blood sugars were to be obtained before meals and at bedtime and Humalog insulin was to be administered if the blood sugar was 151 or higher. The doses of insulin was to be given per the results of the blood sugar results (sliding scale). The Medication Administration Record (MAR), dated 12/2024, indicated the blood sugar was not obtained to determine if insulin was required on 12/1/14 at 9 p.m., 12/8/24 at 11:30 a.m., 5:30 p.m., and 9 p.m., 12/21/24 at 9 p.m., and 12/28/24 at 5:30 p.m. and 9 p.m. The MAR, dated 1/2025, indicated the blood sugar was not obtained to determine if insulin was required on 1/8/25 at 9 p.m., 1/11/15 at 9 p.m., 1/13/24 at 9 p.m., 1/15/25 at 9 p.m., 1/27/25 at 9 p.m., 1/29/25 at 11:30 a.m., and 1/30/25 at 5:30 p.m. and 9 p.m. The Director of Nursing (DON) was informed of the missed blood sugar monitoring on 2/18/25 at 11 a.m. No further information was provided at end of the Exit Conference on 2/18/25 at 3:42 p.m. A facility glucose testing policy, dated 1/2/21 and received as current from the DON, indicated the Physician's Order was to be reviewed prior to the testing and all results of the testing were to be recorded on the MAR. A facility medication administration policy, dated 2/17/20 and received as current from the DON, indicated medications were to be administered in accordance with the Prescriber's orders. This citation relates to Complaint IN00452516. 3.1-48(a)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident's preferences were honored related to allowing the resident to leave their room while in contact isolation for 1 of 1 resident reviewed for choices. (Resident 261) Finding includes: During a random observation on 9/3/24 at 10:31 a.m., Resident 261 indicated she had been confined to her room due to an infection on her back. On 9/4/24 at 3:12 p.m., the resident was observed in her room sitting in her wheelchair. She indicated to LPN 3, who was also in the room, that she was unable to leave her room due to her isolation status. During an interview at the time, LPN 3 indicated she was unsure if the resident could leave her room. LPN 3 was told in shift report that the resident was in contact isolation, but she was a new nurse and was unsure if that meant the resident could not leave her room. The record for Resident 261 was reviewed on 9/4/24 at 11:15 a.m. The diagnoses included, but were not limited to, lymphedema (swelling in arms or legs), hypoxia (inadequate oxygen), difficulty walking, kidney failure, anemia (decrease in red blood cells), and cellulitis (bacterial infection). The Admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact for daily decision making. The resident had no impairment of the upper and lower extremities and used a wheelchair. Eating, personal hygiene, and oral hygiene required set up and clean up assistance. Partial/moderate assistance was required for toileting and shower/bathing, and lower body dressing. A Physician's Order, dated 9/1/24, indicated to place the resident in Contact Isolation related to Methicillin-resistant Staphylococcus aureus (MRSA) in the wound. During an interview on 9/4/24 at 3:16 p.m., CNA 1 indicated the resident used to leave her room all the time, and she had noticed the resident had not left her room in a couple days. She was unaware what contact isolation required and did not know why the resident was not allowed to leave her room. During an interview on 9/4/24 at 3:19 p.m., the ADON indicated as long as the resident's wound was covered, she could leave her room. She was not aware a staff member told the resident otherwise, but she would in-service the staff immediately. During an interview on 9/4/24 at 3:40 p.m., the ADON indicated the wound nurse had told the resident she did not have to leave her room to go to activities. The resident was feeling embarrassed by how much her legs were weeping when they were wrapped. The wound nurse indicated activities could come to her room for a 1:1. The resident had probably misunderstood and thought she had to stay in her room. During an interview on 9/6/24 at 1:59 p.m., the DON and Nurse Consultant indicated they understood the concern with staff not understanding contact isolation and they had no additional information to provide. 3.1-3(u)(1)

Based on record review and interview, the facility failed to ensure staff were knowledgeable regarding the residents' code status for 3 of 5 residents reviewed for advanced directives. (Residents 160, 50, and 261) Findings include: 1. The record for Resident 160 was reviewed on 9/4/24 at 3:28 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, non traumatic subarachnoid hemorrhage, type 2 diabetes, asthma, stroke, depressive disorder, and cognitive communication deficit. The Admission Minimum Data Set (MDS) assessment, completed on 8/28/24, indicated the resident was moderately impaired for daily decision making. During an interview on 9/4/24 at 11:08 a.m., the Assistant Director of Nursing indicated she was not aware of the resident's code status because there was no documentation in the clinical record or in the advance directive binder located at the nursing station. During an interview on 9/4/24 at 11:11 a.m., the Social Service Director (SSD) indicated he would go look on his desk to see if the resident had completed a POST (Physician's Orders for Scope of Treatment) form. During an interview on 9/4/24 at 11:18 a.m., the SSD indicated he had the POST form on his desk which was signed by the resident and signed by the Director of Nursing and another nurse, it was not signed by a Physician or a Nurse Practitioner. The POST form indicated the resident was a full code. When asked why the information had not been passed onto nursing staff, the SSD had no additional information to provide. 48055 2. Resident 50's record was reviewed on 9/3/24 at 3:28 p.m. Diagnoses included, but were not limited to, communication deficit, end stage renal disease, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease. The Admissions Minimum Data Set (MDS) assessment, dated 7/26/24, indicated the resident was cognitively intact. Resident 50 was admitted on [DATE]. There was no code status order and no advanced directives documentation in Resident 50's electronic record or in the advanced directives binder. During an interview on 9/4/24 at 1:35 p.m., RN 1 indicated she could not locate a code status for Resident 50. She was not aware that she did not have access to the code status for this resident. During an interview on 9/4/24 at 1:45 p.m., the Social Service Director (SSD) indicated the resident had a POST form in his office, signed by the resident on 7/23/24 and by the physician on 8/1/24, which indicated their code status wishes. He was not able to provide any information on why the POST form was not in the resident's chart or why nursing staff were not made aware of their code status. 48383 3. The record for Resident 261 was reviewed on 9/4/24 at 11:15 a.m. The diagnoses included, but were not limited to, lymphedema (swelling in arms or legs), hypoxia (inadequate oxygen), difficulty walking, kidney failure, anemia (decrease in red blood cells), and cellulitis (bacterial infection). The Admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact for daily decision making. There was no code status order and no POST form found in the electronic medical record (EMR) for Resident 261. During an interview on 9/4/24 at 1:35 p.m., RN 1 indicated she could not locate a code status for Resident 261. She was not aware that she did not have access to the code status for this resident. During an interview on 9/4/24 at 1:45 p.m., the SSD indicated all 3 residents had POST forms signed by the resident and the Physician indicating their code status wishes. He was not able to provide any information on why the POST forms were not in the resident's chart or why nursing staff were not made aware of their code statuses. A facility policy, titled, Advance Directives, provided by the Director of Nursing as current, indicated the resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advance Directive, as recognized under the state law, has been executed. Documentation concerning this inquiry and the individual response shall include the date the entry was made and the individual making the inquiry. This information shall then be included in the resident's medical record 3.1-4(f)(5)

Based on observation, record review, and interview, the facility failed to ensure the comprehensive assessment was accurate related to dental status for 1 of 17 residents whose comprehensive assessments were reviewed. (Resident 6) Finding includes: During an observation on 9/3/24 at 11:02 a.m. Resident 6's teeth were observed to be caried and broken off. The resident indicated at that time that he was supposed to get new dentures. The record for Resident 6 was reviewed on 9/5/24 at 8:20 a.m. Diagnoses included, but were not limited to, dementia with psychotic disturbance, type 2 diabetes, epilepsy, paranoid schizophrenia, depressive disorders, anxiety disorder, high blood pressure, and PTSD (post traumatic stress disorder) The 3/11/24 Annual Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and had no oral or dental problems. The Modification of the Quarterly MDS assessment, dated 7/25/24, indicated the resident was cognitively intact for daily decision making and had no dental issues. There was no care plan for dental care. During an interview on 9/6/24 at 2:30 p.m., the MDS Coordinator indicated she was unaware the resident's teeth were broken off, discolored, and caried. During an interview on 9/9/24 at 3:00 p.m., the MDS Nurse Consultant indicated she had no additional information to provide. 3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure dependent residents received at least 2 baths a week and had their hair washed at least weekly for 2 of 4 residents reviewed for activities of daily living. (Residents 41 and 158) Findings include: 1. During an interview on 9/3/24 at 11:20 a.m., Resident 41 indicated he sometimes did not get a bed bath 2 times a week and did not get his hair washed at least weekly. The resident's hair was observed to be greasy. The record for Resident 41 was reviewed on 9/5/24 at 2:50 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, post surgical procedure to the digestive system, osteoarthritis of both knees and hips, disc degeneration, kidney disease, rheumatoid arthritis, and type 2 diabetes. The 7/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff all activities of daily living (ADLs) including eating, toileting, repositioning, bathing and personal hygiene. The resident had range of motion impairment to both upper and lower extremities. He had 1 surgical wound upon admission. The Care Plan, dated 7/19/24, indicated the resident required assistance with activities of daily living for bathing. The approaches were to assist with personal hygiene and grooming as needed. The Shower Book indicated the resident was to receive a shower or complete bed bath on Mondays and Thursdays. The resident did not have a complete bed bath on 8/5 and 8/22/24. During an interview on 9/5/24 at 2:45 p.m., the Assistant Director of Nursing indicated she had just brought up shower caps for the residents to get their hair washed. The resident should be bathed at least 2 times a week and be offered to have their hair washed. During an interview on 9/9/24 at 10:30 a.m. , the Director of Nursing indicated the resident was to have at least 2 complete bed baths weekly and be offered to have his hair washed. 2. During an interview on 9/3/24 at 2:03 p.m., Resident 158 indicated she had not had her hair washed since she had been at the facility. The record for Resident 158 was reviewed on 9/5/24 at 1:55 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to, type 2 diabetes, obesity, heart failure, chronic kidney disease, anemia, cardiac pacemaker, osteoarthritis, and high blood pressure. The 8/18/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making was dependent on staff for bathing. The Care Plan, dated 8/13/24, indicated the resident required assistance with activities of daily living including bathing. The Shower Book indicated the resident was to receive a bath on Wednesdays and Saturday. The resident did not receive a complete bed bath on 8/14 and 8/17/24 During an interview on 9/5/24 at 2:30 p.m., the Assistant Director of Nursing indicated she was not aware the resident had not had her hair washed since admission and should have received a completed bed bath at least 2 times a week. 3.1-38(a)(2)(A) 3.1-38(a)(3)(B)

Based on observation, record review, and interview, the facility failed to ensure surgical bandages were changed as ordered by the physician for 1 of 2 resident reviewed for skin conditions non-pressure. (Resident 41) Finding includes: On 9/3/24 at 11:25 a.m., Resident 41 was observed lying in bed wearing a hospital gown. At that time, a surgical bandage was observed to his abdomen with a date of 8/30/24. At 11:35 a.m., the Assistant Director of Nursing (ADON) was asked to come to the room and observe the date on the bandage. During an interview at that time, the ADON indicated the bandage was supposed to be changed three times a week on Monday, Wednesday, and Friday. On 9/6/24 at 12:49 p.m., the Wound Nurse was observed changing the bandage to the surgical wound. The wound was pink and was healing. During an interview at that time, the Wound Nurse indicated the bandage should have been changed on 9/2/24 and she was off that day. Nursing staff were to change the bandages when she was not in the facility. The record for Resident 41 was reviewed on 9/5/24 at 2:50 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to, post surgical procedure to the digestive system, osteoarthritis of both knees and hips, disc degeneration, kidney disease, rheumatoid arthritis, and type 2 diabetes. The 7/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff all activities of daily living (ADLs) including eating, toileting, repositioning, bathing and personal hygiene. The resident had range of motion impairment to both upper and lower extremities. He had 1 surgical wound upon admission. The Care Plan, revised on 9/5/24, indicated the resident had a mid abdomen surgical wound. Physician's Orders, dated 8/28/24, indicated to cleanse the surgical incision to the mid abdomen with normal saline or wound cleanser and pat dry. Cut wound sized pieces of Hydrofera Blue and moisten with normal saline, apply to wound bed and cover with dry dressing every Monday, Wednesday, and Friday. The Treatment Administration Record for 9/2024 indicated the treatment was signed out as being completed on 9/2/24. The surgical wound was last measured by the Wound Nurse Practitioner on 9/4/24. The wound was 9 centimeters (cm) by 0.8 cm and was pink. The wound had decreased in size and was improving. During an interview on 9/6/24 at 2:15 p.m., the Director of Nursing indicated the bandage to the surgical wound should have been changed as ordered by the physician. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer had interventions in place related to not floating their heels when in bed for 1 of 3 residents reviewed for pressure ulcers. (Resident 31) Finding includes: On 9/4/24 at 10:10 a.m. and 3:07 p.m., Resident 31 was observed awake lying in bed. The resident's heels were not floated off the bed. On 9/05/24 at 10:07 a.m., the resident was observed in bed. CNA 1 lifted the resident's blanket by his feet and the resident did not have his heels floated off the bed. The record for Resident 31 was reviewed on 9/04/24 at 9:35 p.m. The diagnoses included, but were not limited to, diabetes, hemiplegia (paralysis on one side), encephalopathy (swelling in the brain), dementia, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated the resident was severely impaired for daily decision making. The resident had impairment on both sides of his lower extremities and used a wheelchair. The resident had a stage 2 pressure ulcer. A Care Plan, dated 4/18/24, indicated the resident had impaired skin integrity. A Physician's Order, dated 1/27/24, indicated to suspend or offload heels when in bed every shift. A Physician's Order, dated 1/27/24, indicated to administer [NAME]-[NAME] Oil External Ointment ([NAME]-[NAME] Oil) to right and left heels topically one time a day for supplement. The undated Wound Rounds summary tab in the EMR (electronic medical record) indicated the resident had a deep tissue pressure injury to the left heel that was resolved on 3/7/24. During an interview on 9/6/24 at 1:58 p.m., the Director of Nursing (DON) indicated Resident 31 should have had his heels floated. No additional information was provided. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a peg tube (a tube inserted into the stomach for nutrition) was cleaned on a daily basis and according to facility policy for 1 of 2 residents reviewed for peg tubes. (Resident 41) Finding includes: On 9/3/24 at 11:22 a.m., Resident 41 was observed lying in bed wearing a hospital gown. At that time, there was a tube observed near a bandage on his abdomen. The area under the flange had dried crusty blood noted. During an interview at that time, the resident indicated the wound nurse cleaned around the tube when she changed his bandages. On 9/6/24 at 12:49 p.m., the Wound Nurse was observed changing the resident's surgical bandage on his abdomen. During an interview at that time, the Wound Nurse indicated the peg tube was solely placed for decompression and was not used for feeding or flushes. The record for Resident 41 was reviewed on 9/5/24 at 2:50 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, post surgical procedure to the digestive system, osteoarthritis of both knees and hips, disc degeneration, kidney disease, rheumatoid arthritis, and type 2 diabetes. The 7/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff all activities of daily living (ADLs) including eating, toileting, repositioning, bathing and personal hygiene. The resident had range of motion impairment to both upper and lower extremities. He had 1 surgical wound upon admission. There was no care plan for the care of the peg tube. There were no physician's orders for the care of or to monitor the peg tube. During an interview on 9/6/24 at 1:00 p.m., the Wound Nurse indicated she cleaned around the peg tube and stoma site when she changed his bandages. On the days she worked, which was Monday through Friday, she saw the resident just to make sure the bandage was clean and in place. During those visits, she did look at the peg tube, however, if there was no drainage and it looked okay, she would not clean around it. When she did clean around the peg tube, there was no place in the clinical record to document she had completed the care. During an interview on 9/6/24 at 1:04 p.m., LPN 1 indicated she was aware the resident had a peg tube, however, she had never cleaned around the stoma site because she had always thought the wound nurse completed the task. During an interview on 9/6/24 at 1:06 p.m., the Assistant Director of Nursing indicated there were no orders to monitor, assess or clean the peg tube site on a daily basis. During an interview on 9/6/24 at 2:15 p.m., the Director of Nursing (DON) indicated the peg tube was to be cleaned at least daily. The current 2/15/21 Gastrostomy/Jejunostomy Site Care policy, provided by the DON on 9/9/24 at 10:30 a.m., indicated it was the policy of the facility to provide gastrostomy and jejunostomy site care to decrease the risk of infection. The procedure was to obtain a physician order to include the following information resident room and number, type of solution for cleansing and frequency of treatment. 3.1.44(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident's PICC (peripherally inserted central catheter) line had Physician's Orders for the care and monitoring of a PICC line for 1 of 1 residents reviewed for PICC lines. (Resident 31) Finding includes: During an observation on 9/3/24 at 11:21 a.m., Resident 31's PICC line bandage was dated 8/29/24 and was peeling off on the top of the dressing. During an observation on 9/4/24 at 10:11 a.m., the PICC line bandage was dated 8/29/24 and was peeling off on the top of the dressing. The record for Resident 31 was reviewed on 9/4/24 at 9:35 p.m. The diagnoses included, but were not limited to, diabetes, hemiplegia (paralysis on one side), encephalopathy (swelling in the brain), dementia, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated the resident was severely impaired for daily decision making. The resident had impairment on both sides of his lower extremities and used a wheelchair. There was no Care Plan for a PICC line or Intravenous therapy. There were no active orders for PICC line care or intravenous therapy. During an interview on 9/6/24 at 1:58 p.m., the DON indicated there should have been PICC line orders for Resident 31. No additional information was provided. 3.1-47(a)(2)

Based on record review and interview, the failed to ensure a PRN (as needed) psychotropic medication was not ordered longer than 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 25) Finding includes: The record for Resident 25 was reviewed on 9/5/24 at 10:35 a.m. Diagnoses included, but were not limited to, left lung cancer, type 2 diabetes, stroke, osteoarthritis, heart disease, depressive disorder, repeated falls, high blood pressure, paranoid schizophrenia, and atrial fibrillation. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 7/16/24, indicated the resident was cognitively intact for daily decision making and received insulin, an antipsychotic, an anxiolytic, an antidepressant, an anticoagulant, and hypoglycemic medications. Physician's Orders, dated 7/17/24, indicated Alprazolam (Xanax, an anti-anxiety medication) 0.5 milligrams (mg), give 1 tablet by mouth every 8 hours as needed for anxiety. The Medication Administration Record (MAR) for the month of 8/2024 indicated the Alprazolam was administered five times and on the 9/2024 MAR, the medication was administered two times. During an interview on 9/6/24 at 2:42 p.m., the Assistant Director of Nursing indicated the scheduled dose of Xanax was discontinued in July and was then ordered as prn. The resident did ask for the medication and the daughter would call to make sure she had received it. The current 9/2/20 Psychotropic Medication-Gradual Dosage Reduction policy, provided by the Director of Nursing on 9/9/24 at 10:30 a.m., indicated . PRN hypnotic, antianxiety, or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and extended duration . 3.1-48(a)(2)

Based on record review and interview, the facility failed to ensure a resident received the necessary treatment and services related to insulin administration for 1 of 3 residents reviewed for insulin administration. (Resident B) The deficient practice was corrected on 6/9/23, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern, completed an audit of residents who received insulin, and provided an inservice for staff on confirming and discontinuing Physician's orders. Finding includes: Closed record review for Resident B was completed on 6/20/23 at 9:38 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, and congestive heart failure. The 5-Day MDS (Minimum Data Set) assessment, dated 6/5/23, indicated the resident was cognitively intact and received insulin injections. A current care plan indicated the resident was at risk for complications related to diabetes. The interventions included, monitor for side effects and effectiveness of medications, and to monitor for any signs and symptoms of hyperglycemia (high blood sugar)/ hypoglycemia (low blood sugar). A Physician's Order, dated 5/31/23, indicated insulin glargine (Lantus) 30 units at bedtime. A Physician's Order, dated 6/6/23, indicated insulin glargine 30 units daily at 8:00 a.m. There were no orders for blood sugar monitoring. The Medication Administration Record (MAR), dated 6/2023, indicated the resident had received insulin glargine 30 units at both 8:00 a.m. and 8:00 p.m. on 6/6/23, 6/7/23, and 6/8/23. A Progress Note, dated 6/9/23 at 5:44 a.m., indicated the resident was not arousable. Her blood sugar was 31 and she was given glucagon (medication to increase blood sugar) IM (intramuscularly). Her blood pressure was 118/64 and pulse was 90. The Physician was notified, and the resident was sent to the emergency room (ER). Interview with the DON (Director of Nursing) on 6/20/23 at 11:40 a.m., indicated there were no orders for routine blood sugar monitoring. The Physician had entered a new order for the insulin to be given at 8:00 a.m. but had not discontinued the 8:00 p.m. dose. The resident had received both the 8:00 a.m. and 8:00 p.m. insulin doses on 6/6/23, 6/7/23, and 6/8/23. The resident was supposed to receive the 8:00 a.m. insulin dose only. She was sent to theER on [DATE] with low blood sugar and remained in the hospital at this time. The facility had identified the resident had received multiple doses of insulin, completed an audit of residents who received insulin, and provided an inservice for staff on confirming and discontinuing Physician's orders. A Facility policy, titled Physician's Orders-Entering and Processing, received as current, indicated .5. Following a Physician visit, a licensed nurse will check for any orders that require confirmation under Clinical>orders>pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed . This Federal tag relates to Complaint IN00410811. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure to follow up with the nurse practitioner's (NP) orders for obtaining outside behavioral health services which resulted in a resident displaying continued tearfulness and emotional distress. (Resident 28) Finding includes: On 6/20/22 at 2:15 p.m., Resident 28 indicated she was in need of outside resources for mental health and depression. She indicated she had ongoing, worsening depression symptoms. During the interview, it was noted she had increased tearfulness and crying. On 6/21/22 at 3:33 p.m., the resident had noted tearfulness and she asked again if the facility had made any appointments with an outside psychological service. The resident stressed again how her depression was worsening and she felt she needed to see a professional regarding her mental health. She indicated that she was dependent on staff for ADL's (activities of daily living) as she could no longer walk, she stayed in her room and did not have the desire to participate in activities. The resident was not observed out of her room at all during the survey. Resident 28's record was reviewed on 6/21/22 at 1:38 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 5/12/22, indicated the resident had been feeling down, depressed, or hopeless for 7-11 days out of the last 14 days. She had trouble falling or staying asleep, or sleeping too much for 7-11 days out of the last 14 days. She had been feeling tired or having little energy for 2-6 days out of the last 14 days. A Referral Form, dated 4/12/22, from a NP assessing the resident indicated to arrange for ambulatory psychiatry to assess the resident. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician's Progress Note, dated 4/11/22 at 12:31 p.m., indicated the resident was reporting severe anxiety and depression. A Physician's Progress Note, dated 4/15/22 at 8:01 p.m., indicated the resident was seen and she reported she was depressed. The Physician increased the [MEDICATION(S)] (a medication to treat anxiety and depression) to 10 milligrams (mg) daily. A Physician's Progress Note, dated 6/11/22 at 10:51 p.m., indicated the resident was feeling hopeless and depressed. The Physician increased her dose of [MEDICATION(S)] to 20 mg daily. Interview with the Director of Nursing (DON) on 6/23/22 at 10:30 a.m., indicated there was no follow up for the ambulatory psychological services after they received the referral. The DON indicated after speaking with the referring NP, the NP indicated she sent the referral for outside psychological services due to the resident having increased emotional distress, tearfulness, and crying while she was assessing her. 3.1-43(a)(1)

Based on observation, record review and interview, the facility failed to implement adequate supervision measures to prevent a cognitively impaired resident deemed at risk for elopement from exiting the building. The resident left the building unattended around 3:30 a.m. on 11/2/21 and was found by security on rounds at a nearby office park and taken to the local hospital for evaluation. The facility is located within 1 mile of a major interstate and adjacent to a busy 4 lane road. (Resident D) The immediate jeopardy began on 11/2/21 when the resident had exited the facility without supervision. The alarm to the second floor door he exited was activated. The door to the outside was on the same alarm, so no secondary alarm went off as the resident left the facility. The resident was located at a nearby office park by a security company on rounds and was taken to the local hospital for evaluation by EMS, who had been called by the local police department. The Administrator, Assistant Director of Nursing (DON) and Regional Nurse Consultant were notified of the immediate jeopardy at 3:00 p.m. on 11/12/21. The immediate jeopardy was removed, and the deficient practice corrected on 11/5/21 prior to the start of the survey and was therefore Past Noncompliance. Finding includes: The record for Resident D was reviewed on 11/13/21 at 11:45 AM. Diagnoses included, but were not limited to unspecified [CONDITION(S)], traumatic subdural hematoma, dementia with behaviors, and repeated falls. An Admission Minimum Data Set (MDS) assessment, dated 9/30/21, indicated the resident was cognitively impaired. The resident was initially admitted on [DATE] to the Assisted Living Legacy locked unit and sent to the hospital on 9/24/21 after a fall. He was readmitted from the hospital on 9/30/21 to the skilled nursing unit. An Indiana Department of Health (IDOH) reportable incident, dated 11/2/21 at 6:30 p.m., indicated, Resident exited from the facility at 3:36 a.m. Staff initiated protocol. Police were called to assist. Resident was located with police assistance at 4:27 am. Abrasion to left knee. MD and family contacted. Resident sent to ER for eval [evaluation]. Resident returned to facility. MD orders will be followed. Social Services will assess for S/S [signs/ symptoms] of distress. Head to toe assessment completed. Care plans will be reviewed and changes made as needed. A Follow up, dated 11/5/21, indicated, MD and family contacted. [Resident's name] BIMS [cognitive evaluation] is a 5 [cognitively impaired]. Resident exited facility at 3:36 a.m He was located and taken to the ER for eval [evaluation] at 4:27 a.m. Resident returned to the facility at 7:30 a.m. from the hospital. Head to toe assessment completed with abrasion noted to left knee. No other injuries noted. [Resident's name] held the egress alarmed door for 15 seconds which allowed the door to open. He walked down the stairwell and exited the building. Maintenance verified that the doors were functioning properly. Door company called to verify the doors were functioning properly. Door company installed an individual mag lock to the exit door. MD orders followed. Safety checks initiated, no further incidents. With family consent, resident transferred back to secured dementia care unit. Social Services assessed for s/s of distress, none noted. Care plan reviewed and updated. An elopement assessment, dated 9/30/21, indicated high risk for elopement. No wanderguard was placed. An Elopement Care Plan was initiated on 5/4/21. Resident D was at risk for Elopement due to diagnoses of Dementia, ability to ambulate independently, history of attempting to exit the facility approaching the facility door and closely following behind visitors exiting. Approaches included, but were not limited to, redirect the resident away from doors as needed, encourage resident to participate in facilities and structured programming, add mural to outside door, resident's information placed in an Elopement Binder at the Nursing Station. A Fall Care Plan was initiated on 11/4/2021. The Care Plan indicated the resident had a history of falls as evidenced by admitting with stitches from a fall. Approaches included to help the resident to his destination if seen walking unsteadily, approach resident to slow down when walking, review new medications ordered. Resident was started on [MEDICATION(S)] (medication to treat dementia) by the Neurologist. Physical and Occupational therapy to evaluate. The local Police Department report, dated 11/2/21, indicated they were dispatched at 3:59 a.m. to investigate a suspicious person report. The police arrived to the area and saw the resident in a nearby business complex. Upon arrival, I located an elderly male in the vestibule of this building. He was very cold and confused, although he could identify himself as [name] but could provide no further information. Medics were called to take the resident to the hospital to be evaluated. It was determined the male party was missing from as adjacent nursing home, who was notified of his location. Nurses' Note, dated 11/2/2021 at 3:50 a.m., indicated, Writer was notified that res [resident] was missing off unit by staff personnel. Writer initiated code pink alert and began looking room to room and though-out unit/s. writer notified 9-1-1 an reported findings and informed family member of information. 9-1-1 personnel called writer to inform writer that res was located and transferred to hospital SLM for eval and treatment. ER given reported by writer. Per The Weather Channel, the local high temperature on 11/2/21 was 47 degrees Fahrenheit; the low (at night) was 28 F. (https://weather.com) Interview with the Administrator on 11/12/21 at 10:00 a.m., indicated CNA 1 heard an alarm during resident care and noticed Resident D was not on the unit. She checked the unit door and saw nothing. The unit nurse returned from break at that time and called the police. The police called the facility at 4:27 a.m. to notify of Resident D being evaluated in the local emergency room . Telephone interview with CNA 1 on 11/13/21 at 11:00 a.m. indicated the nurse had left the floor on break at the time of the incident. The census on the floor was 25 residents. CNA 1 was in another resident's room at the time. Resident D had been seated in the common area. CNA 1 heard an alarm while providing care to another resident. After completing care, CNA 1 exited the room. Resident D was no longer in the common area. The CNA checked the door at the end of the hall and did not see anything. The CNA then checked the area on the other end of the hall and did not see the resident. CNA 1 then notified other facility staff and a facility wide search was initiated. Follow up interview with the administrator on 11/15 21 at 2:30 p.m. indicated the facility had targeted educational inservicing for staff to address resident-specific supervision needs based on root cause analysis, especially when covering break times. The facility Elopement Policy, created on 2/12/21 was reviewed on 11/13/21 at 2:00 p.m The Policy was dated 02/12/21. The policy indicated it was the intent of the facility to be aware of it's residents' usual habits and locations as reasonably. Per IDOH elopement is recognized as a resident with cognitive deficits who was found outside the facility and whose whereabouts were unknown or whose return involves law enforcement. This past noncompliance Immediate Jeopardy began on 11/2/2021. The Immediate Jeopardy was removed and the the deficient practice corrected by 11/5/21 after the facility implemented a systemic plan that included the following actions: House wide assessment of all residents identified as wanderers or at risk for elopement, including resident-specific supervision needs. The assessments were all place in the Elopement binder at the Nursing Station. Staff inservicing had occurred prior to all staff returning to work and elopement drills were conducted. Random staff from various departments were interviewed and able to correctly answer questions related to the Elopement protocols, including resident-specific supervision needs. As as additional measure, the upper stairway door & downstairs exit door were placed on different alarm circuits. This Federal tag relates to Complaint IN 351. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident who was admitted with an open area received the necessary treatment and services to promote healing related to the lack of treatment, assessment and monitoring which resulted in an unstageable pressure ulcer 4 days later. (Resident C) The facility also failed to assess and obtain treatments for pressure ulcers in a timely manner for 3 of 5 residents reviewed for pressure ulcers. (Residents C, B and D) Findings include: 1. The closed record for Resident C was reviewed on 4/14/21 at 2:21 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 2/10/21. The resident did not return to the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 2/3/21, indicated the resident was not cognitively intact and was severely impaired for decision making. The resident was an extensive assist with one-person physical assist for bed mobility and limited assist with 1-person physical assist for dressing, eating and toileting. The resident weighed 137 pounds and had no history of weight loss. The resident received a mechanically altered diet and had 1 unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) noted upon admission. A Care Plan, dated 2/8/21, indicated the resident had alteration in skin integrity as evidenced by pressure ulcers. In the History and Physical from the hospital, dated 1/28/21, a note by the Registered Dietitian (RD), indicated the resident had a pressure ulcer to the right hip. A Full Clinical Body Observation completed at the time of admission to the facility, dated 1/29/21 at 12:58 a.m., indicated area to right hip isn't open, instead is pink and mostly healed, coccyx area wound 7 cm (centimeters) in diameter. Nurses' Notes, dated 1/29/21 at 1:00 a.m., indicated the resident arrived at the facility around 5:00 p.m., accompanied by EMT (Emergency Medical Technician). The resident was alert with confusion. Area to right hip appears pink in color, and appeared to be mostly healed, attempted to assess area better multiple times and resident began covering area with arm with resistance. There was no other documentation, or an assessment of the coccyx wound. There were no Physician's Orders obtained for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Nurses' Notes, dated 2/2/21 at 12:36 p.m., indicated Physical Therapy and CNA notified this writer of open area to coccyx and right hip area. Event opened, wound referral filled out. Order for wound doctor and wound nurse to eval and treat. A Wound Assessment form, dated 2/2/21, indicated 7.5 cm by 7.0 cm by .2 cm depth wound to coccyx, not previous documented. Dressing from hospital on dated 1/28/21. Wound Measurements, dated 2/2/21, indicated the coccyx was a new unstageable pressure ulcer with 100% necrotic eschar tissue covering the wound. The surrounding skin was with a 4 cm wound edge of dark purple or rusty discoloration. Physician's Orders, dated 2/2/21, indicated clean coccyx with normal saline and apply dry dressing daily. Clean areas (2) to right rip with normal saline and apply [MEDICATION(S)] dressing every 72 hours. Nurses' Notes, dated 2/4/21 at 4:01 p.m., indicated the resident was seen by the wound physician who removed the dead tissue by [MEDICATION(S)] the coccyx pressure sore. The Wound Physician's Notes, dated 2/4/21, indicated an unstageable (necrosis) pressure ulcer was present to the sacrum, measuring 5 cm by 5.8 cm. There was 100% of thick adherent necrotic tissue covering the wound bed. The physician performed a surgical excisional debridement to the sacral wound. The physician removed 29.00 cm of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissue. The Wound Physician's Notes, dated 2/4/21, indicated the right hip measured 1.1 cm by 1.3 cm by 0.2 cm and was identified as a stage 2 pressure ulcer. Physician's Orders, dated 2/5/21, indicated clean area to sacrum with normal saline and apply [MEDICATION(S)] and hydrogel gauze and dry dressing daily and air mattress for pressure relief. Interview with the Director of Nursing (DON) on 4/15/21 at 11:00 a.m., indicated there was no policy to indicate who can assess wounds and if the floor nurses were certified in wound care, then they could stage the wound. The floor nurse was to put a referral Wound Assessment form in the wound book to notify the wound nurse there was a resident with a new open area. The wound nurse currently worked Monday, Wednesday and Thursdays, and was part time. Interview with the DON on 4/16/21 at 1:30 p.m., indicated there was no assessment or documentation of the coccyx open area at the time of admission including color, drainage, or stage. There was no treatment obtained for the coccyx pressure ulcer until 2/2/21 (4 days after admission). 2. The closed record for Resident B was reviewed on 4/14/21 at 9:07 a.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 11/9/20. The resident did not return to the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 10/8/20, indicated the resident was not cognitively intact. The resident needed limited assist with 1 person physical assist with transfers, dressing, toileting and eating. The resident had 1 fall with no injury since the last assessment. The resident had no pressure sores and received [CONDITION(S)] while resident. Nurses' Notes, dated 11/3/20 at 2:22 p.m., indicated there were 2 open areas (shearing) noted to the left and right buttock. The physician was notified and orders were received. Wound referral placed in wound book. An Event form, dated 11/3/20, indicated right buttock (0.5 centimeters (cm) x 0.3 cm) and left buttock (2 cm x 1 cm). Areas were pink. No other assessment was completed for the open areas. Physician's Orders, dated 11/3/20, indicated cleanse left and right buttocks with normal saline or wound wash, pat dry and apply [MEDICATION(S)] twice a week on Monday and Thursday. The Treatment Administration Record (TAR) for the month of 11/2020, indicated the [MEDICATION(S)] dressing was signed out only 1 time on 11/5/20 for both the left and right buttocks. There was no wound assessment or documentation of the newly acquired pressure ulcers performed by the wound nurse. There was no Care Plan for pressure sores. Interview with the Director of Nursing (DON) on 4/15/21 at 11:00 a.m., indicated there was no policy to indicate who can assess wounds and if the floor nurses were certified in wound care, then they could stage the wound. The floor nurse was to put a referral Wound Assessment form in the wound book to notify the wound nurse there was a resident with a new open area. The wound nurse currently worked Monday, Wednesday and Thursdays, and was part time. Interview with the Director of Nursing on 4/16/21 at 1:30 p.m., indicated there was no documentation of any further wound measurements or any other wound assessments completed before the resident was sent out to the hospital. 3. The closed record for Resident D was reviewed on 4/15/21 at 10:15 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 2/4/21, indicated the resident was moderately impaired for daily decision making and was an extensive assist with bed mobility and transfers. The resident was identified as having one Stage 2 pressure ulcer, one Unstageable pressure ulcer and three Deep Tissue Injuries that were all present on admission. The Care Plan, dated 2/8/21, indicated the resident had an alteration in skin integrity as evidenced by pressure ulcer(s) related to decreased mobility and decreased cognition. Interventions included, but were not limited to, complete skin check and observe for complications such as pain, odor, changes in characteristics, increase in necrotic tissue, infection, [CONDITION(S)], and [CONDITION(S)] (bone infection). Notify the Physician immediately if observed. The Braden Scale assessment, dated 2/5/21, indicated the resident scored a 17, a low risk for developing pressure ulcers. A Physician's Order, dated 2/5/21, indicated the resident was to receive [MEDICATION(S)] (a topical antiseptic) to his left heel daily. The area was to be left open to air. The treatment was discontinued on 2/17/21 when the resident was sent to the hospital. Weekly Wound Measurements completed by the Wound Physician on 2/11/21, indicated the area to the resident's left heel was an unstageable pressure area that measured 2.5 centimeters (cm) x 6 cm x undetermined. Nurses' Notes, dated 2/17/21 at 7:25 a.m., indicated the resident was transferred to the hospital due to a change in mental status. Nurses' Notes, dated 2/20/21 at 6:17 p.m., indicated the resident was readmitted to the facility. Per the hospital report, the resident had Methacillin-resistant Staphylococcus aureus (MRSA) to his left heel wound. The wound was observed and covered with a foam dressing. The resident's physician ordered for the Wound Nurse to see the wounds. The order was entered under general orders. No treatment orders for the left heel were obtained upon the resident's readmission on 2/20/21. An entry in the nursing progress notes, dated 2/21/21 at 9:22 p.m., indicated the wound to the left heel was cleaned and covered. A Physician's Order, dated 2/22/21, indicated the Wound Nurse was to see the resident. Nurses' Notes, dated 2/23/21 at 2:02 p.m., indicated the resident was in contact isolation related to MRSA to the left heel. The resident's dressing was changed and heel boots were to be on while he was in bed. The Braden Scale assessment, dated 2/23/21, indicated the resident scored an 11 a high risk for developing pressure ulcers. A Physician's Order, dated 2/24/21, indicated the left lateral heel was to be painted with [MEDICATION(S)] daily and left open to air. The left heel was to be painted with [MEDICATION(S)], let air dry, and protect with dry dressing daily. The resident was seen by the Wound Physician on 2/25/21. The wound to the left heel was identified as being unstageable and measuring 3 cm x 6 cm x undetermined. Treatment rendered to toes and left heel with [MEDICATION(S)] per orders. The February 2021 Treatment Administration Record (TAR), indicated treatment orders for the left heel were obtained on 2/24/21. No treatments were signed out as being completed between 2/20 and 2/23/21. Interview with the Director of Nursing on 4/16/21 at 10:00 a.m., indicated the resident should have been seen by the Wound Nurse and treatment orders should have been obtained in a more timely manner. This Federal tag relates to Complaints IN 272 and IN 157. 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to weekly weights not obtained, meal consumption records not completed, and the Registered Dietitian's (RD) recommendations not followed for residents who were nutritionally at risk, which resulted in a significant weight loss (Resident C) and potential for weight loss (Resident E) for 2 of 5 residents reviewed for nutrition. Findings include: 1. The closed record for Resident C was reviewed on 4/14/21 at 2:21 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 2/10/21. The resident did not return to the facility. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 2/3/21, indicated the resident was not cognitively intact and was severely impaired for decision making. The resident was an extensive assist with one person physical assist for bed mobility and limited assist with 1 person physical assist for dressing, eating and toileting. The resident weighed 137 pounds and had no history of weight loss. The resident received a mechanically altered diet and had 1 unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) noted upon admission. A Care Plan, dated 2/8/21, indicated the resident required a puree diet with nectar thick liquids. The resident weighed 137 pounds on 1/29/21 at the time of admission. The next and last weight was recorded on 2/10/21 and was 124 pounds (a 13 pound weight loss in 12 days). Physician's Orders, dated 1/28/21, indicated monitor and record weight weekly times 4 then monthly. There was no weight obtained on 2/4/21. An RD Admission Progress Note, dated 2/2/21 at 12:13 p.m. indicated hospital records state resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Had been on TPN (total parental nutrition) with a stop date of 1/26/21. Hemodialysis was initiated on 1/15/2021, and last one was on 1/20/21. Current diet was pureed with nectar thick liquids. Per Speech therapist, the resident needed to be fed and was holding oral food. The resident was a 1 to 1 feed and to alternate puree food with nectar thick liquids. The resident's current weight was 137 pounds with a body mass index of 22.17 [within normal range]. Hospital labs: 1/25/21 Glucose 109, BUN [tests kidney function] 45 H [high], Cr [Creatinine, tests kidney function] 1.5 H, [MEDICATION(S)] [protein levels] 2.4 L [low], Ca [calcium] 8.3 L, 1/26/21 Hgb [hemoglobin] 7.4 L, and 1/27/21 BUN 51 H, Cr 1.6 H, CO2 2 L, and Ca 8.0 L. Recommend clarify diet order as general pureed diet with nectar thick liquids. Variable by mouth intakes noted. Recommend add super cereal at breakfast and frozen nutritional treat with lunch and dinner daily to support oral intakes and weight stability. On weekly weights x 4 weeks, then monthly, for admission protocol. Refer to RD as needed. An RD Progress Note, dated 2/9/21 at 1:58 p.m., indicated the resident now has a pressure ulcer to the sacrum. Please refer to RD note dated 2/2/21 for full assessment. Maintain recommendations to clarify diet order as general pureed diet with nectar thick liquids and to add super cereal at breakfast and frozen nutritional treat with lunch and dinner daily to support oral intakes and weight stability. Physician's Orders, dated 1/28/21, indicated pureed diet with nectar thick liquids and monitor and record breakfast, lunch and dinner intake. There were no Physician's Orders for the frozen nutritional supplement or to add super cereal at breakfast. The meal consumption record for 1/2021 and 2/2021 indicated the following: Breakfast intake was not completed on 1/31, 2/5 and 2/9/21. Lunch intake was not completed on 1/31, 2/1, 2/5, and 2/9/21. Interview with the Director of Nursing on 4/16/21 at 1:45 p.m., indicated weekly weights were not completed as ordered by the Physician and the RD's recommendations were not followed through for the nutritional frozen treat and the super cereal. The resident did have a significant weight loss since admission. 2. The record for Resident E was reviewed on 4/14/21 at 10:19 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital on 3/16/21 and readmitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 3/10/21, indicated the resident had short and long term memory issues and was moderately impaired for daily decision making. The resident required extensive assistance with eating and required a mechanically altered diet. On 3/10/21, the resident weighed 189 pounds. On 4/1/21, the resident's readmission weight was 170 pounds, indicating a significant weight loss of 10% A Physician's Order, dated 4/1/21, indicated to monitor and record the resident's weight weekly for 4 weeks then monthly. The resident's weight for 4/8/21 was not documented. On 4/13/21, the resident weighed 177 pounds. The April 2021 Physician's Order Summary (POS), indicated the resident was to receive a pureed no concentrated sweet diet with thin liquids and his breakfast, lunch and dinner intake was to be documented. The April 2021 food consumption log, indicated no lunch intake was documented on 4/2 and no breakfast or lunch intake was documented on 4/5, 4/7, and 4/10/21. Interview with CNA 3 on 4/13/21 at 1:10 p.m., indicated the resident needed assistance with his meals and his intake varies. Interview with the Director of Nursing on 4/16/21 at 10:00 a.m., indicated a weekly weight should have been obtained on 4/8/21 and his food intake should have been documented for all 3 meals. This Federal tag relates to Complaint IN 272. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure the Physician was notified of abnormal X-ray results after falls for 1 of 3 residents reviewed for falls. This resulted in a delay in treatment of [REDACTED]. Finding includes: 1. The closed record for Resident D was reviewed on 8/31/17 at 9:04 a.m. [DIAGNOSES REDACTED]. The resident was currently hospitalized . The Admission MDS (Minimum Data Set) assessment, completed on 5/25/17, indicated Resident D required extensive staff assistance with transfers, bed mobility, walking in rooms and the corridor, and dressing. The resident had one fall with injury since admission. physician's orders [REDACTED]. A Nursing Progress Note, completed on 7/9/17 at 2:09 p.m., indicated the resident was in the dining room and was easily agitated. He walked over to the exit door and pushed on the exit door until it opened and fell on his left side. A Nursing Progress Note, completed on 7/9/17 at 3:09 p.m., indicated the CNA took the resident to the bathroom per his request. The resident complained of pain to the left leg and was unable to hold the left leg/foot up when staff were propelling him in the wheel chair and had difficulty standing to sit on the toilet. The Nurse Practitioner was notified and staff received orders to obtain Stat x-rays of the left hip, left ribs, left shoulder, wrist, and elbow. Nursing Progress Notes, completed between 7/9/17 through 7/11/17, did not indicate results of the above X-rays were received or reviewed by the Physician or Nurse Practitioner. On 7/11/17 at 2:02 a.m., the resident was found by his roommate shaking. Upon assessment, the resident was having [MEDICAL CONDITION] activity [MEDICATION NAME] (6) minutes. The Physician was called and the resident was sent to the hospital emergency room at 2:21 a.m. The resident was readmitted to the facility on [DATE] at 6:36 p.m. A Nurse Practitioner Progress Note, completed on 7/24/17 at 10:20 p.m., indicated the resident was recently hospitalized for [REDACTED]. A physician progress notes [REDACTED]. There was no documentation related to the 7/9/17 X-ray results. A Nurse Practitioner Progress Note, completed on 8/21/17 at 8:33 p.m., indicated the resident was examined for spitting up saliva with thick mucus. The resident was to be sent to the hospital. There was no documentation related to the 7/9/17 X-ray results. The results of the 7/9/17 X-rays were reviewed. A [MEDICAL CONDITION] of the femur of indeterminate age was noted. These results were read by the Radiologist on 7/9/17 at 11:18 p.m. A facility Incident Report was initiated on 8/22/17. Resident D had a fall on 7/9/17 and X-rays were ordered at the time. The resident was last sent to the hospital on [DATE] and had not been discharged from the facility since. On 8/22/17 the resident's son informed staff the resident remained at the hospital. a CT Scan was completed at the hospital on [DATE] and indicated the resident had a left his fracture. An Investigation was initiated. The Nursing staff were interviewed. No Staff reported obtaining or notifying the Physician of the left [MEDICAL CONDITION] reported on 7/9/17. The facility obtained the results of a 8/22/17 CT scan of the abdomen. The CT scan revealed an impacted [MEDICAL CONDITION] femoral neck ([MEDICAL CONDITION]) which appeared of indeterminate age. The facility X-ray service was called on 8/22/17 and indicated the report of the left [MEDICAL CONDITION] was faxed to the facility on [DATE] at 11:18 p.m. Hospital records from 8/21/17 to current were obtained and reviewed. A Physical Examination, completed by an Orthopedic Physician on 8/22/17 at 8:36 a.m., indicated Resident D was seen and examined. The resident was mildly confused and did not respond to questioning. The left leg was shortened and externally rotated. A CT scan of the abdomen and pelvis, completed on 8/22/17, indicated there was an impacted femoral neck [MEDICAL CONDITION] femoral neck, which appeared to be the healing stage was identified. The resident will need to have surgical treatment of [REDACTED]. An H&P (History and Physical) was completed by the attending Physician on 8/21/17 at 10:49 a.m. The resident's son reported the resident stopped walking for the last two weeks, stopped using the wheel chair, had not been getting out of bed, and had complaints of left hip pain. Upon Physical Exam, the resident was noted with left hip being very tender tender to range of motion. The resident was able to move all extremities except the left leg, as he has a hard time moving because of the fracture. The resident had a fall which led to the left femoral neck fracture which occurred roughly around two weeks ago. Some healing was occurring at the fracture site. An open reduction and internal fixation surgery was needed. A left hip Hemiarthoplasty operation was preferred for a displaced femur fracture on 8/25/17. The facility Physical Therapy Notes were reviewed. The resident received Physical Therapy on numerous occasions in the facility. During an interview on 8/3/17 at 11:45 a.m., Physical Therapist 1 indicated Resident D completed several therapy events for Resident D. His mobility had declined after the fall. The Physical Therapist had not been aware of the fracture until after it was noted in the hospital in August. Resident D never complained of pain during therapy sessions but his mobility status did decline. During an interview on 8/31/17 at 10:39 a.m., the Director of Nursing indicated Resident D fell on [DATE] and X-rays were ordered. No Physician were notified of the results on the x-rays ordered on [DATE]. The resident's family spoke with a Nurse at the facility on 8/22/17 and informed the Nurse the resident had a [MEDICAL CONDITION]. The facility obtained the CT and X-ray reports. The X-ray noted a fracture and upon speaking to the X-ray service the report was faxed to the facility at 11:18 p.m. No staff member indicated they had received any X-ray reports for the resident. The facility staff should have made calls to the X-ray company to determine the results of the STAT x-ray results starting on the day the day the X-rays were ordered and completed at the facility. The facility policy titled Notification of Resident Change in Condition Policy was provided by the Assistant Director of Nursing (ADON) on 8/3/17 at 9:25 a.m. The ADON indicated the policy was the one currently being used by the facility. The policy indicated Licensed Nurses were to promptly notify the Physician with any need to alter treatment significantly, any significant change in a resident's physical status. This Federal tag relates to Complaint IN 310. 3.1-49(j)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident received necessary care and treatments for pressure ulcers, related to assessment, following physician's orders [REDACTED]. (Resident #F) Findings include: 1. During the initial tour on 06/23/14 at 10:25 a.m., The Director of Health Services (DHS), indicated Resident #F was interviewable, dependent on staff for activities of daily living (ADLs), and had a Stage One (intact skin with non-blanchable redness) pressure ulcer on her buttocks. Resident #F's record was reviewed on 06/24/14 at 8:30 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted into the facility on [DATE]. A Quarterly MDS Assessment, dated 05/15/14, indicated the resident's cognition was intact, had no behaviors, required extensive assistance of one for bed mobility, had one Stage I pressure ulcer, and had no pressure ulcers present on admission to the facility. An Individual Plan Report, updated 02/25/14 and reviewed on 05/25/14, indicated the resident had a Stage I area to her left buttock, to observe the wound for healing with care, measure the wound weekly, reposition and turn the resident frequently, follow the physicians orders for wound treatment, the CNA's were to observe the skin during care and report concerns to the Nurse and the Nurses' were to document any new skin areas and notify the physician of any skin deficits. A) The resident was observed in bed laying on her back on 06/23/14 at 10:25 a.m., 11:10 a.m., 12:35 p.m., and 1 p.m. (resident had been moved up on the mattress in bed) The resident had a pillow under her left shoulder, and her buttock was still on the mattress at 2:45 p.m. During an interview on 06/23/14 at 12:35 p.m., Resident #F indicated the staff do not offer to turn and reposition her often. During an interview on 06/23/14 at 1 p.m., Resident #F indicated the staff came in and repositioned her a, "little". (The resident remained on her back but had been moved up toward the head of the bed) During an interview on 06/23/14 at 2:45 p.m., the resident indicated she has not asked to be turned, so maybe this was why the staff have not turned her. During an interview on 06/23/14 at 2:45 p.m., the resident's husband indicated the staff do not turn her correctly. He indicated they do not turn her so her buttocks was off the bed. A facility policy, titled, "Turning and Repositioning", dated 10/07, and received as current from the DHS, indicated, "...Turning and repositioning is not routinely documented as this a (sic) normal nursing standard of practice that will be performed in accordance with the resident's care plan..." B) A Nurses' Note, dated 05/14/14 at 3 p.m., indicated the resident had a Stage I 1 cm (centimeter) x (by) 3.2 cm to the buttocks, which was red in color. The note indicated there was a new physician's orders [REDACTED]. A physician's orders [REDACTED]. A pressure ulcer assessment form, dated 05/14/14, indicated the resident had a Stage I (intact skin with non-blanchable redness) pressure area on the buttock which measured 1 cm x 3.5 cm with 0.25 cm depth (area was open with depth-Stage II-partial thickness loss of dermis). The form indicated the area was not present on admission and the treatment was [MEDICATION NAME] (dressing). The pressure ulcer assessment form indicated the left buttock area's measurements were as followed: 5/21/14- 1 cm x 3.4 cm x 0.25 cm depth, Stage I pressure area, red in color with moderate amount of exudate, and the [MEDICATION NAME] dressing continued. 05/28/14- 2 cm x 3.4 cm x 0.1 cm depth, Stage I, red in color, and the [MEDICATION NAME] dressing continued. 06/06/14- 2 cm x 3.4 cm x 0.1 cm depth, no stage marked, red in color and now [MEDICATION NAME] (pressure ulcer ointment) and [MEDICATION NAME] was now ordered. 06/11/14- 2 cm x 3.4 cm x 0.1 cm depth, Stage I, red with moderate exudate, no current treatment marked. 6/18/14- 2 cm x 3.4 cm, 0.1 cm depth, Stage I, red with moderate exudate, treatment of [REDACTED]. There was a lack of documentation to indicate the resident had other pressure areas on the buttock/coccyx area. A skin impairment assessment, dated 05/31/14 indicated there was excoriation to the bilateral outer buttock, which was read and a new order for [MEDICATION NAME] (ointment) had been ordered. The assessment form indicated the area had been resolved on 06/22/14. There was a lack of documentation to indicate the resident had other areas of concern. A Skin Impairment Circumstance, Assessment and Intervention form, dated 05/14/14, indicated the resident had a Stage I area on the buttocks and the resident's physician and family were notified. A Skin Impairment Circumstance, dated 05/31/14 indicated the resident had a Stage I area and excoriation on the buttock, and the "resident has a 1 x 3.2 (cm) area to the inner buttock and excoriation to the outer buttock" and an order for [REDACTED]. During an observation of the residents pressure area, on 06/23/14 at 2:55 p.m., with the resident's husband present, RN #1 positioned the resident so she could observe and measure the area. RN #1 removed the resident's brief, and three pressure areas were observed. RN #1 measured each area as follows: Coccyx: 3.5 cm (centimeter) by 2 cm with small area on the top with a 0.1 depth. RN #1 indicated the wound had yellow slough. She indicated the area was a Stage III (full thickness loss, slough may be present but does not obscure the depth of tissue loss). RN #1 then indicated the area was unstagable (slough/eschar; suspected deep tissue injury in evolution). Left buttocks (upper wound): 1.5 cm by 1 cm. RN #1 indicated the area was unstagable and had dark tissue covering the area. Left buttocks (lower wound): 2.1 cm by 1.5 cm. RN #1 indicated the area was unstagable and necrotic. While RN #1 was measuring the areas, she indicated the resident was going to have to be turned more often. She indicated the area was one big area when she last measured it on 06/11/14 and the area was getting better. Measurement of the area on 06/11/14 was 2 cm by 3.4 cm by 0.1 cm depth, area was not large enough to cover the other area located on the coccyx. During an interview on 06/23/14 at 3:15 p.m., Resident #F's husband indicated he had seen the area 2-3 weeks ago and it was small, he indicated the area was worse. He indicated he did not know about the other two areas. During an interview on 06/23/14 at 3:18 p.m., the DHS indicated the nurses' should have seen the areas were getting worse. She indicated the area started as a Stage I (the area had a 0.25 cm depth when first identified). She indicated she had just ordered an air mattress for the resident. During an interview on 06/24/14 at 9 a.m., the DHS indicated the [MEDICATION NAME] was ordered on [DATE] when the area first opened. She indicated she had spoke with the nurses who had cared for the resident and they indicated they knew about the areas but had not documented the areas. She indicated the nurses had not followed through with measuring and assessment of the areas. She indicated she could not find documentation to indicate the physician and the family were made aware of all the areas. She indicated the nurses thought the [MEDICATION NAME] was suppose to be used for all three areas. She indicated the resident had one pressure area on 05/31/14 and an interview with the CNA who cares for the resident and the CNA indicated the other areas had been there for about a week. She indicated she was unaware of the resident's pressure areas and had thought the first area was a stage I so she had not looked at the area. During an interview on 06/24/14 at 10:05 a.m., the RN Nurse Consultant indicated she had spoke with RN #1 and RN #1 had transposed the measurements. She indicated RN #1 thought if it began at a Stage I then she should always keep the pressure area at a Stage I. She indicated the Nurses' had not assessed the areas correctly. She indicated there was one area then bridged into two areas. The RN Consultant indicated she measured the areas as follows on 06/23/14: Coccyx- 3.5 cm x 2.0 x 0.1 depth, large amount of exudate, yellow/brown 100%, and unstageable. Left buttock (upper)- 1.5 cm x 1 cm, unstageable, black 100% Left buttock (lower)- 2.1 cm x 1.5 cm, unstageable, 100% black During an interview on 06/26/14 at 11:15 a.m., the RN Nurse Consultant indicated the nurses' had not assessed the pressure areas correctly. During an interview on 06/26/14 at 12:20 p.m., the DHS indicated Resident #F had not been discussed in CAR (clinically at risk), she indicated, "we missed that one". A non-dated facility policy, titled, "Pressure Prevention Guidelines", received from the DHS on 06/24/14 at 10 a.m., indicated, "...Inspect the skin daily during care for signs of breakdown or changes to the skin...Establish an individualized turning schedule if resident is immobile or compromised. Frequency of Position (sic) change is individualized. Notify the nurse to document if the resident refuses turning intervention...Weekly CAR (clinically at risk) review as warranted..." This Federal Tag relates to complaints IN 482 and IN 997. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to follow the resident's plan of care related to the implementation of pressure relieving devices for 2 of 4 residents reviewed for pressure ulcers in the sample of 8. This resulted in the development of an unstageable pressure ulcer and a Stage III pressure ulcer. (Residents #B and #C) Findings include: 1. On 12/13/13 at 8:55 a.m., Resident #B was observed sitting in a wheel chair the unit Dining Room. The resident had blue Multipodus boots on both of her feet. The record for Resident #B was reviewed on 12/12/12 at 2:00 p.m. The resident's [DIAGNOSES REDACTED]. The resident was originally admitted to the facility in 2010 and was last readmitted on [DATE]. Review of the 10/18/12 Nursing Admission Assessment & Collection Data form indicated the resident was admitted at 1:00 p.m. The form indicated the resident required assistance of two staff members for transfers, ambulation and toileting. The form indicated the resident's skin was intact and skin plan of care interventions on the form included for the resident to be turned and repositioned, heels to be elevated off surfaces, and pressure relieving devices to be provided. A Skin Impairment Circumstance Investigation form was initiated on 11/12/12. The form indicated wounds were observed on the resident's right heel and left outer ankle. The 11/2012 Treatment Administration Record indicated there were Physician orders [REDACTED]. The Physician orders [REDACTED]. There was another physician's orders [REDACTED]. There was also an order [REDACTED]. Two Pressure/Stasis/Arterial/Diabetic Ulcer Assessment forms were initiated on 11/12/12. The first form indicated a an Unstageable pressure ulcer was observed on the resident's right heel. The skin was intact and black in color and the area measured 5.0 cm x 6.5 cm with no depth recorded. The following assessments of the wound were recorded as follow: 11/14/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 11/22/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 11/28/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 12/05/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 12/12/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color The second form indicated a Stage III pressure ulcer was identified on the left outer ankle and the wound measured 2 cm x 1 cm and no depth recorded. The wound color was white and Santyl was applied. The following assessments of the wound were recorded as follows: 11/14/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, yellow in color, treatment with Santyl. 11/21/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, 20% red color, 80% yellow in color 11/28/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, 20% red color, 80% yellow in color 12/05/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, 95% red, 5% yellow in color 12/12/12- Stage III, 1.0 cm x 0.8 cm, undetermined depth, no drainage, 100% red in color When interviewed on 12/13/12 at 11:00 a.m., the Interim Director of Nursing indicated the areas to the resident's right heel and left ankle were first observed on 11/12/12. The Interim Director of Nursing indicated the facility ordered a pressure relieving mattress at that time as the resident had identified risk factors noted prior to 11/12/12. The Interim Director of Nursing indicated the mattress the resident was on prior to 11/12/12 was not a pressure relieving mattress. 2. The closed record for Resident #C was reviewed on 11/13/12 at 9:00 a.m. The resident was admitted to the facility from the hospital on [DATE]. The resident was discharged to the hospital on [DATE]. The resident's [DIAGNOSES REDACTED]. The 10/19/12 Nursing Admission Assessment & Data Collection form was reviewed. The form indicated the resident was admitted at 6:40 p.m. via an ambulance. The form also indicated the resident required assistance with grooming, transfers, bathing, dressing, eating, and toileting. The form also indicated the resident had a Stage I or greater wound and the corresponding body diagram indicated a Stage II wound was present on the sacral/coccyx area and 26 staples were noted along the spinal column. The Skin Plan of Care on the form indicated the resident was to have a pressure relieving device to the bed. An Assessment Review and Considerations form was completed on 10/19/12. This form indicated the resident had mobility impairment and medical [DIAGNOSES REDACTED]. Two Pressure/Stasis/Arterial/Diabetic Ulcer Assessment forms were initiated on 11/12/12. The first form indicated a Stage III (an ulcer with full thickness tissue loss without bone, tendon, or muscle exposed) pressure ulcer was present on the resident's coccyx and the color of the wound was yellow. The pressure ulcer measured 3.0 cm x 1.0 cm with depth of 0.5 cm. The following wound assessments were recorded on the form: 11/14/12- Stage III, 2.5 cm x 1.0 cm, undetermined depth, wound color 100% yellow, no drainage 11/21/12- Stage III, 1.0 cm x 0.8 cm, undetermined depth, wound 60% red and 40% yellow, no drainage. 11/28/12- Stage III, 1.0 cm x 0.6 cm , undetermined depth, wound 80% red, 20% yellow, no drainage 12/5/12- Stage III, 1.0 cm x 0.6 cm, undetermined depth, wound 90% red, 10% yellow, no drainage. The second form indicated a Stage II pressure ulcer was present on the resident's right inner buttock. The wound measured 1.5 cm x 1.0 cm and was red in color. The following wound assessments were recorded on the form: 11/14/12- Stage II, 2.5 cm x 1.0 cm, wound 100% red, no drainage present. 11/21/12- Stage II, 0.5 cm x 0.3 cm, wound 100% red, no drainage present. 11/28/12- Area resolved. When interviewed on 12/13/12 at 11:00 a.m., the Interim Director of Nursing indicated residents were to have a low air loss or pressure relieving mattress if they had multiple Stage II pressure ulcers, Stage III or higher ulcer, high risk factors, or were on bedrest. This federal tag relates to Complaint IN 199. 3.1-35(g)(2)

Based on observation, record review, and interview, the facility failed to ensure pressure relieving devices were in place for residents identified with pressure ulcers or at risk for the development of pressure ulcers for 2 of 4 residents reviewed for pressure ulcers in the sample of 8. This resulted in the development of an unstageable pressure ulcer and a Stage III pressure ulcer. (Residents #B and #C). The facility also failed to ensure individual treatments were in place for residents with multiple pressure ulcers for 2 of 4 residents reviewed for pressure ulcers in the sample of 8. (Residents #C and #E) Finding include: 1. On 12/13/13 at 8:55 a.m., Resident #B was observed sitting in a wheel chair the unit Dining Room. The resident had blue Multipodus boots on both of her feet. The record for Resident #B was reviewed on 12/12/12 at 2:00 p.m. The resident's [DIAGNOSES REDACTED]. The resident was originally admitted to the facility in 2010 and was last readmitted on [DATE]. Review of the 10/18/12 Nursing Admission Assessment & Collection Data form indicated the resident was admitted at 1:00 p.m. The form indicated the resident required assistance of two staff members for transfers, ambulation and toileting. The form indicated the resident's skin was intact and skin plan of care interventions on the form included for the resident to be turned and repositioned, heels to be elevated off surfaces, and pressure relieving devices to be provided. A Skin Impairment Circumstance Investigation form was initiated on 11/12/12. The form indicated wounds were observed on the resident's right heel and left outer ankle. The 11/2012 Treatment Administration Record indicated there were Physician orders obtained on 11/12/12. The Physician orders were to cleanse the area to the left outer heel with wound cleanser, pat dry, apply Santyl to wound bed, and cover the area with a clean dressing every day. There was another Physician's order to apply skin prep ( a wipe to dry skin on the area) to the right heel every shift. There was also an order for [REDACTED]. Two Pressure/Stasis/Arterial/Diabetic Ulcer Assessment forms were initiated on 11/12/12. The first form indicated a an Unstageable pressure ulcer was observed on the resident's right heel. The skin was intact and black in color and the area measured 5.0 cm x 6.5 cm with no depth recorded. The following assessments of the wound were recorded as follow: 11/14/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 11/22/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 11/28/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 12/05/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color 12/12/12- Unstageable wound, 5.0 cm x 6.5 cm in size, skin intact , black in color The second form indicated a Stage III pressure ulcer was identified on the left outer ankle and the wound measured 2 cm x 1 cm and no depth recorded. The wound color was white and Santyl was applied. The following assessments of the wound were recorded as follows: 11/14/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, yellow in color, treatment with Santyl. 11/21/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, 20% red color, 80% yellow in color 11/28/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, 20% red color, 80% yellow in color 12/05/12- Stage III, 1.5 cm x 1.5 cm, undetermined depth, no drainage, 95% red, 5% yellow in color 12/12/12- Stage III, 1.0 cm x 0.8 cm, undetermined depth, no drainage, 100% red in color When interviewed on 12/13/12 at 11:00 a.m., the Interim Director of Nursing indicated the areas to the resident's right heel and left ankle were first observed on 11/12/12. The Interim Director of Nursing indicated the facility ordered a pressure relieving mattress at that time as the resident had identified risk factors noted prior to 11/12/12. The Interim Director of Nursing indicated the mattress the resident was on prior to 11/12/12 was not a pressure relieving mattress. 2. On 12/13/12 at 10:45 a.m., LPN #1 was observed completing a wound care treatment for [REDACTED]. A scant amount of bloody drainage was observed on the dressing. A pressure ulcer was observed to the resident's coccyx. The open area measured approximately 1 cm (centimeter) x .5 cm with a red center. No odor was noted. There were no other open areas on the resident's coccyx or buttock areas. The record for Resident #E was reviewed on 12/12/12 at 1:30 p.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to facility from the hospital on [DATE]. Review of the 10/24/12 hospital Rehabilitation records indicated the resident had a decubitus (pressure ulcer) to the sacral area and was receiving wound care. Review of the 11/6/12 admission Physician orders indicated there were orders to apply Santyl (an ointment to debride ulcers) to the right great toe two times a day and also apply [MEDICATION NAME] (an ointment to treat wounds) cream to the right great toe two times a day. There were no Physician orders for any treatment to the coccyx or buttock areas. A Physician order was written on 11/12/12 to cleanse the area on the resident's coccyx with wound cleanser, pat dry, and apply Santyl to the wound bed and cover the area every other day. Review of the 11/6/12 (no time documented) Nursing Admission Assessment & Data Collection form indicated the resident had a left [MEDICAL CONDITION] and required assistance with transfers, ambulation, bathing, toileting, and dressing. The form also indicated the resident did not have a Stage I wound or greater present and the resident was not at risk for developing pressure ulcers. There was a body diagram on the Nursing Admission Assessment & Data Collection form to note any skin impairments observed. The only areas marked on diagram were a bruise to the resident's head and sutures to the left hip area. The Skin Plan of Care on the form did not indicate a pressure relieving device was to be in place to the resident's bed. An Assessment Review and Considerations form completed on 11/6/12 indicated staff were to mark if the resident had risk factors of mobility impairment, past history, or medical [DIAGNOSES REDACTED]. A Skin Impairment Circumstance, Assessment and Intervention form was initiated on 11/12/12 (no time listed). The form indicated the resident had two Stage II (an ulcer with partial thickness loss of the skin dermis with a red or pink ulcer bed) pressure ulcers. The pressure areas were located on the resident's left inner buttock and the coccyx areas. Two Pressure/Stasis/Arterial/Diabetic Ulcer Assessment forms were initiated on 11/12/12. The first form indicated a Stage III (an ulcer with full thickness tissue loss without bone, tendon, or muscle exposed) pressure ulcer was present on the resident's coccyx and the color of the wound was yellow. The pressure ulcer measured 3.0 cm x 1.0 cm with depth of 0.5 cm. The following wound assessments were recorded on the form: 11/14/12- Stage III, 2.5 cm x 1.0 cm, undetermined depth, wound color 100% yellow, no drainage 11/21/12- Stage III, 1.0 cm x 0.8 cm, undetermined depth, wound 60% red and 40% yellow, no drainage. 11/28/12- Stage III, 1.0 cm x 0.6 cm , undetermined depth, wound 80% red, 20% yellow, no drainage 12/5/12- Stage III, 1.0 cm x 0.6 cm, undetermined depth, wound 90% red, 10% yellow, no drainage. The second form indicated a Stage II pressure ulcer was present on the resident's right inner buttock. The wound measured 1.5 cm x 1.0 cm and was red in color. The following wound assessments were recorded on the form: 11/14/12- Stage II, 2.5 cm x 1.0 cm, wound 100% red, no drainage present. 11/21/12- Stage II, 0.5 cm x 0.3 cm, wound 100% red, no drainage present. 11/28/12- Area resolved. Review of the 11/13/12 Nutrition Assessment and Data Collection form indicated the Registered Dietitian noted resident stated he had a wound to the coccyx for eight months. The form also indicated the resident currently had open areas to the coccyx, left upper buttock, and right great toe. The Registered Dietitian's recommendations included to monitor the resident's oral intake and add 4 ounces of 2.0 Nutritional Supplement three times a day for skin healing. When interviewed on 12/13/12 at 11:00 a.m., the Interim Director of Nursing indicated the resident's open area to the coccyx was present and not identified when admitted . The Interim Director of Nursing indicated the coccyx wound was first observed on 11/121/2 when the facility performed skin checks for the residents. The Interim Director of Nursing indicated the pressure ulcer was a Stage III when it was first observed and treatment orders and a specialty low air loss mattress were ordered at that time The Interim Director of Nursing indicated residents were to have a low air loss or pressure relieving mattress if they had multiple Stage II pressure ulcers, Stage III or higher ulcer, high risk factors, or were on bedrest. The Interim Director of Nursing indicated the resident had been receiving Home Health care before his hospitalization and had the wound then. The Interim Director of Nursing indicated the resident should have received treatment for [REDACTED]. The Interim Director of Nursing indicated the pressure relieving devices should have been initiated upon admission for a Stage III pressure ulcer. 3. The closed record for Resident #C was reviewed on 11/13/12 at 9:00 a.m. The resident was admitted to the facility from the hospital on [DATE]. The resident was discharged to the hospital on [DATE]. The resident's [DIAGNOSES REDACTED]. The 10/19/12 Nursing Admission Assessment & Data Collection form was reviewed. The form indicated the resident was admitted at 6:40 p.m. via an ambulance. The form also indicated the resident required assistance with grooming, transfers, bathing, dressing, eating, and toileting. The form also indicated the resident had a Stage I or greater wound and the corresponding body diagram indicated a Stage II wound was present on the sacral/coccyx area and 26 staples were noted along the spinal column. The Skin Plan of Care on the form indicated the resident was to have a pressure relieving device to the bed. An Assessment Review and Considerations form was completed on 10/19/12. This form indicated the resident had mobility impairment and medical [DIAGNOSES REDACTED]. There were two Pressure/Stasis/Diabetic Ulcer Assessment forms completed for the resident. The first form indicated an Unstageable pressure ulcer was first observed on the resident's coccyx upon admission to the facility on [DATE]. The pressure ulcer measured 5.5 cm x 1 cm with depth of 0.2 cm, the wound bed was red/yellow in color, no drainage was noted, and the treatment being used was Santyl ointment. The following wound assessment was recorded: 10/24/12 -Unstageable, measuring 7.6 cm x 6 cm with undetermined depth, moderate amount of bloody drainage, wound bed with 50% red, 50% slough, no odor noted, and the treatment was Santyl. The section on the form titled "current preventative interventions" was blank. There were no further assessments of the wound recorded on the form. The second form indicated a Stage II pressure ulcer was first observed on the resident's right inner gluteus upon admission to the facility on [DATE]. There were no measurements recorded, the color of the wound was red, no odor was noted, and the treatment being used was Santyl. The following wound assessment was recorded: 10/24/12- Stage II, measuring 2 cm x 1.2 cm with less then 0.1 cm depth, the wound was 100% red and no drainage or odor noted, and the treatment being used was Santyl. The section on the form titled "current preventative interventions" was blank. There were no further assessments of the wound recorded on the form. Review of the 10/19/12 admitting Physician orders indicated there was an order to cleanse the wound to the coccyx with wound wash, pat dry, and apply Santyl with an [MEDICATION NAME](a type of dressing). There were no Physician orders for wound care to the right inner gluteus area. Review of the 10/2012 Treatment Record indicated the above ordered treatment was signed out as being completed. There was no documentation of any treatment being performed on the right inner gluteus wound. When interviewed on 12/13/12 at 11:00 a.m., the Interim Director of Nursing indicated residents were to have a low air loss or pressure relieving mattress if they had multiple Stage II pressure ulcers, Stage III or higher ulcer, high risk factors, or were on bedrest. When interviewed on 12/13/12 at 1:45 p.m., the Interim Director of Nursing indicated the resident had two pressure ulcer as per the wound assessment sheets and there should have been a separate order for each wound as they were different stages. The Interim Director of Nursing also indicated the pressure ulcer to the right gluteal area should have been measured upon admission. The Interim Director of Nursing indicated the wound sheets noted treatment being done to the areas was Santyl. The Interim Director of Nursing indicated she had a listing of resident's with pressure relieving specialty or low air loss mattress and it did not appear the resident had a pressure relieving mattress which she should have had in place due to her wounds and risk factors. This federal tag relates to Complaint IN 199. 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure residents were free of significant medication errors related to the administration of anticoagulant (medications to prevent blood clotting) and anticonvulsant (medications to control [MEDICAL CONDITION] activity) medications for 2 of 6 residents reviewed for medication errors in the sample of 6. This resulted in the hospitalization for one resident who developed [MEDICAL CONDITION] after receiving the incorrect dose of an anticoagulant medication. (Residents #D and #E) Findings include: 1. The record for Resident #E was reviewed on 10/22/12 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was sent to the hospital on [DATE] and was readmitted to the facility on [DATE]. Review of the 10/12 Physician orders [REDACTED]. Another order was written on 10/4/12 to hold the [MEDICATION NAME] 2 milligrams on 10/4/12 for one day and then begin [MEDICATION NAME] 1 milligram daily. There was also an order [REDACTED]. The 10/12 MAR (Medication Administration Record) was reviewed. The ordered dose of [MEDICATION NAME] 2 milligram was circled as not given on 10/4/12 and circled with the word "hold" on 10/5/12. There was hand written line though the columns with the dates and "d/c 10/4/12 see new order" was handwritten across the column. There was a hand written entry on second page of the MAR for [MEDICATION NAME] 1 milligram orally to be given daily at 5:00 p.m. The medication was signed out as given 10/6/12, 10/7/12, 10/8/12, and 10/9/12 at 5:00 p.m. Vitamin K 5 milligrams IM was also signed out as given on 10/10/12 at 4:00 p.m. Review of the laboratory test results indicated a PT/INR test was completed on 10/4/12. the results were PT 35.6 and INR 3.5. The laboratory results indicated the Physician was notified of the above results on 10/4/12 and Physician orders [REDACTED]. There was also an order [REDACTED]. A PT/INR was completed on 10/8/12. The results were PT 44.0 and INR 4.4. There was no documentation of the Physician being notified of the 10/8/12 results. A weekly PT/INR was completed on 10/10/12 based on the Physician order [REDACTED]. The results were PT 118.8 and INR 12.8. The 10/12 Nurses' Notes were reviewed. A late entry for 10/10/12 (no time listed) indicated the the Physician was made of aware of the Critical laboratory test results and orders were received to administer Vitamin K ( a medication used to decrease the effects of [MEDICATION NAME]) 5 milligrams IM (intramuscularly) one time and to hold [MEDICATION NAME] until further notice. The entry also indicated no breakthrough bleeding or [MEDICAL CONDITION] was noted. An entry made on 10/11/12 at 2:00 p.m., indicated the resident had a large amount of blood noted in the stool and the resident was sent to the hospital 911. When interviewed on 10/23/12 at 8:00 a.m., the Clinical Support Nurse indicated when investigating the resident's hospitalization and elevated PT/INR level it appeared the Nurses may have interpreted the written order on the MAR for 1 milligram of [MEDICATION NAME] to be 7 milligrams. The Nurse indicated they reviewed the resident's orders, pharmacy punch cards, and the MAR. The Nurse indicated staff working on this shift the 10/6/12 thru 10/8/12 were interviewed. The facility investigation concluded the resident received [MEDICATION NAME] 1 milligram on 10/6/12 and 10/7/12 and 7 milligrams on 10/8/12 and 10/9/12 resulting in the resident's PT/INR levels rising significantly.. The Nurse indicated LPN #1 worked 10/8/12 and 10/9/12 and signed out the doses of [MEDICATION NAME] on those two days. We first noted this error on 10/11/12 when audits were being done on residents receiving [MEDICATION NAME]. 2. The record for Resident #D was reviewed on 10/22/12 at 11:00 a.m. The resident's [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] and was re admitted to the facility in 9/24/12. A Change in Condition Form completed on 9/20/12 at 7:42 a.m., indicated the CNA notified the Nurse that the resident was having a [MEDICAL CONDITION] and at 8:03 a.m., the resident was noted to have another [MEDICAL CONDITION]. The Physician was notified and orders were received to send the resident to the emergency room at the hospital. Review of the 10/12 MAR (Medication Administration Record) indicated there was a physician's orders [REDACTED]. The administration times were to be upon rising, at lunch, and hs (hour of sleep). All the medication was signed out as given from 10/1/12 lunch time through 10/8/12 at upon rising times. The order was initially written on 9/24/12. The 10/12 MAR indicated [REDACTED]. Directly below the above line [MEDICATION NAME] 100 mg tablet - give 4 tablets orally every bedtime for 90 days was listed. The medication was signed out as given at bedtime 10/1/12 through 10/6/12. The MAR indicated [REDACTED]. Review of the 10/12 Physician order [REDACTED]. Review of the laboratory tests results indicated a [MEDICATION NAME] level was obtained on 10/10/12. The level was 11.7. The therapeutic level was listed to be (8-12). When interviewed on 10/23/12 at 12:10 p.m., the Interim Director of Nursing indicated she met with Resident #D's family on Monday 10/8/12. She indicated the family voiced concerns related to observing a Nurse starting to administer [MEDICATION NAME] pills to the resident on 10/7/12 when she was supposed to receive the medication in a liquid form. The Interim Director of Nursing indicated she reviewed the resident's record and medications and determined there was a medication error. The Interim Director of Nursing indicated the resident had been receiving [MEDICATION NAME] in both the pill form and the liquid form at night from 10/1/12 through 10/6/12 due to a transcription error. The Interim Director of Nursing indicated the Nurse did not administer both the pill form and the liquid form of the [MEDICATION NAME] on 10/7/12. She indicated the medication cart was checked and both [MEDICATION NAME] and [MEDICATION NAME] pills were in the cart. She also indicated the Nurse who worked on the 10/7/12 did not document anything about the doses nor did the Nurse notify her of the discrepancy on 10/7/12. The Interim Director of Nursing indicated she informed the Physician of the medication error on 10/8/12 and clarified the order for the medication. She also indicated the resident was noted to be lethargic on 10/10/12 and the Physician was notified and a [MEDICATION NAME] level was ordered. The Interim Director of Nursing indicated the 10/10/12 level was normal. This federal tag relates to Complaints IN 692 and IN 202. 3.1-48(c)(2)

A. Based on record review and interview, the facility failed to ensure a thorough investigation was conducted for a new onset of vaginal bleeding noted for a resident who was cognitively impaired and required extensive assistance from staff for completing activities of daily living. The facility also failed to ensure a thorough investigation was completed when an allegation was made indicating this resident had injuries that were not self inflicted, and a vaginal tear was documented in hospital records. This affected 1 of 3 residents reviewed for allegations of abuse in the sample of 3. (Resident #C) Due to the lack of thorough investigation, this deficient practice had the potential to affect the 54 residents residing on the health care units who were not protected from further potential abuse, of the 116 residents residing in facility. In addition, the facility failed to immediately report and initiate investigations in a timely manner for 2 of 2 residents in the sample of 3 who voiced mistreatment by staff and failed to suspend the employees involved in the allegations (Residents #B and #D), and failed to initiate an investigation and report a resident to resident altercation for 1 of 2 resident to resident altercations reviewed in the supplemental sample of 3. (Residents #E and #J) The Immediate Jeopardy began on 9/23/12 when Resident #C was observed with a new onset of vaginal bleeding and an investigation into the bleeding was not initiated. The facility Executive Director, Interim Director of Health Services, and Clinical Support Nurse were notified of the Immediate Jeopardy on 10/4/12 at 4:50 p.m. The Immediate Jeopardy was removed on 10/5/12 at 6:00 p.m., but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. B. Based on record review and interview, the facility also failed to ensure reference checks were completed during the hiring process for 1 of 5 employee files reviewed (RN #1). Findings include: A.1. The closed record for Resident #C was reviewed on 10/4/12 at 1:30 p.m. The resident's [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE]. Review of the 8/16/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 2. This indicated the resident's cognitive patterns were severely impaired. The assessment also indicated the resident required extensive assistance from staff for personal hygiene, eating, dressing, and toilet use. The assessment also indicated the resident required extensive assistance of two or more persons for bed mobility and transfers. A care plan, initiated on 8/13/12, indicated the resident had impaired cognitive skills as evidenced by decision making problems and memory problems. Another care plan, initiated on 8/13/12, indicated the resident had impaired communication, or the potential for, as her primary language was not English. Care plan interventions included for a communication board to be utilized as an alternate form of communicating. The 9/2012 Nurses' Notes were reviewed. The first entry made on 9/23/12 was completed at 10:00 a.m. This entry indicated the resident presented with vaginal bleeding. The Physician and family were notified and orders were obtained to send the resident to the hospital for an evaluation and treatment. There was no assessment of the resident's vaginal area in this entry. There was only one entry made on 9/22/12. This entry was made at 11:00 a.m. There was no documentation of the resident having any vaginal bleeding in this entry. There was only one entry made on 9/21/12. This entry was made at 5:00 p.m. There was no documentation of the resident having any vaginal bleeding in this entry. Hospital documents from the emergency room , which were in the resident's clinical record, were reviewed. There was a faxed date of 9/28/12 typed on the top right hand corner, indicating they were faxed to the facility on [DATE]. emergency room records dated 9/23/12 indicated the resident was sent to the emergency room for an evaluation of vaginal bleeding, and the resident had a history of [REDACTED]. The records indicated there was bleeding around the vagina, no signs of injury around the vagina, and blood clots and discharge from the vagina. The records also indicated the Physician was unable to evaluate the cervix due to the resident being uncooperative, as the resident did not follow commands and was not orientated. Additional hospital records were obtained on 10/4/12 at 3:00 p.m. A 9/23/12 Internal Medicine note, completed by the Physician who was the resident's attending Physician at the facility she was admitted from, indicated the resident was not able to communicate anything, had severe [MEDICAL CONDITION], and the resident was seen in the emergency room . The note confirmed the resident was having bleeding from the vagina and not the rectum. A pelvic examination indicated the resident was actively bleeding from the vagina and no bleeding was noted upon a rectal exam. The note also indicated the resident was status [REDACTED]. The note also indicated the resident "might have a vaginal [MEDICAL CONDITION] of some ulcer, possibility of maceration with a hard object should also be considered in demented patient which may have caused laceration and bleeding." A Gynecology Consult Note dated 9/23/12 indicated the resident was admitted for vaginal bleeding and an examination under anesthesia was required. A 9/25/12 physician progress notes [REDACTED]." An Operative Record dated 9/26/12 indicated an examination was performed under anesthesia and a speculum examination was done. Small abrasions were noted at the vaginal vault and some bleeding was noted. The abrasions were cauterized. A 9/26/12 physician progress notes [REDACTED]. The Assessment section of the note indicated "vaginal bleeding....did she masturbate with a hard object or was it a sexual abuse in the nursing home cannot be determined as patient is demented and cannot give a history..." When interviewed on 10/4/12 at 2:10 p.m. Social Worker #1 indicated the resident's son came into the facility to pick up the resident's dentures and eye glasses on 9/24/12. The Social Worker indicated she gave them to the resident's son at that time. The Social Worker indicated the resident's son did not say anything about the resident's condition at this time. The Social worker indicated the resident's son came back to the facility another time after the above date. The Social Worker indicated he came back to the facility with another person. The Social Worker indicated she could not remember the exact date of this visit. The Social Worker indicated she asked the son how he was doing and the other visitor told the son "don't say anything." The Social Worker indicated she then asked the son and the other visitor if there was something wrong and requested they come into her office to talk. The Social Worker indicated the other visitor indicated "she has injuries and they are not self inflicted, and we may have a case." The Social Worker indicated to both of them she was going to call the Executive Director to come and talk with them. The Social Worker indicated she tried calling and paging the Executive Director while they were both still in her office but did not get an answer, and the resident's son and the other visitor gave her a business card and left the facility. The Social Worker indicated she then went to the Executive Director's office and informed her what had happened in her office, and that the visitor indicated the resident had injuries that were not self inflicted and gave the card to the Executive Director. When interviewed on 10/4/12 at 2:35 p.m., the Executive Director indicated the Social Worker informed her of the resident's son and the visitor being in the facility and indicating the resident had some vaginal bleeding and it was "not self inflicted." She indicated this was either last Thursday or Friday. The Executive Director indicated at that time she reviewed the resident's clinical record and called the hospital for the emergency room records. The Executive Director reviewed the Emergency Records that were in the resident's record and indicated the date of the fax written on the records was the date the visitors were in and this date was 9/28/12. The Executive Director indicated she also then spoke with the Nurse who was caring for the resident at the time she was sent to the hospital on [DATE], the CNA who was working that shift, and the Nurse who worked the shift before. The Nurse who sent the Resident #C to the hospital for the vaginal bleeding indicated this was the first time the resident had any vaginal bleeding. The Nurse on the night shift indicated there were no problems with the resident in the night shift. When interviewed on 10/4/12 at 3:20 p.m., the Executive Director indicated she spoke to the male CNA caring for the resident on the day she was sent out to the emergency room and asked him if he had noticed any bleeding in the resident's brief or if there had been any problems with the resident, and none were voiced. The Executive Director indicated the three staff members were interviewed, but no written statements were available. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated the Incident and Accident Program was to be referred to for investigation procedures. The facility policy, titled "Accident and Incident Reporting Guidelines," was reviewed on 10/4/12 at 2:00 p.m. The policy was dated 11/2010. The policy indicated all accidents, incidents, and allegations of abuse, including injuries of unknown source, were to be reported to the department supervisor as soon as discovered or when information of occurrence is learned. The policy also indicated reporting of incidents, accidents, and abuse to state and federal agencies shall be in accordance with agency guidelines. The Immediate Jeopardy that began on 9/23/12 was removed on 10/5/12 when the facility inserviced staff on the Abuse Policy and procedures and reporting any unusual occurrence to their supervisor at the time of the occurrence. All staff working on 10/5/12 had been inserviced. The facility interim Director of Nursing provided a listing of all facility employees with a monitoring system to ensure each employee was inserviced prior to the start of their next scheduled shift. Department Heads were inserviced on the facility Accident and Incident Reporting guidelines to include immediate reporting to the Executive Director/DHS (Director of Health Services) and initiation of investigations. Random verbal audits of several residents were initiated to ensure residents felt safe and their needs were addressed. The audits were to continue. An investigation of Nursing Staff assigned as working the unit for 24 hours prior to the incident was initiated. Incident logs from 7/2012 to current were reviewed for any other potential occurrences. The Immediate Jeopardy was removed on 10/5/12 at 6:00 p.m., but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because inservicing needed to be provided to all staff prior to returning to work and the facility needed to ensure ongoing monitoring was in place to ensure all allegations of abuse or mistreatment were evaluated thoroughly. A.2. The record for Resident #B was reviewed on 10/4/12 at 10:00 a.m. The resident's [DIAGNOSES REDACTED]. The 7/5/2012 Minimum Data Set (MDS) admission assessment indicated the BIMS (Brief Interview for Mental Status) score was 15. This score indicated the resident's cognitive patterns were intact. An Indiana State Department of Health Incident Report Form was reviewed on 10/4/12 at 10:30 a.m. This incident report form indicated an incident occurred on 8/12/12 at 3:45 p.m. The form indicated the resident reported she did not want the CNA from the midnight shift taking care of her as the CNA was mean and nasty. The report indicated the Immediate Action taken included suspension of CNA #1 and initiating an investigation. The form also indicated the Executive Director was notified. An Accident/Incident Report was initiated on 8/12/12. The report indicated the resident complained that a CNA was mean and nasty to her and would not help her move her leg. The incident occurred on 8/12/12 at 3:45 p.m. The report also indicated this was reported to the Unit Manager and the resident had no injury. The report was signed as completed by the RN Unit Manager. The facility's investigation was reviewed. The investigation indicated CNA #1 was identified as the CNA working on the night shift 8/11/12 through 8/12/12. The employee time card record for CNA #1 indicated the employee did work the night shift starting on 8/12/12 at 9:57 p.m. and ending on 8/13/12 at 6:13 a.m. When interviewed on 10/4/12 at 11:50 a.m., LPN #6 indicated she was in the resident's room with a CNA on 8/12/12 and the resident voiced the concern that a CNA on the night shift had been mean to her. The LPN indicated she filled out a concern form at the time and reported the concern to the Unit Manager, who was in the facility at the time the above concern was reported to her. When interviewed on 10/4/12 at 12:25 p.m., the Unit Manager indicated on 8/12/12 at around 3:00 p.m. the Nurse reported to her that Resident #B had indicated a staff member was mean to her. The Unit Manager indicated she was in the facility at the time the Nurse reported this to her. The Unit Manager indicated she did not report this to anyone until the next day when she informed the DON. The Unit Manager indicated the DON then instructed her to interview Resident #B. When interviewed on 10/4/12 at 12:05 p.m., the Executive Director indicated CNA #1 was not suspended at the time the allegation was reported to the Unit Manager as per the facility policy. The Executive Director indicated the CNA time card indicated the CNA worked the night shift on 8/12/12 after the incident was reported on 8/12/12 at 3:45 p.m. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated the Incident and Accident Program was to be referred to for investigation procedures. The policy also indicated upon identification of suspected abuse and neglect protection for the safety of the resident is to be provided and may included 1:1 monitoring, moving of the resident, and suspending employees pending the outcome of the investigation. A.3. The record for Resident #D was reviewed on 10/4/12 at 11:30 a.m. The resident's [DIAGNOSES REDACTED]. The 9/21/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 15. This indicated the resident's cognitive patterns were intact. A Resident Concern form was initiated by Social Service #2 on 9/22/12 at 3:35 p.m. The form indicated the resident informed the above staff member he would like to speak to the Unit Manager or DHS (Director of Health Services) regarding a CNA on the midnight shift had refused to help him reposition in bed and told him he do can it himself. An Indiana State Department of Health Incident Report Form was reviewed on 10/4/12 at 10:30 a.m. The report form indicated an incident occurred on 9/22/12 at 3:45 p.m. The incident description indicated the resident verbalized to Social Service #2 that a CNA on the midnight shift refused to help him reposition in bed. The report indicted the Immediate Action taken included suspension of the CNA and initiating an investigation. Review of the facility's investigation indicated the DON interviewed Resident #D and CNA #6 on 9/25/12. Review of CNA #6's time card records indicated the CNA worked the night shift on 9/23/12. The CNA started work at 9:57 p.m. on 9/23/12 and punched out on 9/24/12 at 6:03 a.m. When interviewed on 10/4/12 at 1:10 p.m., the Clinical Support Nurse indicated the Social Service staff did not inform management of the concern until the staff morning meeting on 9/24/12, and the Social Service staff indicated they then informed her the resident's concern was an allegation of abuse and needed to be investigated and an investigation was started. When interviewed on 10/4/12 at 1;15 p.m., the Executive Director indicated she was first aware of the resident's concern at the 9/24/12 morning staff meeting and instructed the DON to initiate an investigation. The Executive Director indicated the CNA was not suspended at the time of the allegation. The Executive Director indicated the CNA did not work after 9/24/12 when the allegation was first brought up by Social Service at the 9/24/12 morning staff meeting. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated the Incident and Accident Program was to be referred to for investigation procedures. The policy also indicated upon identification of suspected abuse and neglect protection for the safety of the resident is to be provided and may included 1:1 monitoring, moving of the resident, and suspending employees pending the outcome of the investigation. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated an Accident and Incident Report was to be completed and the Incident and Accident Program was to be referred to for investigation procedures. The policy indicated the Executive Director was to be notified of allegations of abuse immediately. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated an initial report was to be initiated immediately and reported to the applicable state agencies within not more the 24 hours A.4. The record for Resident #E was reviewed on 10/4/12 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. The 7/12/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 6. The score indicated the resident's cognitive patterns were severely impaired. The 7/5/12 Nursing Admission Assessment & Data Collection indicated the resident was admitted on [DATE] and the resident had no behaviors at present but did have a history of behaviors. The Mood and Behavior Plan of Care included on the Data Collection above form indicated staff were to approach the resident in a calm manner, assess the resident for behaviors, provide medication per physician's orders [REDACTED]. An "Altercation/Concern Circumstance Assessment and Intervention" form was initiated by Nursing staff on 7/10/12 at 5:00 p.m. The form indicated the resident threw a glass of water at another resident in the dining room. The form indicated the resident had cognitive or memory impairment and difficulty following directions and understanding. The Prevention Update section on the form was completed by the Nurse who initiated the form. Updates circled included to remove the resident from the situation, engage the resident in activities, and encourage family visits. The form was reviewed by the IDT (Interdisciplinary Team) on 7/11/12. This section of the form was signed by four staff members which included ADON, Nursing staff and Social Worker #1. There were no other interventions added by the IDT team. The name of the resident who Resident #E threw the glass of water at was not listed on the above form. Review of the Social Service Progress Notes indicated there were no Social Service progress notes related to the above incident. When interviewed on 10/9/12 at 11:00 a.m., the Clinical Support Nurse indicated the resident threw a cup of water at Resident #J and also at a staff member on 7/10/12. The Clinical Support Nurse also indicated there was no Incident/Accident Report available related to the above resident to resident altercation. The Clinical Support Nurse indicated the facility protocol requires staff to complete an Incident Report related to resident to resident altercations and to notify the Executive Director of the incident. The Clinical Support Nurse indicated there were no records available to indicate the above incident was reported to the Indiana State Department of Health as required. When interviewed on 10/9/12 at 1:10 p.m., CNA #7 indicated she was present on 7/10/12 when Resident #E threw a cup of water at Resident #J. The CNA indicated both the residents were seated at the table along with Resident J's husband. The CNA indicated she asked Resident #J if she was OK and then Resident #E threw a cup at her also. When interviewed on 10/9/12 at 11:50 a.m., the Interim DON (Director of Nursing) indicated she was the Assistant Director of Nursing at the time of the above 7/10/12 incident. The Interim DON indicated the resident to resident altercation was reviewed in the IDT morning meeting the following day and the DON was present at this meeting. The Interim Director of Nursing indicated the DON at that time was to "follow up" with the incident. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated an Accident and Incident Report was to be completed and the Incident and Accident Program was to be referred to for investigation procedures. The policy indicated the Executive Director was to be notified of allegations of abuse immediately. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated an initial report was to be initiated immediately and reported to the applicable state agencies within not more the 24 hours. The facility policy, titled "Accident and Incident Reporting Guidelines," was reviewed on 10/4/12 at 2:00 p.m. The policy was dated 11/2010. The policy indicated an Accident and Incident Form was to be completed for known accidents and abuse allegations. The policy indicated the forms were to include the circumstances surrounding the occurrence, names of witness and their accounts of the occurrence and the statements were to be reviewed by the Administrative staff. The policy indicated all accidents, incidents, and allegations of abuse, including injuries of unknown source, were to be reported to the department supervisor as soon as discovered or when information of occurrence is learned. The policy also indicated reporting of incidents, accidents, and abuse to state and federal agencies shall be in accordance with agency guidelines. The policy also indicated the Accident and Incident form A.5. The record for resident #J was reviewed on 10/9/12 at 12:00 p.m. The resident's [DIAGNOSES REDACTED]. The 7/17/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 5. This indicated the resident's cognitive skills for were severely impaired. The 7/12 Nurses' Notes and Skilled Nursing Assessment and Data Collection notes were reviewed. There was no documentation of the resident being involved in any resident to resident altercation on 7/10/12. There was no "Altercation/Concern Circumstance Assessment and Intervention" form initiated by Nursing staff on 7/10/12. There was no documentation of an assessment of the resident's physical or psychosocial status related to the 7/10/12 resident to resident altercation. When interviewed on 10/9/12 at 11:00 a.m., the Clinical Support Nurse indicated the Resident #E threw a cup of water at Resident #J and also at staff member on 7/10/12. The Clinical Support Nurse indicated she identified Resident #J in as the resident who Resident #E threw the cup of water on in reviewing the 7/10/12 resident to resident Altercation report. The Clinical Support Nurse also indicated there was no Incident/Accident Report available related to the above resident to resident altercation. The Clinical Support Nurse indicated the facility protocol requires staff to complete an Incident Report related to resident to resident altercations and to notify the Executive Director of the incident. The Clinical Support Nurse indicated the above occurrence should have been documented on an "Altercation/Concern Circumstance Assessment and Intervention form in the Resident #J's clinical record including follow up assessment of the resident's condition as per the facility policies. B. The facility Employee Files were reviewed on 10/5/12 at 12:00 p.m. The file for RN #1 indicated the RN was hired on 7/26/12. There were no reference checks in the employee's file. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated all employees were to be screened for a history of abuse, neglect, or misappropriation of property during the hiring process. The policy also indicated screening included obtaining reference checks from previous/current employers. When interviewed on 10/9/12 at 10:00 a.m., the Executive Director indicated there were no reference checks in the RN's file. The Executive Director indicated they obtained the reference checks on 10/8/12. The Executive Director indicated reference checks were to be completed for employees during the hiring process according to the facility's Abuse Policy. This federal tag relates to Complaint IN 473. 3.1-28(c) 3.1-28(d) 3.1-28(e)

A. Based on record review and interview, the facility failed to ensure their abuse and neglect policy and procedure was implemented related to the failure to ensure a thorough investigation was conducted for a new onset of vaginal bleeding noted for a resident who was cognitively impaired and required extensive assistance from staff for completing activities of daily living. The facility also failed to ensure a thorough investigation was completed when an allegation was made indicating this resident had injuries that were not self inflicted, and a vaginal tear was documented in hospital records. This affected 1 of 3 residents reviewed for allegations of abuse in the sample of 3. (Resident #C) Due to the lack of thorough investigation, this deficient practice had the potential to affect the 54 residents residing on the health care units who were not protected from further potential abuse, of the 116 residents residing in facility. In addition, the facility failed to immediately report and initiate investigations in a timely manner for 2 of 2 residents in the sample of 3 who voiced mistreatment by staff and failed to suspend the employees involved in the allegations (Residents #B and #D), and failed to initiate an investigation and report a resident to resident altercation for 1 of 2 resident to resident altercations reviewed in the supplemental sample of 3. (Residents #E and #J) The Immediate Jeopardy began on 9/23/12 when Resident #C was observed with a new onset of vaginal bleeding and an investigation into the bleeding was not initiated. The facility Executive Director, Interim Director of Health Services, and Clinical Support Nurse were notified of the Immediate Jeopardy on 10/4/12 at 4:50 p.m. The Immediate Jeopardy was removed on 10/5/12 at 6:00 p.m., but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. B. Based on record review and interview, the facility failed to implement their abuse and neglect policy and procedure, related to the failure to ensure reference checks were completed during the hiring process, for 1 of 5 employee files reviewed (RN #1). Findings include: A.1. The closed record for Resident #C was reviewed on 10/4/12 at 1:30 p.m. The resident's [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE]. Review of the 8/16/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 2. This indicated the resident's cognitive patterns were severely impaired. The assessment also indicated the resident required extensive assistance from staff for personal hygiene, eating, dressing, and toilet use. The assessment also indicated the resident required extensive assistance of two or more persons for bed mobility and transfers. A care plan, initiated on 8/13/12, indicated the resident had impaired cognitive skills as evidenced by decision making problems and memory problems. Another care plan, initiated on 8/13/12, indicated the resident had impaired communication, or the potential for, as her primary language was not English. Care plan interventions included for a communication board to be utilized as an alternate form of communicating. The 9/2012 Nurses' Notes were reviewed. The first entry made on 9/23/12 was completed at 10:00 a.m. This entry indicated the resident presented with vaginal bleeding. The Physician and family were notified and orders were obtained to send the resident to the hospital for an evaluation and treatment. There was no assessment of the resident's vaginal area in this entry. There was only one entry made on 9/22/12. This entry was made at 11:00 a.m. There was no documentation of the resident having any vaginal bleeding in this entry. There was only one entry made on 9/21/12. This entry was made at 5:00 p.m. There was no documentation of the resident having any vaginal bleeding in this entry. Hospital documents from the emergency room , which were in the resident's clinical record, were reviewed. There was a faxed date of 9/28/12 typed on the top right hand corner, indicating they were faxed to the facility on [DATE]. emergency room records dated 9/23/12 indicated the resident was sent to the emergency room for an evaluation of vaginal bleeding, and the resident had a history of [REDACTED]. The records indicated there was bleeding around the vagina, no signs of injury around the vagina, and blood clots and discharge from the vagina. The records also indicated the Physician was unable to evaluate the cervix due to the resident being uncooperative, as the resident did not follow commands and was not orientated. Additional hospital records were obtained on 10/4/12 at 3:00 p.m. A 9/23/12 Internal Medicine note, completed by the Physician who was the resident's attending Physician at the facility she was admitted from, indicated the resident was not able to communicate anything, had severe [MEDICAL CONDITION], and the resident was seen in the emergency room . The note confirmed the resident was having bleeding from the vagina and not the rectum. A pelvic examination indicated the resident was actively bleeding from the vagina and no bleeding was noted upon a rectal exam. The note also indicated the resident was status [REDACTED]. The note also indicated the resident "might have a vaginal [MEDICAL CONDITION] of some ulcer, possibility of maceration with a hard object should also be considered in demented patient which may have caused laceration and bleeding." A Gynecology Consult Note dated 9/23/12 indicated the resident was admitted for vaginal bleeding and an examination under anesthesia was required. A 9/25/12 physician progress notes [REDACTED]." An Operative Record dated 9/26/12 indicated an examination was performed under anesthesia and a speculum examination was done. Small abrasions were noted at the vaginal vault and some bleeding was noted. The abrasions were cauterized. A 9/26/12 physician progress notes [REDACTED]. The Assessment section of the note indicated "vaginal bleeding....did she masturbate with a hard object or was it a sexual abuse in the nursing home cannot be determined as patient is demented and cannot give a history..." When interviewed on 10/4/12 at 2:10 p.m. Social Worker #1 indicated the resident's son came into the facility to pick up the resident's dentures and eye glasses on 9/24/12. The Social Worker indicated she gave them to the resident's son at that time. The Social Worker indicated the resident's son did not say anything about the resident's condition at this time. The Social worker indicated the resident's son came back to the facility another time after the above date. The Social Worker indicated he came back to the facility with another person. The Social Worker indicated she could not remember the exact date of this visit. The Social Worker indicated she asked the son how he was doing and the other visitor told the son "don't say anything." The Social Worker indicated she then asked the son and the other visitor if there was something wrong and requested they come into her office to talk. The Social Worker indicated the other visitor indicated "she has injuries and they are not self inflicted, and we may have a case." The Social Worker indicated to both of them she was going to call the Executive Director to come and talk with them. The Social Worker indicated she tried calling and paging the Executive Director while they were both still in her office but did not get an answer, and the resident's son and the other visitor gave her a business card and left the facility. The Social Worker indicated she then went to the Executive Director's office and informed her what had happened in her office, and that the visitor indicated the resident had injuries that were not self inflicted and gave the card to the Executive Director. When interviewed on 10/4/12 at 2:35 p.m., the Executive Director indicated the Social Worker informed her of the resident's son and the visitor being in the facility and indicating the resident had some vaginal bleeding and it was "not self inflicted." She indicated this was either last Thursday or Friday. The Executive Director indicated at that time she reviewed the resident's clinical record and called the hospital for the emergency room records. The Executive Director reviewed the Emergency Records that were in the resident's record and indicated the date of the fax written on the records was the date the visitors were in and this date was 9/28/12. The Executive Director indicated she also then spoke with the Nurse who was caring for the resident at the time she was sent to the hospital on [DATE], the CNA who was working that shift, and the Nurse who worked the shift before. The Nurse who sent the Resident #C to the hospital for the vaginal bleeding indicated this was the first time the resident had any vaginal bleeding. The Nurse on the night shift indicated there were no problems with the resident in the night shift. When interviewed on 10/4/12 at 3:20 p.m., the Executive Director indicated she spoke to the male CNA caring for the resident on the day she was sent out to the emergency room and asked him if he had noticed any bleeding in the resident's brief or if there had been any problems with the resident, and none were voiced. The Executive Director indicated the three staff members were interviewed, but no written statements were available. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated the Incident and Accident Program was to be referred to for investigation procedures. The facility policy, titled "Accident and Incident Reporting Guidelines," was reviewed on 10/4/12 at 2:00 p.m. The policy was dated 11/2010. The policy indicated all accidents, incidents, and allegations of abuse, including injuries of unknown source, were to be reported to the department supervisor as soon as discovered or when information of occurrence is learned. The policy also indicated reporting of incidents, accidents, and abuse to state and federal agencies shall be in accordance with agency guidelines. The Immediate Jeopardy that began on 9/23/12 was removed on 10/5/12 when the facility inserviced staff on the Abuse Policy and procedures and reporting any unusual occurrence to their supervisor at the time of the occurrence. All staff working on 10/5/12 had been inserviced. The facility interim Director of Nursing provided a listing of all facility employees with a monitoring system to ensure each employee was inserviced prior to the start of their next scheduled shift. Department Heads were inserviced on the facility Accident and Incident Reporting guidelines to include immediate reporting to the Executive Director/DHS (Director of Health Services) and initiation of investigations. Random verbal audits of several residents were initiated to ensure residents felt safe and their needs were addressed. The audits were to continue. An investigation of Nursing Staff assigned as working the unit for 24 hours prior to the incident was initiated. Incident logs from 7/2012 to current were reviewed for any other potential occurrences. The Immediate Jeopardy was removed on 10/5/12 at 6:00 p.m., but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because inservicing needed to be provided to all staff prior to returning to work and the facility needed to ensure ongoing monitoring was in place to ensure all allegations of abuse or mistreatment were evaluated thoroughly. A.2. The record for Resident #B was reviewed on 10/4/12 at 10:00 a.m. The resident's [DIAGNOSES REDACTED]. The 7/5/2012 Minimum Data Set (MDS) admission assessment indicated the BIMS (Brief Interview for Mental Status) score was 15. This score indicated the resident's cognitive patterns were intact. An Indiana State Department of Health Incident Report Form was reviewed on 10/4/12 at 10:30 a.m. This incident report form indicated an incident occurred on 8/12/12 at 3:45 p.m. The form indicated the resident reported she did not want the CNA from the midnight shift taking care of her as the CNA was mean and nasty. The report indicated the Immediate Action taken included suspension of CNA #1 and initiating an investigation. The form also indicated the Executive Director was notified. An Accident/Incident Report was initiated on 8/12/12. The report indicated the resident complained that a CNA was mean and nasty to her and would not help her move her leg. The incident occurred on 8/12/12 at 3:45 p.m. The report also indicated this was reported to the Unit Manager and the resident had no injury. The report was signed as completed by the RN Unit Manager. The facility's investigation was reviewed. The investigation indicated CNA #1 was identified as the CNA working on the night shift 8/11/12 through 8/12/12. The employee time card record for CNA #1 indicated the employee did work the night shift starting on 8/12/12 at 9:57 p.m. and ending on 8/13/12 at 6:13 a.m. When interviewed on 10/4/12 at 11:50 a.m., LPN #6 indicated she was in the resident's room with a CNA on 8/12/12 and the resident voiced the concern that a CNA on the night shift had been mean to her. The LPN indicated she filled out a concern form at the time and reported the concern to the Unit Manager, who was in the facility at the time the above concern was reported to her. When interviewed on 10/4/12 at 12:25 p.m., the Unit Manager indicated on 8/12/12 at around 3:00 p.m. the Nurse reported to her that Resident #B had indicated a staff member was mean to her. The Unit Manager indicated she was in the facility at the time the Nurse reported this to her. The Unit Manager indicated she did not report this to anyone until the next day when she informed the DON. The Unit Manager indicated the DON then instructed her to interview Resident #B. When interviewed on 10/4/12 at 12:05 p.m., the Executive Director indicated CNA #1 was not suspended at the time the allegation was reported to the Unit Manager as per the facility policy. The Executive Director indicated the CNA time card indicated the CNA worked the night shift on 8/12/12 after the incident was reported on 8/12/12 at 3:45 p.m. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated the Incident and Accident Program was to be referred to for investigation procedures. The policy also indicated upon identification of suspected abuse and neglect protection for the safety of the resident is to be provided and may included 1:1 monitoring, moving of the resident, and suspending employees pending the outcome of the investigation. A.3. The record for Resident #D was reviewed on 10/4/12 at 11:30 a.m. The resident's [DIAGNOSES REDACTED]. The 9/21/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 15. This indicated the resident's cognitive patterns were intact. A Resident Concern form was initiated by Social Service #2 on 9/22/12 at 3:35 p.m. The form indicated the resident informed the above staff member he would like to speak to the Unit Manager or DHS (Director of Health Services) regarding a CNA on the midnight shift had refused to help him reposition in bed and told him he do can it himself. An Indiana State Department of Health Incident Report Form was reviewed on 10/4/12 at 10:30 a.m. The report form indicated an incident occurred on 9/22/12 at 3:45 p.m. The incident description indicated the resident verbalized to Social Service #2 that a CNA on the midnight shift refused to help him reposition in bed. The report indicted the Immediate Action taken included suspension of the CNA and initiating an investigation. Review of the facility's investigation indicated the DON interviewed Resident #D and CNA #6 on 9/25/12. Review of CNA #6's time card records indicated the CNA worked the night shift on 9/23/12. The CNA started work at 9:57 p.m. on 9/23/12 and punched out on 9/24/12 at 6:03 a.m. When interviewed on 10/4/12 at 1:10 p.m., the Clinical Support Nurse indicated the Social Service staff did not inform management of the concern until the staff morning meeting on 9/24/12, and the Social Service staff indicated they then informed her the resident's concern was an allegation of abuse and needed to be investigated and an investigation was started. When interviewed on 10/4/12 at 1;15 p.m., the Executive Director indicated she was first aware of the resident's concern at the 9/24/12 morning staff meeting and instructed the DON to initiate an investigation. The Executive Director indicated the CNA was not suspended at the time of the allegation. The Executive Director indicated the CNA did not work after 9/24/12 when the allegation was first brought up by Social Service at the 9/24/12 morning staff meeting. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated the Incident and Accident Program was to be referred to for investigation procedures. The policy also indicated upon identification of suspected abuse and neglect protection for the safety of the resident is to be provided and may included 1:1 monitoring, moving of the resident, and suspending employees pending the outcome of the investigation. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated an Accident and Incident Report was to be completed and the Incident and Accident Program was to be referred to for investigation procedures. The policy indicated the Executive Director was to be notified of allegations of abuse immediately. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated an initial report was to be initiated immediately and reported to the applicable state agencies within not more the 24 hours A.4. The record for Resident #E was reviewed on 10/4/12 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. The 7/12/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 6. The score indicated the resident's cognitive patterns were severely impaired. The 7/5/12 Nursing Admission Assessment & Data Collection indicated the resident was admitted on [DATE] and the resident had no behaviors at present but did have a history of behaviors. The Mood and Behavior Plan of Care included on the Data Collection above form indicated staff were to approach the resident in a calm manner, assess the resident for behaviors, provide medication per physician's orders [REDACTED]. An "Altercation/Concern Circumstance Assessment and Intervention" form was initiated by Nursing staff on 7/10/12 at 5:00 p.m. The form indicated the resident threw a glass of water at another resident in the dining room. The form indicated the resident had cognitive or memory impairment and difficulty following directions and understanding. The Prevention Update section on the form was completed by the Nurse who initiated the form. Updates circled included to remove the resident from the situation, engage the resident in activities, and encourage family visits. The form was reviewed by the IDT (Interdisciplinary Team) on 7/11/12. This section of the form was signed by four staff members which included ADON, Nursing staff and Social Worker #1. There were no other interventions added by the IDT team. The name of the resident who Resident #E threw the glass of water at was not listed on the above form. Review of the Social Service Progress Notes indicated there were no Social Service progress notes related to the above incident. When interviewed on 10/9/12 at 11:00 a.m., the Clinical Support Nurse indicated the resident threw a cup of water at Resident #J and also at a staff member on 7/10/12. The Clinical Support Nurse also indicated there was no Incident/Accident Report available related to the above resident to resident altercation. The Clinical Support Nurse indicated the facility protocol requires staff to complete an Incident Report related to resident to resident altercations and to notify the Executive Director of the incident. The Clinical Support Nurse indicated there were no records available to indicate the above incident was reported to the Indiana State Department of Health as required. When interviewed on 10/9/12 at 1:10 p.m., CNA #7 indicated she was present on 7/10/12 when Resident #E threw a cup of water at Resident #J. The CNA indicated both the residents were seated at the table along with Resident J's husband. The CNA indicated she asked Resident #J if she was OK and then Resident #E threw a cup at her also. When interviewed on 10/9/12 at 11:50 a.m., the Interim DON (Director of Nursing) indicated she was the Assistant Director of Nursing at the time of the above 7/10/12 incident. The Interim DON indicated the resident to resident altercation was reviewed in the IDT morning meeting the following day and the DON was present at this meeting. The Interim Director of Nursing indicated the DON at that time was to "follow up" with the incident. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated an Accident and Incident Report was to be completed and the Incident and Accident Program was to be referred to for investigation procedures. The policy indicated the Executive Director was to be notified of allegations of abuse immediately. The policy indicated the Executive Director was accountable for investigating and reporting allegations. The policy also indicated an initial report was to be initiated immediately and reported to the applicable state agencies within not more the 24 hours. The facility policy, titled "Accident and Incident Reporting Guidelines," was reviewed on 10/4/12 at 2:00 p.m. The policy was dated 11/2010. The policy indicated an Accident and Incident Form was to be completed for known accidents and abuse allegations. The policy indicated the forms were to include the circumstances surrounding the occurrence, names of witness and their accounts of the occurrence and the statements were to be reviewed by the Administrative staff. The policy indicated all accidents, incidents, and allegations of abuse, including injuries of unknown source, were to be reported to the department supervisor as soon as discovered or when information of occurrence is learned. The policy also indicated reporting of incidents, accidents, and abuse to state and federal agencies shall be in accordance with agency guidelines. The policy also indicated the Accident and Incident form A.5. The record for resident #J was reviewed on 10/9/12 at 12:00 p.m. The resident's [DIAGNOSES REDACTED]. The 7/17/12 Minimum Data Set (MDS) admission assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 5. This indicated the resident's cognitive skills for were severely impaired. The 7/12 Nurses' Notes and Skilled Nursing Assessment and Data Collection notes were reviewed. There was no documentation of the resident being involved in any resident to resident altercation on 7/10/12. There was no "Altercation/Concern Circumstance Assessment and Intervention" form initiated by Nursing staff on 7/10/12. There was no documentation of an assessment of the resident's physical or psychosocial status related to the 7/10/12 resident to resident altercation. When interviewed on 10/9/12 at 11:00 a.m., the Clinical Support Nurse indicated the Resident #E threw a cup of water at Resident #J and also at staff member on 7/10/12. The Clinical Support Nurse indicated she identified Resident #J in as the resident who Resident #E threw the cup of water on in reviewing the 7/10/12 resident to resident Altercation report. The Clinical Support Nurse also indicated there was no Incident/Accident Report available related to the above resident to resident altercation. The Clinical Support Nurse indicated the facility protocol requires staff to complete an Incident Report related to resident to resident altercations and to notify the Executive Director of the incident. The Clinical Support Nurse indicated the above occurrence should have been documented on an "Altercation/Concern Circumstance Assessment and Intervention form in the Resident #J's clinical record including follow up assessment of the resident's condition as per the facility policies. B. The facility Employee Files were reviewed on 10/5/12 at 12:00 p.m. The file for RN #1 indicated the RN was hired on 7/26/12. There were no reference checks in the employee's file. The facility policy, titled "Abuse and Neglect Procedural Guidelines," was reviewed on 10/4/12 at 12:45 p.m. The policy had a revised date of 9/16/2011. The policy indicated all employees were to be screened for a history of abuse, neglect, or misappropriation of property during the hiring process. The policy also indicated screening included obtaining reference checks from previous/current employers. When interviewed on 10/9/12 at 10:00 a.m., the Executive Director indicated there were no reference checks in the RN's file. The Executive Director indicated they obtained the reference checks on 10/8/12. The Executive Director indicated reference checks were to be completed for employees during the hiring process according to the facility's Abuse Policy. This federal tag relates to Complaint IN 473. 3.1-28(a)

Based on record review and interview, the facility failed to provide and assess a resident for sufficient fluid intake, for 1 of 7 residents reviewed for dehydration in a sample of 7. The resident was transferred to the hospital with severe dehydration after only being in the facility five days. (Resident #B) Findings include: Resident #B's closed record was reviewed on 04/19/12 at 9:20 a.m. The resident's admitted was 2/29/12, and [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] at 1:18 p.m. The admission assessment, dated 02/29/12 at 11:15 a.m., indicated the resident was independent with eating, had no signs or symptoms of dehydration, skin turgor fair, mucous membranes were pink and moist, and was alert and oriented. The admission nutrition care plan, dated 02/29/12, indicated to provide adequate hydration. The Skilled Nursing Assessment and Data Collections (daily Nurses' Notes) indicated: 03/01/12 11-7 shift indicated the resident's skin turgor was fair and mucous membranes pink and moist. 03/02/12 3-11 shift indicated the resident's skin turgor was fair and mucous membranes pink and moist. 03/03/12 1:15 a.m. indicated the resident's skin turgor was fair and mucous membranes pink and moist. 03/04/12 11-7 shift indicated the resident's skin turgor was fair and mucous membranes pink and moist. The Nurses' Notes, dated 03/03/12 at 4 p.m., indicated, "Res (resident) c/o (complains of) not eating. Was given hot dog & shake & chips. Was served supper also..." The Nurses' Notes, dated 03/04/12 at 11:30 a.m., indicated, "...c/o nausea...family in and wanting Res sent to ER...Family insistent Res be sent out..." The resident's fluid intake records indicated the following total fluid intakes: 03/01/12-340 cc's (cubic centimeters) 03/02/12-220 cc's 03/03/12-200 cc's 03/04/12-660 cc's An ambulance transfer record, dated 03/04/12 at 1:18 p.m., indicated, "...pt (patient) is c/o (complaints) nausea, poor appetite, & poor oral intake for approximately a week. Pt's skin is tenting (poor turgor noted)..." Resident #B's emergency room physician notes, dated 03/04/12, indicated, "... Positive for nausea, vomiting and abdominal pain...oriented to person, place, and time...BUN (kidney test) 84 (normal 7-21) Creatinine (kidney function) 3.64 (normal 0.50-1.20) Calcium 6.3 (Normal 8.5-10.5) Sodium 126 (normal 135-145) Potassium 5.7 (normal 3.4-5.3) Chloride 80 (Normal 97-108)..." Resident #B's [MEDICATION NAME] consult note, dated 03/05/12, indicated, "...At the nursing home, the patient has been quite nauseous frequently...The last few days she has been getting dehydrated and feeling lightheaded...At the time of presentation to the emergency room , the patient was clearly significantly dehydrated..." A physician consult, dated 03/06/12, indicated, "...Within a five day period of time, she became very lightheaded and dehydrated and was readmitted to (hospital name)..." During an interview on 04/19/12 at 2:10 p.m., LPN #3 indicated the family wanted the resident sent to the hospital due to nausea. She indicated the resident had not vomited. During an interview on 04/20/12 at 9 a.m., the Regional Vice President indicated the facility had found no other intake records. She indicated she could not comment on the resident's liquid intake because she did not know if the resident took other fluids during the day and the staff had not recorded it. This Federal tag relates to Complaint IN 360. 3.1-46(b)

Based on observation, record review, and interview, the facility failed to implement the Registered Dietician's (RD) recommendations following a weight loss, which resulted in a further significant weight loss for Resident D and failed to reweigh a resident as recommended by the RD, which indicated Resident F had a significant weight loss when the monthly weight was obtained, for 2 of 5 residents reviewed for weight loss in a total sample of 5. Findings include: 1. Resident D's record was reviewed on 3/6/12 at 11:40 a.m. Resident D's [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] and 1/31/12. A weight record indicated the resident's weight on 1/9/12 was 191 pounds and 1/31/12 was 177 pounds. These were the only weights documented on the weight record. An Assessment Review and Considerations form (readmission assessment), dated 1/31/12, indicated the resident did not have any risk factors that may contribute to weight loss. A nutrition progress note by the Registered Dietician, dated 2/6/12, indicated "Resident received for readmission...Resumed on Mech (Mechanical) Soft Diet oral intake of meals averaging 79.3% Readmission weight 177# (pounds) which indicated weight loss 14# from previous admission (arrow pointing down 7.3% /month) significant weight loss...this readmission no [MEDICAL CONDITION] noted...recommend resume 3 oz (ounce) (90 ml) (milliliters) Resource (liquid supplement) 2.0 BID (twice a day) between meals. Monitor for continued weight loss." The resident's record lacked an order for [REDACTED]. A Nutrition care plan, updated 2/10/12, indicated significant weight loss upon readmission from the hospital. Interventions indicated "...administer nutritional support as ordered, supplements...weigh and monitor results per policy." A 14 day Minimum Data Set (MDS) Assessment, dated 2/14/12, indicated the resident needed extensive assistance of one staff member for eating, weight was 177 pounds, weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on physician-prescribed weight-loss regimen. A Meal Intake Detail Report for February 2012, indicated the resident ate 25-100% of breakfast, 50-100% of lunch, and 45-100% of dinner. The report lacked documentation of intake for breakfast on 2/6, 2/9, 2/10, 2/11, 2/14, 2/18, 2/20, and 2/23, for lunch on 2/5, 2/6, 2/7, 2/11, 2/17, 2/18, 2/20, and 2/21, and for dinner on 2/5 and 2/19. A Meal Intake Detail Report, dated 03/12, lacked documentation to indicate the resident consumed any breakfast on March 2, 3, 4, and 6, 2012 and any lunch on March 2, 3, 4, and 6, 2012. On March 5 and 7, 2012 the resident consumed 50-75% of breakfast and lunch. The report indicated the resident consumed 50-100% of supper on March 2-6, 2012. During an observation on 3/6/12 at 12:32 p.m., RN #2 and RN #3 weighed Resident D in her wheelchair. Resident D's weight with the wheelchair was 225.4 pounds and the wheelchair weight was 64.8 pounds. This indicated the resident's weight was 160.6 pounds (weight loss of 16.4 pounds since 1/31/12 or 9.2% in 1 month and 6 days). During an interview on 3/6/12 at 12 p.m. with RN #2, she indicated they didn't get the dietary recommendation and that is probably why there was not an order for [REDACTED]. During an interview on 3/6/12 at 12:30 p.m. with RN #2, she indicated there were no weights for February and March. During an observation on 3/6/12 at 1:11 p.m., Resident D received puree vegetables, potatoes, and beef. During an observation on 3/6/12 at 1:12 p.m., CNA #8 started to feed Resident D. CNA #8 indicated the feeders are the last ones to get served so they can sit down and feed them. CNA #8 indicated Resident D is not always the greatest eater. 2. During an observation on 03/07/12 at 9:15 a.m., Resident #F was sitting at a dining room table, on the plate in front of the resident was puree eggs, toast and ground sausage. The resident had not ate any of the breakfast. During an interview at the time of the observation, the resident indicated she did not like her food. She indicated she did not like the food ground up. During an observation on 03/07/12 at 9:20 a.m., the resident had still not ate any of the her breakfast, the Acting Director of Nursing asked the resident if she was finished with her breakfast and offered to get the resident different food. The resident refused the offer of different food. The Acting Director of Nursing then removed the untouched plate from in front of the resident. Resident #F's record was reviewed on 03/07/12 at 10:10 a.m. The resident's [DIAGNOSES REDACTED]. The Admission/5-day Minimum Data Set assessment, dated 12/07/11, indicated the resident required extensive assistance with eating, had no swallowing disorder, and no significant weight loss. The care plan, dated 12/09/11, indicated the resident required extensive assistance for eating and would receive an assistance of one. A care plan, dated 12/09/11, 01/11/12. and 01/27/11 indicated the resident had a questionable significant weight loss upon return from the hospital, leaves 25% or more of food uneaten, has swallowing problems, and received a tube feed [MEDICATION NAME]. The interventions included to monitor and report to the physician significant weight loss and weigh and monitor results. The Skilled Nursing Assessment, date 03/03/12 indicated the resident had short term and long term memory problems and may not understand part of the communication. The physician's recapitulation orders, dated 03/12, indicated the resident had a order for a puree diet and a [MEDICATION NAME] tube feeding of Glucerna (liquid supplement) one can, five times a day. The resident's return admission assessment, dated 01/04/12, indicated a weight of 190.6. The weight detail report, received from the Acting DoN (Director of Nursing) on 03/07/12 at 9:45 a.m. indicated the resident's weight on 02/02/12 was 240 pounds, which was a 25.9% weight increase and the resident's weight on 03/03/12 was 183.4, which was a 23.5% weight loss. A nutrition progress note, dated 02/20/12, indicated, "...Obtain current weight to evaluate for any weight change..." During an interview on 03/07/12 at 9:45 a.m., the Acting DoN indicated the facility should have reweighed the resident on 02/02/12 when the resident weighed 240. She indicated the 240 pounds was not accurate and the facility never got an accurate weight on the resident. She indicated the weight on 03/03/12 was a significant weight loss. She indicated no one got the resident's weight after the Registered Dietician recommended an accurate weight to evaluate for weight loss. This Federal tag relates to Complaint IN 877. 3.1-46(a)(1) 3.1-46(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents' maintained acceptable parameters of nutrition and follow up on the Registered Dietician's (RD) recommendations to prevent weight loss for 3 of 3 resident's with significant weight loss (Residents #9, #20, and #37) and failed to re-weigh a resident per the RD recommendations for 1 of 1 closed records reviewed in a total sample of 12. (Resident #122) Findings include: 1. Resident #37's record was reviewed on 2/13/12 at 12:50 p.m. Resident #37's [DIAGNOSES REDACTED]. The resident's recapitulation orders, dated 02/12, indicated an order for [REDACTED]. An admission MDS (minimum data set) assessment, dated 12/31/11, indicated the resident's cognition was moderately impaired. The resident had not had any weight loss and his weight was 150.1 pounds. The resident's admission assessment, dated 12/24/11, indicated the resident's weight was 150 pounds. A care plan, dated 1/6/12, indicated "Resident at nutritional risk...leaves 25% or more food uneaten at most meals...interventions...Provide/monitor intake of diet/fluids...offer substitutes if 50% or less is consumed...weigh and monitor results..." During an interview on 2/14/12 at 10:12 a.m., RN #124 indicated residents were weighed on admission and then in 2 weeks and then monthly. She indicated Resident #37 had not been weighed like he was supposed to be; two weeks after admission and then monthly. She indicated the resident's weight on 1/4/12 was 137 pounds. (This was a 8.6 percent weight loss in 11 days.) The dietary intake records, dated 01/02/12 through 01/31/12, indicated the resident's breakfast consumption was 15-100%, with no breakfast intake documented for 01/22/12 and 01/24/12. The dietary intake records, dated 01/02/12 through 01/31/12, indicated the resident's lunch consumption was 60-100%, with no lunch intake documentation for 01/22/12 and 01/24/12. The dietary intake records, dated 01/02/12 through 01/31/12, indicated the resident's dinner consumption was 75-100%, with no dinner consumption documented for 01/06/12 and 01/30/12. A Nutrition Assessment and Data Collection form completed by the RD, dated 1/4/12 at 3:45 p.m., indicated the resident's weight on admission was 150.1 pounds. The resident's diet order was mechanical soft. The supplemental nutrition was 25 grams of whey protein powder daily. The assessment indicated "Resident receives mechanically altered food consistency d/t (due to) impaired dentation-' loose dentures.' Resident consumes < (less than) 75% of meals. Resident with increased (indicated with an arrow) nutritional needs...Receiving protein supplement but need for increased (indicated by an arrow) kcal (calories) increased (indicated by an arrow) protein. Recommend D/C (discontinue) whey protein powder and begin 90 ml (milliliters) Resource 2.0 tid (three times a day) between meals. Supplement will provide 540 kcals (calories)/22.5 gms (grams) protein/day. Monitor weight, oral intake...Weight may be affected by recent increase (indicated by an arrow) [MEDICAL CONDITION] medication...." The resident's record lacked documentation to indicate the physician had been notified of the resident's weight loss or of the RD recommendations. A "Resident First Conference Notes", dated 1/11/12, indicated "...Nutrition weight stable..." A weight change report, indicated the resident's weight on 2/3/12 was 134.2 pounds. There was a lack of documentation of any other weights on the form.. There was a lack of any further documentation in the dietary notes related to the resident's weight loss. During an interview on 2/14/12 at 10:12 a.m., RN #124 indicated she thought the RD recommendations went to the DoN (Director of Nurses) and were supposed to be faxed to the physician for any new orders. She indicated she was unable to find any where anything had been done related to the resident's weight loss and the RD recommendations. During an interview on 2/14/12 at 11:50 a.m., the DoN indicated there should be documentation of the physician being notified of the RD recommendations either in the nurses' notes or an order if the physician had given a new order. During an interview on 2/14/12 at 11:54 a.m., the DoN indicated weights were done on admission and monthly unless the RD recommended weights be done more often. She indicated she was aware the resident had lost some weight but not how much. She indicated the resident had lost 3 pounds from January weight to February weight. She indicated she was going to contact the RD and see if she wants the resident on weekly weights. 2. Resident #20's record was reviewed on 2/15/12 at 11 a.m. Resident #20's [DIAGNOSES REDACTED]. A care plan, dated 1/11/12, indicated "Resident at nutrition risk...leaves 25% or more of food uneaten at most meals...Interventions...Administer nutritional supplement as ordered...Provide/monitor intake...Weigh and monitor results..." A Nutrition Assessment and Data Collection form completed by the RD, dated 1/9/12 at 12:15 p.m., indicated the resident's weight on 1/6/12 upon admission to the facility was 163.8 pounds. The assessment indicated "...To met (sic) estimated nutritional needs recommend add 3 oz (ounce) Resource 2.0 tid (three times a day) between meals. Supplement will add 540 kcals/22.5 gms protein/day. If resident consumes supplements & 60% of meals expect nutritional needs to be met..." A physician's orders [REDACTED]. This was 10 days after the dietary recommendation had been made. The resident's January 2012, MAR (Medication Administration Record) indicated the Resource was to be given at 10:30 a.m., 2:00 p.m., and 8 p.m. The resident's February 2012, MAR indicated [REDACTED]. A "Weight Change Report" indicated the resident's weight on 02/02/12 was 250 pounds and on 2/3/12 was 146 pounds. This was a greater than 10% weight loss in less than 1 month. There was a lack of documentation to indicate the residents weight had been obtained since 01/06/12 through 02/02/12. A change in condition form, dated 02/02/12 at 1:10 p.m., indicated the resident had [MEDICAL CONDITION] of the bilateral lower legs, was had received 40 milligrams of [MEDICATION NAME] twice a day. The resident's physician recapitulation orders, dated 02/12, indicated the resident had been receiving [MEDICATION NAME] 40 milligrams twice a day since 01/07/12. There was a lack of documentation in the resident's record of any information of the resident's significant weight loss. During an interview on 2/15/12 at 12:01 p.m., the DoN indicated the only weight she had for the resident other than what was already in the chart was 250 pounds and then a re-weight on 2/3/12 of 146 pounds. During an interview on 2/15/12 at 12:35 p.m., RN #124 indicated she was not able to find anything in the resident's chart related to the weight loss. She indicated there was just the admission weight in the chart. She indicated they had received an order for [REDACTED]. 3. Resident #122's closed record was reviewed on 2/15/12 at 2:25 p.m. Resident #122's [DIAGNOSES REDACTED]. A Nutrition Assessment and Data Collection form completed by the RD, dated 1/9/12 at 1:30 p.m., indicated the resident's weight upon admission on 1/4/12 was 137.4 pounds. The assessment indicated "...Hospital records indicate hx (history) of [MEDICAL CONDITION]- obtain re-weight as admit wt (weight) 137.4 # (pounds). Appears to be weight error..." A care plan, dated 1/11/12, indicated "Resident at nutrition risk...Interventions...Weigh and monitor results..." During an interview on 2/15/12 at 2:55 p.m., the ADoN (Assistant Director of Nurses) indicated she would check to see if she could find where a re-weight had been completed for the resident. During an interview on 2/16/12 at 12:25 p.m., the Corporate Nurse Consultant indicated they were not able to find anything related to the resident being re-weighed. An undated facility policy, titled "Guidelines for Weight Tracking" received, from the DoN as current on 2/15/12 at 9:40 a.m., indicated "...Residents will have their weight taken and recorded upon admission to establish a baseline...The facility dietician will review the resident's nutritional status, ideal body weight, and current weight to implement a nutritional program when warranted....Residents who have a weight that seems out of normal range shall be re-weighed to determine accuracy...The physician, responsible party and dietician shall be notified of a weight variance of > (greater than) 5%..." 4. Resident #9's record was reviewed on 2/15/12 at 11:30 a.m. Resident #9's [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 2/8/12, indicated Resident #9's weight was 96.8 pounds upon admission to the facility. The admission assessment indicated the resident required one assist for eating. The resident's admission orders [REDACTED] A February 2011, physician's orders [REDACTED]. A Nutrition Assessment and Data Collection form, dated 2/8/12, indicated "...FLUID IMBALANCE RISK FACTORS: (checked yes) DIURETIC TX (treatment) [MEDICAL CONDITION]: (checked no)...Recommend d/c (discontinue) Ensure Plus...Begin 3oz (ounces) Resource 2.0 bid (twice a day) between meals...Monitor for signs/symptoms of increase fluid retention, monitor weight, oral intake, healing of incision, available labs...." There was a lack of documentation in the resident's record indicating the Ensure Plus had been discontinued and the Resource 2.0 started. There was a lack of documentation in the resident's record of any further weights on the resident. A physician's orders [REDACTED]. Strategies-cut into small pieces, small bites and sips. no straws, upright position during and 30 min (minutes) p/ (after) intake." The resident had been receiving a mechanical soft diet with nectar thick liquids. There was not a nutritional care plan for the resident documented in the resident's record. Resident #9 was observed on 2/14/12 at 5:47 p.m., receiving a mechanical soft diet with nectar thick liquids during the supper meal. The resident's family member indicated she had been telling the facility for four days the resident was supposed to be receiving a regular diet. The resident's dietary card indicated the resident was to receive a mechanical soft diet. During an interview on 2/15/12 at 11:50 p.m. CNA #90 indicated she had weighed Resident #9 on the scale and the resident weighed 89.4 pounds. CNA #90 indicated the weight she obtained for the resident was accurate. This was a 7.4 pound weight loss since 2/8/12. During an interview on 2/15/12 at 12:25 p.m., the Nurse Consultant indicated she had seen the weight and would tell the DoN (Director of Nursing). She indicated the resident's diet order should have been changed immediately. During an interview on 2/15/12 at 5:58 p.m., the DoN indicated the diet orders should have been changed immediately. An interview on 2/15/12 at 11:05 a.m., the Speech Therapist indicated she knew the family member was upset and told the family member if it happens again to come and see her. The Speech Therapist indicated the order for the diet was in the resident's chart. 3.1-46(a)(1) 3.1-46(a)(2)

Based on record review and interview, the facility failed to monitor residents' PT (pro-time) and INR (international normalized ratio) (laboratory blood clotting test) levels as ordered, which resulted in a resident receiving Vitamin K (given for blood coagulation) due to a critically high PT/INR (Resident #B) and the facility also failed to notify resident's physicians timely of high PT/INR's, which resulted in changes in the resident's [MEDICATION NAME] orders. This affected 3 of 4 residents who received [MEDICATION NAME] in a sample of 4. (Residents #B, #D, and #E) In addition to the residents in immediate jeopardy, the facility failed to monitor a PT and INR for 1 of 2 residents receiving [MEDICATION NAME] in a supplemental sample of 2. (Resident #F) The immediate jeopardy began on 10/10/11 when the facility failed to notify a resident's physician in a timely manner of a high PT/INR, which the physician held the [MEDICATION NAME] for two days, failed to notify two other resident's physicians timely of high PT/INR's and failed to protect the resident from undue adverse medication consequences by not obtaining a PT/INR as ordered by the physician. The Executive Director, Director of Nursing, Corporate RN Consultant, and the Divisional Vice President were notified of the immediate jeopardy at 5:45 p.m. on 10/24/11. The immediate jeopardy was removed on 10/25/11 at 3:50 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident #B's record was reviewed on 10/24/11 at 2:15 p.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted into the facility on [DATE] from the hospital. An admission order, dated 10/08/11 indicated an order for [REDACTED]. A PT/INR result, dated 10/10/11, indicated the resident's PT was high at 36.6 (normal 10-12) and the INR was high at 4 (normal 2-3). The results indicated they had been faxed to the facility on [DATE] at 8:52 a.m. Written on the bottom of the PT/INR results indicated the physician was notified of the results at 2:40 p.m., no date was documented. The writing indicated, "Hold [MEDICATION NAME] x(times) 2 days, then resume @ (at) 2 mg, PT/INR on Mon. 10/17/11." A nurses' note, dated 10/12/11 at 2:40 p.m., indicated, "Spoke c/ (with) (physician's name), informed him abnormal labs. Rec'v (received) new orders..." A physician's telephone order, dated 10/12/11 at 2:40 p.m., which was two days after the facility had been notified of the PT/INR results, indicated, "(1) Hold [MEDICATION NAME] x2 day (sic) (2) then resume [MEDICATION NAME] @ 2 mg daily (3) Draw PT/INR on Mon 10/17/11". The resident's MAR (Medication Administration Record), dated 10/11, indicated the resident received 2.5 mg of [MEDICATION NAME] on 10/10/11 and 10/11/11 at supper and the [MEDICATION NAME] was held on 10/12/11 and 10/13/11. The MAR, dated 10/11, indicated the resident received [MEDICATION NAME] 2 mg daily at supper on 10/14/11, 10/15/11, 10/16/11, and 10/17/11. The MAR, dated 10/11, indicated the resident was scheduled to get a PT/INR on 10/17/11. There were no initials on the MAR indicated [REDACTED]. The resident's record lacked documentation to indicate a PT/INR had been completed on 10/17/11. A PT/INR result, dated 10/18/11, indicated a high PT of 85.5 (normal 10-12) and a critical INR of 10.4 (normal 2-3). A physician's telephone order, dated 10/18/11 at 8:30 a.m., indicated, "(1) Give vitamin K 10 mg IM (intramuscularly) now (2) Repeat PT/INR 10/19/11 (3) Hold [MEDICATION NAME] today" The PT/INR results, dated 10/19/11, indicated a PT at 31.7 and INR at 3.4. During an interview on 10/24/11 at 3:05 p.m., the Corporate RN Consultant indicated the lab company had not drawn the PT/INR on 10/17/11. During an interview on 10/24/11 at 4:15 p.m., the DHS (Director of Health Services) indicated a lab requisition had not been filled out for the PT/INR on 10/17/11. During an interview on 10/24/11 at 4:35 p.m., the DHS indicated the facility had not been aware the PT/INR had not been completed on 10/17/11 until 10/24/11 at 3:05 p.m. A facility policy, dated 11/22/08 and received from the DHS as current, titled, "Lab Tracking Guidelines", indicated, "To facilitate a method of tracking laboratory tests ordered and monitor test has been completed in a timely manner...2. The nursing staff or person designated by the Executive Director or Director of Health Services shall monitor the "Tracking Log" to ensure tests have been completed per the physician's order. 3. When results are received it shall be so noted on the "Tracking Log" with the physician notified of the results..." 2. Resident #D's record was reviewed on 10/24/11 at 11:50 a.m. The resident's [DIAGNOSES REDACTED]. A PT/INR lab result, dated 10/04/11, and faxed to the facility on [DATE] at 7:17 a.m., indicated the resident's physician was notified of the high PT result of 28.7 and INR of 3.1, on 10/05/11 at 2 p.m., which was over 24 hours after the results had been faxed to the facility. A physician's order, dated 09/27/11 at 8 p.m., indicated the resident had received [MEDICATION NAME] 5 mg alternating every day with [MEDICATION NAME] 2.5 mg. A physician's telephone order, dated 10/05/11 at 2 p.m., indicated to discontinue the previous order for [MEDICATION NAME] and to start [MEDICATION NAME] 2.5 mg for two days then [MEDICATION NAME] 5 mg for one day and alternate the doses, and to repeat the PT/INR in 10 days on 10/15/11. There was a lack of documentation to indicate the PT/INR had been completed on 10/15/11 as ordered by the physician. A PT/INR result, dated 10/18/11, indicated a PT of 20.4 and an INR of 2.1. The writing on the bottom of the result form indicated to continue the same dose ([MEDICATION NAME]) and to repeat the PT/INR in two weeks. During an interview on 10/24/11 at 12:15 p.m., RN #1 indicated the PT/INR had not been completed because 10/15/11 was a week-end (Saturday). She indicated there was no physician's order to change the date of the PT/INR. During an interview on 10/24/11 at 1:10 p.m., RN #1 indicated the lab company will do labs on the week-end but they are considered STAT (immediately) and the nurse has to call them. She indicated the nurse had not called the lab to tell them the PT/INR was ordered for 10/15/11. 3. Resident #E's record was reviewed on 10/24/11 at 12:30 p.m. The resident's [DIAGNOSES REDACTED]. A physician's telephone order, dated 10/12/11 indicated an order for [REDACTED]. A PT/INR result, dated 10/17/11, indicated the results were faxed to the facility on [DATE] at 8:15 a.m. The PT/INR results indicated the facility had attempted to notify the resident's physician on 10/17/11 at 1:15 p.m., 2:30 p.m., 7:15 p.m., and 10:15 p.m. of the residents high PT at 33 and INR at 3.6. The form indicated the physician had not responded to the pages. The PT/INR results indicated the physician had been made aware of the PT/INR results on 10/18/11 at 8 a.m. (24 hours later). The physician had wrote on the PT/INR results to see order. A signed physician's order, dated 10/19/11 at 2:20 p.m., indicated to hold the [MEDICATION NAME] 10/19/11 and then to start [MEDICATION NAME] 1 mg daily. The resident's MAR, dated 10/11, indicated the resident had an order for [REDACTED]. A physician's order, dated 10/20/11, indicated to hold the [MEDICATION NAME] for two days and to repeat the PT/INR on Saturday 10/22/11. There was a lack of documentation to indicate the PT/INR had been completed on 10/22/11. During an interview on 10/24/11 at 12:45 p.m., the DoN indicated the PT/INR had not been completed on 10/22/11 as ordered. During an interview on 10/24/11 at 1:10 p.m., RN #1 indicated the nurse had not called the lab company to tell them the PT/INR had been ordered for 10/22/11. The facility policy titled "Physician Notification Guidelines" was received as current from the Executive Director on 10/24/11 at 6:00 p.m.,indicated "...To ensure the resident's physician is aware of all diagnostic testing results or change of condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care...12. If the attending physician does not respond to notification attempts after three phone calls the Medical Director and Director of Health Services should be notified for further instructions." 4. The record for Resident #F was reviewed on 10/25/11 at 9:10 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. A Physician's Order dated 10/7/11, indicated the resident was to receive [MEDICATION NAME] (a blood thinner) 5 milligrams (mg) by mouth daily. The resident did not have any laboratory orders for a PT/INR at the time of admission. The plan of care dated 10/18/11, indicated the resident was at risk for bleeding related to anti-coagulant use and aspirin use. The interventions indicated to provide the anti-coagulant medication as prescribed by the physician, and report lab results to physician and follow physician recommendations for abnormal labs. A Physician's Order dated 10/24/11, indicated the resident was to have a STAT PT/INR. The results were dated 10/24/11 and faxed to the facility at 7:45 p.m. The resident's [MEDICATION NAME] (PT) was high at 58.6. Normal 10-12 seconds. The resident's INR value was critical at 6.8. The physician was notified at 7:50 p.m., and orders were received to hold the [MEDICATION NAME] for two days and repeat the PT/INR on 10/27/11. On 10/27/11, the resident's [MEDICATION NAME] was to be decreased from 5 mg to 3 mg daily. The "Resident Coag Testing Record" located in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with LPN #1 on 10/25/11 at 10:18 a.m., indicated that when a resident was admitted on [MEDICATION NAME], she would notify the physician and ask for PT/INR orders. She further indicated the residents on [MEDICATION NAME] usually have a PT/INR drawn weekly. Interview with the DHS on 10/25/11 at 10:55 a.m., indicated the resident did not have a physician's order for a PT/INR at admission. She indicated the PT/INR drawn on 10/24/11 was the first one that had been drawn since admission. She further indicated the frequency of the lab draw was determined by the physician and that PT/INR's were usually drawn once a week or once every two weeks for residents receiving [MEDICATION NAME]. The immediate jeopardy that began on 10/10/11 was removed on 10/25/11 when the facility had audited the residents' records who received [MEDICATION NAME] for PT/INR's and other laboratory testing. and deficiencies were corrected. The facility obtained orders for PT/INR's for residents who did not have physician's order to monitor. Quality Assurance audits were initiated to monitor PT/INR and other labs to ensure they are completed as ordered, timely physician notification, and changes in resident orders. 28 of 35 nurses had been inserviced and the nurses who had not been inserviced are scheduled to be inserviced prior to reporting for duty. Four nurses were interviewed and they were able to state the facility protocol for lab results, physician notification, and ordering new lab tests. The DHS or her designee will audit all physician orders and labs daily, seven days a week, including [MEDICATION NAME] tracking logs for deficiencies and nurses will be re-inserviced on the [MEDICATION NAME] monitoring process and correct any deficiencies if they are found. Audits will be completed seven days a week for two months, then four times a week for two months, then three times a week for two months. The DHS will report findings to the Quality Assurance Committee monthly for six months. This federal tag relates to complaint IN 705. 3.1-48(a)(3)