Every finding on record at Spring Mill Meadows

Based on interview and record review, the facility failed to ensure care plan meetings were held quarterly, the residents and the residents' representatives were invited to participate, and to develop a comprehensive care plan related to a PICC line (peripherally inserted central catheter) and enhanced barrier precautions for 4 of 20 residents reviewed for care plans. (Resident 40, 57, 5 and 2)Findings include: 1. During an interview, on 7/30/25 at 10:51 a.m., Resident 40 indicated he had not been to a care plan meeting to discuss his care at the facility. The clinical record for Resident 40 was reviewed on 8/5/25 at 1:40 p.m. The diagnoses included, but were not limited to, hypertension, major depressive disorder, and hemiparesis and hemiplegia following unspecified cerebrovascular disease. There was no documentation in the clinical record to indicate Resident 40 had a care plan meeting in 2025. During an interview, on 8/1/25 at 2:21 p.m., Social Service Worker 6 indicated it had been a while since the resident had a care plan meeting. Care plan meetings were supposed to be held every 90 days. The last care meeting for Resident 40 was on 12/26/24. 2. During an interview, on 7/31/25 at 10:48 a.m., Resident 57 indicated she had not been invited to care planning meetings quarterly to discuss her care at the facility. The clinical record for Resident 57 was reviewed on 7/31/25 at 1:39 p.m. The diagnoses included, but were not limited to, major depressive disorder, anxiety disorder, and chronic obstructive pulmonary disease. There was no documentation in the clinical record to indicate Resident 57 had a care plan meeting from 7/2/24 to 3/27/25. A progress note, dated 3/18/25, indicated a care plan meeting would be scheduled for 4/2/25 at 1:30 p.m., in the resident's room. The documented care plan meeting, on 4/2/25 at 1:30 p.m., was not located in the clinical record. During an interview, on 8/1/25 at 2:51 p.m., Social Service Worker 7 indicated care plan meetings would be documented in an observation or progress note. Social Service Worker 7 reviewed the observations and progress notes and indicated the care plan meeting for Resident 57 had not been completed. She completed a care plan meeting with Resident 57 in April (2025) but did not take notes during the meeting or document the care plan meeting in the record. 3. During an observation, on 7/30/25 at 10:57 a.m., Resident 5 had a Foley catheter and a PICC line. The clinical record for Resident 5 was reviewed on 8/4/25 at 2:39 p.m. The diagnoses included, but were not limited to, necrotizing fasciitis, obstructive and reflux uropathy, and urinary retention. A care plan history report, dated 6/24/25 to 7/8/25, indicated Resident 5 had an infection and was currently on IV (intravenous) antibiotics which was discontinued on 7/7/25. A nursing progress note, dated 7/8/25 at 4:12 p.m., indicated Resident 5's PICC line was in place in his right upper arm and without signs of infection. The comprehensive care plans for Resident 5 did not indicate the care plan had been updated since his baseline care plan and did not include his PICC line or enhanced barrier precautions for his Foley catheter. During an interview, on 8/4/25 at 3:31 p.m., the Director of Nursing (DON) indicated she was not sure why the PICC line was discontinued in the comprehensive care plan. The Minimum Data Set (MDS) Coordinator reviewed and managed residents' care plans. During an interview, on 8/5/25 at 10:37 a.m., the MDS Coordinator indicated the PICC line was discontinued from Resident 5's care plan because the resident's antibiotic treatment via the PICC line had ended on 7/5/25 or 7/6/25. When treatments were completed, the care plans would be standardized. There must have been a communication error regarding Resident 5's PICC line. 4. During an observation, on 7/30/25 at 12:30 p.m., Resident 2 had a Foley catheter drainage bad attached to the bed frame and a PICC line in his right upper arm. The clinical record for Resident 2 was reviewed on 8/1/25 at 11:15 a.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy, urethral discharge, and pain. The clinical record indicated Resident 2 was readmitted to the facility, on 6/5/25, from the hospital with a Foley catheter. A physician's order, dated 6/6/25, indicated a Foley catheter was in place. A care plan, dated 6/6/25 and last revised 7/24/25 at 9:21 a.m., indicated Resident 2 required an indwelling urinary catheter related to obstructive uropathy. The care plan did not include enhanced barrier precautions which were required for residents with an indwelling device. During an interview, on 8/4/25 at 3:31 p.m., the DON indicated she was not sure why the care plan did not include enhanced barrier precautions for the Foley catheter. During an interview, on 8/5/25 at 12:26 p.m., the Executive Director indicated the policy titled Comprehensive Care Plan Policy covered care plan meetings. A current facility policy, titled Comprehensive Care Plan Policy, dated as last reviewed in 10/2019 and provided by the Director of Nursing on 8/4/25 at 1:44 p.m., indicated .It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical nursing mental and psychosocial needs. The policy did not cover when care plan meetings were to be held. 3.1-35(a) 3.1-35(b)(1) 3.1-35(c)(1) 3.1-35(c)(2)(A) 3.1-35(c)(2)(C) 3.1-35(c)(2)(C) 3.1-35(d)(2)(B) 3.1-35(e)

Based on observation, interview and record review, the facility failed to ensure Personal Protection Equipment (PPE) was used during care for residents on Enhanced Barrier Precautions (EBP), staff removed soiled gloves after cleaning a catheter line and prior to touching items in a resident's environment, to ensure EBP signage was posted, and to properly store a bed pan for 5 of 5 residents reviewed for infection control. (Resident 67, 81, 6, 2 and 5)Findings include:1. During an observation, on 7/31/25 at 8:10 a.m., a sign was posted outside Resident 67's door to indicate the resident was on EBP precautions. During the observation, LPN 1 was observed to perform hand hygiene and put on clean gloves. She was not observed to put on a gown. LPN 1 attached a piston syringe to the gastrostomy tube, flushed the line with water, administered liquid gabapentin (a medication for neuropathy and/or seizures), flushed the line again, and then reconnected the nutrition line. LPN 1 was not observed to use a gown throughout the procedure. During an interview, on 7/31/25 at 8:22 a.m., LPN 1 indicated EBP required the use of a gown, and she did not use one. The clinical record for Resident 67 was reviewed on 7/31/2025 at 9:42 a.m. Diagnoses included, but were not limited to, gastronomy status, hemiplegia and hemiparalysis following cerebral infraction (stroke), and dysphagia (difficulty swallowing) following a cerebral infraction. A current care plan, dated 8/15/24, indicated Resident 67 was at risk of transferring or becoming colonized with multidrug resistant bacteria (MDRO) due to the use of a gastronomy tube and a history of MDRO. An intervention was to identify through signage and the medical record the use of enhanced barrier precautions. 2. During an observation of catheter care, on 8/4/25 at 11:28 a.m., with CNA 5 and the Infection Preventionist, CNA 5 performed catheter care using the appropriate enhanced barriers. Once CNA 5 had completed cleaning the catheter line, she placed the soiled linen into a bag, placed a brief on the resident, dressed him, and covered the resident up. CNA 5 handled the resident's call light and used the resident's bed controls to adjust the bed. She was not observed to remove her gloves or wash her hands after performing catheter care or prior to handling the call light or the bed controls. During an interview, on 8/4/25 following the observation, the Infection Preventionist indicated CNA 5 should not have handled the resident's call light with the gloves she used to perform catheter care. The clinical record for Resident 81 was reviewed on 8/4/25 at 10:44 a.m. The diagnoses included, but were not limited to, muscle weakness, cognitive communication deficient, and difficulty walking. A care plan intervention, dated 5/15/25, indicated .Use standard precautions including hand hygiene. 3. During an observation, on 8/1/25 at 1:45 p.m., the door to Resident 6's room was closed, a green EBP sign was posted to the left of the door, above Resident 6's room number. The surveyor knocked on the door and Qualified Medication Aide (QMA) 12 opened the door and indicated she was providing patient care. QMA 12 was observed to be wearing blue gloves but was not observed wearing a gown (PPE). During an interview, on 8/1/25 at 1:55 p.m., QMA 12 indicated she was providing incontinent care for Resident 6. She indicated she knew Resident 6 was in EBP but forgot to put the proper PPE on (gown) and was only wearing gloves. The clinical record for Resident 6 was reviewed on 8/1/25 at 1:29 p.m. The diagnoses included, but were not limited to, respiratory failure, tracheostomy status, and gastrostomy status. A care plan, dated as last revised on 7/31/25 at 9:54 a.m., indicated Resident 6 was at risk of transferring or becoming colonized with an MDRO (multidrug resistant organism) and required enhanced barrier precautions due to an indwelling medical device with an approach to wear gown and gloves prior to high contact resident care activities. A physician's order for EBP could not be found in the record. 4. During an observation, on 7/30/25 at12:30 p.m., Resident 2 had a Foley catheter drainage bag attached to the bed frame and a PICC (peripherally inserted central catheter) in his right upper arm. EBP/PPE signage was not observed outside or inside Resident 2's room. During an observation and interview, on 7/31/25 at 8:54 a.m., EBP signage was not found outside or inside Resident 2's room. Resident 2 indicated staff did not wear gowns while providing personal care to him. During an interview, on 7/31/25 at 9:02 a.m., Social Service Worker 7 indicated Resident 2 was in enhanced barrier precautions and would have a green sign outside his room labeled EBP as well as a sign located inside the room which demonstrated the proper PPE equipment needed with instructions on when the PPE would need to be utilized. She indicated she did not see any EBP signage. During an interview, on 7/31/25 at 9:04 a.m., CNA 8 indicated EBP would be used for a resident with wounds, a urinary catheter, and/or an IV (intravenous catheter). The clinical record for Resident 2 was reviewed on 8/1/25 at 11:15 a.m. The diagnoses included, but were not limited to, acute cystitis (microscopic blood in the urine), obstructive and reflux uropathy, and urethral discharge. A care plan, dated as last revised 7/24/25 at 9:21 a.m., did not include the need of EBP related to his Foley catheter and PICC line. A physician's order for EBP was not located in the record. 5. During an observation and interview, on 7/30/25 at 11:10 a.m., Resident 5 indicated staff did not wear gowns while providing care for him. EBP/PPE signage was not observed outside or inside Resident 5's room. During an observation and interview, on 8/4/25 at 10:13 a.m., Resident 5 had an unbagged bed pan sitting on his bedside table next to a box of cookies. Resident 5 indicated his call light was on because he wanted someone to clean his bedside table off and wipe it down with a rag. He last used the bed pan the night before, during 3rd shift, and was not sure why the bed pan was on his bedside table. During an interview, on 8/5/25 at 10:14 a.m., Unit Manager 9 indicated he was not sure why the bed pan was on the bedside table, and it should not be there. The clinical record for Resident 5 was reviewed on 8/4/25 at 2:39 p.m. The diagnoses included, but were not limited to, necrotizing fasciitis, obstructive and reflux uropathy, and retention of urine. A care plan, dated as last revised 7/7/25 at 9:47 a.m., did not include the need of EBP related to his Foley catheter and PICC line. During an interview, on 8/4/25 at 3:31 p.m., the Director of Nursing (DON) indicated Resident 5 was admitted with the Foley catheter and PICC line in place, both which required the resident to be placed in EBP. A current facility policy, titled Enhanced Barrier Precautions (EBP) Education, undated and received from the DON on 8/1/25 at 10:40 a.m., indicated .Before providing care to a resident with Enhanced Barrier Precautions (EBP) .Correctly put on gown and gloves .Gown before gloves A current facility skill competency, titled Catheter Care (Urinary), dated as last revised 6/25 and received from the Infection Preventionist on 8/4/25 at 11:50 a.m., indicated .Remove gloves .Perform hand hygiene A current facility policy, titled Nursing Department Infection Control, dated as last revised 12/2024 and received from the DON on 8/4/25 at 9:01 a.m., indicated .To ensure that resident(s) are is provided in a safe and sanitary manner to prevent the spread of infection.The nursing staff shall follow infection control guidelines to prevent the spread of infection.Bedside personal equipment, such as.bedpan, shall be maintained in a sanitary condition. This shall include.storing equipment in a way that prevents cross contamination.place clean/disinfected equipment in a clean plastic bag. 3.1-18(b) 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team (IDT) determined that a resident was safe to self-administer medications and to obtain a physician's order for self-administration for 1 of 1 resident reviewed for self-administration of medication. (Resident 57)Findings include:During an observation and interview, on 7/31/25 at 2:59 p.m., Resident 57 had 2 respiratory inhalers on her bed. Resident 57 indicated her inhalers had been at bedside with her for a long time and she kept the inhalers within arm's reach, either on her bed or in her bedside table drawer.During an observation and interview, on 8/1/25 at 8:55 a.m., Resident 57 had 3 respiratory inhalers with her at bedside. Resident 57 indicated she self-administered the medications, and the nurse would bring her replacements when the medications were empty.At bedside the 3 respiratory inhalers were:1. Spiriva 1.25 mcg (microgram), dated 5/20/25, with instructions to discard by 8/9/25.2. Albuterol rescue inhaler with 15 doses remaining.3. Breo Ellipta, dated 5/21/25, with 18 out of 30 doses remaining. The clinical record for Resident 57 was reviewed on 7/31/25 at 1:39 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, shortness of breath, and anxiety disorder.A care plan, dated 3/24/25, indicated Resident 57 self-administered her medications although she had no order to self-administer, would seek outside sources for medication, and administer the medication herself.A care plan, dated 7/29/25, indicated Resident 57 exhibited cognitive impairment in which her cognition shifted between intact and moderately impaired.A care plan, dated 7/31/25, indicated Resident 57 chose to self-administer medications. The resident preferred to take her oral medication at her leisure with a preference of the nurse to leave her medication at the bedside table. The approach to this care plan was for the facility to complete a medication self-administration request/evaluation.A nursing progress note, dated 5/21/25, indicated that while cleaning Resident 57's room multiple inhalers and breathing treatment vials were found. Some of the medications found contained labels different than the facility's pharmacy label.The physician's orders included, but were not limited to,1. Spiriva Respimat 1.25 mcg, with instructions to inhale 2 puffs, once a day.2. A physician's order for the Albuterol inhaler was not located in the medical record.3. Breo Ellipta 200-25 mcg/dose, with instructions to inhale 1 puff daily, rinse mouth with water after, and spit out. A physician's order for Resident 57 to self-administer medication was not located in the medical record.An IDT evaluation which included the medications appropriate and safe for self-administration, the resident's physical capacity, the resident's cognitive status, the resident's capability to follow directions and know when medications needed to be taken, the resident's comprehension of instructions for the medications including the dose, timing, and signs of side effects, and the ability to ensure medication was stored safely and securely for Resident 57 to self-administer medication was not located in the medical record.During an interview, on 7/31/25 at 2:50 p.m., the Director of Nursing (DON) indicated in the past Resident 57 used to self-administer her respiratory medications and had a self-administration evaluation. Resident 57 had experienced a change in cognition, and the self-administration was removed.A current facility policy, titled Self-Administration of Medications, dated as last revised 1/2015 and received from the DON on 8/4/25 at 9:01 a.m., indicated .It is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed medications, as allowable under state regulations. The facility will provide instruction for all residents choosing to and capable of self-administration.If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the [ Self-Administration of Medication Assessment] observation.A physician order will be obtained specifying the resident's ability to self-administer medications and, if necessary, listing which medications will be included in the self-administration plan.The licensed nurse will instruct the resident regarding proper administration of medication.Storage of self-administrated medications will comply with state and federal regulations. All bedside medications will be maintained in a secured location in the resident's room.The resident's care plan will be updated to include self-administration.3.1-11(a)

Based on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was signed by the resident or resident's representative for 1 of 3 residents reviewed for beneficiary notices. (Resident 68)Findings include:The beneficiary notices were reviewed on 8/4/25 at 3:00 p.m.A NOMNC document indicated the skilled services for Resident 68 would end on 6/16/25. The document indicated to sign to show you received, understood the notice, and was notified the service coverage would end on the date of the notice. The decision could be appealed by contacting the Quality Improvement Organization (QIO).The signature section was dated 6/13/25 and the signature of the patient or representative was blank and indicated Resident 68 was unable to sign due to their cognition.There was no documentation to indicate anyone had signed on behalf of Resident 68 to show they received and understood the notice of non-coverage.During an interview, on 8/4/25 at 3:35 p.m., the Executive Director (ED) indicated Resident 68 could not sign the NOMNC due to their cognition. She was not sure why it was not signed and if the resident could not sign it, then the representative would sign it. During an interview, on 8/04/25 at 4:05 p.m., the ED indicated the NOMNC was not signed by the resident or representative.The facility did not provide a beneficiary notices policy by the time of exit.3.1-4(f)(3)

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was updated when new diagnoses or psychotropic medications were added for 2 of 2 residents reviewed for PASARR. (Residents 3 and 79)Findings include:1. The clinical record for Resident 3 was reviewed on 7/31/25 at 2:51 p.m. The diagnoses included, but were not limited to, Alzheimer's disease with late onset, anxiety disorder, and major depressive disorder.A PASARR level I screen, dated 10/30/23, indicated Resident 3 did not have a diagnosis of dementia or neurocognitive disorder and was not taking donepezil or memantine. It indicated if changes occurred, a new screen must be submitted.A neurobehavior status exam note, dated 11/27/24, indicated Resident 3 displayed severe cognitive impairment on the brief cognitive assessment with impaired memory performance. Resident 3's history, symptoms, and current presentation appeared consistent with dementia with an etiology likely related to Alzheimer's disease. The established diagnosis list included late onset Alzheimer's disease and moderate dementia with mood disturbance.A physician's order, dated 12/5/24, indicated to give donepezil (a medication used to treat cognitive symptoms associated with Alzheimer's disease) 5 milligrams (mg) at bedtime.A behavioral health progress note, dated 12/11/24, indicated to increase donepezil from 5 mg to 10 mg for the diagnosis of Alzheimer's disease.A physician's order, dated 12/19/24, indicated to increase donepezil from 5 mg to 10 mg at bedtime.A current physician's order, dated 12/23/24, indicated to give donepezil 10 mg at bedtime.A psychiatry progress note, dated 1/2/25, indicated to start memantine (a medication used to treat moderate to severe Alzheimer's disease) 5 mg for diagnosis of Alzheimer's disease.A physician's order, dated 1/3/25, indicated to give memantine 5 mg once a day.A psychiatry progress note, dated 2/7/25, indicated the resident had no history of dementia on the PASARR and had current medications of donepezil and memantine.A physician's order, dated 2/7/25, indicated to increase the memantine to 5 mg twice a day.A significant change in status minimum data set assessment, dated 2/12/25, indicated the resident had a new diagnosis of Alzheimer's disease.A current physician's order, dated 3/7/25, indicated to give memantine 10 mg twice a day.A current physician's order, dated 5/1/25, indicated to increase sertraline (an antidepressant medication) from 50 mg to 75 mg per day.A care plan, dated 5/16/25, indicated Resident 3 required a dressing and grooming program related to Alzheimer's disease which started on 2/24/25.A psychiatry consult note, dated 6/17/25, indicated the resident's PASARR showed no history of dementia and late onset Alzheimer's disease and moderate dementia with mood disturbance was on her current diagnosis list.During an interview, on 8/5/25 at 10:16 a.m., Social Services 7 indicated a PASARR update should have been completed after the new diagnosis of Alzheimer's disease was determined and with any new medications or increased doses. 2. The clinical record for Resident 79 was reviewed on 8/1/25 at 9:15 a.m. The diagnoses included, but were not limited to, anxiety disorder, major depressive disorder without psychotic features, insomnia, depression, and adult failure to thrive.A PASARR level I, dated 6/30/25, indicated the resident had taken alprazolam (a medication used to treat anxiety) within the past six months but it had been discontinued. It did not indicate the resident was currently taking any psychotropic medications. It indicated if changes occurred or new information refuted these findings, a new screen must be submitted.A hospital Discharge summary, dated [DATE], indicated the resident was to continue to take alprazolam 1 milligram (mg) as needed and duloxetine (an antidepressant medication) 60 mg once a day.A physician's order, dated 7/3/25, indicated to give duloxetine 60 mg once a day and alprazolam 1 mg at bedtime as needed.A social service progress note, dated 7/8/25, indicated Resident 79's PASARR Level I was checked for accuracy.A physician's order, dated 7/11/25, indicated to give alprazolam 1 mg three times a day.A social services progress note, dated 7/12/25, indicated the resident expressed signs of suicidal ideation with thoughts of harming herself and a plan of action.A physician's order, dated 7/14/25, indicated to give bupropion (an antianxiety medication) 150 mg twice a day.A physician's progress note, dated 7/15/25, indicated Resident 79 had continued duloxetine and alprazolam as needed on 7/7/25, but then on 7/15/25 alprazolam had changed from as needed to routinely three times a day and Resident 79 was started on bupropion for worsening depression and anxiety.During an interview, on 8/5/25 at 10:28 a.m., Social Services 6 and 7 indicated they thought Resident 79 was admitted on only 1 psychotropic medication and the admission PASARR had been accurate. Social Services 7 indicated all admission medications should have been on the PASARR, or a new one should have been completed immediately. Resident 79's depression and anxiety had increased during her stay, so medications had been increased and added. The resident had expressed the intent to stab herself with a knife at breakfast on 7/12/25.A current facility policy, titled PASRR Policy, dated 11/17 and provided by the Director of Nursing on 8/1/25 at 2:30 p.m., indicated .PASRR assessments are updated with significant changes in mental and physical status.3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission and included enhanced barrier precautions for 2 of 4 residents reviewed for baseline care plans. (Resident 5 and 79) Findings include: 1. During an observation, on 7/30/25 at 10:57 a.m., Resident 5 was lying in bed with a Foley catheter drainage bag attached to the bed frame and a PICC line (peripherally inserted central catheter used for medication administration and blood draws) was in his right arm. The clinical record for Resident 5 was reviewed on 8/4/25 at 2:39 p.m. The diagnoses included, but were not limited to, necrotizing fasciitis, obstructive and reflux uropathy, and urinary retention. A nursing progress note, dated 6/24/25, indicated Resident 5 was admitted to the facility by ambulance. An assessment was obtained by the staff, which included, but were not limited to, a PICC line in the right upper extremity and a Foley catheter in place. A physician's order, dated 6/24/25, indicated to monitor the PICC line site daily for warmth, redness or swelling. A physician's order, dated 7/18/25, indicated Resident 5 had a Foley catheter. A baseline care plan history report, dated 6/24/25 to 7/8/25, indicated Resident 5 had an infection and was currently on IV (intravenous) antibiotic therapy. A baseline care plan history report, dated 6/24/25 to 7/8/25, indicated Resident 5 required assistance with his ADLs (activities of daily living), which included, but were not limited to, Resident 5 had a Foley catheter. The baseline care plan did not include enhanced barrier precautions, which were required for a resident with an indwelling device. During an interview, on 8/4/25 at 3:31 p.m., the Director of Nursing (DON) indicated Resident 5 was admitted to the facility from the hospital with the PICC line and Foley catheter in place. She was not sure why the baseline care plan did not include enhanced barrier precautions. 2. The clinical record for Resident 79 was reviewed on 8/1/25 at 9:15 a.m. The diagnoses included, but were not limited to, anemia, anxiety disorder, major depressive disorder without psychotic features, chronic obstructive pulmonary disease, emphysema, insomnia, weakness, adult failure to thrive, age-related osteoporosis, and pain. A nursing progress note, dated 7/3/25 at 3:12 p.m., indicated the resident was admitted to the facility from the hospital. A physician's order, dated 7/3/25, indicated to give duloxetine (an antidepressant medication) 60 milligrams (mg) once a day. A care plan history report, dated 7/3/25 to 8/4/25, indicated the baseline care plan was started on 7/7/25. During an interview, on 8/5/25 at 10:47 a.m., the Clinical Support Nurse indicated the baseline care plan should have been completed within 48 hours by 7/5/25. During an interview, on 8/5/25 at 10:50 a.m., Social Services 6 and 7 indicated the Minimum Data Set (MDS) Coordinator typically created the baseline care plan. Since Resident 79 admitted after the MDS Coordinator was gone for the day 3-day holiday weekend, it did not get completed until she returned on Monday, 7/7/25. A current facility policy, titled IDT Baseline Care Plan, dated 4/2023 and received from the Director of Nursing (DON) on 8/5/25 at 12:20 p.m., indicated .Baseline Care Plan will be . initiated within 48 hours of admission to the facility .Baseline Care Plan will include, but not limited to the following.The instructions needed to provide effective and person-centered care that meets professional standards of quality care; The resident's immediate health and safety needs; Physician's orders .Baseline Care Plan interventions/changes impacting care provided by CNAs will be available to CNAs via resident profile 3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure physician's orders were followed related to obtaining and documenting weekly weights following an admission and to notify the physician when a bladder scan showed greater than 400 milliliters for 2 of 2 residents reviewed for quality of care. (Resident 5 and 11)Findings include:1. During an interview, on 7/30/25 at 11:05 a.m., Resident 5 indicated he did not eat every meal and believed he had lost weight but was not sure how much weight he had lost. The clinical record for Resident 5 was reviewed on 8/4/25 at 2:39 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, depression, and morbid obesity due to excess calories. A physician's order, with a start date of 6/24/25 and an end date of 7/22/25, indicated Resident 5 was to be weighed weekly for 4 weeks. A care plan, dated 6/30/25, indicated Resident 5 presented with nutritional concerns, which included, but were not limited to, weight fluctuations related to diuretic therapy. The goal was to maintain the current weight without significant weight changes in the next 30 days. The documented weights recorded by the facility for Resident 5 in the vitals tab of the electronic health record indicated Resident 5 had only been weighed twice since his admission on [DATE]. The Treatment Administration Record (TAR), from 6/24/25 to 7/22/25, did not contain documented weights for the 4 weeks on admission according to the physician's order. During an interview, on 8/5/25 at 1:35 p.m., the Director of Nursing (DON) indicated weights would be documented in the vitals tab. She reviewed the electronic health record (EHR) and indicated the weights were not obtained. The staff should have obtained and documented the weights according to the physician's order. 2. The clinical record for Resident 11 was reviewed on 8/1/25 at 9:25 a.m. The diagnoses included, but were not limited to, complete paraplegia (complete loss of movement to the lower limbs), hemiplegia (complete paralysis on one side of the body), and hemiparesis (weakness on one side of the body). A physician's order, with a start date of 5/16/25, indicated to complete bladder scans every 6 hours on each shift and to call the physician if there was greater than 400 milliliters (ml). A Treatment Administration Record (TAR) indicated the following bladder scans were above 400 ml with no notification to the physician: a. On 7/4/25, at 6:00 a.m., the scan was 600 ml. b. On 7/9/25, at 12:00 a.m., the scan was 600 ml. c. On 7/9/25, at 12:00 p.m., the scan was 500 ml. d. On 7/13/25, at 12:00 p.m., the scan was 500 ml. e. On 7/17/25, at 6:00 p.m., the scan was 451 ml. f. On 7/23/25, at 12:00 a.m., the scan was 600 ml. g. On 7/23/25, at 6:00 a.m., the scan was 600 ml. h. On 7/25/25, at 12:00 a.m., the scan was 500 ml. i. On 7/25/25, at 6:00 a.m., the scan was 500 ml. j. On 7/27/25, at 12:00 a.m., the scan was 500 ml. k. On 7/27/25, at 6:00 a.m., the scan was 500 ml. l. On 7/28/25, at 12:00 a.m., the scan was 500 ml. m. On 7/28/25, at 6:00 a.m., the scan was 500 ml. n. On 7/28/25, at 6:00 p.m., the scan was 500 ml. During an interview, on 8/1/25 at 10:30 a.m., Registered Nurse 16 indicated notification to the physician would be documented in the progress notes. During an interview, on 8/1/25 at 3:50 p.m., the Director of Nursing (DON) indicated she was unsure about the physician's order and would need check on it. During an interview, on 8/5/25 at 10:29 a.m., the DON indicated the order was discontinued. The physician wanted the order discontinued and the order should have been discontinued after 72 hours. A current facility policy, titled Resident Change of Condition, dated as last revised on 4/2023 and received from the Clinical Support Nurse on 8/5/25 at 1:50 p.m., indicated .The nurse in charge is responsible for notification of the physician.prior to the end of assigned shift when a significant change in the resident's condition is noted.Document resident change of condition and response on the Progress Notes and continue in the nursing progress notes if necessary. Documentation will include time and family/physician response. The facility did not provide a following physician's orders policy by the time of exit. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a physician's order for the use of oxygen was prescribed for 1 of 3 residents reviewed for respiratory care. (Resident 16)Findings include:During an observation, on 7/30/25 at 12:35 p.m., Resident 16 was wearing oxygen which was set on 4.5 L (liters per minute).During an observation, on 7/31/25 at 10:34 a.m., Resident 16 was wearing oxygen which was set on 5 L.The clinical record for Resident 16 was reviewed on 7/31/25 at 2:25 p.m. The diagnoses included, but were not limited to, edema, moderate persistent asthma, and shortness of breath.A care plan, dated 6/19/25, indicated the resident had the potential for impaired gas exchange related to asthma. Interventions included, but were not limited to, administer oxygen as ordered.There was no physician's order for the use of oxygen, the type of oxygen delivery system, when to administer (such as continuous or intermittent and/or when to discontinue), the prescribed flow rates, or when to monitor SpO2 levels and vital signs located in the medical record.During an interview, on 7/31/25 at 2:30 p.m., Registered Nurse (RN) 16 indicated she could not locate a physician's order for oxygen and there should be an order.During an interview, on 8/05/25 at 1:53 p.m., the Clinical Support Nurse indicated the medication administration policy was what they used for the oxygen order policy. The facility treated oxygen like a medication. A current facility policy, titled Medication Administration (Medication Pass Procedure), dated as last revised on 4/2025 and received from the Director of Nursing on 8/1/25 at 10:40 a.m., indicated .The 5 rights of medication performed: Right Resident, Right Medication, Right Dose, Right Route, Right Time. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the attending physician documented in the resident's medical record the rationale for not acting upon a pharmacist's recommendations for 1 of 5 residents reviewed for drug regimen review. (Resident 57) Findings include:The clinical record for Resident 57 was reviewed on 7/31/25 at 1:39 p.m. The diagnoses included, but were not limited to, dementia, major depressive disorder, and chronic pain syndrome.The monthly drug regimen reviews, for Resident 57, indicated the following:1. A recommendation, dated 8/27/24, indicated discontinue the lispro (insulin) sliding scale and relax A1C range. Closely monitor glucose levels with any change in diabetic therapy to guide further adjustments. The recommendation was declined by the physician without a rationale.2. a. A recommendation, dated 10/30/24, indicated to attempt a gradual dose reduction to hydroxyzine (an antihistamine sometimes used to treat anxiety) times 14 days and then discontinue. The facility did not provide the section of the document with the physician's signature to indicate whether the recommendation was accepted or declined.b. A recommendation, dated 2/21/25, indicate to discontinue hydroxyzine. The resident had an order for duloxetine (an antidepressant and antianxiety medication). If anxiety persists, consider buspirone (an antianxiety). The physician signed the recommendation but did not indicate whether the recommendation was accepted or declined.3. a. A recommendation, dated 10/30/24, indicated to discontinue meloxicam (a non-steroidal anti-inflammatory medication for pain) and initiate acetaminophen 500 mg, 2 tabs two times a day. The resident also received morphine immediate release 7.5 mg tabs, two times a day. The recommendation was declined by the physician without a rationale.b. A recommendation, dated 1/28/25, indicated to discontinue meloxicam and initiate acetaminophen 500 mg, 2 tabs two times a day. The resident also received morphine immediate release 7.5 mg tabs, two times a day. The recommendation was declined by the physician without a rationale.c. A recommendation, dated 4/29/25, indicated to discontinue meloxicam and initiate acetaminophen 500 mg (milligram), 2 tabs two times a day. The resident also received morphine immediate release 7.5 mg tabs, two times a day. The recommendation was declined by the physician without a rationale.4. a. A recommendation, dated 2/21/25, indicated to consider discontinuing docusate (for constipation) for insufficient quality evidence to support the effectiveness of docusate. If a routine laxative was deemed necessary, to initiate Miralax. The recommendation was declined by the physician without a rationale.b. A recommendation, dated 4/29/25, indicated consider discontinuing docusate for insufficient quality evidence to support the effectiveness of docusate, if a routine laxative was deemed necessary, to initiate Miralax. The recommendation was declined by the physician without a rationale.During an interview, on 8/4/25 at 10:08 a.m., the Director of Nursing (DON) indicated not all the facility's physicians included a rationale on the drug regimen reviews when they were declined.The facility did not provide any rationales for the declined drug regimen reviews prior to the survey exit date.The current facility policy, titled Medication Regimen Reviews and Pharmacy Recommendations, dated as last revised on 10/2018 and received from the DON, did not include the need for physicians to include a rationale when a recommendation made by the pharmacist was declined.3.1-25(i)

Based on observation, interview and record review, the facility failed to ensure two tuberculin bottles, containing solution, had been labeled with an open date and a medication had a legible label for 1 of 3 medication storage refrigerators reviewed for medication storage. (PACU medication refrigerator)Findings include: During an observation with the Director of Nursing, on 8/1/25 at 11:20 a.m., the PACU medication storage refrigerator was found to contain a liquid medication with a dried crusty substance on the bottle and label. The label was not legible. Also found in the refrigerator were two open bottles of tuberculin which contained solution and did not have an open date.During an interview, on 8/1/25 at 11:22 a.m., the Director of Nursing indicated the bottles should have been labeled when open and then the solution was good for 30 days. A current facility policy, titled Medication Storage and Expiration Policy, dated 11/24 and received from the Director of Nursing on 8/4/25 at 2:35 p.m., indicated .Facility staff should record the date opened on the primary medication container .when the medication has a shortened expiration date once opened .Facility should destroy and reorder medications with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions 3.1-25(k)(6)

Based on observation and interview, the facility failed to ensure refrigerator temperatures were monitored and documented to maintain proper temperatures and to discard food before the expiration date for 1 of 2 refrigerators reviewed for food storage. (the reach-in cooler)Findings include:1. During an observation, on 7/30/25 at 9:55 a.m., a foul odor was noted inside the reach-in cooler, upon opening the door. There were 2 thermometers located inside the reach-in cooler, both read 54 degrees.2. During a second observation, on 7/30/25 at 9:59 a.m., both thermometers in the reach-in cooler again read 54 degrees.The reach-in cooler temperature document, titled Equipment Temperature Monitoring, located on the front of the reach in cooler lacked recorded temperatures on 7/29/25 and 7/30/25. It was observed to have a documented time of 2:00 p.m. but lacked documentation of the temperature inside the reach-in cooler. It was also missing a time and temperature on 7/30/25.Items observed inside the reach-in cooler included, but were not limited to, milk, juice, prepped side salads, and a stick of butter with a discard date of 7/27/25.During an interview, on 7/30/25 at 9:55 a.m., [NAME] 14 indicated an odor was present when the door was opened and the door had been opened recently while staff put items inside the cooler.During an interview, on 8/1/25 at 12:35 p.m., the Kitchen Manager indicated the cooler must have stopped working sometime during the night of 7/29/25 because during the previous shift, the temperature inside the cooler was normal.A current facility policy, titled Food Storage, dated as last revised 5/24 and received from the Executive Director on 7/30/25 at 10:19 a.m., indicated .Food is stored at an appropriate temperature and by methods designed to prevent contamination .Food items that are not considered potentially hazardous.will be labeled when opened and, to ensure quality, used or disposed of within 90 days of opening or per the use-by-date, whichever comes first.Temperatures for refrigerators should be <41 degrees Fahrenheit.Thermometers should be checked utilizing an internal thermometer at least two times each day. Temperatures should be recorded prior to breakfast preparation and again prior to dinner service.If temperature of refrigerator is above 40 degrees F, take food temperatures of item(s) stored within.3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a staff member followed the facility policy and procedure related to the use of a gait belt during a transfer which resulted in a resident fall for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in an abrasion on the resident's forehead and a fracture of the right femur. The deficient practice was corrected on 5/5/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: During a telephone interview, on 5/27/25 at 8:47 a.m., Resident B's family indicated the resident was a fall risk. He was in the hall, heard a thump, and entered to find the resident on the floor. The resident had blood coming from her head. The CNA did not have a gait belt. He told the facility to call the paramedics. He indicated the resident sustained a right femur fracture (broken bone in the upper leg) and had emergency surgery the following day. The clinical record for Resident B was reviewed on 5/27/25 at 9:15 a.m. The diagnoses included, but were not limited to, muscle weakness, chronic respiratory failure, and chronic kidney disease with heart failure. A fall risk assessment, dated 4/1/25, indicated Resident B was at a high fall risk. A care plan, dated 4/2/25, indicated Resident B was a new admission and required implementation of services. An intervention, dated 4/2/25, indicated to provide fall prevention interventions. A physician's order, dated 4/23/25, indicated the resident could get up when she wanted with assistance of a staff member. A Minimum Data Set (MDS) assessment, dated 4/29/25, indicated Resident B required substantial/maximal assistance to transfer from sitting to standing and was cognitively intact. A facility falls event document, dated 5/4/25, indicated Resident B had a witnessed fall. The resident hit her head, said her head hurt, and it was decided the resident needed to go to the emergency room for further evaluation. The CNA was transferring the resident from the bed to the wheelchair and the resident fell backwards. A hospital emergency room note, dated 5/4/25 at 4:08 p.m., indicated Resident B presented to the emergency department. The resident's son was present and indicated he knocked on the resident's door at the facility, heard a loud thump from the resident's room, entered, and observed his mother on the floor with the aid standing there. He told the emergency room staff the CNA was transferring his mother to the wheelchair, slipped, and dropped her. The resident had sustained an abrasion to the right side of the forehead and the right leg was resting in an external rotation. A radiology report, dated 5/4/25, indicated Resident B had sustained a nondisplaced intertrochanteric fracture of the proximal right femur. A facility document, titled Approaches on Profile, undated, indicated Resident B was an assistant of 1 person with transfers. A facility document, titled Employee Communication Form, indicated, on 5/4/25, CNA 2 failed to use a gait belt during a transfer which resulted in a fall with injury. CNA 2 was aware all transfers required the use of a gait belt if a mechanical lift was not used. The document was signed by CNA 2 and the Director of Nursing on 5/4/25 and by the Executive Director on 5/5/25. During an interview, on 5/27/25 at 10:15 a.m., the Director of Therapy indicated Resident B's therapy evaluation indicated a stand assist of one (1), standing pivot transfer with a gait belt on. During a telephone interview, on 5/27/25 at 10:56 a.m., CNA 2 indicated Resident B had experienced loose stools all day. The resident wanted to get up and go to the bathroom. The wheelchair was present at the side of the bed. The resident stood up and CNA 2 was holding the resident's pants. The resident fell back onto her side. CNA 2 indicated the resident had a small amount of blood from the right temple area. The resident was a one person transfer per care sheet (a sheet which told the interventions/needs the resident required). CNA 2 indicated she did not have a gait belt on Resident B and there were no care sheets available that day or the day prior. The facility had a policy to use gait belts and told staff to use gait belts. The resident's family member was at the facility when the incident occurred. During an interview, on 5/27/25 at 12:19 p.m., the Director of Nursing indicated the use of a gait belt was standard and CNA 2 should have used a gait belt. Gait belts were provided upon hire as part of the uniform. During an interview, on 5/28/25 at 9:56 a.m., CNA 3 indicated gait belts were to be used anytime a resident needed to stand/transfer if they did not require a mechanical lift. During an interview, on 5/28/25 at 9:49 a.m., RN 4 indicated a gait belt should be used anytime a resident needed to be transferred. During an interview, on 5/28/25 at 9:48 a.m., CNA 5 indicated the gait belt was to be used anytime staff helped a resident transfer. A facility document, titled Nurse Aide/Certified Nurse Aide Job Specific Orientation Plan, dated as completed 6/24/24 and received from the Director of Nursing on 5/28/25 at 9:50 a.m., indicated CNA 2 had completed her CNA training including, but not limited to, .Gait belt policy/Proper body mechanics A current facility procedure, titled Transfer to Wheelchair, dated as last reviewed in 9/2023 and received from the Director of Nursing on 5/27/25 at 12:10 p.m., indicated .Procedure Steps .place gait belt around resident's waist .Grasp belt securely on both sides .Help resident to pivot to front of wheelchair .remove gait belt A current facility policy, titled Gait Belts, dated 2/20/20 and received from the Director of Nursing on 5/27/25 at 12:19 p.m., indicated .Use of gait belts serves to reduce the risk of injury to patient/resident as well as to staff members .It is the policy for all Therapy and Wellness staff to utilize gait belts to assist patients who are not independent with transfers and ambulation .Failure to comply will result in disciplinary action and may lead to termination The deficient practice was corrected by 5/5/25 after the facility implemented a systemic plan which included an investigation, education on gait belt use, and audits were initiated for other residents and for ensuring staff had and were using gait belts. This citation relates to Complaint IN00458980. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident received a medication for cancer as ordered, follow-up appointments with an oncologist were scheduled, and the facility's medical director did not discontinue a medication without consulting with the resident's oncologist for 1 of 2 residents reviewed for quality of care. (Resident B) This deficient practice resulted in Resident B having no follow-up oncology care to prevent further spread of the metastasis to the bone related to his prostate cancer. Findings include: An email, dated 1/16/25, indicated there were concerns with Resident B's treatment plan for his metastatic prostate cancer. In February 2023, the resident was placed on docetaxel (chemotherapy) and Nubeqa (a hormone therapy medication used to treat prostate cancer) at the cancer center. In April 2023, his pain was much improved, and his prostate-specific antigen had dropped which indicated the treatment was working well. In September 2023, Resident B continued to receive treatment, and his cancer medications were being provided/covered by the specialty pharmacy. In October 2023, the resident was admitted to the long-term care nursing facility. The clinical record for Resident B was reviewed on 2/11/25 at 2:30 p.m. The diagnoses included, but were not limited to, malignant neoplasm of prostate gland, post traumatic seizures, atrial fibrillation, and systolic heart failure. A hospital document, titled After Visit Summary, dated 10/9/23, indicated the resident was being discharged to a long-term care facility and to schedule a follow-up with oncology related to a cancer diagnosis. A nursing progress note, dated 10/9/23 at 9:56 p.m., indicated the resident was admitted to the facility. The physician on call verified the resident's admission orders, the pharmacy was aware of the orders and the medications which needed sent to the facility. A physician's order, dated 10/9/23, indicated to start Nubeqa (darolutamide) 600 mg (milligram) orally twice a day on 10/10/23 for a diagnosis of malignant neoplasm of the prostate. The order indicated it was a telephone order taken by LPN 1. A nursing progress note, dated 10/11/23 at 3:53 p.m., indicated LPN 2 notified the pharmacy the resident's Nubeqa was missing. The pharmacy technician indicated a script was needed from the physician for the medication. LPN 2 notified the nurse practitioner Nubeqa needed a script. A nursing progress note, dated 10/12/23 at 3:43 p.m., indicated LPN 2 notified the pharmacy regarding the resident's missing Nubeqa. The pharmacy technician indicated the medication was a high-cost medication. A nurse practitioner progress note, dated 10/13/23 at 10:27 a.m., indicated Resident B's medications and orders were reviewed. She indicated he was to be given Nubeqa 600 mg orally twice a day for the diagnosis of metastatic prostate cancer. A physician's order, dated 10/19/23 at 8:17 a.m., indicated to discontinue the resident's Nubeqa 600 mg twice a day. The reason for discontinuing the medication was because it was a High Cost Medication. There was no documentation the physician consulted with the resident's oncologist before discontinuing the medication. There was no documentation the resident had a follow-up appointment or any consultation with the oncologist until 1/16/25 which was 15 months after the resident admitted to the facility. A nursing progress note, dated 1/16/25 at 3:51 p.m., indicated the resident returned from his cancer center appointment. His next appointment with the cancer center would be on 1/30/25 at 12:30 p.m. A nursing progress note, dated 1/30/25 at 1:26 p.m., indicated LPN 1 spoke with Resident B's guardian and the prostate cancer had spread. She was deciding on whether to place the resident on hospice. A social service progress note, dated 2/3/25 at 4:27 p.m., indicated the social worker spoke with the resident's legal guardian who indicated Resident B would transition to hospice related to his cancer diagnosis. A nursing progress note, dated 2/3/25 at 6:46 p.m., indicated the resident was admitted to hospice. During an interview, on 2/11/25 at 1:50 p.m., the Director of Nursing indicated the resident's chemotherapy drug was ordered following his discharge from the hospital. The Medical Director at that time chose to discontinue the medication because it was a high-cost medication. When a resident was on a high-cost medication normally the facility placed the medication on hold until they were dismissed from the facility. She did not know the resident had an oncology referral appointment when he was discharged from the hospital. He had no oncology follow-up appointments as far as she knew until 1/16/25. The Medical Director who discontinued the medication was no longer employed at the facility. The facility had been unable to reach him to obtain any further information related to discontinuing Resident B's cancer medication or his cancer treatment since he was admitted in 2023. A current facility policy, titled Nursing Admission/Return Admission Policy and Procedure, dated as revised 07/2024 and provided by the Director of Nursing on 2/11/25 at 1:30 p.m., indicated .Physician orders .Upon admission, physician orders must be obtained .Transcribe the admission orders from the original orders sent from the hospital or physician's office .Transcribe the routine medication orders to include dosage route, frequency and diagnosis to support the use .Inquire about medications that the resident may still have at home prior to admission to the nursing facility and assure the resident/representative consults with the primary care physician or community pharmacist before taking previously prescribed, unused medications, including over-the-counter medications .Verification of orders .The admitting nurse must call the attending physician to verify all orders upon admission. Pharmacy notification .Pharmacy notified of new admit/readmit .Discharge Summary .Residents being admitted from the hospital must have a discharge summary. If not present at admission, contact the transferring facility for a copy Darolutamide (Last revised 9/15/22) and retrieved on 2/18/25 from the National Library of Medicine MedlinePlus website indicated Darolutamide is also used to treat certain types of prostate cancer (cancer that begins in the prostate [a male reproductive gland]) that have spread to other parts of the body in men in combination with docetaxel. Darolutamide is in a class of medications called androgen receptor inhibitors. It works by blocking the effects of androgen (a male reproductive hormone) to stop the growth and spread of cancer cells .Do not stop taking darolutamide without talking to your doctor .Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests to check your body's response to darolutamide .Brand names Nubeqa This citation relates to Complaint IN00451659. 3.1-37(a)

Based on interview and record review, the facility failed to ensure the physician was notified as ordered according to the physician's ordered parameters, to hold medications according to the physician's ordered hold parameters, and to ensure medications were given as ordered for 5 of 5 residents reviewed for quality of care. (Resident J, H, K, B and 37) Findings include: 1. The clinical record for Resident J was reviewed on 8/22/24 at 3:44 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, chronic kidney disease, and dementia. A care plan, dated 9/15/23 and last reviewed on 6/13/24, indicated the resident was at risk for adverse effects of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) related to the use of glucose lowering medication and the diagnosis of diabetes mellitus. Interventions included, but were not limited to, document the abnormal findings and to notify the physician. A physician's order, with a start date of 1/16/24 and discontinued on 8/14/24, indicated to check Resident J's blood sugar twice a day (BID), with special instructions to notify the physician if the blood sugar was below 70 or greater than 350. The Medication Administration Record (MAR), for July 2024, indicated on 7/10/24, 7/11/24, and 7/12/24, the residents blood sugars were above 350. A physician's order, with a start date of 8/16/24, indicated to check Resident J's blood sugar BID, with special instructions to notify the physician if the blood sugar was below 70 or greater than 350. The MAR, for August 2024, indicated on 8/11/24 the residents blood sugar was above 350. There was no documentation in the clinical record to indicate the physician was notified at the time the blood sugars were found to be outside the ordered parameters. During an interview, on 8/27/24 at 11:29 a.m., the Director of Nursing (DON) indicated she could not provide documentation the physician was notified at the time the blood sugars were found outside of the ordered parameter. 2. The clinical record for Resident H was reviewed on 8/23/24 at 10:58 a.m. The diagnosis included, but were not limited to, chronic systolic congestive heart failure and blood pressure with abnormal findings. A physician's order, with a start date of 7/25/24, indicated to give Hydralazine (a medication to treat high blood pressure) 10 mg (milligrams) two times a day (BID) and to hold the medication for a systolic blood pressure (SBP) above 130. The MAR indicated Hydralazine 10 mg was administered when the systolic blood pressure was below the ordered hold parameter: a. On 7/28/24, for the a.m. and p.m. dose. b. On 8/1/24, for the a.m. dose. c. On 8/2/24, for the a.m. dose. d. On 8/3/24, for the a.m. and p.m. dose. During an interview, on 8/26/24 at 2:37 p.m., an anonymous staff member indicated if the medication was held there would be parentheses around the initials of the nurse and a comment would have been documented on the MAR. During an interview, on 8/26/24 at 4:04 p.m., the DON indicated according to the MAR, Resident H was administered the medication when the systolic blood pressure was outside of the hold parameter. 48525 3. The clinical record for Resident K was reviewed on 8/22/24 at 3:58 p.m. The diagnoses included, but were not limited to, acute systolic heart failure, stage 3 chronic kidney disease, peripheral vascular disease, and essential hypertension. A physician's order, dated 7/2/24, indicated to give Metoprolol succinate (a medication used to lower blood pressure) extended release 100 mg at bedtime and to hold the medication if the systolic blood pressure was below 120 or the heart rate was below 60. The MAR indicated Metoprolol 100 mg was administered when the systolic blood pressure was below the ordered hold parameter: a. On 6/10/24, the systolic blood pressure was 118 and the medication was given. b. On 6/28/24, the systolic blood pressure was 118 and the medication was given. c. On 7/14/24, the systolic blood pressure was 118 and the medication was given. d. On 7/27/24, the systolic blood pressure was 118 and the medication was given. e. On 8/4/24, the systolic blood pressure was 103 and the medication was given. f. On 8/8/24, the systolic blood pressure was 118 and the medication was given. A physician's order, dated 2/7/24, indicated to give furosemide (a diuretic medication) 40 mg every day and to hold if the systolic blood pressure was below 120. The MAR indicated Furosemide 40 mg was administered when the systolic blood pressure was below the ordered hold parameter: a. On 6/10/24, the systolic blood pressure was 118 and the medication was given. b. On 7/11/24, the systolic blood pressure was 114 and the medication was given. c. On 7/12/24, the systolic blood pressure was 111 and the medication was given. d. On 7/28/24, the systolic blood pressure was 118 and the medication was given. e. On 8/9/24, the systolic blood pressure was 112 and the medication was given. f. On 8/16/24, the systolic blood pressure was 116 and the medication was given. g. On 8/20/24, the systolic blood pressure was 108 and the medication was given. During an interview, on 8/28/24 at 9:30 a.m., the DON indicated it appeared according to the MAR, the medications were administered outside of the physician ordered hold parameters. During an interview, on 8/28/24 at 4:47 p.m., the DON indicated they did not have a policy on holding medications. 44598 4. During an interview, on 8/22/24 at 9:47 a.m., Resident B indicated there were several days she missed some of her medications. The clinical record for Resident B was reviewed on 8/22/24 at 3:55 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, sickle-cell trait, diabetes mellitus, chronic kidney disease, rheumatoid arthritis, anxiety disorder, major depressive disorder, and hypertension. A physician's order, dated 7/2/24, indicated to give 1 puff of fluticasone propionate-salmeterol (used for asthma and chronic obstructive pulmonary disease) 500-50 micrograms (mcg) twice a day. The MAR indicated the resident missed the fluticasone propionate-salmeterol dose on 7/3/24, 7/4/24, 7/5/24 and 7/6/24 between 7:00 a.m. and 11:00 a.m. A physician's order, dated 7/2/24, indicated to give 1 puff of tiotropium bromide (to prevent bronchospasms caused by chronic obstructive pulmonary disease) 500-50 micrograms (mcg) twice a day. The MAR indicated the resident missed the tiotropium bromide dose on 7/3/24, 7/5/24 and 7/6/24 between 7:00 a.m. and 11:00 a.m. A physician's order, dated 7/3/24, indicated to give 2 grams of cefazolin reconstitute (an antibiotic every eight hours. The MAR indicated the resident missed the cefazolin reconstitute dose on 7/5/24 at 6:00 a.m. A physician's order, dated 7/5/24, indicated to give 5 milliliters (ml) of nystatin suspension (used for a fungal infection) twice a day. The MAR indicated the resident missed the nystatin suspension dose on 7/5/24, 7/6/24, and 7/7/24 between 7:00 a.m. and 11:00 a.m. A care plan, dated 3/25/24, indicated the resident had the potential for impaired gas exchange and chronic respiratory failure. The interventions included, but were not limited to, administer medication per order and nebulizer treatments as ordered. There was no documentation to indicate the physician was notified of the missing doses of the antibiotics, mouthwash and the inhalers. During an interview, on 8/28/24 at 10:29 a.m., the DON indicated she would have to assume the antibiotic, mouthwash, and inhalers were not given according to the physician's order if the nurses did not sign the MAR and there was no documentation the physician was notified of the missed medication. 5. The clinical record for Resident 37 was reviewed on 8/22/24 at 3:57 p.m. The diagnoses included, but were not limited to, acute on chronic combined systolic and diastolic heart failure, end stage renal disease, peripheral vascular disease, hypertensive emergency and hypertension. A care plan, with a start date of 4/11/22, indicated the resident had ineffective tissue perfusion related to hypertension. The resident had fluctuating blood pressures and a most recent hospitalization for hypertensive emergency. Interventions included, but were not limited to, observe for and document: pallor, cyanosis, dizziness, syncope, shortness of breath, bounding/thready pulse, and headache. A physician's order, dated 7/25/24, indicated to notify the physician if the resident's systolic blood pressure was over 180 or the heart rate was over 110. A vitals log indicated the following: a. On 8/2/24, the resident's systolic blood pressure was 194 on the morning shift and 186 on the night shift. b. On 8/3/24, the resident's systolic blood pressure was 186 on the morning shift. c. On 8/9/24, the resident's systolic blood pressure was 184 on the morning shift and 186 on the night shift. d. On 8/10/24, the resident's systolic blood pressure was 187 on the morning shift. The Electronic Health Record (EHR) did not indicate the physician was notified of the blood pressure readings. During an interview, on 8/27/24 at 12:10 p.m., the DON indicated they would call the physician when blood pressures with call orders were out of the parameters, but the readings were pretty normal for Resident 37, so they put it on an acute (non-urgent) needs list for the physician instead. A current facility policy, titled Resident's Rights, dated 11/2015 and received from the DON on 8/28/24 at 3:51 p.m., indicated .The Resident has a right to be fully informed in advanced about care and treatment and any changes in that care of treatment that may affect the Resident's wellbeing A current facility policy, titled Medication Administration (Medication Pass Procedure), dated as revised 07/2023 and received from the Executive Director on 8/27/24 at 4:20 p.m., indicated .Medication administration will be recorded on the MAR/EMAR or TAR after given The facility did not provide a policy for notification to the physician. This citation relates to Complaint IN00439059. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a facility arranged transfer for a resident included the correct address of the receiving facility for 1 of 1 resident reviewed for discharge. (Resident F). The deficient practice was corrected on 5/23/24, prior to the start of the survey, and therefore was past noncompliance. Finding includes: During an interview, on 8/23/24 at 9:42 a.m., Resident F's daughter indicated the resident was supposed to go to an assisted living facility right down the street from the long-term care facility. The facility had a transport company take the resident to the assisted living facility since she and her brother were working. The transport company did not take her to the assisted living facility and instead took her to the place she lived prior. The transport company driver left the resident in her wheelchair in the driveway of the house next to her previous address. The person who lived in the residence remembered the resident and called her family to let them know the resident was in her driveway. Her brother left work and went to pick up the resident. The long-term care facility told them the Social Services Director (SSD) had made a mistake and put the wrong address down for the transport company. During an interview, on 8/23/24 at 10:02 a.m., Residents F's son indicated the resident was supposed to go to her previous assisted living facility which was just a block down the street. When she was discharged , the transport company took her to her old home address and left her in the driveway in her wheelchair with her belongings. The person who lived in the house next door to her old home address called his sister. The person in the house next door tried to flag the driver down and he just left. The sister notified him, and he went to the address to get the resident. The resident had soiled her clothes. He had to clean her and change her clothes before he could take her to the assisted living facility. The clinical record for Resident F was reviewed on 8/22/24 at 3:57 p.m. The diagnoses included, but were not limited to, malignant neoplasm of an unspecified part to the lung, a fracture of the left femur with routine healing, unspecified dementia without behavioral disturbance, and generalized muscle weakness. A Brief Interview for Mental Status (BIMS) assessment, dated 4/29/24, indicated the resident had a severe cognitive impairment. A progress note, dated 5/17/24 at 5:17 p.m., indicated the Director of Nursing at the assisted living memory care was notified of the resident's discharge date . The resident would not be able to return on the weekend and would need to return on a Monday. The son was notified of the Monday discharge and indicated he would not be able to transport the resident. The son asked the facility to set up the transportation for the resident. A progress note, dated 5/20/24 at 10:07 a.m., indicated the resident planned to discharge home today and would return to her assisted living memory care. The transport company would transport the resident back to the Assisted Living at 1:00 p.m. A progress note, dated 5/20/24 at 12:46 p.m., indicated Resident F was discharged back to her assisted living facility and all belongings were sent with the resident. The progress note did not include who was present with the resident to take her out of the facility and to the assisted living facility. A facility typed statement from the Payroll/Benefits Coordinator, dated 5/20/24, indicated she received a phone call at approximately 1:44 p.m., from Resident F's son. He was asking why his mother was dropped off in a driveway instead of her assisted living facility. At approximately 1:50 p.m., a caller who stated she was Resident F's previous neighbor called to ask why the resident was left in her driveway. The transport driver left the resident there alone and she had memory issues. The neighbor tried to yell and motion to the driver, and he just pulled away from the driveway. While on the phone, the neighbor indicated the son had arrived to pick up the resident. A facility typed statement from the Business Office Manager (BOM), dated 5/20/24, indicated at approximately 12:25 p.m., she was notified the transport company had arrived to pick up Resident F to transport her to her assisted living. The transport driver was waiting for the resident and put her in the van with her personal items. They left the facility at approximately 12:35 p.m. She was notified by the receptionist, at approximately 1:33 p.m., the resident was dropped off at a residential address instead of her assisted living facility. A person identified as the neighbor had called twice and indicated the resident was at her address. The address given to the transportation company was checked and it was noted the resident was sent to a previous home address and not the assisted living facility. The transport company was notified they were given the wrong address. The transport company dispatched a driver back to the address where the resident was left. The resident was not there when the transport company arrived. A printed email message from the owner of the transport company, dated 5/20/24 at 3:52 p.m., indicated she was addressing an incident from 5/20/24. The driver dropped off Resident F at the address given to the transport company. The driver left the resident in the driveway and a lady from the house was outside. The resident did not tell the driver she was at the wrong address. When the driver arrived back to the address, the resident was not there. The driver was notified the resident's son had picked her up. This was not the first time the transport company was given the wrong address. During an interview, on 8/22/24 at 4:18 p.m., the Director of Nursing at the assisted living facility indicated the resident returned to their facility, on 5/20/24 at 4:30 p.m., by family car. The family brought the resident. During an interview, on 8/23/24 at 10:52 a.m., the Social Services Assistant (SSA) indicated the Social Services Director (SSD) made the arrangements for the transfer. The transport company provided the transportation for residents in wheelchairs. The facility had a contract with the transportation company and would pay them for transporting residents. The transport company was given the address on the resident's face sheet instead of the address to the assisted living facility. During an interview, on 8/23/24 at 10:59 a.m., the Executive Director (ED) indicated the facility made a human error and gave the resident's old address to the transport company instead of her assisted living facility address. The resident was taken to the old address, the neighbor saw the resident being dropped off and waved to the driver. The driver just left and did not talk to the neighbors. A current policy, titled Discharge/Transfer, dated 11/15 and received from the ED on 8/27/24 at 11:22 a.m., indicated .Before a facility transfers or discharges a resident, the facility shall .Notify the resident and, if known, a family member or legal representative of the resident, in writing of the transfer or discharge and the reasons for the relocation in a language and manner they understand .Record the reasons in the resident's clinical record .Contents of the notice .The reason for transfer or discharge .The location to which the resident is transferred or discharged The deficient practice was corrected by 5/23/24, after the facility implemented a systemic plan which included audits, changes in the transportation procedure, and education to staff and transport companies. This citation relates to Complaint IN00435561. 3.1-36(a)(3)

Based on interview and record review, the facility failed to ensure the physical therapy recommended method to transfer a resident was used for 1 of 5 residents reviewed for accidents. (Resident E) The deficient practice was corrected on 3/17/24, prior to the start of the survey, and therefore was past noncompliance. Findings include: The clinical record for Resident E was reviewed, on 8/23/24 at 3:03 p.m. The diagnosis included, but were not limited to, morbid obesity, anemia, weakness, and encounter for surgical aftercare following surgery on the digestive system. An event note, dated 3/4/24, indicated Resident E was being transferred by two staff members from her bed to her wheelchair, when her legs gave out and she was lowered to the floor. A written statement by CNA 6, dated 3/4/24, indicated he and another staff member were transferring Resident E by lifting her under both arms from her bed to her wheelchair. When her leg gave out, she was lowered to the floor. A physical therapy (PT) baseline evaluation, dated 1/12/24, indicated a stand and pivot transfer was not attempted due to medical reasons and safety. A PT discharge summary, dated 1/12/24 to 3/1/24, indicated for chair/bed-to-chair transfers staff should use a Hoyer or a sit-to-stand lift. A PT recertification summary, dated 2/23/24 to 3/23/24, indicated for chair/bed-to-chair transfers staff should use a Hoyer or a sit-to-stand lift. A care plan, dated 1/15/24, indicated the resident required assistance with activities of daily living which included bed mobility, transfers, eating, and toileting. An intervention, dated 1/31/24, indicated to use a sit-to-stand lift for transfers. A physician's order for a Hoyer lift or a sit-to-stand lift was not found in the clinical record. An interdisciplinary team (IDT) progress note, on 3/5/24, indicated staff education about transfers was completed. During an interview, on 8/28/24 at 10:39 a.m., the Director of Therapy indicated during a baseline evaluation, if it was unsafe to transfer a resident, the PT would recommend the use of a mechanical lift for transfers. PT would communicate to the nursing staff the recommendation and the nursing staff would place the order. He indicated the nursing staff did put in an order for the use of a Hoyer lift but did not click the box to keep the order open ended and it was immediately discontinued. During an interview, on 8/28/24 at 2:35 p.m., the Director of Therapy indicated he was able to find the documentation and notes from the sit-to-stand evaluation. The sit-to-stand lift was probably added to the care plan by word of mouth. The nursing staff should not attempt to transfer the resident in any way, other than what PT had recommended. The recommendation was to continue to use the Hoyer lift, and the staff should not attempt an under the arm transfer. A current facility policy, titled Fall Management Policy, dated as last revised 8/2022, indicated .A fall refers to unintentionally coming to a rest on the ground, floor, or other lower level .Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls .A care plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factor The deficient practice was corrected by 3/17/24, after the facility implemented a systemic plan which included a thorough audit of resident transfers, skills validation, and all staff members were educated on gait belt, mechanical lifts, and transfers. This citation relates to Complaint IN00429846. 3.1-45(a)(2)

Based on interview and record review, the facility failed to complete an abnormal involuntary movement scale (AIMS) assessment on a resident who started on an antipsychotic for over a month and did not educate about the black box warnings associated with taking an antipsychotic medication while having dementia for 1 of 5 residents reviewed for unnecessary medications. (Resident 37) Findings include: The clinical record for Resident 37 was reviewed on 8/22/24 at 3:57 p.m. The diagnoses included, but were not limited to, generalized anxiety disorder, major depressive disorder, dementia, unspecified psychosis, altered mental status, and insomnia. A physician's order, dated 7/5/24, indicated to administer Risperidone (an antipsychotic medication) 0.25 mg once a day. A physician's order, dated 7/5/24, indicated to administer Risperidone 0.5 mg at bedtime. A care plan, dated 7/25/24, indicated the resident was at risk for adverse effects related to psychotropic medication use. An approach was to complete an AIMS assessment two times per year. An AIMS assessment was completed on 8/27/24 at 8:18 p.m. There were no AIMS assessment completed until over a month after the resident was started on Risperidone. During an interview, on 8/28/24 at 9:30 a.m., the Director of Nursing (DON) indicated the AIMS assessment on 8/27/24 was the first one completed since starting the antipsychotic. During an interview, on 8/28/24 at 11:46 a.m., the DON indicated she was not sure if they completed education on the black box warning of the medication. During an interview, on 8/28/24 at 4:01 p.m., the Executive Director (ED) indicated there was no education on the black box warning after the resident was started on the antipsychotic in July. A study from the National Institute of Health (NIH) indicated typical and atypical antipsychotics carry a black box warning for increased risk of death and cerebrovascular events in patients with dementia. There was no policy provided about education on black box warnings for medications by the time of exit A current policy, titled Psychotropic Management, dated as last reviewed 10/22 and received from the DON on 8/28/24 at 9:50 a.m., indicated .An AIMS assessment will be completed for residents who are taking antipsychotic medication as a tool to monitor for adverse side effects. The assessment should be completed within 72 hours of a new order to initiate an antipsychotic, within 72 hours of an increase in antipsychotic medication and then every 6 months while taking antipsychotic medication 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure medication carts were free of loose medications, label an inhaler, keep narcotic cards free of compromise, and ensure the narcotic count log was correct for 3 of 3 medication carts reviewed for medication storage (medication cart 1, 4 and 3) Findings include: 1. During an observation of medication cart 1, on [DATE] at 2:38 pm, a large round white pill and an orange oval capsule were found lying in the second drawer. A round brown spotted pill, a long white capsule and a long yellow capsule were lying in the bottom of the third drawer. During a narcotic reconciliation, on [DATE] at 2:40 p.m., a card of Tramadol (a pain medication) 25 milligrams (mg) tablets for Resident 20 had white tape on the back of slot 7, holding the tablet in place. 2. During an observation of medication cart 4, on [DATE] at 3:17 p.m., two individual dosages of hydralazine (a blood pressure medication) 25 mg without a pharmacy label were lying in the top drawer of the cart. An individual dose package of sodium chloride 1 gram (gm) without a pharmacy label was lying in the second drawer. A Lupihaler (inhaler for breathing issues) had a handwritten name on the outside without a pharmacy label. During an interview, on [DATE] at 3:20 p.m., LPN 2 indicated she was not sure if the inhaler was being used or not. 3. During an observation of medication cart 3, on [DATE] at 3:49 p.m., a small blue capsule and a larger light and dark green capsules were found in the second drawer. During a narcotic reconciliation with LPN 2, on [DATE] at 3:20 p.m., the medication card for Resident 78 contained 16 Tramadol (a pain medication) 50 milligram (mg) tablets. The narcotic record log indicated the card should have had 15 tablets. A tablet had been signed out at 8:50 a.m. on [DATE] which would have made the count 15. The documentation of the dosage given at 8:50 a.m. was crossed out by LPN 2 at the time of the reconciliation, and she indicated the 8:50 a.m. dose was not given. During an interview, on [DATE] at 2:22 pm, LPN 5 indicated the Tramadol tablet should not be taped. He would destroy the loose pills from the drawer by putting them in the biohazard sharps container. He did not use a Drug Buster. During an interview, on [DATE] at 2:30 p.m., the Unit Manager indicated the narcotic cards should not be taped on the back because she had no idea what the medication was. Medications needed to be destroyed by two nurses. During an interview, on [DATE] at 2:50 p.m., the Director of Nursing (DON) indicated the procedure for medication destruction was for two nurses to place the medication in a Drug Buster. During an interview, on [DATE] at 3:20 p.m., LPN 2 indicated the narcotic reconciliation was not correct. A current facility policy, titled Storage and Expiration Dating of Medications and Biologicals, dated as revised [DATE] and received from the DON on [DATE] at 4:51p.m., indicated .controlled medications must be counted with another designated staff member when there is an exchange of keys A current facility procedure, titled Medication Administration (Medication Pass Procedure), last dated as revised ,d+[DATE] and received from the Executive Director on [DATE] at 4:20 p.m., indicated .administration and inventory of controlled substances were documented according to facility policy A current facility policy, titled Storage and Expiration Dating of Medications and Biologicals, dated as revised [DATE] and received from the DON on [DATE] at 4:51p.m., indicated .facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding .facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions .facility should ensure that medications and biologicals are stored in the container in which they were originally received A current facility policy, titled Disposal/Destruction of Expired or Discontinued Medication, received from the DON on [DATE] at 11:38 a.m., indicated .facility should destroy non-controlled medications in the presence of a registered nurse and witnessed by one other staff member, in accordance with facility policy or applicable law .facility should destroy discontinued or outdated medications by one of three methods .pour medications into a container or plastic bag .an authorized facility staff member may add a substance that renders the medications unusable to the plastic container or bag .place medication containers in a container or box .seal box with strong tape a label the box as medication for destruction .secured in a locked cabinet or room until it disposed or picked up by licensed waste disposal company .facility - approved commercially available drug disposal kit .facility should destroy controlled substances in the presence of a registered nurse and a licensed professional or in accordance with facility policy or applicable law 3XXX,d+[DATE](e)(2) 3XXX,d+[DATE](e)(3) 3XXX,d+[DATE](j) 3XXX,d+[DATE](o)

Based on observation, interview and record review, the facility failed to assist a resident to obtain dentures as recommended during a dental exam for 1 of 3 residents reviewed for dental services. (Resident 20) Finding includes: During an observation, on 8/21/24 at 1:12 p.m., Resident 20 was eating soft foods and was edentulous (had no teeth). During an observation, on 8/22/24 at 9:35 a.m., the resident was eating soft foods for breakfast. The clinical record for Resident 20 was reviewed on 8/23/24 at 9:39 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, bipolar disorder, schizophrenia, dementia with agitation, dysphagia oral phase, and mild intellectual disabilities. A dental examination note, dated 2/8/24, indicated the resident was edentulous, would like dentures, and was a good candidate for dentures. The recommended follow-up was to obtain impressions for complete upper and lower dentures. A facility social services note, entered on 2/28/24, indicated the resident had been seen by the dentist and no new recommendations were made. A care plan, revised on 6/13/24, indicated the resident was edentulous and did not have dentures. During an interview, on 8/28/24 at 11:35 a.m., Resident 20 indicated she would like to have dentures. During an interview, on 8/26/24 at 3:02 p.m., the Social Services Assistant indicated the resident was seen and followed by dental services. The dental service provider was responsible for obtaining the molds for dentures. She would make sure the resident was on the list to be seen. During an interview, on 8/27/24 at 4:15 p.m., the Social Services Assistant indicated there had been no further action to obtain dentures for the resident since the recommendation in February. A current policy, titled Dental Services/Missing Dentures, dated as revised on 9/17 and received from the Executive Director on 8/27/24 at 11:25 a.m., indicated .The facility obtains needed dental services .assists in providing these services and makes prompt referrals for dental services as needed 3.1-24(a)(1)

Based on observation, interview and record review, the facility failed to ensure frozen foods were sealed and to ensure food was free of moisture in 1 of 1 freezer reviewed for food safety. (the walk-in freezer) Finding includes: During a kitchen observation, beginning on 8/21/24 at 12:08 p.m., the walk-in freezer had the following: a. Garlic toast was stored in an unsealed bag inside an opened box. b. Ten pounds of pork sausage links were stored in an unsealed bag inside a wet box. c. Two 5-pound bags of egg omelets were stored in unsealed bag inside an ice-covered box. d. 13.5 pounds of egg rolls were stored in an unsealed wet box. e. 18.9 pounds of [NAME] cheese omelets were stored in an ice-covered box. f. Two 5-pound bags of marinated diced white chicken were stored in an ice-covered box. g. Two boxes of diced ham were stored in an ice-covered box. During an interview, on 8/21/24 at 12:15 p.m., the Dietary Manager indicated he had noticed the ice-covered and wet boxes and questioned the food service delivery person, who indicated it was from condensation. During an interview, on 8/21/24 at 1:36 p.m., Resident 59 indicated the chicken tasted as if it had been frozen, thawed, and then frozen again. During an interview, on 8/21/24 at 3:53 p.m., the Maintenance Supervisor indicated moisture and condensation would form while the staff were stocking supplies. He did not usually manually defrost the freezer, but when he did, he would shut the power off and leave the door open for 10-15 minutes to allow the ice accumulation on the ceiling to thaw. He did this a couple days ago. He did not place anything up to catch the ice as it melted. During an interview, on 8/22/24 at 12:30 p.m., the Administrator indicated the freezer was an auto defrost and should not need to be defrosted. A current policy, titled Food Storage, dated as last revised 5/24 and received from the Director of Nursing on 8/22/24 at 3:49 p.m., indicated .Frozen Foods .Food items should remain frozen solid .Foods should be covered or wrapped tightly .Food items should not be refrozen after being thawed 3.1-21(i)(3)

Based on interview and record review, the facility failed to administer medications to ensure a resident was free from significant medication errors for 1 of 3 residents reviewed regarding medication errors. (Resident G) Resident G required a hospital admission of five days. Finding includes: A document, titled Intake Information, dated 11/2/23, indicated an anonymous complainant had concerns with Resident G having a critically low potassium level and not being treated with the potassium replacement ordered by the Nurse Practitioner (NP). During an interview, on 11/14/23 at 2:45 p.m., the Director of Nursing (DON) indicated Resident G did miss her dose of Potassium liquid, on 10/24/23, after the NP ordered it to be given that day. Agency Nurse 4 went to get the potassium liquid out of the Emergency Drug Kit, and it was not in there. Instead of calling the NP back, as she should have done to obtain further orders, she asked the other nurse on the unit what she should do. They decided to reschedule the medication for the following day after the pharmacy delivered it. The potassium liquid was rescheduled for 10/25/23. The resident's potassium level had dropped even lower, and the NP ordered for her to be sent to the hospital. The record for Resident G was reviewed on 11/15/23 at 10:45 a.m. Diagnoses included, but were not limited to, Enterocolitis due to Clostridium Difficile-recurrent, type 2 diabetes mellitus, arteriosclerosis of coronary artery bypass graft, hypertension, hypokalemia (low potassium levels), and dehydration. A document, titled Medication/Treatment Error Report, dated 10/25/23, indicated Agency Nurse 4 did not give Resident G's potassium liquid now as ordered by the NP. The effect of the error on the resident was her potassium level was low and she was sent to the ER for evaluation. A handwritten statement, dated 10/25/23, by Agency Nurse 4 indicated while she was placing orders in the computer, on 10/24/23, she came across the potassium orders for Resident G. She asked LPN 5 why Resident G could not have potassium tablets, since she could not find the potassium liquid the NP had ordered for her. LPN 5 indicated if there was no potassium liquid, she could move the order until the following day (10/25/23). LPN 5 changed the date and time of the potassium liquid until 10/25/23, after pharmacy delivered the medication to the facility. She asked about changing the potassium lab order for the following day, since it was ordered for the next morning following the potassium liquid doses. LPN 5 indicated she would also change the lab date and time for her. Resident G's potassium levels were reviewed: On 10/13/23 at 6:40 p.m., the level was 3.0 mEq/L. Normal levels were 3.5 to 5.5 mEq/L (liter). On 10/24/23 at 1:10 p.m., the level was 2.7 mEq/L. On 10/25/23 at 1:57 p.m., the level was 2.5 mEq/L. The Electronic Medication Administration Record (EMAR), dated 10/5/23 through 10/31/23, for Resident G included, but were not limited to, the following orders and documentation: 1. An order, dated 10/10/23 thru 10/12/23, indicated to give Fidaxomicin (an antibiotic used to treat C-Diff) 200 mg (milligrams) by mouth twice a day. a. On 10/10/23 at 8:32 p.m., the medication was documented as not administered as the medication was unavailable due to the pharmacy called indicating the medication was not covered. b. On 10/11/23 at 12:28 p.m., the medication was documented as not administered as the medication was unavailable. c. On 10/11/23 at 9:20 p.m., the medication was documented as not administered and the pharmacy was aware. d. On 10/12/23 at 10:10 a.m., the medication was documented as unavailable and will call the pharmacy. 2. An order, dated 10/24/23 at 3:00 p.m., indicated to give potassium chloride liquid by mouth 20 mEq/15 ml, 20 mEq one time now. a. On 10/24/23 at 3:00 p.m., the documentation box was left blank. The medication was rescheduled by a nurse to be given 10/25/23 at 10:00 a.m. 3. An order, dated 10/24/23, indicated to give potassium chloride liquid 20 mEq/15 ml, 20 mEq every two hours for three doses (80 mEq total). a. This medication was scheduled to be given on 10/24/23 at 6:00 p.m. and 8:00 p.m. (There was no third dose scheduled for 10/24/23). The medication was rescheduled by a nurse to be given on 10/25/23 at 12:00 p.m., 2:00 p.m. and 4:00 p.m. 4. An order, dated 10/25/23, indicated to transport the resident to the emergency room (ER) stat (immediately) for a critical potassium level. Resident G's progress notes included, but were not limited to, the following notes: a. 10/12/23 at 10:51 a.m., the NP note indicated the resident was on isolation for C-Diff. She was still reporting diarrhea. The resident indicated she was not receiving her Fidaxomicin due to insurance not covering it. The NP had documented in her notes the resident was receiving her Fidaxomicin until 10/19/23. b. 10/12/23 at 4:45 p.m., Fidaxomicin was a high-cost antibiotic, and the facility was not able to cover it being $10,000 and over. The antibiotic was changed by the physician. c. 10/12/23 at 5:01 p.m., new orders received to start an Intravenous solution of 1/2 Normal Saline at 150 ml/hr. Potassium chloride 20 mEq by mouth twice a day for 5 days. d. 10/13/23 at 10:56 a.m., the NP progress note indicated the resident was experiencing diarrhea and some dizziness with positional changes. e. 10/13/23 at 12:31 p.m., an order was given for the resident to be sent to the ER for an evaluation and treatment of C-Diff due to the fact that she is not able to receive PO [oral] ATB [antibiotic] therapy that is needed to treat c-diff. The medication needed to treat her C-Diff was very expensive and could not be given at the facility, but the hospital was able to administer it. The recent ordered antibiotic therapy (Flagyl and Vancomycin) had not worked for the resident in the past, so she was being sent to the ER. f. 10/21/23 at 11:33 p.m., the resident was readmitted back into the facility from the hospital. g. 10/22/23 at 4:10 p.m., the resident's antibiotic was not available at the facility. The pharmacy indicated the medication was expensive and sent a form to be faxed back to them indicating the facility would cover the cost of the medication prior to sending. h. 10/22/23 at 11:10 p.m., the facility received the resident's Fidaxomicin medication from the pharmacy. i. 10/24/23 at 4:32 p.m., the resident had a low potassium level of 2.7, which was reported to the NP on site and awaiting new orders. j. 10/25/23 at 3:00 p.m., a NP progress note indicated the resident had a Basic Metabolic Panel (BMP) lab drawn that morning, which revealed a critically low potassium level of 2.5. She was symptomatic with complaints her heart felt like it was racing, tingling, muscle spasms, and weakness. She had a potassium level of 2.7, on 10/24/23, and had orders written on that day to administer potassium chloride liquid 20 mEq one dose now, then administer potassium chloride liquid 20 mEq every two hours for three more doses for a total of 80 mEq of potassium chloride. The resident did not receive the potassium chloride liquid replacement and she was now symptomatic with a critically low potassium level of 2.5, which was drawn five hours ago. She had a history of coronary artery disease. It was in the best interest of the resident to be emergently transferred to the hospital for an electrocardiogram (EKG) heart monitoring and IV potassium chloride replacement. k. 10/30/23 at 5:05 p.m., the resident returned from the hospital to be readmitted to the facility. A document, titled Patient Summary Report, dated 10/26/23 at 1:56 p.m., from the hospital indicated Resident G's number one problem was severe hypopotassemia (low potassium level)/hypomagnesemia (low magnesium level). She had ongoing electrolyte abnormalities most likely from chronic diarrhea. Her potassium level was 2.2. She received 40 mEq of oral potassium in the ER and 20 mEq IV. She was placed on telemetry (continuous heart monitoring) due to her significant hypokalemia (low potassium levels). A document, titled Patient Summary Report, dated 10/26/23 at 2:01 p.m., from the hospital indicated Resident G had multiple hospitalization s over the last couple of months related to a complex infection of her left lower extremity. It was treated with antibiotics, and she developed C. Diff which was initially treated with Vancomycin. She was switched to Fidaxomicin. She had trouble receiving the Fidaxomicin at the facility she resided at and was readmitted to the hospital earlier in the month. She was placed back on the medication with plans to finish it out through October 29, 2023, according to the Gastroenterologist. She had a significantly low potassium level, so she was sent to the ER where her potassium level was 2.2 and was started on medication and further evaluation was being completed. During an interview, on 11/15/23 at 12:05 p.m., the Regional Director of Clinical Support (RDCS) indicated there was no policy for following physician's orders. The nurses knew they were to follow physician orders which were given for the residents. During an interview, on 11/15/23 at 2:22 p.m., the NP indicated Resident G had a potassium level of 2.7, on 10/24/23. She was asymptomatic, so she knew she could treat the level in the facility. She ordered potassium liquid 20 mEq (milliequivalent) to be given as a one-time order stat, then 20 mEq to be given three more times two hours apart from each other. A new lab would be drawn the next morning, (10/25/23), to see where the resident was on her level. She indicated she was shocked to see her level had dropped to 2.5 when she got the potassium result back, on 10/25/23 at 3:00 p.m. She thought either the resident did not absorb the potassium and she was going to be dealing with a bigger issue or the potassium liquid was not given as ordered. The NP went to Agency Nurse 4 who had the resident the day and asked if she got the potassium as ordered, on 10/24/23. She was told no because it was unavailable until 10/25/25, so it was rescheduled to be given that day. She gave the order for her to be sent to the emergency room (ER) stat. She seen in the nursing documentation, on 10/25/23 at 10:00 a.m., the resident had complaints of heart fluttering and generally was not feeling good. She was not notified of these symptoms when the resident complained about them. With her cardiac history, she was concerned she would start having increased cardiac issues. When the resident arrived at the ER, her potassium level was 2.2. Her potassium level had been drawn in the morning at the facility, so it had dropped even lower since it as drawn. During an interview, on 11/15/23 at 2:20 p.m., the Director of Nursing (DON) indicated Resident G did not receive her Fidaxomicin (an antibiotic used to treat Clostridium Difficile) 200 mg twice a day because her insurance would not pay for it. The facility pharmacy did not fill the medication prescription as ordered by the physician because they did not carry the medication due to the cost of the medication. The antibiotic was changed to Flagyl (an antifungal used to treat a variety of fungal infections) and Vancomycin (an antibiotic), which she had previously been treated with these medications prior to being placed on the Fidaxomicin. A current policy, titled Medication Administration, undated and provided by the Executive Director (ED) on 11/16/23 at 10:30 a.m., indicated .Any orders that are ordered STAT must be completed within the 4-hour required time frame. Any orders not completed within that time frame the charge nurse must notify the MD/NP for further orders. 2. When receiving any orders in writing or by telephone, if unable to complete the order as prescribed, the charge nurse will notify the MD/NP for further orders. 3. Failure to complete MD/NP orders, failure to enter labs, failure to transcribe orders correctly are considered medication errors .6. If any concerns with MD/NP orders/care, ED/DNS [Director of Nursing Services] will be notified A current policy, titled Medication Errors, dated 11/2018 and provided by the ED on 11/16/23 at 10:30 a.m., indicated .It is the policy of this provider to ensure residents residing in the facility are free of medication errors .The charge nurse will complete a medication error report, including a brief summary of findings. Documentation in the medical record will include physician/family notification, type of error, and assessment of resident. The licensed nurse/QMA responsible for the error will be required to meet with the DNS (Director of Nursing Services)/designee to review the medication error report This Federal tag relates to Complaint IN00421053. 3.1-48(c)(2)

Based on observation, interview and record review, the facility failed to prevent the removal of an incorrect resident with cognitive impairment from the facility by a transport driver resulting in the misplacement of the resident in the community from 6:45 a.m. to 8:40 a.m. for one of one resident reviewed for accidents (Resident B). The immediate jeopardy began on 04/05/2018, when the facility failed to follow policies and procedures to identify and release the correct resident to a transport driver for an appointment. The Executive Director was notified of the immediate jeopardy on 05/15/18 at 3:58 p.m. The immediate jeopardy was removed and the deficient practice corrected on 05/16/18. Findings include: During an observation and interview with Resident B, on 05/14/18 at 12:45 p.m., Resident B was observed to be alert, but was unable to answer questions concerning his current location, date and time. During an interview, on 05/15/18 at 1:06 p.m., the Daughter of Resident B indicated her father was wrongfully removed from the facility, without her knowledge and taken to (Name of Hospital). Resident B's daughter expressed fear that her father who had a [DIAGNOSES REDACTED]. The record for Resident B was reviewed on 05/15/18 at 2:00 p.m. [DIAGNOSES REDACTED]. A review of the Minimum Data Set, indicated Resident B had a BIMs (Brief interview of mental status) score of 5, meaning resident was severely cognitively impaired. An investigative report, provided by the Executive Director, on 5/15/18 at 12:15 p.m., Licensed Practical Nurse (LPN) 1 indicated, .witnessed Driver come off 2nd floor elevator at 6:36 a.m.watched Certified Nurse's Assistant (CNA) 2 escort Driver down by Resident B's room, CNA 2 stopped at linen cart, Driver and CNA 2 went to Resident B's room, Driver stood outside of room in hallway. Writer then witnessed ten minutes later Driver, Resident B and CNA walking down hallway. Driver and Resident B stopped at elevator and went to the first floor at 6:45 a.m An investigative report, provided by the Executive Director (E.D.), on 5/15/18 at 12:15 p.m., the E.D. indicated, .Received a return call from a Nurse Practitioner at the (Name of Hospital) on 4/6/18 at 8:40 a.m.the NP indicated she was told transportation dropped off Resident B in front of radiology the wrong resident was sent to the appointment An investigative report, provided by the Executive Director on 5/15/18 at 12:15 p.m., indicated, E.D. called and spoke with transport supervisor at the (Name of Hospital), he indicated they only use one company (Name of Transport Company). Transport Company Representative asked the E.D. why the driver was able to get into the building .E.D. told him they were educating staff on ensuring drivers checked in at nurses' stations in order to protect the residents An investigative report, provided by the E.D. on 5/15/18 at 12:15 p.m., indicated the nurse on duty, RN 3, who was responsible for Resident B's care, had indicated, .he was aware Resident C had a doctor's appointment on 4/5/18. Resident C was to be picked up at 7:00 a.m. Resident C was up and ready with his paperwork. RN 3 was never notified by CNA 2 or the Driver that a resident was being picked up, or that the driver was in the building During an interview, on 05/15/18 at 10:30 a.m., the E.D. confirmed she was aware Resident B was mistakenly removed from the facility and taken to the (Name of Hospital) on 04/05/18 at 6:45 a.m. The E.D. indicated the Nurse Practitioner from the (Name of Hospital) called the facility to enquire if Resident B belonged to their facility, as the Resident was unable to communicate where he belonged. The E.D. confirmed the wrong resident was sent to the appointment without any identification or documentation. During a telephone interview, on 05/17/18 at 8:18 a.m., the Receptionist in the X-ray Department at (Name of Hospital), indicated the Transportation Driver brought Resident B to the desk and introduced him as Resident C. Resident B was unable to tell the receptionist his name, state why he was there or where he had come from. Staff members who had previously met Resident C indicated the resident at the office was not Resident C. The Receptionist indicated she took Resident B to the Department Supervisor. During a telephone interview, on 05/17/18 at 8:24 a.m., the Department Supervisor at the (Name of Hospital) indicated an unaccompanied and unidentified resident was brought to her from the Receptionist. Resident B did not have a wallet, identification or any paperwork from a healthcare facility to identify him. Resident B was unable to answer questions or say his name. At one point, the Resident B answered yes when asked if he was Resident C. The Department Supervisor tracked down the Transportation Driver to inquire where he picked up Resident B. The Transportation Driver indicated he was told by someone working at the facility that this was Resident C. The Transportation Driver indicated he was not given any paperwork to take to the appointment. The Transportation Driver then took Resident B back to the facility at 8:40 a.m. During a telephone interview, on 05/17/18 at 8:14 a.m., the Nurse Practitioner at the (Name of Hospital) indicated she was made aware of an incident involving Resident B mistakenly being brought to the clinic by a Transport Driver from the (Name of facility). - She called the facility when the Department Supervisor notified her Resident C had not arrived for his scheduled appointment and an unidentified man was brought to the clinic. An in-service provided as a policy, received from the E.D., on 05/15/18 at 12:15 p.m., indicated, .When a resident leaves the facility for an appointment, in order to protect our resident it is very important to confirm it is the correct resident and escort transport staff to charge nurse for correct paperwork. If unsure if correct resident please protect the resident by verifying with charge nurse and accessing resident picture on the profile in the kiosk. Make sure resident is seen by charge nurse to obtain correct paperwork and charge nurse can remove from census in the computer. Upon departure and arrival charge nurse must {access} resident and ensure they are ready for their appointment. All residents must have transport papers before leaving the building. When resident returns from appointments all residents must be checked with charge nurse and all paperwork also given to the charge nurse. It is very important to follow this procedure to protect the safety of all our residents The immediate jeopardy that began on 05/15/18 was removed on 05/16/18 when the facility provided in-servicing education to staff, updated policies and posted signs in the facility. This Federal tag relates to complaint IN 982. 3.1-45(a)(2)

A. Based on observation, interview and record review, the facility failed to ensure a resident did not elope from the facility and follow facility policy for elopement of a resident who eloped and was outside the facility for greater than an hour and a half with whereabouts unknown for 1 of 1 resident reviewed for elopement ( Resident GG). The Immediate Jeopardy began on 5/21/17 when the facility failed to implement their elopement procedure when a front door wanderguard alarm sounded and CNA 1 looked outside the door glass and shut off the alarm and did not notify anyone. The resident exited the building through the front door with a visitor and was not identified as having eloped for greater than 20 minutes. The Elopement protocol was initiated on 5/21/17 at 5:48 p.m., when the resident was not located. The Executive Director (ED), Director of Nursing Services Specialist ,and Administrative Assistant were notified of the Immediate Jeopardy on 5/23/17 at 4:55 p.m. The Immediate Jeopardy was removed on 5/24/17, but noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. B. Based on observation, interview and record review, the facility failed to ensure a safe transfer method was provided to prevent a potential accident hazard (Resident EE), failed to ensure a post fall intervention was followed through to prevent further falls for 1 of 4 residents (Resident N) being reviewed for accidents and failed to ensure medications were not left at the nurses' station and the medication room door was not left open and unattended. Findings include: A.1. During an interview on 5/23/17 at 2:45 p.m., the Executive Director (ED) indicated Resident GG eloped from the building on 5/21/17 at approximately 5:00 p.m. She indicated there was a large birthday party on the secured unit and they believed he exited with a crowd of visitors, then he was seen on video following behind a visitor into the parking lot and she could not see on video where he went from there. She indicated the front door wanderguard alarm sounded and CNA 1, who was working on the moving forward unit went to the front door shut off the alarm, looked out the glass door, did not see anyone in the parking lot and went back to the moving forward unit. She did not open the front door and look out the door into the parking lot to see if there was a resident who had eloped from the facility. She indicated the front door alarm frequently alarmed, so CNA 1 probably thought it alarmed because of the door being held open to long and after looking out the front glass door and not seeing any resident in the parking lot, she thought it was the door being held open to long and went back to the moving forward unit. She indicated CNA 1 did not follow the facility policy for the elopement because she did not go outside the door into the parking lot to look for the resident. The ED indicated the resident walked to the corner of 86th Street and Town road and got tired and sat down in the grass where a police officer found him sitting in the yard and the resident was able to tell the officer his son's name and he looked up his address and he took the resident to his son's house in (Name of City), then the son brought the resident back to the facility at approximately 6:37 p.m. The ED indicated CNA 1 from the moving forward unit probably would not have recognized this resident as a resident from the facility, even if she had opened the front door and stepped out into the parking lot because he was dressed in a plaid shirt, which was tucked into his jeans and he had a nice designer cap on his head, so he did not look like a resident, he looked like a visitor. She indicated she did not notify the police. She was getting ready to notify the police when the resident's son called her at 6:30 p.m., and told her he was bringing him back to the facility. The record of Resident GG was reviewed on 5/23/17 at 3:20 p.m. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated the resident had a BIMS (Brief Interview for Mental Status) of 00 meaning he had severe cognitive impairment. The resident had a Care Plan dated 11/25/16 with a revised date 5/22/17, which addressed the problem he was at risk for elopement according to the Elopement Risk Assessment as evidenced by his wandering around the facility and his severely impaired cognition. The resident would often wear his coat and hat and state he needed to go home. He stood by the locked doors and pushed buttons on the keypad. He had a history of [REDACTED]. Approaches include, but were not limited to, 2/3/17--Wanderguard per MD (Medical Doctor) order, 11/25/16--**Resident at risk for Elopement**, All facility exits secured .Resident resides on a secured unit. The resident had a Care Plan dated 11/25/16 with a revised date 3/21/17, which addressed the problem returning to the community was not possible for him due to he needed 24 hour care. His discharge goal was to remain in the facility. The resident had a Care Plan dated 12/1/16 with a revised date 3/21/17, which addressed the problem he was at risk for falls due to impaired cognition due to the [DIAGNOSES REDACTED]. Approaches included, but were not limited to, 12/1/16--Call light in reach, Environmental changes: as needed A Progress note dated 5/21/17 at 5:20 p.m., indicated The writer notified by CNA that res (resident) could not be found on the locked unit. Unit thoroughly searched with no results. Weekend supervisor notified et (and) medicare unit, LTC (Long Term Care) unit, kitchen, basement, facility grounds all searched et (and) res was not able to be found. Several staff members left facility in their vehicles to search for resident. Res last seen by staff eating dinner in dining room at 4:55 p.m. A Progress note dated 5/21/17 at 7:00 p.m., indicated Res returned to locked unit with son. Skin assessment performed. Skin WDI (warm, dry, intact). No bruising or redness. Wander guard remains on R (right) ankle .15 minute monitoring for safety. A Progress note dated 5/22/17 at 12:03 p.m., indicated bx (behavior) f/u (follow up) from 5/21/17 B (Behavior): Resident followed visitors off unit and eloped from facility. Silver Alert called immediately and resident search conducted around facility and immediate surrounding area. A (Action): Resident was found and brought back to facility. Skin assessment performed. Resident's wanderguard was intact on right leg. Wander guard functioning appropriately . He was also recently sent to the ER d/t (due/to) seizure activity. R (Response): Resident followed visitors out of locked unit and facility. I (Intervention): Immediate search conducted. ED, DNS (Director of Nursing Services), family and physician notified immediately. 15 minute checks continued. Continue to check placement and function. Elopement assessment and care plan reviewed and updated. An (Name of Company) New/Worsening Behavior Communication Event form dated 5/21/17 at 10:28 p.m., indicated this resident's behavior occurred on 5/21/17 at 5:03 p.m., at the facility. He eloped from a locked unit in the facility. His recent medical issues were he was sent to theER on [DATE] for seizure activity. A Handwritten statement dated 5/22/17 by CNA 1 indicated .On 5/21/17 around 5:00 pm the front door alarm went off I was working on moving forward. When I heard it I pressed the button on the wall and it kept going, so next I went to the door where the alarm was going off and entered the code and looked outside I looked and didn't see a car or a person anywhere besides the nurse behind me, maybe 2 nurses. They informed me the light was still blinking and turned the key to reset it. The only person I saw was a young guy in yellow shorts as I was standing there. I honestly didn't know why it went off because there wasn't a resident, a visitor or a car in sight. A handwritten statement dated 5/21/17, by LPN 3 indicated This nurse had last seen res (Name of Resident) in dining room at 4:55 pm. At 5:20 pm CNA notified this writer that res could not be located on unit. Unit thoroughly searched with no results. Weekend supervisor notified that res was not on locked unit, moving forward, LTC unit, basement, kitchen, facility ground searched with no result. Several staff members left in vehicles to search for res. ED in facility et notified staff at approximately 6:30 PM that res had been located by police et was returning to facility with son. Res now on locked unit A Service Call Report from (Name of Company) dated 5/22/17, indicated the facility had an elopement and they wanted all the doors in the facility with alarms tested to ensure they were functioning properly. Resolution: after speaking with customer found that resident who eloped was in fact wearing a securecare transmitter after viewing video from cctv (closed circuit tv) system determined resident followed a visitor out of the building. tested all exterior door locking systems and found all working properly. Also reset time on dvr one hour forward (7 am to 8 am). During an interview on 5/23/17 at 3:39 p.m., CNA 4 indicated the resident was eating his dinner on 5/21/17 at around 5 p.m. On that day, he left some of his food on his plate and he usually ate all his food, which was abnormal for this resident, so he went to look to see if he was in the bathroom and he was not, so he went to report to his nurse he was not able to locate the resident. The memory care unit staff looked for Resident GG on the unit and they could not find him, then the charge nurse told the weekend manager and the ED was told. There was a birthday celebration for another resident, so extra visitors were on the unit and we thought he went out with the visitors. If the alarm sounded at the front door, CNA 4 indicated he would go to the front door and shut the alarm off, then he would open the front door and look out the front door into the parking lot to see if there was a resident in the parking lot, then tell the charge nurse and they would do a head count. There was no head count completed at 5:20 p.m., when the resident was suspected missing. He indicated they did not do a head count until after the resident was determined to be missing off the unit. During an interview on 5/23/17 at 3:53 p.m., the Weekend Supervisor indicated on 5/21/17 at approximately 5:48 p.m., LPN 3 (Charge Nurse) from memory care came upstairs on second floor and indicated she was unable to find Resident GG. The Weekend Supervisor called a Code Silver, at that time and she told the second floor staff to search all rooms, closets, bathrooms and under the beds. She went downstairs and told all the first floor staff to do the same thing. Her, LPN 1, LPN 2 (nurse from moving forward), went outside to the parking lot and LPN 2 drove in her car looking for the resident. They checked back by the garden homes and the perimeter of the building. They checked out on the sidewalk to the left and right of the facility. The Weekend Supervisor went to the right to a little ways past the sports equipment store and LPN 3 went left. She called the ED at that time (approximately a little after 6 p.m.) to let her know what was going on and the ED indicated she was on her way and to check the building again. The SSD got the policy out at that time and implemented the policy and they notified the family the resident was missing. The Weekend Supervisor came back to the building and no one had found him and the ED was at the facility at that time. The Weekend Supervisor drove through the housing addition behind the building and she was on her way back to the facility when they called and said they found him. She indicated LPN 3 (Resident GG's nurse from the memory care unit) indicated the memory care staff had been looking for him for 10-15 minutes prior to notifying the Weekend Supervisor, that she had a missing resident. She indicated the front door alarm usually sounded all day long because someone held it open to long, so CNA 1 probably did not realize the resident had went out with his wanderguard on. When the front door alarm sounded the person who shut the alarm off was supposed to go outside and look in the parking lot to see if there was a resident out in the parking lot and notify someone in charge, so a head count could be done at that time, to see if there was a resident missing and if so, who was the resident. She indicated there was no head count done prior to 5:48 p.m., when she implemented the elopement protocol by calling the Code Silver to determine, which resident was missing. On 5/23/17 at 3:36 p.m. and 6:59 p.m., an attempt to call CNA 1 regarding the incident of the elopement of Resident GG, which occurred on 5/21/17. She did not answer her phone and a message was left. During an interview on 5/23/17 at 7:00 p.m., the resident's family member indicated on 5/21/17, sometime after 5:00 p.m., he could not remember the exact time someone from the facility called him and told him his father was missing. He indicated the person told him his father was missing and he told the person on the phone it was ok, his father was on a locked unit, he could not get out of the locked unit, so he had to be hiding somewhere in a bathroom or someone else's room, so they needed to find him. The facility called him back a while after that and asked if he had been to the facility and taken out his father from the facility without signing him out and not telling someone and he indicated he would never take his dad out of the facility without signing him out and they needed to find him. He indicated approximately one to one and half to two hours later someone rang his doorbell and he looked on his camera and seen a (Name of city) police officer standing at his front door. When he went to the door the officer asked him if he knew a (Name of Resident GG) and he indicated that was his father and the officer indicated he had him in his car, he had found him wandering the streets near 86th Street in (Name of city). He indicated he was in shock because his dad had gotten out of the facility when he was supposed to be behind locked doors. He indicated the officer told him his dad was able to give him his birthdate and his full name. He indicated his dad could ambulate by himself, but was in a confused state. He called the facility and told them he had his dad and was returning him. He returned with his father to the facility at approximately 7:00 p.m. He indicated he was Incredibly upset. When he asked how his father got out of the facility he was told there was a large gathering for another resident and when their family members left he left out the memory care doors with them. The ED watched on the video and seen the resident exit the front doors behind a visitor. During a review of the facility video with the Executive Director, Director of Operation and 3 other cooperate staff on 5/24/17 at 8:49 a.m., the following was observed. At that time, the ED indicated the video time stamp was one hour off from real time. On 5/21/17 at 3:53 p.m., (video time) the resident was observed to follow a man/visitor down the hallway to the front entrance door. At the door, the visitor entered the key pad code and opened the door. Resident GG followed the visitor out the door. The alarm sounded on the door at that time. At 3:54 p.m., (video time) CNA 1 came to the front entrance door, shut off the alarm and looked out the glass window of the front door. There was no other staff observed in that same area. She did not open the door to look outside the door. During an interview at that time, the ED indicated at no time was the police notified even though it was over an hour before the resident was returned to the facility. During an interview on 5/24/17 at 9:30 a.m., the Social Service Director (SSD) indicated she was unsure of times, but as soon as she was informed by the memory care unit nurse a resident was possibly missing she went to each unit and had them initiate a head count. She indicated everyone but Resident GG was accounted for. She indicated the DON and Executive Director (ED) were notified and a second search was initiated. She indicated at no time was the police notified of a missing resident and she had been in contact with the resident's family member. During an interview on 5/24/17 at 9:40 a.m., the Admission's Director indicated she received a text message from the ED on 5/21/17 at 6:43 p.m., for her to report to the facility. When she arrived, the resident's family member was on his way to the facility bringing Resident GG back. She indicated she contacted the (Name of Police Department) and spoke to (name of officer). The officer indicated he was alerted to an individual who was lost at Township Line Road, between 86th and 96th street, close to Brewster. He indicated Resident GG had an armband on from (name of hospital) with his name and birthdate on it. The officer was able to look up the resident's address and attempted to take him home. As the officer was driving the resident to (Name of City), the resident stated his (Name of family member) lived close by. The officer then looked up the family member's name and took the resident to his home. An Elopement Drill Checklist undated contained the following,Elopement Drill Procedure: Drill is announced using the overhead page announcement of : CODE SILVER followed by the unit of the missing resident Each charge nurse coordinates a head count of their assigned iron. Each charge nurse coordinates a head count of their assigned area. Charge nurse of missing resident checks for other explanations of absence (LOA book, medical appt, therapy, etc), Each charge nurse coordinates a search of their assigned area including resident rooms, restrooms, shower rooms, offices, service areas, etc. Results of search are reported to the charge nurse of the missing resident. If the resident has not been found within 10 minutes, the ED ad DNS are notified. Assigned search coordinator (charge nurse, ED, DNS) coordinates another search of the facility as well as the grounds. Drill concludes after a thorough search of the facility/grounds areas been reported to the Search coordinator. A current policy titled Elopement (Risk and Missing Resident) dated 4/97 and revised 10/13, provided by the Executive Director (ED) on 5/23/17 at 3:00 p.m., contained the following, Policy: It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident, ensuring appropriate action is taken . MISSING RESIDENT PROCEDURE: 1. If a resident's whereabouts is unknown, the following measures will be implement immediately: a. The charge nurse of the missing resident is notified of the need to locate the resident. b. The charge nurse uses the overhead paging code; CODE SILVER followed by the unit of the missing resident. c. Each charge nurse coordinates a head count pf every resident in their assigned area. d. The charge nurse of the missing resident will check for other explanations for the resident's absence (LOA, sign out book, medical appointment, visitors, outings, therapy treatment, etc). e. Each charge nurse coordinates a search of their assigned area including resident rooms, restrooms, closets, shower rooms, hallways, offices, service-areas like kitchen, laundry, etc. f. Results of the search will be reported to the charge nurse of the missing resident. If the resident has not been located within 10 minutes of initialing the search, the charge nurse will notify the Executive Director and Director of Nursing Services. 2. Assigned Search Coordinator (ED, DNS, or charge nurse of missing resident) will coordinate another searched the facility as well as the facility grounds. 3. If the resident is not located after this search, the responsible part, physician, and the police will be notified in that order. 4. Staff will continue to search the facility and grounds, expanding into surrounding neighborhoods. 5. The Search Coordinator will copy the Elopement Risk Profile to give to the police or any staff who are unfamiliar with the resident. 6. The Executive Director will notify the Director of Operations. 7. ISDH will be notified per ASC Unusual Occurrence Reporting Policy in regards to Elopement. The Immediate Jeopardy that began on 5/21/17 was removed on 5/24/17, when the facility had implemented the following steps: place signage at each exit to inform visitors not to let anyone go out a door with them, inserviced all working facility staff on the elopement policy and procedure, conducted elopement drills, assessed all residents for risk of elopement, had doors checked for proper functioning and checked all wander guards for proper placement and functioning, but the noncompliance remained out of compliance at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy related to the need to continue ongoing education and observe effectiveness of training. B. 1. On 5/1/17 at 5:58 p.m., CNA 11 and LPN 5 was observed transferring Resident EE from his bed to his wheelchair without a gait belt. Both staff members placed one of their arms under each arm of the resident and stood him up by raising him up under his arms. His sweatpants were raised to his mid-thighs already. The staff members were pulling up his pants prior to pivoting him and LPN 5 had ahold of the band and back of his sweatpants and was pulling on the back and the band of them pulling them up while pivoting him and they sat him in his wheelchair. During an interview on 5/17/17 at 6:30 a.m., CNA 11 indicated she should have used a gait belt to transfer the resident. She indicated she usually transferred him by herself and used a gait belt, but since LPN 5 was in the room she helped her transfer him this morning. During an interview on 5/17/17 at 10:57 a.m., LPN 5 indicated she did not have a gait belt to use for transfers, but all the CNA's have gait belts to use for transfers. The record review for Resident EE was completed on 5/25/17 at 10:51 a.m. [DIAGNOSES REDACTED]. A Resident Profile sheet dated 5/22/17 indicated 5/12/17--Assist of two with transfers A quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated he was an extensive assist with two person transfer for transfers. B. 2. On 5/17/17 at 6:08 a.m., Resident N was observed laying sideways in his bed, his call light was on the floor and his bed alarm was disconnected. At that time, LPN 8 indicated the resident was at risk for falls. The record review for Resident N was completed on 5/22/17 at 10:08 a.m. [DIAGNOSES REDACTED]. The resident had a Care Plan dated 10/5/16 with a revised date 5/1/17, which addressed the problem he was at risk for falls due to impaired mobility, impaired vision, use of medications for high blood pressure and psychotropics, a language barrier and a history of falls. Approaches included, but were not limited to, 5/1/17--bed alarm, check placement and function Q (every) shift . Call light in reach A Resident Profile sheet dated 5/22/17, indicated .5/1/17--bed alarm, check placement and function Q (every) shift B. 3. During an initial tour on 05/17/17 at 5:15 a.m., LPN 7 was in attendance the following was observed: Eleven medication cards and one bottle of medication were observed on the counter at the second floor nurses' station unattended. One medication card contained aspirin, one medication card contained vitamin B12, two medication cards contained memantidine. At that time, LPN 7 indicated the medication was delivered from the pharmacy and should have been put in the locked medication cart or medication room. The second floor medication room door was not closed securely. By the door of the medication room was a crate of several cards of medications. At that time, LPN 7 indicated the medication room door should always be shut, but sometimes it is not pulled closed tightly. LPN 7 indicated the medications in the crate were to be returned to the pharmacy. A current policy titled Fall Management Program dated 7/2001 with a revised date 7/2016, provided by DNSS on 5/24/17 at 4:30 p.m., contained the following, .Procedure: Fall Risk: .3. A care plan will be developed at tie of admission with specific care plan interventions to address each resident's fall risk factors. Care plan including interventions and fall risks will be reviewed at least quarterly .6. The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet A current policy titled Transfer to Chair/Wheelchair-Two Person dated 4/2014, provided by the DNSS on 5/24/17 at 4:30 p.m., contained the following, Procedure Steps: 7. Place gait belt around resident's waist . 9. Staff should reach around resident's back and grasp gait belt with one hand. Staff hands should be close. Staff's other hand should grasp gait belt midway between resident's side and front .12. Each staff should use the gait belt to assist the resident from sit to stand .16. Remove gait belt A current facility policy dated 01/01/13, received from the DON on 05/22/17 at 5:00 p.m., indicated, .the facility should not leave medications or chemicals unattended This Federal tag relates to Complaint IN 569 and IN 383 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interviews, the facility failed to contact a specialty care physician's office for further wound treatment and/or wound care orders, after a resident had an office visit, outside the facility and failed to follow policy for wound observation and documentation for 1 of 6 residents reviewed for wound care and follow-up, in a sample of 6. (Resident B) This deficient practice resulted Resident B being admitted to the hospital for intravenous antibiotics for a [DIAGNOSES REDACTED]. Findings include: The clinical record for Resident B was reviewed on 8/24/15 at 2:20 p.m. [DIAGNOSES REDACTED]. Nursing wound care notes, dated 6/18/15 at 1:30 p.m., indicated Resident B had .gangrene to scrotum after penile implant revision. Scrotum necrotic area measures 5.5 x 7 x 0 cm (centimeters). No Tx (treatment) ordered and per MD (medical doctor/physician) no Tx necessary at this time. He does have a f/u (follow up) appt (appointment) with urologist. Further nursing assessments for the scrotum wound, including measurements, were not available. During an interview on 8/26/15 at 4:45 p.m., the Director of Nursing Services (DNS) indicated the facility did not have documentation of Resident B's weekly wound assessment by the wound care nurse. She expected the assessment should have been completed on 6/24/15 because wound rounds were done on Wednesdays. Nursing notes, dated 6/23/15 at 4:28 p.m., indicated Resident B had an appointment with a urologist on 6/25/15 at 10:15 a.m. On 6/25/15 at 11:41 a.m., nursing notes indicated awareness of Resident B's morning appointment and his return to the facility. Clinical documentation did not indicate the urology office was contacted for further information related to wound care and treatment. During an interview, on 8/27/15 at 10:30 a.m., the Unit Manager of the Rehabilitation Unit indicated she did not call the urology office after Resident B returned to the facility, without paperwork, from the urology office visit. Urology notes received from the Urology office on 8/27/15, dated 6/25/15, indicated Resident B was to [MEDICATION NAME](antibiotic), as previously ordered, for the treatment of [REDACTED]. Physician orders [REDACTED]. There were no orders located to resume [MEDICATION NAME] any documentation that indicated [MEDICATION NAME] resumed. Resident B discharged from the facility on 6/29/15 at 7:00 p.m., to another nursing facility as indicated in a nursing note dated 6/29/15 at 7:00 p.m. emergency room physician examination documentation, dated 6/30/15 at 9:45 p.m., indicated Resident B presented with redness and swelling to his scrotum with a large ulcer noted. He was currently [MEDICATION NAME] infection, but the infection was progressing. The left scrotal ulcer measurements were 4 x 6 cm, with surrounding scrotal [MEDICAL CONDITION] and [DIAGNOSES REDACTED], with concern for [DIAGNOSES REDACTED] (a rapidly progressive soft-tissue necrotizing process to the perineal area on patients with associated co-morbidities). [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) were begun for the scrotal infection. Resident B was admitted to the hospital for further treatment and evaluation. The emergency room admission documentation, dated 6/30/15 at 9:56 p.m., indicated admission [DIAGNOSES REDACTED]. A Skin Management Program policy/procedure, with a revision date of 2/2015, was presented by the DNS on 8/26/15 at 4:30 p.m. The procedure indicated the following, 5. Wound rounds will be completed on a weekly basis to assess wounds following the wound meeting guidelines. The facility must have an assigned wound nurse that assesses the wounds on a weekly basis. The wound nurse is responsible for updating the wound composite reports on a weekly basis and reporting the results to the DNS. This Federal tag relates to complaint IN 516. 3.1-37(a)

Based on observations, record reviews, and interviews, the facility failed to identify pressure wounds until the wounds were assessed as unstageable, for 2 of 3 residents, in a sample of 7, reviewed for pressure sores. (Residents B & G) Resident B presented with 3 unstageable ulcers with no prior indication they were observed or assessed. Findings include: 1. The clinical record for Resident B was reviewed on 4/20/15 at 2:45 p.m. [DIAGNOSES REDACTED]. During the initial tour of the facility on 4/20/15, LPN #1 indicated Resident B was totally dependent on staff for care. An Occupational Therapy Plan of Care (Evaluation Only) dated 1/20/15 indicated .Reason for Referral: Nsg (nursing) concerns regarding positioning needs and ability for pt (patient) to get up in Broda Chair. Therapy Necessity: Evaluation only for appropriateness of Broda Chair.Precautions: Multiple contractures BUE (Bilateral Upper Extremities), BLE (Bilateral Lower Extremities), trunk and pelvis.Discharge plans: Home with family following respite care. At this point, skilled OT (Occupational Therapy) services are not recommended. Pt (patient) presents with high risk for skin breakdown due to immobility and multiple flexion contractures, therefore it is not recommended for pt to get up in Broda.Completed assessment of bed positioning in which appropriate wedge cushions and pillows are used for support and for prevention of skin to skin contact.Functional Deficit Other.High risk for Skin breakdown due to pt very thin and multiple contractures/deformities. a.) A document titled, Pressure Wound Skin Evaluation Report, dated 3/27/15, indicated a new skin alteration was assessed to Resident B's left inner knee. Measurement was 1.0 centimeter (cm) x 1.5 cm x 0.1 cm. The area presented as an unstageable pressure wound with necrotic/eschar (black, brown or tan tissue adheres to wound bed) tissue. The wound bed color was described as 80% granulation tissue, 20% eschar. Interdisciplinary Team notes, dated 3/27/15, indicated the following: Resident currently with noted contractures to bilateral lower extremities, slight contractures to bilateral upper extremities which contributes to difficult positioning.recently diagnosed with [REDACTED]. During an interview on 4/21/15 at 2:30 p.m., the Director of Nursing Services (DNS) indicated the unstageable wound to Resident B's left inner knee was noted during a facility wide skin sweep (skin assessments to all residents) on 3/27/15. b.) A pressure wound skin evaluation report, dated 3/30/15, indicated a new skin alteration was assessed to Resident B's right hip. The area presented as an ustageable pressure wound, 3.5 cm x 7 cm x 0.1 cm, with necrotic/eschar tissue. The wound bed color was described as eschar. c.) A pressure wound skin evaluation report, dated 4/08/15, indicated a new skin alteration was assessed to Resident B's right lateral malleolus. The area presented as an ustageable pressure wound with slough (yellow or white tissue adhering to ulcer bed) tissue, 1.0 cm x 0.5 cm x 0.1 cm. The wound bed color was described as slough. On 4/22/15 at 10:50 a.m., during an interview, the DNS indicated CNA's were expected to notify nurses if any skin concerns were observed during a shower or while providing care. Skin assessments were not to be completed or documented by CNA's. Documentation indicated Resident B's wound areas were not assessed until documentation indicated the wounds were unstageable. The DNS indicated unstageable wounds could present within 4 - 6 hours, for an immobile resident with severe contractures and delicate skin. Resident B had varying color and discoloration to his body, therefore making it difficult to determine the possibility of a concern. Discoloration may or may not be present prior to wound rupture, especially with a deep tissue injury. Physician documentation, dated 4/10/15, indicated this was the physicians first assessment of wounds to Resident B's hip, knee, and ankle. 2. The clinical record for Resident G was reviewed on 4/21/15 at 3:00 p.m. [DIAGNOSES REDACTED]. A document titled, Pressure Wound Skin Evaluation Report, dated 2/18/15, indicated a new skin alteration was assessed to Resident G's right heel. The area presented as an unstageable pressure wound with necrotic/eschar tissue, 2.5 cm x 4.2 cm x 0 cm. The wound bed color was described as 100% eschar. The wound care nurse indicated once she was made aware of the skin concern, it was assessed as unstageable. Resident G had a low air loss mattress for prevention of skin breakdown. A care plan, dated 2/4/15, indicated Resident G was at risk for skin breakdown due to extensive assist with ADL's (activities of daily living), [DIAGNOSES REDACTED]. A policy titled Skin Management Program, dated 2/2015, presented on 4/22/15 at 11:00 a.m., by the DNS, indicated the following: It is the policy of (name of the facility) to assess each resident to determine the risk of potential skin integrity impairment, upon admission, quarterly, annually, and with significant change. Residents will have a skin assessment completed no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment. A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and weekly.All alterations in skin integrity will be documented in the medical record.Pressure reduction devices are to be put in place.The wound care nurse will be notified of alterations in skin integrity.Direct care givers will be notified of skin alterations and specific care needs. Residents identified at risk for skin breakdown will have appropriate prevention interventions put into place.A care plan will be developed specific to the resident's needs including prevention interventions.Direct care givers will be notified of the resident's specific prevention interventions. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing any and all skin alteration as reported by the direct caregivers on the shift reported, following the same protocol listed above. This federal tag relates to Complaint #IN 114. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to assess and use prevention techniques for the further development of contractures for 1 of 1 residents, in a sample of 7, reviewed for contractures. (Resident B) Resident B was admitted to the facility and was assessed or treatment provided to prevent the development of severe contractures to his body. Findings include: The clinical record for Resident B was reviewed on 4/20/15 at 2:45 p.m. [DIAGNOSES REDACTED]. During the initial tour of the facility on 4/20/15, LPN #1 indicated Resident B was totally dependent on staff for care. Resident B was observed at 1:30 p.m. on 4/20/15. Contractures were noted to his bilateral feet, toes, fingers, mouth, eyes, bilateral wrists, bilateral knees, bilateral hips, neck, shoulders, bilateral upper and lower arms, and bilateral upper and lower legs. LPN #1 indicated Resident B's contractures were so severe that despite re-positioning every two hours, he contracts back to his contracted position. An admission assessment for November 2014, indicated Resident B had contractures to his bilateral legs. Additional admission assessment of the bilateral leg contractures or other contractures were not provided. Nursing notes indicated the following: 1/06/15- .contractures noted 1/21/15- Resident has several contractures that make it difficult for positioning. An Occupational Therapy Plan of Care (Evaluation Only) dated 1/20/15 indicated .Reason for Referral: Nsg (nursing) concerns regarding positioning needs and ability for pt (patient) to get up in Broda Chair. Therapy Necessity: Evaluation only for appropriateness of Broda Chair.Precautions: Multiple contractures BUE (Bilateral Upper Extremities), BLE (Bilateral Lower Extremities), trunk and pelvis.Discharge plans: Home with family following respite care. At this point, skilled OT (Occupational Therapy) services are not recommended.not recommended for pt to get up in Broda.Completed assessment of bed positioning in which appropriate wedge cushions and pillows are used for support.Frequency /Duration:.Evaluation Only. At 11:00 a.m. on 4/22/15, during an interview, the DNS indicated Resident B was admitted in November 2014, for respite care, for one month, and was still at the facility. Therapy services were not provided for respite stays. The staff expected Resident B would return home after 30 days, therefore therapy services were not added. She indicated the facility did not have a policy related to respite care services. Physical therapy plan of care and Initial Assessment notes, dated 3/30/15, indicated Resident B completes up to 25% of normal range of motion to right and left upper extremities (arms), and to right and left lower extremities (legs). Muscle tone to right and left upper extremities and to right and left lower extremities was described as hypertonic (extreme muscular tension). During an interview on 4/23/15 at 10:58 a.m., the Rehab Services Manager indicated Resident B was admitted for a respite stay. The facility did not have a policy related to respite care services. Therapy services were not offered during a respite stay, but, therapy services were started on 3/31/15, to address Resident B's wounds and positioning. These services were started secondary to the wounds and to prevent further injury. She added Resident B could not tolerate stretching exercises due to the severity of his contractures, at this time. This federal tag relates to Complaint #IN 114. 3.1-42(a)(2)

Based on record review and interview, the facility failed to ensure nursing staff notified a physician in a timely fashion regarding a significant change of condition resulting [MEDICAL CONDITION] and gangrene, for 1 of 5 residents reviewed for notification of physician in a sample of 5. (Resident D) Findings include: The record for Resident D was reviewed on 9/25/13 at 9:45 A.M. [DIAGNOSES REDACTED]. The SBAR (Situation Background Assessment Recommendations) Tool dated 9/6/13 at 1:23 A.M., indicated, "...Assessment...Resident had 1 blister intact on medial lower left extremity, 1 blister open on lateral lower left extremity, 1 blister intact on big toe. Resident lower left extremity had discoloration which is black/ necrotic and cold to touch...." The progress notes for 9/6/13 at 8:53 A.M., indicated,"...Resident had fluid filled blisters on lower left extremities and one that is open. Medial lower left extremity 1 intact fluid filled blister/Nursing(SIC) 1.4 cm(centimeter) x 0.9 cm, lateral lower left extremity open 3.4 cm x 2.6 cm, big toe lower left extremity intact fluid filled blister 0.8 cm x 0.8 cm. Lower left extremity is ischemic (lacking blood flow), cold to touch, and had no pedal or popliteal pulse. Physician called two times throughout night with no reply back at 1:42 A.M., and 2:34 A.M. Resident son called and message left for him to call facility. 8:55 A.M. Physician returned call and new order received to send resident to emergency room for evaluation and treatment...." The hospital emergency room report dated 9/6/13 indicated, "...positive for gangrenous changes to left forefoot, positive for [MEDICAL CONDITION], positive dorsal and lateral and mid foot blisters, foot is cold, pulses unpalpable...." The hospital history and physical dated 9/6/13 at 4:15 P.M., indicated, "...Skin...left foot black, cold doppler pulse...Impression/Assessment: 1. Left gangrenous foot-exam finding synthesis of gangrene of left foot. Patient is now septic...." In an interview on 9/26/13 at 2:30 P.M., with the Director of Nursing Services and the Executive Director, the Director of Nursing Services indicated the physician was not notified soon enough and another staff should have been called in the middle of the night when the significant change had occurred. This Federal tag relates to Complaint IN 811. 3.1-5(a)(2)

Based on observation, record review and interview, the facility failed to ensure timely treatment to a change in skin condition for 1 of 1 residents reviewed for non pressure wounds and for failure to ensure treatment of [REDACTED]. Findings include: 1. The record for Resident D was reviewed on 9/25/13 at 9:45 A.M. [DIAGNOSES REDACTED]. The SBAR (Situation Background Assessment Recommendations) Tool dated 9/6/13 1:23 A.M. indicated, "...Assessment...Resident had 1 blister intact on medial lower left extremity, 1 blister open on lateral lower left extremity, 1 blister intact on big toe. Resident lower left extremity had discoloration which is black/ necrotic and cold to touch...." The progress notes for 9/6/13 at 8:53 A.M., indicated,"...Resident had fluid filled blisters on lower left extremities and one that is open. Medial lower left extremity 1 intact fluid filled blister/Nursing(SIC) 1.4 cm(centimeter) x 0.9 cm, lateral lower left extremity open 3.4 cm x 2.6 cm,, big toe lower left extremity intact fluid filled blister 0.8 cm x 0.8 cm. Lower left extremity is ischemic (lacking blood flow), cold to touch, and had no pedal or popliteal pulse. Physician called two times throughout night with no reply back at 1:42 A.M., and 2:34 A.M. Resident son called and message left for him to call facility. 8:55 A.M., Physician returned call and new order received to send resident to emergency room for evaluation and treatment...." The hospital emergency room report dated 9/6/13 indicated, "...positive for gangrenous changes to left forefoot, positive for [MEDICAL CONDITION], positive dorsal and lateral and mid foot blisters, foot is cold, pulses unpalpable...." The hospital history and physical dated 9/6/13 at 4:15 P.M., indicated, "...Skin...left foot black, cold doppler pulse...Impression/Assessment: 1. Left gangrenous foot-exam finding synthesis of gangrene of left foot. Patient is now septic...." In an interview on 9/26/13 at 2:30 P.M., with the Director of Nursing Services and the Executive Director, the Director of Nursing Services indicated the significant change in the skin area was not addressed soon enough. She also indicated if the physician was not able to be reached, another staff should have been called in the middle of the night when the significant change had occurred. 2. The resident review for Resident F was completed 9/26/13 at 10:15 A.M. [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated the resident was not able to be interviewed as resident unable to be understood and was severely cognitively impaired. The progress notes dated 8/24/13 indicated Resident F had developed an unstagable area on her coccyx. The shower sheets for Resident F were reviewed. The shower sheets indicated, "9/12/13 ...open area...Comments Signs of pain when washing buttocks..." An observation of the resident during wound care on 9/26/13 at 1:50 P.M., was done with the Director of Nursing Services (DNS) LPN #2 and Certified Nursing Aide #3. LPN #2 was cleaning the residents wound when Resident F moaned. LPN # 2 responded by indicating she understood the wound cleanser was cold. The resident moaned again as she was rolled from her side to her back. The resident was observed having a furrowed brow. LPN #2 responded to the resident's moan by indicating to the resident she was almost done. In an interview on 9/26/13 at 2:00 P.M., with LPN #2, who was also the Unit Manager for the 200 unit, she indicated was not sure what the nurses were doing for pre treating or treating the resident's pain for her wound. LPN #2 upon reviewing the Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. The resident had not received any as needed medications for pain all month. In an interview with the DNS on 9/26/13 at she indicated if she observed a resident moaning during a wound treatment she would expect the nurse after performing treatment to check and see if the resident had received any pain medications. The pain management policy dated 1/03, indicated, "...Non-interviewable resident The pain management program will be determined based upon staff observation of non-verbal signs of pain as follows: NON-VERBAL SOUNDS (crying, whining, gasping, moaning, or groaning)...FACIAL EXPRESSIONS (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth)...." This Federal tag relates to Complaint IN 811. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure resident families and physicians were notified for possible intervention for 4 of 9 residents reviewed for notification in a sample of 22. (Residents "D", "G", "N" and "K"). Findings include: 1. The record for resident "D" was reviewed on 07-26-13 at 11:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's current plan of care, originally dated 10-20-11, indicated the resident was at risk for skin breakdown due to [MEDICAL CONDITIONS], a history of traumatic amputation, osteo[DIAGNOSES REDACTED] and cardiac conditions and a history of skin breakdown. Interventions to this plan of care included "assess and document skin condition weekly and as needed. Notify MD (medical doctor) of abnormal findings." Review of the resident record indicated the following: "Event: 07-19-13 at 11:23 p.m. burst blister on left second toe - new area. (measurement) 1.0 cm (centimeters) by 1.0 cm by 0.1 cm, pink with no drainage and no odor. [MEDICATION NAME] covered with gauze covering." "Progress note: 07-20-13 at 11:01 p.m. blister to 2nd left toe assessed this shift. Reddish appearance, no pain or discomfort noted related to bursted blister." "Progress note: 07-21-13 at 9:53 p.m. Pt. (patient) left toe continues to be red in color." "Progress note: 07-22-13 at 8:11 a.m. blister on left second toe is weeping clear fluid. Resident complains of discomfort when dressing area. Will continue to monitor." "Observation report: 07-22-13 at 11:37 p.m. - burst blister on left second toe - small open area on burst blister. Pain at site. Mild intensity. Resident makes facial expressions (i.e. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth)." "Progress note: 07-24-13 at 12:27 a.m. (family member) here and claimed that she was not informed of the blister on 2nd toe of left foot. Examined toe and found toe condition was much deteriorated since initial assessment on 07-19-(13). Called MD and ADNS (assistant director of nurses) and given resident new treatment ordered with [MEDICATION NAME] to wound, cover with gauze and wrap with Kerlix. [MEDICATION NAME] HCL (a narcotic [MEDICATION NAME]) 50 mg (milligrams) - 2 tablets three times a day for pain. MD requested Podiatry consult ASAP (as soon as possible). SS (social service) given request." "Progress note: 07-24-13 8:39 a.m. (family member) in to visit at breakfast and voiced concern pertaining to wound to left foot. Alternate nurse redressed wound this morning and states she noted that the toe was swollen with yellow drainage." "Observation report: 07-24-13 at 2:59 p.m. Currently experiencing pain and has had pain in the last 5 days. The pain made it hard to sleep and limited activities. The resident described the pain as 'frequent, heavy and severe during the changing of the dressing on the toe.'" A review of the hospital record on 07-26-13 at 8:10 a.m., indicated the concerned family member made a determination to take the resident to the local area hospital emergency room . A review of the emergency room physician documentation, dated 07-24-13 at 9:50 a.m., indicated the resident was "brought by medics secondary to 7 days of foot ulcer. (family member) saw her last night and noted increased foot pain. Unknown duration. RN (Register Nurse) said stated Monday as a blister. Cleaned wound and dressed." "Physical Examination - left foot second toe, ulcerated with necrotic tissue, warm foot to touch, not able to palpate pulse." "The left second toe [MEDICAL CONDITION] and [DIAGNOSES REDACTED]tous locally. On the left second toe ulcer located at the IPJ (interpharangeal joint) is macerated, is dorsal and measures 1.2 cm by 2.0 cm with exposed bone which appears to be the head of the proximal phalanx. There is also an ulcer noted on the lateral side of the second toe of the left foot." "Impression/Assessment: left second toe infection - podiatry consulted and can operate on toe on 07-29-(13)." The hospital podiatry exam, dated 07-24-13 at 11:30 a.m., indicated the "patient presents with left 2nd ulcer. patient's daughter states she was told it started as a blister on Monday 22nd, 2013. Left second toe is [MEDICAL CONDITION] and [DIAGNOSES REDACTED]tous with the ulcer located at IPJ (interphalangeal joint) is macerated. Bone is exposed, head of the proximal phalanx. Ulcer size is dorsally 1.2 cm by 2.0 cm with probing to the bone. Also ulcer noted on lateral side of the second toe. During an interview on 07-28-13 at 12:35 p.m., a concerned family member indicated when she arrived at the facility, "tears were streaming down (resident's) face. She needed something for the pain. I was upset because no one notified me. Even though (resident) had the pressure ulcer they kept trying to put her shoes back on her. I talked to (name of licensed nurse #11) and told him I wanted to see how bad the area was. When I took off her sock I couldn't believe what I saw. She is a diabetic and I know what that can mean. I talked to the DON (Director of Nurses) and told her I had a major concern. She said she would be up to the room but she never came. I told them to call 911." The Director of Nurses indicated she received a "typed" statement from the licensed nurse (#11). "I found it under my office door when I got here this morning." Review of the typed statement by Registered Nurse #11 on 07-29-13 at 11:00 a.m., indicated the licensed nurse independently performed a treatment on a resident without a physician order/intervention on two occasions. The typed note as follows: "On Friday July 19, 2013 I was the charge nurse for the second floor, Team Three, which included (name of resident "D"). At 10:30 p.m., one of the night aides informed me that the resident had a sore on the second toe of her left foot. Upon assessment of the toe, I determined that there was a blister that had ruptured. The opening of the blister was red in color and there was evidence of some drainage, but there was no foul odor present. The blister was treated with [MEDICATION NAME] and covered with gauze. I communicated with the night nurses, taking over Team Three, that this event had been started on the computer and that the doctor, DNS (Director of Nursing Services) to inform her of the situation. I contacted the MD through the answering service, but there was no response by the end of my shift. Before I left, I stressed to BOTH night nurses the importance of communicating the patient's change in status to her (family member) after the MD had been contacted the next morning before the end of their shift." The licensed nurse indicated he was not scheduled to work the following weekend and returned to work on Monday July 22, 2013. "When I returned to work for my shift on Monday, July 22, 2013, the nurse giving me report for Team Three stated that the patient's dressing had been changed on the affected toe and no further description was provided. The shift proceeded; the dressing on the patient's toe was observed and nothing was observed as remarkable at that time.""On Tuesday July 23, 2013, after the patient had been put to bed, her (family member) arrived for a visit. I was in the middle of the evening med. (medication) pass and was preparing to start the normal patient treatments (including changing the patient's toe dressing) when the patient's (family member) came to me and stated that her mother had complained of pain in her affected foot. When the (family member) saw the dressing on her mother's toe, she stated that she had not been informed that there had been a change in the situation and that this dressing was needed. When the patient's (family member) informed me that she had not been notified, I was very upset...the patient's (family member) was understandably irate and stated that she should have been contacted at any time such a discovery was made. I agreed with her and proceeded to change the dressing on the patient's foot. The dressings, which had loosened, were covered with dark, foul smelling drainage. The sore on the toe was now fully opened to the point that bone and sinew were exposed. I assessed this to be an emergency situation. I applied [MEDICATION NAME] and a gauze dressing to the toe and wrapped the entire foot with a Kerlix bandage. I then contacted the MD through his answering service, stating that I had an emergency. When the MD returned the call, I described the wound to him, how I had dressed it and told him that the resident was in a great deal of pain. The MD ordered paid (sic) medication based on what was immediately available on site, agreed with the treatment I had performed and also ordered a Podiatry consult which I communicated to Social Services. Shortly after that the Floor Supervisor called and I informed her of the situation. She called the ADNS (assistant director of nursing services), who then called to speak with me about the resident. She agreed with the treatment and said that the resident's shoe should not be put on the affected foot. Upon returning to the resident, I administered the prescribed pain medication. The (family member) seemed upset but stated that she was going home and would return early the next morning." The licensed nurse #11, failed to immediately inform the resident's physician for intervention, related to the blister. In addition, the licensed nurse failed to again alert the physician for intervention and treatment, and independently provided a treatment to this dependent resident. 2. The record for resident "G" was reviewed on 07-29-13 at 8:10 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. During an interview on 07-29-13 at 8:00 a.m., the Director of Nurses indicated the resident had been improperly transferred on 07-26-13, by Certified Nurses Aide #13, in which the resident fell to the floor and sustained a head injury. The Director of Nurses indicated the resident was sent to the hospital for evaluation. A review of the facility Event Report, dated 07-26-13 indicated the resident was being "toileted in the shower room and further indicated that when the CNA responded to her call light the resident told the CNA she needed to be toileted and would need the help from another staff member to transfer and CNA state 'No I can do it, while attempting to transfer resident from toilet to w/c (wheelchair) resident became weak and CNA was unable to stop her fall." The event report indicated the resident had a hematoma to the right side of forehead which measured 10.5 centimeters by 4.5 centimeters. Hematoma observed to right side of forehead et (and) resident c/o (complained of) headache." The notation section dated 07-26-13 at 6:10 p.m., indicated the resident was "observed becoming lethargic and expressing a need to go to sleep. Family at bedside. MD (medical doctor) notified et n.o. (new order) received to send to ER (emergency room ) for eval (evaluation) and treat. (treatment)." Review of the hospital record, dated 07-26-13, indicated the following: "The patient presents with fall while being helped with transfer to chair and then fell with nurse assistant, hit anterior head and also right foot and ankle pain, no LOC (loss of consciousness), no neck pain, no chest pain, no blood thinners. The course/duration of symptoms is constant. The character of symptoms is pain. The degree at onset was moderate. Right anterior forehead swelling. Radiology Impression: [MEDICAL CONDITION]: No dislocation. There appears to be a step-off in the subcapital region of the second metatarsal bone. This findings is suspicious for acute fracture. Please correlate clinically." "Exam: CT (cat scan) of the head without contrast - Impression: Right frontal scalp soft tissue swelling/hematoma." Further review of the hospital record instructed the resident that she "had a head injury. HOME CARE: Do not take aspirin after a head injury." Review of the resident's Medication Administration Record [REDACTED]." The administration record indicated the nursing staff gave the resident the aspirin on 07-27-13 and again on 07-28-13. The record lacked physician notification for instruction as to whether the resident should continued the aspirin therapy. 3. The record for Resident "N" was reviewed 07-31-13 at 9:10 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had physician orders, dated 06-10-13 for a urinalysis with a culture and sensitivity due to pain during urination. A subsequent notation indicated the resident received physician orders [REDACTED]. In addition, the physician instructed the nursing staff on 07-01-13 for a urinalysis with a culture and sensitivity after the completion of the antibiotic. A review of the resident's Medication Administration Record [REDACTED]. Review of the urinalysis, collected on 07-02-13 indicated the resident's urine remained cloudy, with few bacteria, and 3+ for leukocytes. The record lacked documentation the physician had been notified the resident had not completed the antibiotic treatment as ordered. 4. The record for resident "K" was reviewed on 07-29-13 at 2:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident had impaired skin integrity to the right lower leg as "blisters, weeping skin and 3+ [MEDICAL CONDITION]." A review of the resident's plan of care, dated 07-19-13 instructed the nursing staff to "assess wound weekly documenting measurements and description, notify MD (medical doctor) of worsening or no change in wound or for signs of infection, treatment as ordered." The "event report" dated 07-19-13 indicated the area to the right lower extremity upper measured 0.9 cm (centimeters) by 0.5 cm by < (less than) 0.1 cm. A review of the physician orders, dated 07-19-13 instructed the nursing staff to "cover fluid filled blisters to RLE (right lower extremity - shin) with dry dressing daily until resolved. The resident progress note, dated 07-26-13 at 10:50 a.m. indicated the right lower extremity presents as "2 dried blisters, no drainage, no s/sx (signs or symptoms) of infection, no pain, areas open to air, noted to have 3+ [MEDICAL CONDITION] to bilateral lower extremities." During interview on 07-29-13 at 2:00 p.m., the Director of Nurses confirmed the blisters had "burst" but the nursing staff had not contacted the physician to update about the change in the resident's right lower extremity for possible additional intervention. During the daily exit conference on 07-29-13 at 3:15 p.m., the Director of Nurses indicated the physician was notified and would be at the facility that evening. A record review on 07-31-13 at 10:00 a.m., indicated a physician order [REDACTED]. Discontinue the dry drsg (dressing) to right lower extremity from 07-19-13." The record lacked timely notification of the physician for possible interventions. 5. Review of facility policy on 07-26-13 at 1:30 p.m., titled "Resident Change of Condition," dated as "revised 03-10," indicated the following: "POLICY (bold type) It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party and that appropriate, timely and effective intervention occurs." "2. Acute Medical Change - a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. b. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention. c. The responsible party will be notified that there has been a change in the resident's condition and what seeps are being taken." This Federal tag relates to Complaints IN 445 and IN 446. 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure nursing staff notified a physician in a timely fashion regarding a significant change of condition resulting [MEDICAL CONDITION] and gangrene, for 1 of 5 residents reviewed for notification of physician in a sample of 5. (Resident D) Findings include: The record for Resident D was reviewed on 9/25/13 at 9:45 A.M. [DIAGNOSES REDACTED]. The SBAR (Situation Background Assessment Recommendations) Tool dated 9/6/13 at 1:23 A.M., indicated, "...Assessment...Resident had 1 blister intact on medial lower left extremity, 1 blister open on lateral lower left extremity, 1 blister intact on big toe. Resident lower left extremity had discoloration which is black/ necrotic and cold to touch...." The progress notes for 9/6/13 at 8:53 A.M., indicated,"...Resident had fluid filled blisters on lower left extremities and one that is open. Medial lower left extremity 1 intact fluid filled blister/Nursing(SIC) 1.4 cm(centimeter) x 0.9 cm, lateral lower left extremity open 3.4 cm x 2.6 cm, big toe lower left extremity intact fluid filled blister 0.8 cm x 0.8 cm. Lower left extremity is ischemic (lacking blood flow), cold to touch, and had no pedal or popliteal pulse. Physician called two times throughout night with no reply back at 1:42 A.M., and 2:34 A.M. Resident son called and message left for him to call facility. 8:55 A.M. Physician returned call and new order received to send resident to emergency room for evaluation and treatment...." The hospital emergency room report dated 9/6/13 indicated, "...positive for gangrenous changes to left forefoot, positive for [MEDICAL CONDITION], positive dorsal and lateral and mid foot blisters, foot is cold, pulses unpalpable...." The hospital history and physical dated 9/6/13 at 4:15 P.M., indicated, "...Skin...left foot black, cold doppler pulse...Impression/Assessment: 1. Left gangrenous foot-exam finding synthesis of gangrene of left foot. Patient is now septic...." In an interview on 9/26/13 at 2:30 P.M., with the Director of Nursing Services and the Executive Director, the Director of Nursing Services indicated the physician was not notified soon enough and another staff should have been called in the middle of the night when the significant change had occurred. This Federal Deficiency was cited on August 1, 2013. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-5(a)(2)

Based on observation, record review and interview, the facility failed to ensure a dependent resident received proper care and services, in that when a resident had a blister, the nursing staff (registered nurse #11) failed to inform the physician for immediate intervention, and made a determination to treat the affect area without a physician order. When the blistered area ruptured, and continued to deteriorate, the licensed nurse (#11) again made the determination for a treatment without a physician order. This deficient practice occurred over a 6 day period and resulted in the resident being admitted to the local area hospital, and required traumatic amputation of a toe for 1 of 3 residents reviewed for ulcers in a sample of 22. (Resident D). Findings include: The record for resident "D" was reviewed on 07-26-13 at 11:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's Annual history and physical examination [REDACTED]." A review of the resident's Minimum Data Set Assessment, dated 06-13-13, indicated the resident was dependent on the nursing staff for transfers, bed mobility, dressing and hygiene. In addition, the assessment indicated the resident was "at risk" for pressure ulcers, but did not have a pressure ulcer at the time of the assessment and further indicated the resident had no foot problems. The resident's current plan of care, originally dated 10-20-11, indicated the resident was at risk for skin breakdown due to [MEDICAL CONDITIONS], a history of traumatic amputation, osteo[DIAGNOSES REDACTED] and cardiac conditions and a history of skin breakdown. Interventions to this plan of care included "assess and document skin condition weekly and as needed. Notify MD (medical doctor) of abnormal findings." Review of the resident record indicated the following: "Event: 07-19-13 at 11:23 p.m. burst blister on left second toe - new area. (measurement) 1.0 cm (centimeters) by 1.0 cm by 0.1 cm, pink with no drainage and no odor. [MEDICATION NAME] covered with gauze covering." "Progress note: 07-20-13 at 11:01 p.m. blister to 2nd left toe assessed this shift. Reddish appearance, no pain or discomfort noted related to bursted blister." "Progress note: 07-21-13 at 9:53 p.m. Pt. (patient) left toe continues to be red in color." "Progress note: 07-22-13 at 8:11 a.m. blister on left second toe is weeping clear fluid. Resident complains of discomfort when dressing area. Will continue to monitor." "Observation report: 07-22-13 at 11:37 p.m. - burst blister on left second toe - small open area on burst blister. Pain at site. Mild intensity. Resident makes facial expressions (i.e. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth)." "Progress note: 07-24-13 at 12:27 a.m. (family member) here and claimed that she was not informed of the blister or 2nd toe on left foot. Examined toe and found toe condition was much deteriorated since initial assessment on 07-19-(13). Called MD and ADNS (assistant director of nurses) and given resident new treatment ordered with [MEDICATION NAME] to wound, cover with gauze and wrap with Kerlix. [MEDICATION NAME] HCL (a narcotic [MEDICATION NAME]) 50 mg (milligrams) - 2 tablets three times a day for pain. MD requested Podiatry consult ASAP (as soon as possible). SS (social service) given request." "Progress note: 07-24-13 8:39 a.m. (family member) in to visit at breakfast and voiced concern pertaining to wound to left foot. Alternate nurse redressed wound this morning and states she noted that the toe was swollen with yellow drainage." "Observation report: 07-24-13 at 2:59 p.m. Currently experiencing pain and has had pain in the last 5 days. The pain made it hard to sleep and limited activities. The resident described the pain as 'frequent, heavy and severe during the changing of the dressing on the toe.'" The resident's record indicated scheduled pain medication, original physician order [REDACTED]." A review of the hospital record on 07-26-13 at 8:10 a.m., indicated the concerned family member attempted to have the resident seen by a local Podiatrist, but was unable to have the area assessed immediately, and made the determination to take the resident to the local area hospital emergency room . A review of the emergency room physician documentation, dated 07-24-13 at 9:50 a.m., indicated the resident was "brought by medics secondary to 7 days of foot ulcer. (family member) saw her last night and noted increased foot pain. Unknown duration. RN (Register Nurse) said stated Monday as a blister. Cleaned wound and dressed." "Physical Examination - left foot second toe, ulcerated with necrotic tissue, warm foot to touch, not able to palpate pulse." "The left second toe [MEDICAL CONDITION] and [DIAGNOSES REDACTED]tous locally. On the left second toe ulcer located at the IPJ is macerated, is dorsal and measures 1.2 cm by 2.0 cm with exposed bone which appears to be the head of the proximal phalanx. There is also an ulcer noted on the lateral side of the second toe of the left foot." The hospital History and Physical, dated 07-24-13 at 1530 (3:30 p.m.) indicated the "left second toe with ulcer on toe on IPJ (interpharangeal joint) with yellow slough - oriented to self only." "Impression/Assessment: left second toe infection - podiatry consulted and can operate on toe on 07-29-(13)." The hospital podiatry exam, dated 07-24-13 at 11:30 a.m., indicated the "patient presents with left 2nd ulcer. patient's daughter states she was told it started as a blister on Monday 22nd, 2013. Left second toe is [MEDICAL CONDITION] and [DIAGNOSES REDACTED]tous with the ulcer located at IPJ (interphalangeal joint) is macerated. Bone is exposed, head of the proximal phalanx. Ulcer size is dorsally 1.2 cm by 2.0 cm with probing to the bone. Also ulcer noted on lateral side of the second toe. On 07-26-13 at 8:45 a.m., the hospital Podiatrist was at the resident's bedside and indicated the ulceration was the result of "pressure." During observation on 07-26-13 at 8:45 a.m., the resident was observed lying in bed. The hospital RN removed the dressing to the area and as she removed the dressing a pungent odor permeated the air. The nurse indicated the ulceration was located over the "knuckle." A thick yellow serosanguinous drainage was observed between the great toe and second toe. The nurse also identified an additional ulcerated area on the side of the second two and between the great toe and second toe." Further interview on 07-26-13 at 8:45 a.m., with the Medical Student in attendance with the Podiatrist, indicated she was present when the resident arrived at the emergency room . "We took pictures of her foot when she arrived in ER (emergency room ). The area was wet and macerated when she came in. There didn't seem to be an acute infection but there is a sinus tract that runs along the toe and is part of the opened area." During an interview on 07-28-13 at 12:35 p.m., a concerned family member indicated when she arrived at the facility, "tears were streaming down (resident's) face. She needed something for the pain. I was upset because no one notified me. Even though (resident) had the pressure ulcer they kept trying to put her shoes back on her. I talked to (name of licensed nurse #11) and told him I wanted to see how bad the area was. When I took off her sock I couldn't believe what I saw. She is a diabetic and I know what that can mean. I talked to the DON (Director of Nurses) and told her I had a major concern. She said she would be up to the room but she never came. I told them to call 911." Interview on 07-26-13 at 1:00 p.m., the Director of Nurses indicated she had notified Registered Nurse #11 to come to the facility for counseling regarding the situation and Resident "D." On 07-29-13 at 9:00 a.m., the Director of Nurses indicated the licensed nurse failed to come to the facility as indicated on 07-26-13, but was allowed to work the weekend. The Director of Nurses indicated she received a "typed" statement from the licensed nurse. "I found it under my office door when I got here this morning." Review of the typed statement by Registered Nurse #11 on 07-29-13 at 11:00 a.m., indicated the following. "On Friday July 19, 2013 I was the charge nurse for the second floor, Team Three, which included (name of resident "D"). At 10:30 p.m., one of the night aides informed me that the resident had a sore on the second toe of her left foot. Upon assessment of the toe, I determined that there was a blister that had ruptured. The opening of the blister was red in color and there was evidence of some drainage, but there was no foul odor present. The blister was treated with [MEDICATION NAME] and covered with gauze. I communicated with the night nurses taking over Team Three that this event had been started on the computer and that the doctor, DNS (Director of Nursing Services) to inform her of the situation. I contacted the MD through the answering service, but there was no response by the end of my shift. Before I left, I stressed to BOTH night nurses the importance of communicating the patient's change in status to her (family member) after the MD had been contacted the next morning before the end of their shift." The licensed nurse indicated he was not scheduled to work the following weekend and returned to work on Monday July 22, 2013. "When I returned to work for my shift on Monday, July 22, 2013, the nurse giving me report for Team Three stated that the patient's dressing had been changed on the affected toe and no further description was provided. The shift proceeded; the dressing on the patient's toe was observed and nothing was observed as remarkable at that time.""On Tuesday July 23, 2013, after the patient had been put to bed, her (family member) arrived for a visit. I was in the middle of the evening med. (medication) pass and was preparing to start the normal patient treatments (including changing the patient's toe dressing) when the patient's (family member) came to me and stated that her mother had complained of pain in her affected foot. When the (family member) saw the dressing on her mother's toe, she stated that she had not been informed that there had been a change in the situation and that this dressing was needed. When the patient's (family member) informed me that she had not been notified, I was very upset...the patient's (family member) was understandably irate and stated that she should have been contacted at any time such a discovery was made. I agreed with her and proceeded to change the dressing on the patient's foot. The dressings, which had loosened, were covered with dark, foul smelling drainage. The sore on the toe was now fully opened to the point that bone and sinew were exposed. I assessed this to be an emergency situation. I applied [MEDICATION NAME] and a gauze dressing to the toe and wrapped the entire foot with a Kerlix bandage. I then contacted the MD through his answering service, stating that I had an emergency. When the MD returned the call, I described the wound to him, how I had dressed it and told him that the resident was in a great deal of pain. The MD ordered paid (sic) medication based on what was immediately available on site, agreed with the treatment I had performed and also ordered a Podiatry consult which I communicated to Social Services. Shortly after that the Floor Supervisor called and I informed her of the situation . She called the ADNS (assistant director of nursing services), who then called to speak with me about the resident. She agreed with the treatment and said that the resident's shoe should not be put on the affected foot. Upon returning to the resident, I administered the prescribed pain medication. The (family member) seemed upset but stated that she was going home and would return early the next morning." Interview on 07-29-13, at 1:00 p.m., the Director of Nurses indicated she had no documentation to indicated when the blister first appeared, and did not have any "shower sheets," which would have included a description of the resident's skin condition, that would have alerted the nursing staff of the affected area. The licensed nurse #11, failed to immediately inform the resident's physician for intervention, related to the blister. In addition, the licensed nurse failed to again alert the physician for intervention and treatment, and independently provided a treatment to this dependent resident. From 07-19-13 through 07-24-13, at least four shifts of nurses, had contact with the resident and continued to provide a treatment to a resident without a physicians order related to the use of [MEDICATION NAME] ointment and a dressing. This Federal tag relates to Complaint IN 446. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure timely treatment to a change in skin condition for 1 of 1 residents reviewed for non pressure wounds and for failure to ensure treatment of [REDACTED]. Findings include: 1. The record for Resident D was reviewed on 9/25/13 at 9:45 A.M. [DIAGNOSES REDACTED]. The SBAR (Situation Background Assessment Recommendations) Tool dated 9/6/13 1:23 A.M. indicated, "...Assessment...Resident had 1 blister intact on medial lower left extremity, 1 blister open on lateral lower left extremity, 1 blister intact on big toe. Resident lower left extremity had discoloration which is black/ necrotic and cold to touch...." The progress notes for 9/6/13 at 8:53 A.M., indicated,"...Resident had fluid filled blisters on lower left extremities and one that is open. Medial lower left extremity 1 intact fluid filled blister/Nursing(SIC) 1.4 cm(centimeter) x 0.9 cm, lateral lower left extremity open 3.4 cm x 2.6 cm,, big toe lower left extremity intact fluid filled blister 0.8 cm x 0.8 cm. Lower left extremity is ischemic (lacking blood flow), cold to touch, and had no pedal or popliteal pulse. Physician called two times throughout night with no reply back at 1:42 A.M., and 2:34 A.M. Resident son called and message left for him to call facility. 8:55 A.M., Physician returned call and new order received to send resident to emergency room for evaluation and treatment...." The hospital emergency room report dated 9/6/13 indicated, "...positive for gangrenous changes to left forefoot, positive for [MEDICAL CONDITION], positive dorsal and lateral and mid foot blisters, foot is cold, pulses unpalpable...." The hospital history and physical dated 9/6/13 at 4:15 P.M., indicated, "...Skin...left foot black, cold doppler pulse...Impression/Assessment: 1. Left gangrenous foot-exam finding synthesis of gangrene of left foot. Patient is now septic...." In an interview on 9/26/13 at 2:30 P.M., with the Director of Nursing Services and the Executive Director, the Director of Nursing Services indicated the significant change in the skin area was not addressed soon enough. She also indicated if the physician was not able to be reached, another staff should have been called in the middle of the night when the significant change had occurred. 2. The resident review for Resident F was completed 9/26/13 at 10:15 A.M. [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated the resident was not able to be interviewed as resident unable to be understood and was severely cognitively impaired. The progress notes dated 8/24/13 indicated Resident F had developed an unstagable area on her coccyx. The shower sheets for Resident F were reviewed. The shower sheets indicated, "9/12/13 ...open area...Comments Signs of pain when washing buttocks..." An observation of the resident during wound care on 9/26/13 at 1:50 P.M., was done with the Director of Nursing Services (DNS) LPN #2 and Certified Nursing Aide #3. LPN #2 was cleaning the residents wound when Resident F moaned. LPN # 2 responded by indicating she understood the wound cleanser was cold. The resident moaned again as she was rolled from her side to her back. The resident was observed having a furrowed brow. LPN #2 responded to the resident's moan by indicating to the resident she was almost done. In an interview on 9/26/13 at 2:00 P.M., with LPN #2, who was also the Unit Manager for the 200 unit, she indicated was not sure what the nurses were doing for pre treating or treating the resident's pain for her wound. LPN #2 upon reviewing the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident had not received any as needed medications for pain all month. In an interview with the DNS on 9/26/13 at she indicated if she observed a resident moaning during a wound treatment she would expect the nurse after performing treatment to check and see if the resident had received any pain medications. The pain management policy dated 1/03, indicated, "...Non-interviewable resident The pain management program will be determined based upon staff observation of non-verbal signs of pain as follows: NON-VERBAL SOUNDS (crying, whining, gasping, moaning, or groaning)...FACIAL EXPRESSIONS (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth)...." This Federal Deficiency was cited on August 1, 2013. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure dependent residents were identified with pressure areas and received treatment as indicated by the physician to prevent additional deterioration of a pressure ulcer for 3 of 10 residents reviewed for wound care in a sample of 22 (Residents "E", "D" and "A"). Findings include: 1. The record for resident "E" was reviewed on 07-26-13 at 1:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set Assessment, dated 05-13-13, indicated the resident required extensive assistance with bed mobility, toileting and hygiene. In addition the assessment indicated the resident was always incontinent of bowel and bladder and at risk for pressure ulcers. A review of the resident's current plan of care, dated 06-04-13, indicated the resident had "impaired skin integrity due to IAD (incontinence associated [MEDICAL CONDITION]) to the sacrum and a subsequent plan of care, dated 08-13-12, which identified the resident with self care deficit. During an observation on 07-26-13 10:15 a.m., with the second floor Unit Manager in attendance, a pungent urine odor was obvious in the hallway in the vicinity of the resident's room. A request was made to check this resident for incontinence, and the Unit Manager indicated she could tell the resident was "wet." A second request was made to check the resident. Upon entrance to the resident's room, the urine odor was very strong. The resident was in bed, with her breakfast tray still present on the overbed table. As the Unit Manager removed the overbed table, the resident's bedspread was covered with a red liquid. The Unit Manager indicated, "Oh it looks like she spilt her juice." As the Unit Manager removed the bedspread, the sheet, resident's gown, and quilted underpad all had the spillage from the red liquid. The liquid had seeped all the way through the linens and gown. The resident said, "I'm cold." The Unit Manager indicated the resident was cold because she was not only wet from the red liquid, but also because she had urinated. A request was made to turn the resident. As the Unit Manager turned the resident the two quilted under pads as well as the bed linens and gown were saturated with urine, which extended from the resident's waist level to her knees. During this observation, the Unit Manager identified a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) pressure ulcer on the resident's right buttocks. As the Unit Manager pulled on the resident's right hip area, the resident stated "Oh that hurts." A certified nurses aide entered the resident's room and indicated that even though this resident was part of her assignment, she hadn't been in to see the resident "until just now, because (name of another Certified Nurses Aid) was suppose to give her, her shower this morning. I guess she has been sitting here all this time." At 11:25 a.m., the Unit Manager indicated the Stage 2 pressure ulcer measured 0.4 cm (centimeters) by 0.5 cm by 0.1 cm. 2. The record for resident "D" was reviewed on 07-26-13 at 11:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's Annual history and physical examination no rash, no pressure ulcers." A review of the resident's Minimum Data Set Assessment, dated 06-13-13, indicated the resident required extensive assistance by the nursing staff for transfers, bed mobility, dressing and hygiene. In addition, the assessment indicated the resident was "at risk" for pressure ulcers, but did not have a pressure ulcer at the time of the assessment. In addition the resident was incontinent of bowel and bladder. The resident's current plan of care, originally dated 10-20-11, indicated the resident was at risk for skin breakdown due to [MEDICAL CONDITIONS], a history of traumatic amputation, osteo[DIAGNOSES REDACTED] and cardiac conditions and a history of skin breakdown. Interventions to this plan of care included "assess and document skin condition weekly and as needed. Notify MD (medical doctor) of abnormal findings." A review of the hospital record on 07-26-13 at 8:10 a.m., indicated the resident was referred to the hospital "wound/skin evaluation" team, on 07-24-13 at 16:22 a.m. due to an observed pressure ulcer on the resident's sacral area. The documentation indicated the resident had a "Stage 1 (a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues), sacral pressure ulcer - and assessed as a healed sacral pressure ulcer with no pigmented skin and pinpoint superficially denuded site within the healed area that appears to have been caused by friction." Treatment interventions included a "[MEDICATION NAME] foam dressing with border over the sacral pressure ulcer, with turn/tilt at least every 2 hours and pressure relief from bilateral heels and a waffle static air mattress." During an observation on 07-26-13 at 8:10 a.m., the resident was observed in bed. The hospital nurse was at the resident's bedside and indicated the resident had been admitted through the emergency room . "She was admitted with a Stage 1 pressure ulcer." During this observation the registered nurse removed the physician ordered dressing. The resident's coccyx was pink with slight reddened areas. The area was not opened. 3. The record for resident "A" was reviewed on 07-26-13 at 11:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. During the initial tour of the facility on 07-26-13 at 10:00 a.m., the Unit Manager identified this resident as "dependent upon staff" for care. A review of the resident's Minimum Data Set Assessment, dated 07-18-13 indicated the resident required extensive assistance with bed mobility, transfer, dressing, hygiene, and toileting. In addition the assessment indicated the resident was always incontinent of bowel and bladder and at risk for pressure ulcers. A review of the resident's current plan of care, and originally dated 02-09-11, indicated the resident was at risk for pressure ulcers related to dependence upon staff for bed mobility and incontinence of bowel and bladder. Interventions included "treatment as ordered." The record indicated the resident had a physician order, dated 07-27-13 for a treatment - "[MEDICATION NAME]" to the left buttocks every shift and as needed for soilage." A review of the "event report" dated 07-27-13 at 6:22 p.m., indicated the resident had a "new area - a Stage 2 on the left buttocks which measured 1.1 cm by 0.3 cm by < (less than) 0.1 cm." During an observation on 07-29-13 at 10:30 a.m., the resident was observed lying on the right side while in bed. A request was made to CNA # 12 to observe the resident's buttocks. The CNA informed the resident of the need to turn her and check "her bottom." The CNA pulled back the sheet, and then turned the resident. The resident was observed with her slacks pulled down to her knees and during this observation, the physician ordered treatment was not present on the resident's coccyx or left hip area. The resident's coccyx was bright red in color. This Federal tag relates to Complaint IN 445. 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to ensure a dependent resident received care and services to prevent a fall with injury in that when a resident required toileting, the nursing staff failed to follow the resident's plan of care and request the assistance of another staff member in the transfer from the wheelchair to the commode. The CNA improperly transferred the resident independently, which resulted in the resident being dropped onto the floor and sustained significant bruising to her head and injury to the foot/ankle. This deficient practice effected 2 of 3 residents reviewed for falls in a sample of 22. (Resident "G" and "B"). Findings include: 1. The record for resident "G" was reviewed on 07-29-13 at 8:10 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's Minimum Data Set Assessment, dated 06-01-13 indicated the resident required extensive assistance with two staff members when toileting. Further review of the Assessment indicated the resident was unable to balance herself without the assistance of staff members in regard to moving from a seated to a standing position, moving on and off toilet, and surface to surface transfers. A review of the resident's current plan of care, originally dated 08-13-12, indicated the resident had "self care deficit related to decreased cognition, weakness, multiple sclerosis, neoplasm of the meringues, history of CVA (cerebral vascular accident) and required 2 staff assist with transfers." Review of the facility Resident Care Sheets, on 07-26-13 at 11:30 a.m., indicated the nursing staff were educated in the need for the resident transfer of 2 staff members. During an interview on 07-29-13 at 8:00 a.m., the Director of Nurses indicated the resident had been improperly transferred on 07-26-13, by Certified Nurses Aide #13, in which the resident fell to the floor and sustained a head injury. The Director of Nurses indicated the resident was sent to the hospital for evaluation. A review of the facility Event Report, dated 07-26-13 indicated the resident was being "toileted in the shower room and further indicated that when the CNA responded to her call light the resident told the CNA she needed to be toileted and would need the help from another staff member to transfer and CNA stated 'No I can do it, while attempting to transfer resident from toilet to w/c (wheelchair) resident became weak and CNA was unable to stop her fall." The event report indicated the resident had a hematoma to the right side of forehead which measured 10.5 centimeters by 4.5 centimeters. The "notation" section indicated This writer summoned to shower room per activities staff. Upon entering room, resident was observed sitting on bottom on floor in front of the toilet. Resident was fully clothed with shoes and LLE (left lower extremity) brace, however pants and brief were pulled down. Resident stated that she had been using the toilet and when finished she put on the call light for assistance. When the CNA entered the room, resident states that she told the CNA she would need another staff member to assist with the transfer. The CNA stated, 'no I can do it' and attempted to transfer resident by herself. During the transfer resident became weak and CNA was unable to stop her fall Hematoma observed to right side of forehead et (and) resident c/o (complained of) headache." The notation section dated 07-26-13 at 6:10 p.m., indicated the resident was "observed becoming lethargic and expressing a need to go to sleep. Family at bedside. MD (medical doctor) notified et (and) n.o. (new order) received to send to ER (emergency room ) for eval (evaluation) and treat. (treatment)." Review of the hospital record, dated 07-26-13, indicated the following: "The patient presents with fall while being helped with transfer to chair and then fell with nurse assistant, hit anterior head and also right foot and ankle pain, no LOC (loss of consciousness), no neck pain, no chest pain, no blood thinners. The course/duration of symptoms is constant. The character of symptoms is pain. The degree at onset was moderate. Right anterior forehead swelling. Radiology Impression: osteoporosis: No dislocation. There appears to be a step-off in the subcapital region of the second metatarsal bone. This findings is suspicious for acute fracture. Please correlate clinically." "Exam: CT (cat scan) of the head without contrast - Impression: Right frontal scalp soft tissue swelling/hematoma." During an observation on 07-29-13 at 8:15 a.m., the resident was seated in the main dining room, waiting for breakfast. The resident's right forehead was observed with a circular bruised area,which spanned from the eyebrow area to the scalp. The resident wore a boot type device to the right ankle/foot. When interviewed, about the pain associated with the head injury or ankle, the resident slightly touched her right forehead and indicated her head still hurt from the fall, as well as her ankle. "they told me, my ankle is just sprained but it hurts more than that." 2. The record for resident "B" was reviewed on 07-26-13 at 1:07 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's Minimum Data Set assessment dated [DATE] indicated the resident required extensive assistance with bed mobility. The resident's current plan of care, originally dated 08-11-11 indicated the resident was a "fall risk." Interventions to this plan of care included "start date: 08-11-11 provide appropriate assistive devices such as low bed, mats on floor," and an updated approach "start date 05-20-13 floor mat at bedside." A review of the progress notes, dated 06-19-13 at 12:04 a.m., indicated "pts (patients) son came in and found pt on floor LPN (licensed practical nurse) and CNA (certified nurses aide) put pt back to bed. assessment done, no injuries noted." A subsequent notation dated 06-19-13 at 12:03 p.m., indicated IDT (interdisciplinary team) Fall Review: 06-18-13 approx. (approximately) 11:00 p.m. un-witnessed fall, res. (resident) was found on floor by (family member). Nurse was notify (sic) by son. New interventions: low bed, mat on floor. low air loss mattress." Although the "approach" to the plan of care already included a low bed and a mat on the floor, the intervention was not in place at the time the resident was found by the family member. This Federal tag relates to Complaint IN 445. 3.1-45(a)(2)

Based on observation, interview and record review the facility failed to ensure a resident with a history of falls, received the assistive devices and supervision required as indicated in the resident's current plan of care, which resulted in significant bruising and a laceration for 1 of 5 residents reviewed for falls in a sample of 14. (Resident "I"). Findings include: The record for Resident "I" was reviewed on 06-13-13 at 11:10 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set assessment dated [DATE] and 05-19-13 indicated the resident had severe cognitive impairment, was incontinent of bowel and bladder and was unable to stabilize self without staff assistance when moving from a seated to standing position, walking, turning around, moving on or off the toilet and surface to surface transfers. A review of the resident's current plan of care dated 01-28-13 indicated the resident "has [MEDICAL CONDITION], noted to have increased restlessness i.e. attempting to crawl out of bed." Interventions to this plan of care included "Observe for safety, assess for toileting need, pain, discomfort." A plan of care dated 12-21-10 indicated "Resident at risk for falling r/t (related to) her use of [MEDICAL CONDITION] medication, antidepressant medication, incontinence, and her need for assistance with transfers and mobility." Interventions to this plan of care included "provide proper, well maintained footwear, provide an environment free of clutter, resident not to be seated in recliner to reduce risk of falls." The resident progress notes indicated on 05-10-13 at 10:19 p.m., the resident "was found on floor of (resident) room on roommates side. Another resident witnessed (resident) trying to put roommates shoes on and then losing balance. Resident hit left temple on hardwood floor. Vitals and neurochecks revealed nothing remarkable. Res. (Resident) developed large hematoma (7 centimeters diameter) under skin on left temple. Ice pack was applied after res. was returned to bed. Swelling was visibly reduced after 1 hour. Will continue to monitor." The facility IDT (Interdisciplinary team) note dated 05-13-13 at 9:24 a.m. indicated "Res. unable to explain what happened, d/t (due to) dementia. Was not incont. (incontinent) recent increase in P.M. [MEDICATION NAME] (an antidepressant) noted, med (medication) was admin. (administered) prior to fall, root cause" loss of balance, un-assisted transfer, fall interventions not in place." The nurses progress notes, dated 05-14-13 at 2:23 p.m., indicated "Hematoma to left temple et (and) ecchymosis/[MEDICAL CONDITION] to left eye." A subsequent nurses progress note dated 05-17-13 at 7:45 a.m., indicated "Res found sitting on the floor with back against the recliner. No injuries noted at this time." The facility IDT note dated 05-20-13 at 6:41 a.m. indicated the resident "was found on floor in lounge, seated on bottom, with back against recliner. prior to fall res. was in recliner. Res. unable to explain what happened related to dementia. Was not incont., recent increase in [MEDICATION NAME] noted. Root cause: fall interventions not in place, resident seated in recliner unattended." Interview on 06-14-13 at 11:45 a.m., the Assistant Director of Nurses indicated the resident was not suppose to be left unattended in the recliner. She was left unsupervised." A nurses note dated 06-10-13 at 8:01 a.m. indicated "Res. found on the floor bleeding from the right side of her head lying in urine. Upon examination noted that the res. had a knot and laceration on right side of her head. When trying to move res. she begun to grab her right hip stating it hurt and crying out in pain. Tried to stand res. up and was not successful due to the pain res. was experiencing in right hip. ADON (assistant director of nurses) notified and MD (medical doctor), MD advised to send to ER (emergency room ) for eval (evaluation) and TX (treatment). Res. son notified." The IDT notes dated 06-11-13 at 8:18 a.m. indicated "Un-witnessed fall on 06-10-13 at approx. (approximately 3:30 a.m., res, found on floor in room, seated bleeding from right side of head lying in urine, res. was sent to ER due (sic) of pain in lower extremities. Res. was unable to explain what happened r/t dementia, family and MD notified, new orders received. Root cause of fall: Res needed to be toileted. Immediate intervention: neuro checks, send to ER for immediate evaluation." Observation on 06-14-13 at 11:15 a.m., the resident was observed laying in bed. The resident had extensive bruising to the right eye and surrounding area, maroon in color, and a laceration to the right side of the forehead. A review of the ambulance report dated 06-10-13 at 3:40 a.m., indicated "Fall caused by loss of balance. Scene findings: blood. Alert to person. Laceration 1.3 inches. Direct pressure applied." The resident was transported to the local area emergency roiagnom on [DATE] and was assessed, "Fall and hit head on A/C (air conditioning) unit. Injury to the right forehead. [MEDICAL CONDITION] -"received 5 sutures to her forehead." This Federal tag relates to Complaint IN 211. 3.1-35(g)(2)

Based on observation, interview and record review the facility failed to ensure a resident with a history of falls, received the assistive devices and supervision required to prevent significant bruising and a laceration for 1 of 5 residents reviewed for falls in a sample of 14. (Resident "I"). Findings include: The record for Resident "I" was reviewed on 06-13-13 at 11:10 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had physician orders [REDACTED]. Review of the Nursing Spectrum Drug Handbook on 06-19-13 at 12:00 p.m., indicated the medication was classified as an " antiplatelet inhibitor, " with the following precautions: " Adverse reaction - Hematologic: bleeding. Patient monitoring - Monitor patient for unusual bleeding or bruising: drug significantly increases risk of bleeding. " A review of the resident's Minimum Data Set assessment dated [DATE] and 05-19-13 indicated the resident had severe cognitive impairment, was incontinent of bowel and bladder and was unable to stabilize self without staff assistance when moving from a seated to standing position, walking, turning around, moving on or off the toilet and surface to surface transfers. A review of the resident's current plan of care dated 01-28-13 indicated the resident "has insomnia, noted to have increased restlessness i.e. attempting to crawl out of bed." Interventions to this plan of care included "Observe for safety, assess for toileting need, pain, discomfort." A plan of care dated 12-21-10 indicated "Resident at risk for falling r/t (related to) her use of psychotropic medication, antidepressant medication, incontinence, and her need for assistance with transfers and mobility." Interventions to this plan of care included "provide proper, well maintained footwear, provide an environment free of clutter, resident not to be seated in recliner to reduce risk of falls." The resident progress notes indicated on 05-10-13 at 10:19 p.m., the resident "was found on floor of (resident) room on roommates side. Another resident witnessed (resident) trying to put roommates shoes on and then losing balance. Resident hit left temple on hardwood floor. Vitals and neurochecks revealed nothing remarkable. Res. (Resident) developed large hematoma (7 centimeters diameter) under skin on left temple. Ice pack was applied after res. was returned to bed. Swelling was visibly reduced after 1 hour. Will continue to monitor." The facility IDT (Interdisciplinary team) note dated 05-13-13 at 9:24 a.m. indicated "Res. unable to explain what happened, d/t (due to) dementia. Was not incont. (incontinent) recent increase in P.M. Trazodone (an antidepressant) noted, med (medication) was admin. (administered) prior to fall, root cause" loss of balance, un-assisted transfer, fall interventions not in place." The nurses progress notes, dated 05-14-13 at 2:23 p.m., indicated "Hematoma to left temple et (and) ecchymosis/edema to left eye." A subsequent nurses progress note dated 05-17-13 at 7:45 a.m., indicated "Res found sitting on the floor with back against the recliner. No injuries noted at this time." The facility IDT note dated 05-20-13 at 6:41 a.m. indicated the resident "was found on floor in lounge, seated on bottom, with back against recliner. prior to fall res. was in recliner. Res. unable to explain what happened related to dementia. Was not incont., recent increase in Trazodone noted. Root cause: fall interventions not in place, resident seated in recliner unattended." Interview on 06-14-13 at 11:45 a.m., the Assistant Director of Nurses indicated the resident was not suppose to be left unattended in the recliner. She was left unsupervised." A nurses note dated 06-10-13 at 8:01 a.m., indicated "Res. found on the floor bleeding from the right side of her head lying in urine. Upon examination noted that the res. had a knot and laceration on right side of her head. When trying to move res. she begun to grab her right hip stating it hurt and crying out in pain. Tried to stand res. up and was not successful due to the pain res. was experiencing in right hip. ADON (assistant director of nurses) notified and MD (medical doctor), MD advised to send to ER (emergency room ) for eval (evaluation) and TX (treatment). Res. son notified." The IDT notes dated 06-11-13 at 8:18 a.m. indicated "Un-witnessed fall on 06-10-13 at approx. (approximately 3:30 a.m., res, found on floor in room, seated bleeding from right side of head lying in urine, res. was sent to ER due (sic) of pain in lower extremities. Res. was unable to explain what happened r/t dementia, family and MD notified, new orders received. Root cause of fall: Res needed to be toileted. Immediate intervention: neuro checks, send to ER for immediate evaluation." Observation on 06-14-13 at 11:15 a.m., the resident was observed laying in bed. The resident had extensive bruising to the right eye and surrounding area, maroon in color, and a laceration to the right side of the forehead. Although the Nurse Progress Notes indicated the physician had been notified of the falls with injury, the notation lacked documentation the physician had been apprised the resident remained on Plavix. The resident's medication administration record for 05-2013 and 6-2013 indicated the resident received the medication Plavix daily from 05-10-13 at the time of the first fall with a head injury through 06-14-13. Interview on 06-19-13 at 3:00 p.m., the Administrator indicated a discussion was conducted "this morning when he came to the facility," about the resident's use of the antiplatelet medication. A review of the ambulance report dated 06-10-13 at 3:40 a.m., indicated "Fall caused by loss of balance. Scene findings: blood. Alert to person. Laceration 1.3 inches. Direct pressure applied." The resident was transported to the local area emergency roiagnom on [DATE] and was assessed, "Fall and hit head on A/C (air conditioning) unit. Injury to the right forehead. Forehead laceration -"received 5 sutures to her forehead." This Federal tag relates to Complaint IN 211. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview the facility failed to maintain proper hydration for 1 resident in a sample of 6, based on the individual residents needs. (Resident D) Findings include: The record for resident D was reviewed on 12-7-10 at 8:30 A.M. [DIAGNOSES REDACTED]. Resident D was admitted to the facility from the hospital on 10-27-10 with a physician's orders [REDACTED]. The result of the BMP drawn on 10-27-10 was as follows: Blood Urea Nitrogen (BUN): 50 (normal 6-20) Creatinine: 2.34 (normal 0.70-1.20) Potassium: 4.8 (normal 3.7-5.5) The record included a care plan dated 11-7-10 with a "Problem" of "History of [MEDICAL CONDITION]." The "Goal" indicated "Labs will be obtained as ordered." The "Approach" indicated "1. CBC and BMP as ordered and notify physician of abnormals. 2. Report for signs and symptoms for change in mentation." The record also included a care plan dated 11-7-10 with a "Problem" of "At risk for fluid imbalance due to use of diuretic." (The resident medications included [MEDICATION NAME], a diuretic, 40 mg (milligrams) twice each day.) The "Goal" indicated "Resident will be free from signs and symptoms of fluid volume deficit." The "Approach" indicated "1. Administer medications as ordered. 2. Document and notify MD of signs and symptoms of fluid volume deficit: dry mucous membranes, thirst, weight loss, decrease in blood pressure, weak/rapid pulse, change in mental status, decreased urine output, abnormal labs, poor skin turgor." The "Care Area Triggers" dated 11-7-10 indicated "Dehydration: Triggered due to receiving diuretic daily to treat history of pleural effusion. Skin turgor is within normal limits and mucous membranes are moist. BMP and CBC are monitored weekly and MD is made aware.: The "Food/Fluid Intake Record" for the resident indicated the first week in November 2010 he was eating 75-100% of each meal and consuming over 1500 cc (cubic centimeters) of fluid combining fluids taken with meals and medications. The result of the BMP drawn on 11-9-10 was as follows: Blood Urea Nitrogen (BUN): 83 (normal 6-20) Creatinine: 2.89 (normal 0.70-1.20) Potassium: 6.0 (normal 3.7-5.5) The record did not include an assessment of the residents physical condition. The record indicated the resident's facility physician was notified of the BMP results on 11-11-10. The record included a copy of an office visit note from the outside internal medicine physician dated 11-10-10. The record did not include information about the facility staff contacting this physician about abnormal lab results or change in the resident's condition necessitating the office visit. At this office visit the physician discontinued the use of the [MEDICATION NAME] and [MEDICATION NAME] (a cardiac medication). The note also indicated an "Impression" of "Urinary Tract Infection." The "Food/Fluid Intake Record" indicated starting on 11-9-10 the resident's food consumption decreased to 50% of each meal. On 11-10-10 and 11-11-10 the resident refused the evening meal and fluids entirely. On 11-12-10 and 11-13-10 he refused the evening meal and consumed 120 cc of fluids during meal time. On 11-11-10 the resident consumed 660 cc total for the day combining fluids taken with meals and with medications. The Nurse's Notes dated 11-11-10 at 9:40 P.M. indicated, "Appetite good- feeds self." The result of the BMP drawn on 11-12-10 was as follows: Blood Urea Nitrogen (BUN): 92 (normal 6-20) Creatinine: 3.38 (normal 0.70-1.20) Potassium: 6.0 (normal 3.7-5.5) Hand written on the lab results were the notes, "(Name of facility MD) called 11-12-10" and "Faxed to (name of outside Internal Medicine MD) office 11-12-10." The Nurse's Note dated 11-12-10 at 8:30 P.M. indicated the resident fell in his room with out any injuries noted. The Nurse's Notes dated 11-12-10 at 10:00 P.M. indicated, "Resident not eating to (sic) well. Has mouth sores. Refused meals on 11-11-10 and 11-12-10 dinner. Dr. notified of situation. Nurse requesting 2-Cal or Ensure (dietary caloric supplements)" No update to the care plan was made concerning food or fluid consumption. The Nurse's Notes for 11-13-10 included only temperature, pulse, respiration rate and blood pressure, and the notation of "F/U (follow up) fall continues." The Nurses Notes dated 11-14-10 at 7:00 P.M. indicated, "Resident refusing most of meals. Given (dietary) supplements. C/O (complains of) gum soreness and redness noted in mouth. Given pain meds, yogurt and applesauce. Tol(erated) well, helpful result. Res(ident) and POA (Power of Attorney) stated that res(ident) was having appointment set up for denture work due to not fitting right MD notified of oral discomfort- left message. VS (vital signs) 97.2-66-16, O2 sat(uration) 94% on room air, 110/70. Resident takes off O2 frequently, MD notified- no SOB (shortness of breath), no [MEDICAL CONDITION] noted." A MD order dated 11-15-10 at 11:30 A.M. indicated an order for [REDACTED]. The result of the BMP drawn on 11-15-10 was as follows: Blood Urea Nitrogen (BUN): 105 (normal 6-20) Creatinine: 4.23 (normal 0.70-1.20) Potassium: 6.9 (normal 3.7-5.5) Hand written on the lab report was, "MD notified 11-15-10. Resident sent to ER." The record included a "History and Physical" completed at the hospital dated 11-15-10 at 4:05 P.M. which indicated,"Acute [MEDICAL CONDITION] in [MEDICAL CONDITION]- [DIAGNOSES REDACTED]. With his level of BUN and potassium he will likely need [MEDICAL TREATMENT]." The record included a physician's hospital note dated 11-15-10 at 5:32 P.M. indicated the resident's potassium level upon arrival at the hospital was 7.9. The resident was admitted to the intensive care unit. The record indicated the resident was re-admitted to the facility on [DATE] without needing [MEDICAL TREATMENT]. The record included a "Progress Note" dated 11-20-10 written by the facility physician which indicated, "hospitalized with Acute [MEDICAL CONDITION]. Has [MEDICAL CONDITION] with a baseline creatinine of 1.9. admitted to (hospital) 11-15-10 with a creatinine of 4.3. felt to be prerenal secondary to dehydration with decreased po intake." This Federal Tag relates to complaint number IN 711. 3.1-46(b)