Every finding on record at St Augustine Home for the Aged

Based on interview and record review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed after an increase of an antipsychotic medication secondary to continued and increased behaviors for 1 of 1 resident reviewed for PASARR. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 6/27/25 at 1:32 p.m. The diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, and dementia with moderate psychotic disturbances. A Level I PASARR, dated 4/28/25, indicated Resident 2 did not currently have a known or suspected developmental condition or diagnosis that affects intellectual and/or adaptive functioning. The document also indicated if a status change occurred, symptoms increased, or other information suggested a potential serious mental illness, then the nursing facility must submit an updated screen to reevaluate the need for a PASARR Level II behavioral health evaluation. A physician's order, dated 4/22/25, indicated to administer Risperdal (an antipsychotic) 0.5 milligram (mg), with instructions to give one half tablet (0.25 mg), two times a day for psychosis. A physician's order, dated 5/7/25, indicated to administer Risperdal 0.5 mg, two times a day for psychosis. Resident 2's diagnosis of dementia with moderate psychotic disturbances was entered on 5/14/25. The change of the medication order was an increase in the dose of the antipsychotic medication. A psychiatric visit form, dated 5/27/25, indicated Resident 2 had an increase in dose of Risperdal on 5/7/25 which was effective, but her behaviors increase at bedtime. The treatment plan was to increase the dose of Risperdal. A physician's order, dated 5/27/25, indicated to administer Risperdal 0.5 mg, three times a day. The change of the medication order was an increase in the dose of the antipsychotic medication. An updated PASARR screen was not located in the clinical record after dose had been increased. During an interview, on 6/30/25 at 10:42 a.m., the Social Services Director indicated a referral for a new PASARR screen should be submitted if there was a change in condition, if a psychotropic medication was started, and if there was a dose increase in psychotropic medications. During an interview, on 6/30/25 at 12:12 p.m., the Indiana Care Service Helpline indicated a new referral for a Level II would be submitted as soon as possible for an increase in dose of mental health medications and for any significant change in status. A current facility policy, titled Preadmission Screening and Resident Review, dated 2/2017 and received from the Director of Nursing on 6/30/25 at 1:56 p.m., did not include when a new referral for Level II screen would be submitted. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure a medication was held according to the physician's order for 1 of 1 resident reviewed for quality of care. (Resident 8) Findings include: The clinical record for Resident 8 was reviewed on 6/27/25 at 10:48 a.m. The diagnoses included, but were not limited to, congestive heart failure, atrial fibrillation, and type 2 diabetes. A physician's order, dated 12/20/23, indicated to give metoprolol (a medication to reduce blood pressure) 12.5 milligrams (mg) by mouth 2 times per day with instruction to hold the medication for a systolic blood pressure less than 110 or a heart rate less than 55. A review of the Medication Administration Record (MAR) indicated metoprolol 12.5 mg was administered against the physician's hold orders on the following dates: a. On 3/3/25, the medication was administered in the evening with a systolic blood pressure of 109. b. On 3/12/25, the medication was administered in the evening with a systolic blood pressure of 109. c. On 4/3/25, the medication was administered in the morning with a systolic blood pressure of 105. d. On 4/7/25, the medication was administered in the evening with a systolic blood pressure of 108. e. On 4/23/25, the medication was administered in the evening with a systolic blood pressure of 107. f. On 5/4/25, the medication was administered in the morning with a systolic blood pressure of 100. g. On 5/5/25, the medication was administered in the evening with a systolic blood pressure of 109. h. On 5/27/25, the medication was administered in the evening with a systolic blood pressure of 106. During an interview, on 6/30/25 at 1:48 p.m., the Director of Nursing (DON) indicated that if the medication was held, there would be a number 4 in the MAR indicating it was held with a nursing note. There were no nursing notes, and it appeared the metoprolol was administered. During an interview, on 7/1/25 at 11:11 a.m., Registered Nurse (RN) 4 indicated if the blood pressure was below parameters, the order would be followed and the medication held. A current facility policy, titled MEDICATION, ADMINISTRATION, dated 8/2018 and received from the DON on 6/30/25 at 1:56 p.m., indicated .It is the responsibility of the nursing professional to be aware of the classification, action, correct dosage, and side effects of a medication before administration .Read and follow any special instructions written on labels 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure medications were dated after the medication was opened, expired blood glucose control solution was disposed of, and chemicals were properly stored for 1 of 1 medication cart and 1 of 1 medication storage room reviewed for medication storage. Findings include: 1. The medication cart was reviewed, on 6/27/25 at 9:00 a.m., and the following were observed: a. In the large top drawer of the medication cart, brimonidine tartrate ophthalmic solution (eye drops) had been opened and the bottle did not include an open date. Dorzolamide/Timolol ophthalmic solution (eye drops) had been opened, and the bottle did not include an open date. b. In the small top drawer of the medication cart, blood glucose control solution (solution used to ensure the blood glucose monitor was working correctly) had been opened on 5/11/25 after the expiration date of 3/1/25. 2. The medication storage room contained Clorox chemicals and a bottle of aerosol Raid (bug killer) stored under the sink. During an interview, on 6/27/25 at 9:21 a.m., QMA 2 indicated the nurse who opened the blood glucose solution should have checked the expiration date before opening and using the solution. The blood glucose control solution was opened after the expiration date and should not have been used or in the medication cart. During an interview and observation of the medication storage room, on 6/30/25 at 11:27 a.m., the Clorox chemicals and aerosol Raid were still stored under the sink. QMA 2 indicated he was not aware items were not to be stored under the sink. A current facility policy, titled Medication Disposal, dated 8/2018 and received from the Director of Nursing (DON) on 6/30/25 at 1:56 p.m., indicated .All expired medications .shall be destroyed A current facility policy, titled Labeling of Medications and Biologicals, dated 5/2023 and received from the DON on 7/1/25 at 9:30 a.m., indicated .All medications and biologicals used in the Home will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications .All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices .Labels for multi-use vials medications must include .the date the vial was initially opened .All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different [(shorter or longer)] date for that opened vial 3.1-25(j) 3.1-25(k)(6) 3.1-25(o)

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a CNA for 1 of 2 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 9/25/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A document, titled Indiana State Department of Health Survey Report System, indicated on 9/17/24 at approximately 7:45 a.m., the Executive Director (ED) was notified Resident B alleged CNA 1 knocked me out. The resident's description of the aide involved was consistent with the description of CNA 1. Later in the day on 9/17/24, a discoloration and raised area presented on Resident B's forehead. Staff interviews confirmed the raised area on Resident B's forehead was not present on the previous shift. The evidence pointed toward the resident's description of the incident to be accurate. CNA 1 was terminated. A handwritten facility statement dated 9/17/24 at 7:30 p.m. and signed by RN 2 indicated Resident B's left eye was slightly swollen. When asked if it hurt, he indicated no, but that's where she hit me. He described the staff member who hit him as that tall, big black one on night shift A handwritten facility statement, dated 9/17/24, and signed by CNA 3 indicated at approximately 2:30 a.m., CNA 3 was on her way to check on a resident when she observed CNA 1 coming out of Resident B's room. CNA 1 was complaining he called her N*****. RN 4 came from the west side of the facility and CNA 1 complained to her Resident B called her a N****** and lied on her indicating she had hit him on the face. CNA 1 and RN 4 went to Resident B's room at that time. When the two of them came back later, RN 4 indicated the resident was having a behavior and called her a N***** also and he did not want to see the two of them again. RN 4 indicated she would document his behavior. A typed facility statement, dated 9/17/24, and signed by RN 5 indicated that morning just past 7:00 a.m., the Director of Nursing (DON) and herself was exiting the elevator when they were approached by CNA 1. CNA 1 was visibly upset, appeared to be crying or had been crying, and was loudly expressing her frustration regarding Resident B. She asked to speak to RN 5 and the DON. CNA 1 spoke about an incident which occurred that morning at approximately 3:00 a.m. When she answered Resident B's call light and he realized it was her, he called her a racial slur. The night nurse was in the hall listening to the exchange, entered the room and he called her a N***** as well. CNA 1 was expressing her frustration this was not the first time he had used this language directed at staff. She felt like he got away with it and nothing was done about it. The DON attempted to calm CNA 1 down. CNA 1 indicated the resident said she had hit him. CNA 1 continued to voice her frustrations because Resident B got away with calling staff racial slurs, lied on her, and almost got her fired. The DON reminded CNA 1; Resident B was on the list which required staff to care in pairs because he did have those known behaviors. A handwritten facility statement, dated 9/17/24, and signed by CNA 1 indicated at approximately 3:00 or 3:30 a.m., Resident B turned his call light on, and she responded. When she opened his door, Resident B indicated N***** I want the nurse get out of my room. She left his room and closed the door. RN 4 was a few feet away behind her and heard the interaction between the resident and CNA 1. A handwritten facility statement, undated, and signed by CNA 7 indicated when she walked into Resident B's room to get him up, he indicated the big, tall girl hit him in the face. He placed his hand on his face where he indicated she hit him. He indicated he would only talk to another nurse, not the one that came in with the girl who hit him. A handwritten facility statement, dated 9/17/24, and signed by RN 8 indicated at the start of her shift, a CNA indicated to her Resident B wanted to talk to the morning nurse. Resident B indicated to RN 8 his night shift CNA (CNA 1) hit him in his forehead. Upon assessing the area, there was no redness or bruise discovered. He indicated he was in the bathroom, pulled the call light, the night aide came into the bathroom, and stated what the F do you want? He indicated the same night shift CNA (CNA 1) was also mean to his wife when she was a resident at the facility. A typed facility statement, undated, and signed by CNA 9 indicated she gave Resident B a shower on the evening of 9/16/24 around 9:00 p.m., and he did not have any skin issues. He did not have any bump or bruise anywhere on his face. On 9/17/24, she observed he had a bump on his forehead. She asked him if he fell . He indicated no he had not and late last night a big woman came into his room and told him to go to bed. She punched him with her fist. A handwritten statement, dated 9/17/24, and signed by RN 4 indicated Resident B requested the nurse at approximately 4:00 a.m. Upon entering the resident's room, he showed frustration and verbalized he did not feel I was the nurse. He began to explain he was knocked out cold just prior to the nurse's arrival. He indicated RN 4 would not believe him either because you're a N***** too. The nurse assessed the resident with no visible injuries to his face, chest or arms. He indicated CNA 1 hit him in the head. The resident did not know the nurse was standing outside of his room observing the interaction between he and CNA 1. RN 4 overheard the resident referring to CNA 1 as the racial slur N***** and a Big black girl. Both staff members exited his room after completing the tasks which needed to be completed. A document, titled PCE-Skin Assessment, dated 9/18/24 at 1:56 p.m., indicated a skin assessment was completed on Resident B. The skin evaluation indicated his left side of his forehead had a 1.5 cm (centimeter) by 1.5 cm brown discoloration with a 0.5 cm circular area of protrusion observed. The record for Resident B was reviewed on 1/13/25 at 12:14 p.m. The diagnoses included, but were not limited to, moderate dementia with mood disturbance, osteoarthritis, abnormal weight loss, nutritional anemia, major depressive disorder, and adult failure to thrive. A nursing progress note, dated 9/17/24 at 3:39 a.m., indicated Resident B pulled his call light and immediately upon the staff member's entrance into his room, he referred to the staff member as a N*****. He indicated he did not need help from either one of them and you people are all alike. You are going to h*** for being a N*****. He continued to demean staff and say cruel things to staff, so they exited the room. A nursing progress note, dated 9/17/24 at 9:08 a.m., indicated the resident voiced being upset with the night shift staff last night. A nursing progress note, dated 9/18/24 at 7:00 a.m., indicated the resident had some slight discoloration to his left frontal forehead observed with tenderness when touched. A nursing progress note, dated 9/18/24 at 8:43 p.m., indicated there was slight swelling observed above his left eye. A nursing progress note, dated 9/19/24 at 7:08 a.m., indicated there was slight swelling observed above his left eye. During an interview, on 1/10/25 at 1:01 p.m., the Human Resource Director indicated CNA 1 was terminated due to the facility's findings during the investigation. Resident B had called CNA 1 a name and he had a mark on his head discovered through their investigation. During an interview, on 1/10/25 at 1:09 p.m., the Executive Director (ED) indicated CNA 1 was terminated for abuse. Resident B's story stayed consistent every time he told it. A knot with discoloration did form on his forehead the day after CNA 1 took care of him, which was not there on the previous shift. During an interview, on 1/13/25 at 11:15 a.m., Resident B indicated he was hit by a staff member, but it was so long ago he did not remember the description of the girl. He heard she no longer worked at the facility, and he was glad. During an interview, on 1/13/25 at 2:15 p.m., the Human Resource Director indicated CNA 1 was terminated for abuse for hitting Resident B on the forehead above his eye. There were inconsistencies in CNA 1 and RN 4's statements, while Resident B's statement stayed consistent and never changed. During an interview, on 1/13/25 at 2:15 p.m., the Director of Nursing (DON) indicated a consideration looked at prior to terminating CNA 1, was the resident was supposed to be cared for in pairs and there was no one else in the room with her to verify she did not hit Resident B. CNA 1 did not follow their policy and procedure of caring for residents in pairs when it was care planned to do so. A document, titled CNA 1's Status for 9/19/2024, dated 9/19/24, indicated CNA 1 was terminated on 9/19/24. She was not eligible for rehire. Her termination was involuntary. She was terminated at the conclusion of an abuse investigation and the abuse allegations against her were found to be substantiated. A current facility policy, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 1/2018 and provided by the ED on 1/10/25 at 1:09 p.m., indicated .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Abuse includes .physical abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical abuse: includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment A current facility policy, titled Resident's [NAME] of Rights, dated 4/2017 and provided by the ED on 1/10/25 at 1:09 p.m., indicated The Resident has the right to a dignified existence that will provide and maintain a supportive environment to promote self-esteem and personal dignity and to ensure that the Resident and civil rights are respected and protected .Personal Rights 1. The Resident has the right to honor and respect at all times and under all circumstances, to courteous and equal consideration from all with whom they come in contact in view of God's creative love for them. Thus, the Resident has the right to expect available care, treatment, services or accommodation to be provided when indicated without consideration based on race, color, creed, sexual orientation, national origin or the nature of the source of payment for care The deficient practice was corrected, by 9/25/24, after the facility implemented a systemic plan that included resident interviews, staff interviews, CNA 1 was terminated and a resident abuse in-service was completed for all employees. This citation relates to Complaint IN00449365. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure a resident's code status was obtained and accurately documented in the clinical record for 1 of 1 resident reviewed for advanced directives. (Resident 171) Finding includes: The clinical record for Resident 171 was reviewed on [DATE] at 2:58 p.m. The diagnoses included, but were not limited to, hypertension, severe protein-calorie malnutrition, hemorrhage from respiratory passages, and anemia. Resident 171 was admitted to the facility on [DATE]. A document, titled Long-Term Care Patient Summary, with post-acute care discharge instructions, dated [DATE], indicated Resident 171 did not have advanced directives. A document, titled Indiana Physician Orders for Scope of Treatment (POST), was prepared on [DATE]. The designation of the resident's preferences related to, attempt resuscitation/CPR, or do not attempt resuscitation/DNR was left blank. A code status was not documented on the face sheet. There was no order addressing code status found in the record. A baseline care plan meeting, completed on [DATE], lacked documentation to show a discussion was had with the resident or resident representative regarding code status preferences. A code status preference was not documented in the care plan for Resident 171. During an interview, on [DATE] at 3:00 p.m., RN 3 indicated a newly admitted resident should have a code status preference documented in their clinical record within 24 hours after being admitted . If a code status was not present in the clinical record, staff would treat the resident as a full code and would perform CPR. During an interview, on [DATE] at 3:06 p.m., the Director of Nursing (DON) indicated Resident 171 did not have a code status documented in his clinical record. The DON was not aware if the resident's preferences was to attempt resuscitation/CPR, or do not attempt resuscitation/DNR due to it was left blank on the POST form. Residents were seen by the physician within 72 hours after admission and a code status would then be documented in the clinical record. The POST form in the clinical record was from Resident 171's previous place of residence. During an interview, on [DATE] at 3:05 p.m., the DON indicated the Social Service Director (SSD) had seen the original POST form for Resident 171 in the clinical record and did not initiate the code status process upon admission. A current policy, titled Advance Directive, dated as last revised ,d+[DATE] and received from the DON on [DATE] at 11:18 a.m., indicated .Document on admission, that Advance Directives exist and place a copy of the Advance Directives in the Resident Medical Record .As Advance Directive are completed or modified, a current copy is kept within the Medical/Nursing Chart .Assist with communication of the Advance Directives, as necessary, to physician, Home staff, hospital staff, Resident, Resident Representative and Family according to Resident's desires 3XXX,d+[DATE](f)(4)(A)(ii) 3XXX,d+[DATE](f)(5)

Based on interview and record review, the facility failed to ensure a resident was assessed and treated for constipation, to ensure a resident was assessed for complications of congestive heart failure and to notify the physician of weight gains outside of the physician's ordered parameters for 3 of 3 residents reviewed for quality of care. (Resident 12, 18 and 11) Finding includes: 1. The clinical record for Resident 12 was reviewed on 9/17/24 at 2:31 p.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, asthma, and constipation. The bowel movement documentation indicated the resident had not had a bowel movement from 8/27/24 to 8/31/24 (5 days). There was no abdominal assessment noted in the record. A physician's order, initiated on 8/31/23, indicated .BOWEL CONSTIPATION PROTOCOL: do not go more than 2 days without a bowel movement, take Miralax 17 grams in 8 ounces of fluids as needed for constipation A physician's order, initiated on 6/21/24, indicated to give half a scoop of Miralax 17 grams in the morning for constipation. A physician's order, initiated on 4/19/24, indicated to give Senna-Docusate Sodium 8.6-50 milligram tablet as needed for constipation twice a day. A physician's order, initiated on 4/19/24, indicated to give Senna-Docusate Sodium 8.6-50 milligrams daily for constipation. A care plan, initiated on 3/30/22, indicated the resident had a potential for constipation related to decreased mobility and medications. Interventions included, but were not limited to, administer stool softener/ laxative as ordered, monitor for symptoms of constipation such as abdominal pain, a distended abdomen and bowel sounds, and administer as needed medications (to promote a bowel movement) after three days. During an interview, on 9/20/24 at 8:45 a.m., RN 1 indicated bowel movements were to be charted by the CNA. The nurse would talk with the resident and ask when they last had a bowel movement. If no bowel movement after three days, then the bowel assessment was to be done and charted in the notes. If the resident had an order for medication the nurse was to administer the medication. If there was no order, the nurse would contact the physician. During an interview, on 9/20/24 at 3:55 p.m., the Director of Nursing indicated she was not able to find documentation of a bowel movement from 8/27/24 to 8/31/24 or an assessment which was completed. The staff should ask the resident if they have had a bowel movement (if not documented) and then follow the facility bowel movement protocol. The protocol consisted of increasing fluids and assessing the bowel sounds. 2. The clinical record for Resident 18 was reviewed on 9/17/24 at 3:33 p.m. The diagnoses included, but were not limited to, congestive heart failure, chronic respiratory failure with hypoxia, and chronic kidney disease. The documented weights indicated the resident weighed 165.3 pounds on 9/2/24 and 170.4 pounds on 9/3/24 which indicated a gain of 5.1 pounds in a 24-hour period. There was no assessment of the lung sounds, edema, or chest pain found in the record. There was no documentation the weight was rechecked for accuracy and there was no note to indicate the physician had been informed of the weight gain. A physician's order, dated 5/31/24, indicated to weigh the resident daily in the morning and to report to the physician a weight gain of greater than three pounds in 24 hours or five pounds in a week for a diagnosis of congestive heart failure. A physician's order, initiated 7/4/24, indicated to encourage a fluid restriction of 1500 milliliters (ml) daily for chronic heart failure. A current care plan, revised on 12/4/23, indicated the resident was at risk for complications due to congestive heart failure, atrial fibrillation and hypertension. She would be free of complications and have clear lung sounds and the heart rate and rhythm would be within normal limits. Interventions included, but were not limited to, monitor for difficulty breathing, weight gain, edema and chest pain, contact the physician as indicated, and weight monitoring as ordered. A current care plan, revised on 8/7/24, indicated the resident was at risk for dehydration related to diuretic therapy, edema, hypertension, congestive heart, and a history of hyponatremia (low sodium levels) with a fluid restriction. Interventions included, but were not limited to, monitor weights as ordered and consult the physician as indicated. During an interview, on 9/20/24 at 8:45 a.m., RN 6 indicated residents with a diagnosis of congestive heart failure (CHF) should have their oxygen saturation levels assessed per physician's order. Daily weights were to be completed, and the physician notified if there was a weight gain. A respiratory assessment was to be done, a reweigh of the resident, and check the resident for edema and skin turgor. An SBAR (a type of assessment to relay information to the physician) should be completed. If after notifying the physician there were new orders, carry out the orders and continue to monitor the resident. 48525 3. The clinical record for Resident 11 was reviewed on 9/17/24 at 2:41 p.m. The diagnoses included, but were not limited to, unspecified dementia, hyperlipidemia, age related osteoporosis, and unspecified atherosclerosis of native arteries of bilateral legs. A physician's order, with a start date of 7/1/24, indicated if a gain or loss of 4 pounds since the last weight, then weigh 4 days consecutively and notify provider if the gain or loss was valid. A vitals log indicated the following weights: On 7/1/2024, the weight was 157.0 pounds. On 8/1/2024, the weight was 156.7 pounds. On 9/1/2024, the weight was 161.5 pounds. On 9/1/24, the resident gained 4.8 pounds compared to the last weight. There was no documentation in the record to indicate the resident had been weighed for 4 days after the weight gain or notification to the provider of the gain had occurred. During an interview, on 9/19/24 at 3:07 p.m., the Director of Nursing (DON) indicated she did not see documentation to indicate the resident was weighed for those 4 days per the order. During an interview, on 9/20/24 at 10:52 a.m., the DON indicated the expectation was staff would follow the physician's orders and if they had any questions, they would call the physician. A current facility policy, titled WEIGHT, LOSS OR GAIN, dated as revised in 8/2018 and received from the Director of Nursing on 9/20/24 at 11:10 a.m., indicated .A Resident with weight gain should be assessed and monitored for signs and symptoms of Congestive Heart Failure A current facility policy, titled Weights, Techniques, dated as revised 8/2018 and received from the Director of Nursing on 9/20/24 at 11:11 a.m., indicated .Residents with a three to five (3-5) lb. loss or gain are reported to the nurse, Supervisor of Director of Nursing A current facility policy, titled Congestive Heart Failure, dated as reviewed 1/2023 and received from the Director of Nursing on 9/19/24 at 2:24 p.m., indicated .In the event of any symptoms of CHF (Congestive Heart Failure) of a Resident, the Physician, Resident Representative, Family will be notified by the Charge Nurse under whose supervision the Resident has been delegated, immediately .Common symptoms are .Weight gain A current facility policy, titled BOWEL AND BLADDER PROGRAM SCHEDULE, was received from the Director of Nursing on 9/20/24 at 11:11 a.m. The policy did not address a bowel protocol. 3.1-37(a)

Based on interview and record review, the facility failed to ensure urinary output was monitored as ordered by the physician for 1 of 1 resident reviewed for catheter care. (Resident 18) Finding includes: The clinical record for Resident 18 was reviewed on 9/17/24 at 3:33 p.m. The diagnoses included, but were not limited to, cerebral ischemia (acute brain injury from impaired blood flow to the brain), heart failure, and chronic respiratory failure with hypoxia (a condition which occurs from lack of oxygen in the blood). A care plan, initiated on 4/27/23, indicated the resident had an indwelling catheter related to bladder obstruction and urinary retention. The interventions included, but were not limited to, monitor and document urinary output per the facility policy. A physician's order, initiated on 4/6/23, indicated to record urinary output every shift. The Medication and Treatment Record, for August 2024, was missing urinary output documentation on the night shift for August 1st, the evening shift on August 18th, the night shift on August 21st, and the day shift on August 27th. During an interview, on 9/20/24 at 8:45 a.m., RN 1 indicated urinary output was to be documented on the Medication Administration Record. A current facility policy, titled .INTAKE AND OUTPUT, dated as last revised in 01/2024 and received from the Infection Preventionist on 9/20/24 at 4:40 p.m., indicated .To ensure adequate hydration levels of certain Residents and to assist in their assessment and management by using I & O (intake and output) record .I&O records are kept on Residents with the following .Foley catheters .record output from catheters 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated for the day it was changed for 3 of 3 residents reviewed for respiratory care. (Residents 18, 12 and 10) Findings include: 1. During an observation, on 9/17/24 at 9:35 a.m., Resident 18 was observed in a recliner in her room. She was found to be using supplemental oxygen at two (2) liters per minute through a nasal cannula. The oxygen line did not have a date to show when the oxygen tubing had been changed. The clinical record for Resident 18 was reviewed on 9/17/24 at 3:33 p.m. The diagnoses included, but were not limited to, cerebral ischemia (acute brain injury from impaired blood flow to the brain), heart failure, and chronic respiratory failure with hypoxia (a condition which occurs from lack of oxygen in the blood). A physician's order, initiated on 7/11/24, indicated to provide oxygen at two (2) liters per minute via nasal cannula for chronic respiratory failure with hypoxia. 2. During an observation, on 9/16/24 at 10:33 a.m., Resident 12 was up in sitting up in her room. She was found to be using supplemental oxygen at two (2) liters per minute through a nasal cannula. The oxygen line did not have a date to show when the oxygen tubing had been changed. The clinical record for Resident 12 was reviewed on 9/17/24 at 2:31 p.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, asthma, and chronic obstructive pulmonary disease (COPD). A physician's order, initiated on 3/12/23, indicated to change and date the oxygen tubing and storage bags every evening shift on Tuesday. A care plan, revised on 5/29/24, indicated the resident had a potential for respiratory complications due to COPD, asthma, chronic respiratory failure with hypoxia, pulmonary fibrosis, and chronic heart failure. She required supplemental oxygen. 3. During an observation, on 9/16/24 at 12:19 p.m., Resident 10 was up in a high back wheelchair in the dining area. He was found to be using supplemental oxygen at two (2) liters per minute through a nasal cannula. The oxygen line did not have a date to show when the oxygen tubing had been changed. The clinical record for Resident 10 was reviewed on 9/20/24 at 12:02 p.m. The diagnoses included, but were not limited to, hypoxemia, heart failure, and obstructive sleep apnea (a sleep disorder which occurs when the upper airway partially or completely collapses during sleep, interrupting breathing). A physician's order, initiated on 8/5/20, indicated the resident may use oxygen at two liters per minute. A care plan, revised on 9/4/24, indicated the resident required supplemental oxygen to maintain adequate oxygenation. During an interview, on 9/17/24 at 2:27 p.m., the Director of Nursing indicated the oxygen tubing should be changed weekly, and the tubing should be labeled with the date it was changed. A current facility policy, titled OXYGENATOR, dated as last revised in 8/18 and received from RN 1 on 9/18/24 at 10:46 a.m., indicated .Nasal cannula/face mask and humidifier must be changed weekly 3.1-47(a)(6)

Based on interview and record review, the facility failed to monitor the use of antibiotics including the use of standardized tools for the appropriateness of antibiotics prescribed for 1 of 5 residents reviewed for unnecessary medications. (Resident 11) Finding includes: The clinical record for Resident 11 was reviewed on 9/17/24 at 2:41 p.m. The diagnoses included, but were not limited to vitamin D deficiency, hypertension, polyosteoarthritis, and age-related osteoporosis. A physician's order, with a start date of 7/23/24, indicated the resident took Keflex (an antibiotic) oral capsule 250 milligrams (mg). During an interview, on 9/20/24 at 3:27 p.m., the Director of Nursing (DON) indicated their physician did the tracking for antibiotics. She was not aware of anybody who did surveillance using the McGeer criteria (surveillance definitions used to identify infections) in the facility. The nurses would report the signs and symptoms to the physician but did not use a specific protocol. There was no documentation of a surveillance tool used for the resident. A current policy, titled Antibiotic Stewardship Program, dated 1/2024 and received from the DON on 9/20/24 at 3:45 p.m., indicated .Infection preventionist - coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff .Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use .The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections .Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to .assessment forms .antibiotic use protocols/algorithms .data collection forms for antibiotic use, process, and outcome measures A current policy, titled Infection Prevention and Control Program, dated 1/2024 and received from the DON on 9/20/24 at 3:45 p.m., indicated .The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the residents' physician's and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections .Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. C. The infection preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program 3.1-18(b)(1)(A) 3.1-18(b)(1)(B) 3.1-18(b)(1)(C)

Based on interview and record review, the facility failed to thoroughly investigate an allegation and immediately take action to prevent further abuse or mistreatment from occurring while the investigation was in progress for 1 of 1 resident reviewed regarding abuse or mistreatment. (Resident 10) Finding includes: The record for Resident 10 was reviewed on 07/07/2023 at 2:21 p.m. Diagnoses included, but were not limited to, dementia with mood disturbance, anxiety disorder, major depressive disorder, total retinal detachment affecting the right eye, general muscle weakness, unsteadiness on feet, and repeated falls. A current MDS (Minimum Data Set) assessment, dated 05/30/2023, indicated the resident had a BIMs (Brief Interview for Mental Status) score of 9, indicating the resident demonstrated a cognitive impairment. A progress note, dated 02/19/2023 at 7:00 p.m., indicated Late Entry .Writer spoke to Resident in regard to her complaint of left wrist pain. There was noticeable redness on her left small finger and knuckle area. When she was asked what happened, she stated, a staff member pulled her very roughly and hurt her wrist. There is no evidence of swelling, redness or swelling on her wrist . An Incident Report to the Indiana State Department of Health, dated 02/19/2023 and provided by the Administrator on 07/10/2023 at 2:31 p.m., indicated on 02/19/2023, Administrator notified this evening that (Resident 10) alleged the woman in the 'yellow hat' was rough with her. (Resident 10) claimed her wrist was sore. The type of injury to the resident was described as .her left wrist was sore. No swelling or visible marks noted. Some redness noted to her left pinkie finger. Preventative measures were identified as There is a staff member that wears a head covering and was assigned to the resident's care. Staff member was sent home pending the outcome of our investigation. The identity of the CNA believed to be involved was revealed by the HRD (Human Resources Director) during an interview on 07/10/2023 at 2:42 p.m. CNA 13 had worked at the facility since 06/09/2015 and according to the HRD had been a [NAME] employee with no complaints of her care to residents during her employment. The HRD indicated CNA 13 was sent home on the evening of 02/19/2023 and resigned her position on 02/23/2023. The actual working hours of CNA 13 was requested and received from Clinical Nurse 12 on 07/10/2023 at 9:22 a.m. According to the timesheets, CNA 13 worked a double shift, clocking in on 02/18/2023 at 2:45 p.m., and clocking out 02/19/2023 at 7:10 a.m. The CNA returned to the facility again on 02/19/2023 at 2:20 p.m., to work her normal evening shift. The CNA was observed to have clocked out at 9:25 p.m., when she was directed to leave the facility pending the investigation. A review of the facility's investigation of the allegation, received from the facility Administrator on 07/10/2023 at 2:31 p.m., contained a typed, unidentified statement, which the facility indicated was a statement from dayshift LPN 4. This statement indicated This morning (Resident 10) reported to me (LPN) that 'the CNA with a yellow band on her head twisted my hand when getting me up to use the bathroom'. When asked when this happened (Resident 10) replied 'at 3 in the morning' .Res (resident's) left wrist slightly red in color. No other signs of abuse seen at that time. During an interview, on 07/11/2023 at 11:25 a.m., Clinical Nurse 12 indicated Sister 1 was informed of the allegation sometime in the morning of 02/19/2023 by LPN 4, but she was unaware of the exact time. Sister 1 indicated she would take care of it and documented the note in Resident 10's clinical record as a late entry at 7:00 p.m., the same day. During an interview, on 07/11/2023 at 2:12 p.m., Sister 1 indicated she had written the late entry in the progress notes, dated 02/19/2023 at 7:00 p.m., however she was unable to recall the time she initially had been notified of Resident 10's allegation on the morning of 02/19/2023. Sister 1 was unable to remember when or who originally informed her of the allegation. When asked the name of the unidentified LPN who authored the unidentified statement contained in the investigation materials, she indicated she was unable to recall. No reason was given when asked why CNA 13 was allowed to return to work on the evening shift of 02/19/2023. The overall facility investigation lacked documentation including interviews with other residents living around or on the same unit as Resident 10 and CNA 13 was allowed to return to the facility on [DATE] to care for residents until the CNA was sent home from the facility at 9:25 p.m. A current policy, titled Abuse, Neglect and Exploitation, received from the Administrator on 07/11/2023 at 2:27 p.m., indicated It is the policy of this home to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation and misappropriation of resident property .Investigation of alleged abuse, neglect and exploitation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur .Protection of Resident .The home will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation .room or staffing, if necessary, to protect the resident(s) from the alleged perpetrator 3.1-28(d)

Based on record review and interview, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed for a resident with a fall resulting in injury, left sided weakness, and increased behavioral issues for 1 of 3 residents reviewed for MDS assessments. (Resident 7) Finding includes: The record for Resident 7 was reviewed on 07/07/23 at 10:26 a.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), dementia, and repeated falls. A nursing progress note, dated 5/16/22 at 1:22 a.m., indicated the resident fell resulting in an injury on the back and a raised area on the back of the head. The initial neurological checks were within normal limits. A physician's progress note, dated 5/16/23 at 10:15 a.m., indicated the spouse noticed differences in the resident's neurological status and was concerned. The facility called 911 for further evaluation. A progress note, dated 5/23/23 at 5:10 p.m., indicated the resident was readmitted into the facility and the MD (Medical Doctor) was notified of the return. A progress note, dated 5/24/23 at 10:30 a.m., indicated the resident was making sexual comments to staff members. A physician's note, dated 5/26/23 at 10:00 a.m., indicated the resident returned from the hospital which determined the diagnoses of a stroke which resulted in left sided weakness and encephalopathy (altered mental status). A physician's note, dated 6/20/23 at 10:00 a.m., indicated care for the resident had been complicated due to inappropriate statements and new actions of sexual nature such as grabbing staff members. The resident had residual left sided hemiparesis (weakness). During an interview, on 07/10/23 at 11:54 a.m., the MDS Coordinator indicated the resident should have had a significant change MDS assessment completed after the resident had declines in more than one area of the health including left sided weakness and increased behavioral issues. A current policy, titled CHANGE IN RESIDENT CONDITION OR STATUS, dated as revised on 08/2018 and received from DON (Director of Nursing) on 7/11/23 at 1:40 p.m., indicated .The MDS Coordinator is to be notified (ASAP) of any physical or mental changes in a Resident so that the need for a Significant Change MDS may be determined 3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure a Registered Nurse was in the facility for 8 hours during a 24-hour period for 9 days of the first quarter of 2023 reviewed for sufficient staffing. (2/4, 2/5, 2/18, 2/19, 2/25, 2/26 and 3/5, 3/11, 3/19) Finding includes: A Payroll-Based Journal (PBJ) Staffing report, for the first quarter of 2023, indicated the facility failed to have Registered Nurse coverage for 02/4, 2/5, 2/18, 2/19, 2/25, 2/26, 3/5, 3/11, and 3/19. During a record review, on 07/11/2023 at 10:19 a.m., the actual worked staffing schedules indicated there was no RN coverage for 02/4, 2/5, 2/18, 2/19, 2/25,2/26, 3/5, 3/11, and 3/19. During an interview, on 07/07/23 at 11:56 a.m., the Facility Scheduler indicated the PBJ staffing showed there was no RN staffing coverage for 6 days in February and 3 days in March. She would have to get with the Human Resources Director to verify if the information on the PBJ was correct. During an interview, on 07/07/2023 at 3:41 p.m., the Human Resources Director indicated they did not have RN coverage on the weekends in February and March due to nursing shortage. She indicated the reporting on the PBJ Staffing report was correct. She confirmed the dates with no RN scheduled or worked were 02/4, 2/5, 2/18, 2/19, 2/25,2/26, 3/5, 3/11, and 3/19. She was aware there needed to be RN coverage every day for 8 consecutive hours a day. She indicated the issue was discussed with the Leadership Team and the Facility Scheduler. During an interview, on 07/10/2023 at 11:45 a.m., the Human Resource Director indicated herself and the Administrator were not aware of the RN staffing issues until after the dates had happened. A current policy, titled RN Administrative Rotation, dated 06/2023 and received from Human Resources Director on 07/11/23 at 10:00 a.m., indicated .To ensure there is a minimum of 8 hours of Registered Nurse (RN) coverage on the weekends and holidays. The administrative RN staff shall rotate the responsibility of ensuring there is proper RN coverage of at least 8 hours per day on Saturdays, Sundays, and Holidays. The RN on duty shall have in his/her possession a designated work phone from the end of the business day on Friday to the beginning of the business day on Monday and on assigned holidays. In the event that there are less than 8 RN hours scheduled on a Saturday, Sunday or Holiday, the RN on duty will be required to report to work for an 8-hour shift. The RN may replace another workday in the same pay period with this shift if his/her job duties permit. The scheduler will make every attempt to schedule a minimum of 8 hours RN coverage. In the event of call off on a Saturday, Sunday, or Holiday resulting in fewer than 8 hours of RN coverage, the Scheduler shall make every effort to replace the call off with another RN. Should RN coverage not be found, the RN on duty shall report to work for a minimum of 8 hours . 3.1-17(b)(3)

Based on observation, interview and record review, the facility failed to ensure medications were disposed of according to regulations and standards of practice for 1 of 5 residents reviewed for medication observation. (Resident 21) Findings include: During a medication observation, on 07/07/23 at 9:48 a.m., LPN 10 prepared the following medications for Resident 21: furosemide (a medication used to decrease fluid in the body) 20 mg (milligrams), acetaminophen (a mild pain medication) 500 mg, prednisone (a steroid) 5 mg, apixaban (a blood thinner) 2 mg, amiodarone HCL (used for an irregular heartbeat) 200 mg and mixed with pudding. The resident refused the medications due to nausea. The nurse took the medication into the soiled utility room and flushed them down the hopper (a flushing rim sink used for disposal of blood or body fluids) (e.g., bedpan washing). During an interview, on 07/07/23 at 10:00 a.m., LPN 10 indicated she had disposed of them in the hopper before. During an interview, on 07/10/23 at 11:30 a.m., LPN 4 indicated she disposed of refused medications in the biohazard needle container. During an interview, on 07/11/23 at 10:55 a.m., the Director of Nursing indicated the facility did not have a policy for drug destruction and did not know where the logs were kept for destruction. She was not aware if the staff logged the medications which had been destroyed. During an interview, on 07/11/23 at 11:08 a.m., Clinical Nurse 3 brought policies for medication disposal and indicated the Drug Buster (a liquid used to dispose of medications) should have been used to dispose of the medications. During an interview, on 07/11/23 at 11:27 a.m., Clinical Nurse 12 indicated she would destroy medications in the Drug Buster. She indicated LPN 10 should have disposed of the medications in the Drug Buster. A current policy, titled Discontinued Medications, dated as reviewed on 5/16/19 and received from the Clinical Nurse on 07/11/23 at 11:00 a.m., .discontinued medications not returned to the pharmacy are destroyed in accordance with the Medication Destruction Policy .if in question please refer to State and Federal laws regarding medication disposal 3.1-25(o)

Based on interview and record review, the facility failed to employ a licensed facility Administrator for the period of February 2022 through the exit date of the survey, July 1, 2022. This deficient practice had the potential to affect 25 of 25 residents residing in the facility. Finding includes: During an interview, on 07/01/2022 at 3:43 p.m., the Mother of the facility indicated the previous Administrator had been terminated the end of February 2022 and the facility had been without an Administrator since. Mother indicated she was licensed in two other states, but not Indiana. She had applied to the Indiana Professional Licensing (IPL) board to transfer her license to the state of Indiana at the end of April but had not heard back. She last called to check on the status of her application a week and a half ago and was told the process could take another 7 to 10 days. When questioned, at this time, regarding an interim administrator, Mother denied having an interim Administrator, adding the facility had researched other sources like agency to fill the vacancy, but the agency did not have anyone to provide for them. A current facility policy, titled Administrator Policy, dated as revised on 06/2022 and provided by the Director of Nursing on 07/01/2022 at 3:43 p.m., indicated .the President of the Home's Corporation may serve provisionally within the state of Indiana guidelines. During this time, efforts will be made to secure a permanent Administrator. 3.1-13(q) 3.1-13(t)(1) 3.1-13(t)(2)

Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated after being changed and failed to ensure a nebulizer mask and spacer (a device which helps medication get into the lungs) were stored in a sanitary manor in between treatments for 2 of 2 residents reviewed for respiratory care. (Resident 22 and 20) Findings include: 1. On 06/28/22 at 11:31 a.m., Resident 22's nebulizer mask and spacer were observed uncovered on her dresser and her oxygen tubing did not have a date to indicate when the tubing was last changed. On 06/29/22 at 9:37 a.m., her nebulizer mask and spacer were observed not covered and on her bed side dresser next to her breathing treatment machine. Her oxygen tubing was also not dated. The record for Resident 22 was reviewed on 6/29/22 at 2:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR (Medication Administration Record) for 06/22 was reviewed and indicated the resident received her [MEDICATION(S)]-[MEDICATION(S)] solution as ordered by the physician from 06/01/22 through 06/29/22. During an interview, on 06/30/22 at 11:45 a.m., LPN 2 indicated the resident's nebulizer mask and spacer should be stored in a bag in between uses and when oxygen tubing was changed weekly it should be dated. 2. During an observation, on 06/28/22 at 11:54 a.m., Resident 20 was observed sitting in a recliner in her room. She was observed using oxygen via nasal cannula. The oxygen tubing was not dated. During an observation, on 06/29/22 at 8:44 a.m., Resident 20 was observed walking in the hall with a portable oxygen tank on her walker. The oxygen tubing was not dated. During an observation, on 06/29/22 at 12:59 p.m., Resident 20 was observed in her room. She was receiving oxygen via nasal cannula. The oxygen tubing was not dated. During an observation, on 06/30/22 at 8:51 a.m., Resident 20 was observed sitting in a recliner in her room. She was observed using oxygen via nasal cannula from a portable tank. The oxygen tubing was not dated. The concentrator tubing was also checked and the tubing was found without a date on the tubing. During an interview, on 06/30/22 at 8:53 a.m., LPN 1 indicated oxygen tubing was to be changed weekly and the lines are to be dated at that time. During an observation, on 06/30/22 at 8:55 a.m., with LPN 1 in attendance, the oxygen tubing for both the concentrator and the portable were found to be missing a label to indicated when the line had been changed. At that time, LPN 1 indicated the lines were not dated. The record for Resident 20 was reviewed on 06/28/22 at 1:49 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If needed longer or at a higher amount, notify MD/NP. The oxygen saturation measurements were reviewed and indicated the resident was at 97 percent with oxygen via nasal cannula on 06/29/22 at 5:57 p.m., 98 percent on 06/29/22 at 10:05 a.m., on room air, 99 percent with oxygen via nasal cannula on 06/28/22 at 6:19 p.m., and 94 percent with oxygen via nasal cannula on 06/28/22 at 11:31 a.m. During an interview, on 06/30/22 at 9:19 a.m., the Director of Nursing indicated oxygen tubing was to be changed and dated with the date and nebulizer mask and spacer should have been stored in a bag. A current facility policy, titled OXYGENATOR, dated as revised in 06/2022 and provided by the Director of Nursing on 07/01/22 at 11:47 a.m., indicated .Affix nasal cannula to humidifier, date and change weekly A current facility policy, titled Administering Medications Through A Small Volume (Handheld) Nebulizer, dated as revised on 06/22 and provided by the Director of Nursing on 07/01/22 at 11:50 a.m., indicated .store in plastic bag with the resident's name and the date on it 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to obtain a physician's order, assessment and consent for the use of side rails for 1 of 2 residents reviewed for accidents. (Resident 12) Finding includes: During an observation, on 06/28/22 at 10:50 a.m., Resident 12 was observed resting in bed with a quarter side rail raised on each side of the bed. During an observation, on 06/29/22 at 1:25 p.m., Resident 12 was observed resting in bed with a quarter side rail raised on each side the bed. During an observation, with CNA 3 in attendance, on 06/30/22 at 1:48 p.m., Resident 12 was observed resting in bed with side rails raised on both sides of the bed. At that time, CNA 3 indicated the resident had 2 side rails. The record for Resident 12 was reviewed on 06/28/22 at 2:15 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan, dated as revised on 10/20/21, indicated the resident was at risk for falls and to use side rails as ordered. There was no order for side rails found in the record. There was no assessment for side rails found in the record. There was no consent for side rails found in the record During an interview, on 07/01/22 at 11:05 a.m., the Director of Nursing indicated the facility was unable to find consents for side rails, they did not have an assessment or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A current facility policy, titled BED RAIL USE, dated as revised in 08/2018 and provided by the Director of Nursing on 07/01/22 at 11:47 a.m., indicated .Assess the resident for risk of entrapment from bed rails prior to installation .Obtain informed consent .Obtain physician order 3.1-45 (a)(2)

Based on record review and interview, the facility failed to hold a medication as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications. (Resident 22) Finding includes: The record for Resident 22 was reviewed on 6/29/22 at 2:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR (Medication Administration Record) was reviewed for 06/22 and indicated the medication was administered on the following days: 1. 06/06/22 at 3:30 p.m., BP was 95/66. 2. 06/07/22 at 8:30 a.m., BP was 103/66. A current care plan, dated 01/29/22 and revised on 02/09/22, indicated the resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan, dated 02/16/22 and revised on 06/23/22, indicated the resident was receiving [MEDICATION(S)] related to CHF. Interventions included, but were not limited to, administer medication as ordered. During an interview, on 06/30/22 at 4:10 p.m., the Director of Nursing indicated the resident should not have received the diuretic medication when the resident's BP was outside of the parameters as ordered by the physician and it was her expectation for nursing to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A current facility policy, titled Physician Orders, dated as revised on 08/2018 and provided by the Director of Nursing on 07/01/22 at 2:45 p.m., indicated .Purpose: to ensure that each resident receives the appropriate treatment and medication 3.1-48(a)(1) 3.1-48(a)(3)

Based on observation, record review and interview, the facility failed to monitor temperatures for the nutrition refrigerator and the medication refrigerator located in the medication storage room for 2 of 2 refrigerators reviewed for storage. (2 East Unit ) Finding includes: During an observation, on 06/30/22 at 10:04 a.m., the two refrigerators in the 2 East Medication Storage room were found to have missing temperature checks. A facility document, titled 2 East Supplement Refrigerator Temp Log - January 2022 to December 2022 was missing staff signatures on 06/03, 06/10, 06/11, 06/12, 06/15, 06/17, 06/18, 06/19, 06/20, 06/21, 06/23, 06/24, 06/25, 06/27, 06/28, 06/29 and 06/30/22. A facility document, titled 2 East Refrigerator Temp Log - January 2022 to December 2002, were missing staff signatures on 06/03, 06/11, 06/18, 06/19, 06/20, 06/21, 06/22, 06/23, 06/24, 06/25, 06/28 and 6/29/22. During an interview, on 06/30/22 at 10:04 a.m., LPN 2 indicated the night shift staff were supposed to check the refrigerators every night at 11:00 p.m. The facility failed to check the medication and food refrigerator in the 2 east medication room. A current facility policy, titled Storage of Medications and Biological, dated as reviewed 05/16/18 and received from the Director of Nursing on 07/01/22 at 10:26 a.m., indicated .In accordance with State and Federal laws, manufacturer recommendations or supplier recommendations, the facility must store all medication and biologicals in locked compartments, or storage rooms under proper temperature controls, and permit only authorized personnel to have access to the keys .Refrigerators and freezers used to store drug products are required to maintain the product temperature between the limits as defined on the label .a. Regular maintenance protocols and operating procedures should be in place .iv. Manual temperature checks should be performed per facility policy 3.1-25(m)

Based on interview and record review, the facility failed to prevent a fall by not using the correct amount of staff as indicated in the resident's Minimum Data Set (MDS) assessment (medical data information used for understanding individual resident's needs and abilities) and allowing Certified Nursing Assistants to assess residents abilities related to physical transfers for 1 of 3 resident's reviewed for falls with injuries. (Resident B) This resulted in harm when Resident B had a fall and sustained a fracture to the residents right wrist. Finding includes: The record for Resident B was reviewed on 1/11/22 at 12:10 p.m. Diagnoses included, but were not limited to, Alzheimer's Disease, muscle weakness, history of falling, repeated falls, fracture of right wrist and hand and dementia with behavioral disturbances. A care plan, initiated 1/11/21, indicated the resident had behaviors of yelling out, hitting/punching staff and getting up unassisted. A care plan, initiated 1/15/21, indicated .At times [resident's name] requires a mechanical lift and 2 staff assistance with transfers. [Name of resident] requires - extensive-total assist of 1-2 staff for transfers The resident's quarterly MDS assessment, dated 12/7/21, indicated the resident was severely cognitively impaired, had verbal and physical behavioral symptoms directed towards others and would reject care. She required extensive assistance of 2 or more physical staff for transfers between surfaces (bed to wheelchair). A Fall Risk Assessment, dated 12/2/21, indicated the resident was a high risk for falls. A Health Status note, dated 12/18/21 at 12:19 p.m., indicated .resident had bruising on both hands. right had significant bruising related to the fall. resident stated right hand was painful A Health Status note, dated 12/18/21 at 5:40 p.m. indicated .Mobilex [portable x-ray] out to do x-ray to residents right hand, resident refusing and yelling out .was able to convince resident to allow x-ray to be taken .waiting for results A Health Status note, dated 12/18/21 at 9:33 p.m., indicated Received results of x-ray to right wrist and hand, findings were Acute distal radius fracture .MD notified order to either send to hospital or may have resident go to walk in Ortho Clinic .[family] was ok with waiting for Monday so resident may go to Ortho walk in clinic A Physician's visit note, dated 12/20/21 at 9:15 a.m., indicated the resident was being seen for follow up to a fall with injury on 12/18/21 during a transfer. Initially there were no significant injuries apparent but she later developed significant bruising of her right hand and complained of pain. An x-ray was obtained and the results showed a distal radius fracture. The family was notified, who elected to pursue evaluation at ortho walk in clinic this morning. An addendum to the note indicated the physician was notified by the DON (Director of Nursing) the ortho clinic where the resident was taken to by the family was closed for lunch and the family were unable to take her at a later time that day. The family had elected to have the resident managed by the facility and they did not want to pursue surgery. An incident report, provided by the ED (Executive Director) on 1/11/22 at 1:30 p.m., indicated on 12/18/21, Resident B had become combative during morning care causing the CNA to fall and the resident to fall on top of the CNA. The resident's injuries at that time were noted as, a pink area to her left cheek and a small amount of petechiae (small red or purple spot caused by bleeding into the skin) under her left eye. She had some bruising on her hands assessed later. An x-ray was ordered, on 12/18/21 at 5:40 p.m., and the results showed evidence of a distal radial fracture of her right wrist (a fracture in the bone which was near the wrist, usually fractured as a result of a fall). Documented on an Incident Investigation form, dated 12/21/21, CNA 3 indicated on 12/18/21 when she transferred Resident B from the bed to the wheelchair the resident started to swing her arms and spit in my face. I grabbed her arms because she was going to fall. We both fell and the resident fell on top of me. PT (Physical Therapy) and OT (Occupational Therapy) documents were provided by the DON on 01/12/2022 at 3:35 p.m., and indicated the following: 1. 12/16/21 - the resident completed transfer with moderate assist and verbal cues to keep foot on the floor. She required constant supervision to prevent her from getting up unassisted. 2. 12/17/21 - the resident completed transfer from the recliner to chair with moderate assist with decreased weight bearing on bilateral lower extremities, 2 attempts were required to safely complete the task. During an interview with CNA 5 and CNA 6, on 1/11/22 at 3:55 p.m., they both indicated Resident B was a two person transfer with a gait belt for her safety. CNA 5 also indicated the resident could get resistant and combative with care sometimes but mostly in the morning. During an interview with LPN 7, on 1/11/22 at 4:00 p.m., she indicated Resident B was a two person transfer although sometimes they use the stand-up lift but always with two staff and a gait belt. During an interview with CNA 3, on 1/12/22 at 10:46 a.m., she indicated Resident B was in bed when she provided her routine morning care. She cleaned her up, washed her face and hands and put clean clothes on her. The resident was very cooperative and pleasant. When she stood her up to transfer her, she became combative and started swinging her arms. She held the resident's arms to try to stabilize her and when she backed up she tripped over the wheelchair and they both fell , the resident fell on top of her. She provided care to the resident frequently and she had always stood and pivoted her to her wheelchair by herself although it could take 2 staff sometimes depending on how cooperative and strong the resident feels. During an interview with the Unit Manager, on 1/12/22 at 10:48 a.m., she indicated the resident's behavior could change like a light switch without provocation or any predictable reason. She was recently admitted to a psychiatric hospital because her behaviors became more aggressive. The resident's dementia has become significantly advanced. During an interview with the Restorative CNA, on 1/12/22 at 10:50 a.m., she indicated when she would walk the resident it would take 2 staff. Using a gait belt, she would walk next to the resident and another staff would walk behind pushing the resident's wheelchair. During an interview with the MDS consultant, on 1/12/22 at 12:10 a.m., she indicated care plans were driven by what was documented in the resident's MDS and she confirmed the residents functional status for transfers did not match with what was documented in her care plan. During an interview with the DON, on 1/12/22 at 12:58 p.m., she indicated the resident had at times needed to use a stand up mechanical lift if she was feeling weak or did not have the strength to help with the transfer. This was guided by what PT recommends and what their assessment indicated. If a CNA did not feel it was safe or if the resident could not help then the CNA would get the help of another staff and consider using a mechanical lift. During an interview with PT, on 1/12/22 at 1:31 p.m., he indicated the resident was a moderate assist with transfers depending on her behaviors and mood. The resident has had to use a mechanical lift/stand up lift in the past for transfers. During an interview with the DON, on 1/12/22 at 3:35 p.m., she indicated the facility used the Indiana State Department of Health Nurse Aide Curriculum as guidance for the scope of practice for Certified Nursing Assistants. A CNA could not make any resident assessments. A current facility policy, titled TRANSFER AND LIFTING, dated 2/2018 and provided by the DON on 1/12/22 at 2:50 p.m., indicated .2. Nurses assess and determine lifting and transfer requirements and the procedure used for each resident A current facility policy, titled MECHANICAL LIFT, USE OF, dated 8/2018 and provided by the DON on 1/12/22 at 2:50 p.m., indicated .Nursing staff members will assist resident prior to transferring them .Assure that residents are assessed prior to a transfer A current job description for Certified Nurse Assistant, provided by the DON on 1/12/22 at 2:50 p.m., indicated .The Nursing Assistant is expected to perform routine resident care duties as delegated by the Sister Supervisor and/or Charge Nurse as specified in the Resident's comprehensive assessment and plan of care This Federal Tag relates to Complaint IN 365. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to update and revise a care plan to help prevent a resident from subsequent falls for 2 of 3 residents care plans reviewed for falls (Residents B and D) Findings include: 1. The record for Resident B was reviewed on 1/11/22 at 12:10 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall note, dated 12/18/22 at 6:24 a.m., indicated the resident fell during a transfer this morning. Pink bruising to her left cheek was noted from this fall. A Fall Risk Assessment, dated 12/2/21, indicated the resident was a high risk for falls. Resident B had a care plan in place for falls. The care plan was initiated on 2/22/20 and last revised on 9/22/21. There was not any documentation of further revisions or new interventions put into place after the resident fell on [DATE]. 2. The record for Resident D was reviewed on 1/11/22 at 2:50 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall note, dated 11/7/21 at 3:30 a.m., indicated the resident was observed sitting on the floor in front of the dayroom's entrance door. A laceration to the right back side of her head was noted from this fall. A Fall Risk Assessment, dated 11/2/21, 11/7/21, and 11/15/21, indicated the resident was a high risk for falls. Resident D had a care plan in place for falls. The care plan was initiated on 5/20/19 and last revised on 8/31/21. There was not any documentation of further revisions or new interventions put into place after the resident fell on [DATE]. During an interview, with the MDS (Minimum Data Set) Consultant, on 1/12/22 at 12:10 p.m., she indicated new interventions should be updated and revised in the resident's care plan with each fall the resident had and she did not see where this was done for Resident B and D. During an interview, with the Director of Nursing, on 1/12/22 at 3:35 p.m., she indicated she could not provide a policy or procedure related to updating care plans with new fall interventions with each new fall. This Federal Tag relates to Complaint IN 365. 3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure a root cause analyses were completed and new fall preventative interventions were implemented for 2 of 4 residents reviewed for falls (Residents #23 and #15). This deficit practice resulted in Resident #23 falling fracturing her right femur, which required surgery to repair. Findings include: 1. Resident #23's record was reviewed on 8/19/16 at 9:10 a.m. [DIAGNOSES REDACTED]. The resident had a Care Plan dated 9/20/13 with a revision date 6/16/16, which addressed the problem she had a potential for falls related to the use of a rolling walker for ambulation, occasionally forgot the walker, antidepressant use and needed assistance to stand from a chair. Interventions included, but were not limited to, 9/20/13--Ensure that resident has on non slip footwear when up, Ensure that room is clutter free, Monitor resident for adverse side effects of psychotropic medication such as dizziness, confusion and drowsiness that can contribute to risk of falls, Neurochecks for any fall where resident hit head, Notify MD of falls, Remind resident to use walker for ambulation. Fall risk assessment dated [DATE] at 3:20 p.m., indicated the resident's fall risk score was 16.0 (high risk) Scoring will be as follows: 0-4=no/low risk 5-9=moderate risk 10 or above=high risk The annual MDS (Minimum Data Set) assessment dated [DATE], indicated the resident's BIMS (Brief Interview Mental Status) was 11. Transfer status was limited assistance with one person assist. Resident #23 had falls, which included, but were not limited to, the following dates and times: 5/6/16 at 6:38 p.m.--the resident was trying to pick up a coin off the floor and when she stood up, she lost her balance and fell backwards. She hit her head on the wall and had a lump and a bruise. The 4th and 5th knuckle of her left hand and above the right elbow had a reddened area. She had a skin tear above the right elbow, which measured 1.0 x 1.0 cm (centimeters). The immediate intervention to prevent a future fall was to monitor the resident at the nurses's desk until after supper. 5/28/16 at 4:00 p.m.--the resident was found sitting on the dry floor in front of her recliner chair with only socks on her feet. She indicated she was trying to put her change into her purse. She indicated she had mild discomfort to her buttocks. No immediate intervention was found documented, which was put into place to prevent a future fall. 6/20/16 at 10:55 p.m.--a CNA heard the resident call out and went to her room. The resident was found laying on her back next to her bedside table. Upon assessment her right leg was observed to be rotated outward. She was holding her right hip and complaining of severe pain and crying. Her blood pressure was 144/116. The resident was sent to the hospital for evaluation and treatment. 6/20/16 at 11:35 p.m.--Resident #23 complained of sever pain when she was lifted from the floor to the stretcher by the ambulance personnel. 6/21/16 at 7:23 a.m.--the resident was admitted to the hospital for a right hip and femur fracture. A Hospital Transfer Summary dated 6/24/16, indicated Resident #23 was admitted to the hospital due to a history of falls and a fractured right femur. The resident's discharge [DIAGNOSES REDACTED]. 7/21/16 at 10:53 p.m., (Late Entry)--the resident's bed alarm was heard by staff. She was found sitting on the floor with her back resting against the bed. She indicated she was getting up for breakfast and slipped. 7/22/16 at 7:24 a.m.--the resident was found on the floor yesterday evening at approximately 10:30 p.m., after trying to transfer herself from her bed to the wheelchair unassisted. Shortly after she was placed in her wheelchair she slid forward in the seat and ended up in a precarious position and she was unable to get herself up unassisted. The resident's record lacked fall event reports, any root cause analysis completed and new fall interventions implemented after this resident's falls. Fall event reports were requested from the Director of Nursing on 8/22/16 at 3:30 p.m. A document titled Interventions after falls for Resident: (Name of Resident) was provided by the Inservice Director on 8/23/16 at 3:47 p.m. The document indicated the following regarding the resident's falls: 5/6/16--the resident did not have a fall on that date. 5/28/16--the resident was re-educated to use her call light and her BIMS was an 11, which indicated her mental status was moderately impaired. 6/20/16--the fall intervention was the resident was sent out to the hospital and upon her return from the hospital after hip surgery for [REDACTED]. 7/1/16--the resident was re-educated on the use of the call light and room checks were completed. During an interview on 8/23/16 at 3:47 p.m., the Inservice Director indicated she did not see where Resident #23 had a fall on 5/6/16, but she would go back and look at her record again. 2. During an interview on 8/15/16 at 3:05 p.m., the Inservice Director indicated Resident #15 had a fall on 8/8/16 and she sustained an abrasion to her right wrist. Resident #15's record was reviewed on 8/18/16 at 11:58 a.m. [DIAGNOSES REDACTED]. The resident had a Care Plan dated 4/1/16, which addressed the problem she was a potential for falls related to psychotropic drug use, use of a rolling walker for ambulation, confusion, she paced up and down the halls, wandering and difficulty with balance on transfers. The interventions included, but were not limited to, 10/9/14--Ensure that resident has on non slip footwear when up, 10/9/14--Ensure that room is clutter free, Monitor resident tor adverse side effects of psychotropic medication such as dizziness, confusion and drowsiness that can contribute to risk of falls, Neurochecks for any fall where resident hit head, Notify MD of falls, Remind resident to use walker for ambulation. Resident #15 had falls, which included, but were not limited to, the following dates and times: 2/15/16 at 9:15 p.m.--the resident was laying on her back next to the bed. 3/14/16 at 10:24 a.m.--the resident was found by a CNA in her room. She was observed to be sitting on the floor in front of her bed with her back resting against the bed. She indicated she did not fall, but slid out of bed. 3/23/15 at 6:11 p.m.--the resident's call light was ringing and the nurse entered her room and found her sitting on the floor near her bedside. She was incontinent of diarrhea. The resident indicated she had tried to get up. She had a large area of redness and a small scratch on her mid-back area. 3/24/15 at 11:40 p.m.--the resident was found on the floor next to her bed at 9:15 p.m., She indicated she had been trying to get up and slid out of bed. An IDT (Interdisciplinary Team) note dated 3/23/16 at 8:37 a.m., indicated the resident had a fall on 3/14/16, and was found on the floor with back against the bed. The resident stated she slid out of bed. Staff asked her to wear gripper socks to be. She refused a personal alarm and it was taken off and thrown away. 5/15/16 at 1:16 a.m.--a CNA entered the resident's room while checking on residents and observed her sitting on the floor with her back against the entered the door. She indicated she went to the bathroom in her wheelchair and went to turn off her TV and fell . Her wheelchair was still by her TV. She had proper footwear on (non-skid slippers). 8/8/16 at 4:10 p.m.--the resident was found on the floor in front of the toilet on her buttocks. The resident indicated she slipped off the toilet. Stool and urine was on the floor. The resident sustained [REDACTED]. Resident 23's Fall assessment dated [DATE], indicated her fall risk score was 18.0 (high risk) Scoring will be as follows: 0-4=No Low risk 5-9=Moderate risk 10 or more=high risk The resident's Fall assessment dated [DATE], indicated her fall risk score was 16.0 (high risk) The resident's Fall assessment dated [DATE], indicated her fall risk score was 16.0 (high risk). The resident's record lacked fall event reports. Fall event reports, any root cause analysis completed and new fall interventions implemented after this resident's falls were requested from the Director of Nursing on 8/22/16 at 3:30 p.m. A document titled Interventions after falls for Resident: (Name of Resident) was provided by the Inservice Director on 8/23/16 at 3:47 p.m. The document indicated the following regarding the resident's falls: 2/15/16--insure call light is within reach, Room checks 3/15/16--Ensure call light is within reach, room checks, Order written on 2/18/16 for side rail to be up when in bed. 3/23/16--no interventions 3/24/16--no interventions 5/15/16--Room checks, Re-educate to use call light, Ensure side rail is up when in bed. 8/8/16--Room checks During an interview on 8/23/16 at 3:47 p.m., the Inservice Director indicated these were the only interventions she had for Resident # 23 and # 15's falls and there was no root cause analysis on the document she provided to indicate the cause of the falls. During an interview on 8/24/16 at 10:40 a.m., the Director of Nursing indicated she was not able to give the fall event reports out because those were internal reports. She indicated room checks were when the CNA's check on the resident more frequently. She indicated more frequent was every 10-15 minutes. She indicated the CNA's were not documenting their room checks anywhere to indicate these were being done. During an interview on 8/24/16 at 11:05 a.m., the Director of Nursing indicated during the Risk Management meetings for falls the new fall interventions were supposed to be decided, then implemented. A current policy titled Falls Prevention Guidelines dated 7/2005, provided by the Director of Nursing on 8/23/16 at 3:05 p.m., indicated .Purpose: To ensure the safety and well being of the Resident .Procedure .2. If 'Falls' has been 'triggered' on the MDS, the MDS coordinator or designee will determine if there is a need to proceed to care planning A current policy titled Falls Prevention Program dated 7/2005, provided by the Director of Nursing on 8/23/16 at 3:05 p.m., indicated .Purpose: To reduce the risk of falls and injury. Procedure: 1. Two or more of the following criteria will be present for a Resident to be considered at high risk for falling (a guiding star): a. More than one (1) fall/month, or three (3) falls in six (6) months. b. Falls Risk Assessment indicated Resident at risk for falls, (score > (greater) than 10). c. Pre-admission information from Resident, family and other health care provider indicating there is a has a history of falling .4. When appropriate, alarms will be utilized to promote the safety of the Resident A current policy titled Falls, Repeated dated 7/2005, provided by the Director of Nursing on 8/23/16 at 3:05 p.m., indicated .Procedure: .11. In the Nurses Notes is documented an accurate description of the accident/incident: a. Vital signs and results of initial assessment (including ROM (range of motion) and body search); b. Notification of physician or family that is done. c. Remedial measures and/or treatments. d. In the Resident's own words, state the version of the accident/incident . Repeated Falls: 1. When a Resident falls more than one (1) fall per month or three (3) falls in six (6) months then the Falls Prevention Program is initiated in an interdisciplinary approach 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to ensure pressure ulcers were assessed, interventions implemented, treatment completed to ensure pressure ulcers did not develop or worsen for 3 of 4 residents reviewed for pressure ulcers. (Residents #12, #14, and #40) Resident #12 pressure ulcer deteriorated from stage II to a stage III without treatment change or positioning. Findings include: 1. On [DATE] at 9:15 A.M., Resident #12 was observed lying on her left side and her right heel was lying on the mattress. On [DATE] at 10:00 A.M., the resident was observed lying on her left side and her right heel was lying on the mattress. On [DATE] at 10:50 A.M., Activities Assistant #15 entered the resident's room, spoke to her and turned her television on for her. The resident was observed lying on her left side and her right heel was lying on the mattress. On [DATE] at 11:00 A.M., the resident was observed lying on her left side and her right heel was lying on the mattress. On [DATE] at 12:30 P.M., the resident was lying on her left side and her right heel was lying on the mattress. On [DATE] at 3:26 P.M., Resident #12's right buttock area was observed during a dressing change. The right buttock area was observed with an open area with 15% red, 35% yellowish/white slough (stringy, moist, dead and nonvascular tissue in the process of separating from the viable portions of the body) and 50% blackish/brown eschar (thick, leathery and dead tissue that has lost it's own usual properties and biological activity) tissue to the wound bed. Resident #12's record was reviewed on [DATE] at 9:52 A.M. [DIAGNOSES REDACTED]. The resident's [DATE], Treatment Administration Record recap (Recapitulation) included, but were not limited to the following orders: [DATE]--Concave mattress. [DATE]--Float heels while in bed. [DATE]--Turn every two hours side to side only for decubitus ulcer. The resident had a Care Plan dated [DATE], that addressed the problem she had a Stage III pressure ulcer to her right buttock area. The interventions indicated "[DATE]--Turn resident side to side to maintain pressure off of that area...." A "Wound Evaluation Flow Sheet" dated [DATE], had an "X" marked in the box for pressure ulcer for the wound type. The flow sheet indicated the resident had a wound to her right buttock that was staged as a Stage II wound on [DATE]. The measurement was 0.3 x 0.1 x 0.0 cm (centimeters). The drainage amount was scant and was serosanguineous (a drainage mixed with serous fluid and blood) with a thin consistency. No odor from the wound. The tissue type was 100% [MEDICATION NAME] tissue. The periwound (skin around the wound) margins was intact and the surrounding tissue was intact. The current pressure ulcer treatment was Carraguaze and a dressing that was initiated on [DATE]. The current preventative interventions were an air mattress and turning the resident every two hours and was initiated on [DATE]. The wound status was a new area. A "Wound Evaluation Flow Sheet" dated [DATE], had an "X" marked in the box for pressure ulcer for the wound type. The flow sheet indicated the resident had a wound to her right buttock that was staged as a Stage II wound on [DATE]. The measurement was 2.0 x 2.0 x 0.1 cm (centimeters). The drainage amount was moderate and was serosanguineous with a thin consistency. No odor from the wound. The tissue type was 100% [MEDICATION NAME] tissue. The periwound (skin around the wound) margins was intact and the surrounding tissue was intact. The current pressure ulcer treatment was Carraguaze and a dressing every day that was initiated on [DATE]. The current preventative interventions were an air mattress and turning the resident every two hours and was initiated on [DATE]. The wound status indicated it was deteriorating. A "Wound Evaluation Flow Sheet" dated [DATE], had an "X" marked in the box for pressure ulcer for the wound type. The flow sheet indicated the resident had a wound to her right buttock that was staged as a Stage III wound on [DATE]. The measurement was 8.0 x 7.0 x 0.2 cm (centimeters). The drainage amount was moderate and was serosanguineous with a thin consistency. No odor from the wound. The tissue type was 35% slough (stringy, moist, dead and nonvascular tissue in the process of seperating from the viable portions of the body) , 50% eschar (thick, leathery and dead tissue that has lost it's own usual properties and biological activity) and 15% granulation (red and viable tissue). The periwound (skin around the wound) margins was macerated (moist) and the surrounding tissue was pink and intact. The current pressure ulcer treatment was Carraguaze and a dressing that was initiated on [DATE]. The doctor was notified for a treatment change and a referral to the wound clinic on [DATE] . The current preventative interventions were an air mattress and turning the resident every two hours and was initiated on [DATE]. The wound status was deteriorating. During an interview on [DATE] at 3:43 P.M., LPN #9 indicated the resident acquired her Stage II pressure ulcer to her right buttock area on [DATE] and on [DATE] it was a Stage III that measured 8.0 x 7.0 x 0.2 cm. The physician progress notes [REDACTED]. [DATE]--Indicated the resident developed an open area to her left buttocks and Zinc Oxide as needed every four hours was ordered. [DATE]--Indicated she developed a "small" ulcer on her left heel that was "soft and mushy." The treatment was a [MEDICATION NAME] soak dressing and the staff was to avoid pressure to the resident's heels. [DATE]--Indicated the resident had a "small" pressure ulcer on her buttocks and ankle. The treatment was a Duoderm dressing (a dressing that provides a moist healing environment that allows clean wounds to heal and wounds with dead tissue to debride naturally). [DATE]--Indicated she had a "small" pressure ulcer to her toes that was slow healing. The progress notes indicated the following: [DATE]--Indicated the resident had a new unopened "pea-sized" reddened area on the right buttock. [DATE]--Indicated the resident had Duoderm ordered to her right buttock to be changed every 72 hours. [DATE]--Indicated the resident had a "pea-sized" open area to her right buttock. A "Wound Evaluation Flow Sheet" dated [DATE], had an "X" marked in the box for pressure ulcer indicated the resident had a facility acquired suspected deep tissue injury to her left heel that measured 0.75 x 0.75 x 0.0 cm. The wound margins were brown and the surrounding tissue was brown. Current Preventative Interventions were to elevate the heel off the bed, but the area lacked a date that the intervention was initiated. The form lacked a current treatment for [REDACTED]. The left heel wound was healed on [DATE]. A "Wound Evaluation Flow Sheet" dated [DATE], indicated the resident had a facility acquired wound to her right buttocks that measured 0.5 x 0.3 x 0.1 cm. The form lacked current preventative interventions with a date that they were initiated. The treatment was Duoderm and Zinc Oxide and it was initiated on [DATE]. The wound was healed on [DATE]. A "Wound Evaluation Flow Sheet" dated [DATE], had an "X" marked in the box for pressure ulcer indicated the resident had a facility Stage II that measured 0.5 x 0.5 x 0.0 cm. The treatment was Duoderm applied every 72 hours and it was initiated on [DATE]. The current preventative interventions were turning and repositioning, but the form lacked a date that these interventions were initiated. During an interview on [DATE] at 12:30 P.M., CNA #7 indicated this resident was her responsibility to provide care to for the shift and she was turned at 9:00 A.M. She indicated she had not turned her as of yet, because she had not had time, because she had been busy taking care of her other residents. CNA #7 indicated the back up plan when she got behind in her work load was to ask one of the other CNA's to help her if they were not busy. She indicated if the other CNA's were busy then she was to call one of her supervisors to come and help her. She indicated she had not asked anyone for help. She had just tried to "catch up." During an interview on [DATE] at 1:50 P.M., LPN #1 indicated the resident's right heel "was a little pink, but it was not mushy" She indicated she had not realized that the resident had not been turned for three and a half hours. During an interview on [DATE] at 5:50 P.M., the DoN (Director of Nursing) indicated the residents were to be turned every two hours. 2. On [DATE] at 9:50 A.M., Resident #40 was observed lying on her back with a pillow propped at the right side of her back and she was sitting at a 90 degree angle. The resident's bilateral heels were lying on the mattress. On [DATE] at 10:36 A.M., LPN #1 went into the resident's room and obtained her vital signs. The resident was observed lying on her back with a pillow propped at the right side of her back and she was sitting at a 90 degree angle. The resident's bilateral heels were lying on the mattress. On [DATE] at 10:40 A.M., the Activities Assistant #15 went into the resident's room and said "Good Morning" to her then left the room. The resident was observed lying on her back with a pillow propped at the right side of her back and she was sitting at a 90 degree angle. The resident's bilateral heels were lying on the mattress. On [DATE] at 11:35 A.M., CNA #7 was observed entering the resident's room to give her a bath. The resident was observed lying on her on her back with a pillow propped at the right side of her back and she was sitting at a 90 degree angle. The resident's bilateral heels were lying on the mattress. The resident's bilateral heels were observed to be red and felt mushy. On [DATE] at 2:26 P.M., LPN #1 was observed changing the resident's dressing to her pressure ulcer to her coccyx. LPN #1 placed the dressing supplies, including scissors that were in the resident's dresser drawer on her bare bedside table. She and CNA #14, who was assisting her washed their hands. LPN #1 removed the old dressing and packing from the coccyx wound and she placed both of them in the dirty chux that had urine and stool on it and rolled them into the chux. She did not change her gloves. She cleansed the inside and the outside of the wound with sterile water with two folded 4 x 4 guazes. She packed the open wound with Silver Alginate packing strip that was approximately 1 inch in width with the end of a sterile applicator (a long cotton q-tip). She was not observed to cleanse the scissors before she cut the Silver Alginate packing strip. She covered the wound with a 2 x 2 foam island dressing. She threw her trash away. She gathered the dressing supplies and scissors and placed them back in the resident's dresser drawer and washed her hands. Resident #40's record was reviewed on [DATE] at 4:00 P.M. [DIAGNOSES REDACTED]. The resident's [DATE], Treatment Administration Record recap (Recapitulation) included, but were not limited to, the following orders: [DATE]--Cleanse coccyx wound with purified water or Normal Saline prior to applying clean dressing. Do not scrub or use excessive force, pat dry, pack the wound loosely with Silver Alginate packing (antimicrobial guaze packing used to pack wounds, aided in preventing infections and allowed wounds to heal from the inside to the outside) and fill all the dead space. Leave the tail of the packing material to help with the removal on the side of the wound bed. If on the next dressing change the dressing is dry, moisten it with purified water or Normal Saline prior to the removal. Cover the wound with bordered foam. Cover the open area to the periwound. No order date--Float heels A "Discharge Instruction Details" sheet indicated, Wound Clinic orders dated [DATE], indicated "...offload heels-no pressure to heels...Do not elevate HOB (head of bed) over 30 degrees and limit time spent up in w/c (wheelchair) to decrease friction and pressure to wounded areas..." The resident had a Care Plan with a revision date of [DATE], that addressed the problem she had a Stage IV pressure ulcer to her coccyx area. Interventions indicated "..XXX[DATE]--Treatment as ordered..XXX[DATE]--Reposition resident to maintain pressure off of area where ulcer is present...." A "Wound Evaluation Flow Sheet" dated [DATE], indicated the resident had a facility acquired Stage IV pressure ulcer to her coccyx/sacrum area. The sheet indicated the wound developed on [DATE]. The wound measured 4.4 x 3.0 x 0.3 cm . The wound had serosanguineous drainage and it was thin in consistency with scant foul odor. The wound bed was 20% pink tissue and 80% dark red tissue. The periwound was red and the surrounding tissue was intact. The current treatment was Carraguaze hydrogel dressing. Wound status was worse. A "Wound Evaluation Flow Sheet" dated [DATE], indicated the resident had a facility acquired Stage IV pressure ulcer to her coccyx/sacrum area. The sheet indicated the wound developed on [DATE]. The wound measured 3.0 x 2.0 x 3.0 cm with 11 o'clock to 1 o' clock undermining (the rim of the pressure ulcer was eroding away) tissue . The wound had serosanguineous drainage and it was thin in consistency with scant foul odor. The wound bed was red tissue. The wound margins were defined with the surrounding tissue intact. The current treatment was Silver Alginate packing strip, then cover with foam dressing and the treatment was initiated on [DATE]. Wound Status: Not healing A "Wound Evaluation Flow Sheet" dated [DATE], indicated the resident had a facility acquired Stage IV pressure ulcer to her coccyx/sacrum area. The wound developed on [DATE]. The wound measured 4.0 x 2.5 x 3.0 cm with 12 o' clock to 12 o'clock undermining tissue . The wound had serosanguineous drainage thin in consistency and a scant foul smelling odor. The wound bed was red-granulation tissue and less than 25% slough. The wound margins were defined and the surrounding tissues were intact. The current treatment was silver alginate, cover with foam and change the dressing every other day and as needed for soilage. The treatment was initiated on [DATE]. Wound status was not healing. The resident's coccyx pressure ulcer treatment had not been changed since [DATE] even though the wound was not healing. No wound sheets prior to [DATE] was provided by the end of the exit conference on [DATE]. During an interview on [DATE] at 11:35 A.M., CNA #7 indicated the resident was lying on her back and she placed a pillow on the right side of her to relieve some of the pressure off her bottom when she was lying on her back. She indicated the resident's heels were to be floated off the bed with pillows and the resident's heels were lying on the mattress. During an interview on [DATE] at 4:00 P.M., the DoN (Director of Nursing) indicated the HOB should not have been elevated in the 90 degree position. A current policy titled "DRESSING, NON STERILE" dated ,[DATE], provided by the DoN on [DATE] at 2:45 P.M., indicated "...PURPOSE: To protect, to absorb drainage and to promote healing of the wound... 5. Remove soiled dressing and place in trash bag... 6. Wash hands and apply new gloves. 7. Cleanse wound and surrounding tissue with prescribed solution and dry with guaze...." 3. The closed clinical record for Resident #14 was reviewed on [DATE] at 2:44 P.M. [DIAGNOSES REDACTED]. The resident was originally admitted to the health care section of the facility on [DATE], following a fall in her independent apartment that resulted in a [MEDICAL CONDITION]. She was discharged again to hospital on [DATE] for a [MEDICAL CONDITION] from a perforated [DIAGNOSES REDACTED] ulcer, and was readmitted to the facility on [DATE]. She expired on [DATE] at 4:35 P.M. A progress note, dated [DATE], indicated "Arrived on unit... Skin assessment shows bruises on arms and legs post IV and fall. Bottom is red." There were no other progress notes from ,[DATE] to discharge on [DATE] related to the red bottom or other skin issues. On [DATE], the physician gave an order for [REDACTED]. A "Skin Assessment," dated [DATE] and completed by a unit nurse, indicated "Home from the hospital this eve. Has bruises on legs and arms post IV and fall. Bottom red." There was no additional descriptive information related to the red bottom. A "Skin Assessment," dated [DATE] and completed by the same unit nurse, indicated the resident had no pressure ulcers, with pale, normal/warm, and dry skin. There was no additional descriptive information related to the status of the resident's skin. The March, 2014 MAR (Medication Administration Record) had nurse initials documenting the DuoDerm was applied on ,[DATE] and [DATE]. During an interview on [DATE] at 2:09 P.M., the Director of Nursing indicated the "Skin Assessments" documentation was all that she was able to locate, related to the resident's skin assessments and condition. The Admission MDS was completed on [DATE], with an Assessment Reference Date (ARD--the last day of the observation period) of [DATE]. Section M, for assessment of the skin, covered a time frame of 7 days prior to the ARD. For Resident #14, the time period would have been from ,[DATE] to [DATE]. The coding at this section indicated the resident was at risk for developing a pressure ulcer, had no current unhealed pressure ulcer at Stage 1 or higher. had a surgical wound and skin tears. There was no identification of any skin issue that would have required a DuoDerm skin treatment beginning on [DATE]. In an interview on [DATE] at 9:00 A.M. the MDS Coordinator indicated she did not see or examine the resident's bottom upon admission ([DATE]), and none of the nurses had said anything to her about the resident's "red bottom." She took the order for the Duoderm on [DATE], and saw the area either later the same day or the next day. She indicated she thought the coccyx area may "just have been excoriated," but she could not recall for sure. She indicated the nurses completing the computer "Skin Assessment" forms should use Section 1 to describe any areas of a resident's body where the skin was altered (rashes, scars, skin tears, abrasions, bruises, surgical incisions, etc.) The MDS Coordinator indicated a barrier cream was the treatment of [REDACTED]. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)