Every finding on record at Valley View Healthcare Center

Based on record review and interview the facility failed to follow the orders to discontinue an ordered anticoagulant for 1 of 5 residents reviewed for medications. (Resident B) Findings include: A record review was completed for Resident B on 5/28/2026 at 2:29 P.M. Diagnoses included, but were not limited to, hemiparesis following cerebral infarction affecting right dominant side and left non-dominant side and essential hypertension. A Discharge with Return Anticipated Minimum Data Set (MDS) assessment, dated 5/19/2026, indicated Resident B's cognition was intact and he took an anticoagulant and antiplatelet. Physician Orders for Resident B included, but were not limited to: -12/17/2026 Eliquis 5 milligrams (mg) 1 by mouth two times a day for blood thinner. On 2/24/2026 Resident B had a visit with his cardiologist. Documents sent back to the facility after the visit included an order, written on a prescription form, to discontinue the Eliquis on 3/26/2026. However, the medication was not discontinued until 4/24/2026. During an interview on 6/2/2026 at 2:10 P.M., the Regional Risk Management Nurse indicated the Eliquis should have been discontinued on 3/26/2026 when the physician's order had been received. A current, undated policy, titled, Physician Orders was provided by the Administrator on 6/2/2026 at 2:59 P.M. The policy indicated, .The nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. This citation relates to Intake 303680. 410 Indiana Administrative Code (IAC) 16.2 - 3.1-37(a)

Based on record review and interview, the facility failed to transcribe and implement physician ordered hydration, nutrition and medications for a newly admitted resident. This practice resulted in the resident being hospitalized with a hyperosmolar hyperglycemic state (a critical, often fatal, complication from type 2 diabetes defined by severe hyperglycemia [high blood sugar] and extreme dehydration) that included a blood sugar level of 954 milligrams per deciliter (mg/dL) and extreme hypovolemic depletion (loss of extracellular fluid such as blood/salt/water) for 1 of 3 residents reviewed for quality of care. (Resident B) This practice had the potential to affect all newly admitted residents. The immediate jeopardy began on 1/4/26 when the facility failed to record and implement admission orders for critical medications and nutrition/hydration. The Administrator, Director of Nursing and Regional Director of Clinical Services were notified of the immediate jeopardy on 2/6/2026 at 12:00 P.M. The Immediate Jeopardy was removed, on 2/7/26 at 10:15 A.M., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes:A closed record review for Resident B was completed on 2/4/2026 at 10:55 A.M. Diagnoses included, but were not limited to: hemiplegia following a cerebral infarction (stroke), diabetes mellitus type 2, gastrostomy and dysphagia.Resident B was admitted to the facility on [DATE] from a rehabilitation hospital.A Discharge with Return Anticipated Minimum Data Set (MDS) assessment, dated 1/8/2025, indicated Resident B was comatose and eating assistance was not applicable due to having a feeding tube. Cognitive status could not be established due to Resident B's primary language being Russian.A Nursing Progress Note, on 1/4/2026 at 11:38 A.M., indicated Resident B had been admitted to the facility, was alert but nonverbal, had a feeding tube with continuous tube feeding with Vital 1.2 at 55 milliliters per hour.An Interdisciplinary Team Conference Note from the rehabilitation hospital, dated 12/23/2025 and provided to the facility at the time of the facility admission on [DATE], indicated the following medications were to be administered:- Levetiracetam (Keppra, anti-seizure medication) 500 milligrams twice daily- Aspirin 81 milligrams daily- Jardiance (a diabetic medication) 10 milligrams daily- Hydrochlorothiazide (a diuretic) 12.5milligrams daily- Lantus (long-acting) Insulin 100 units per milliliter inject 40 units every 12 hours subcutaneously- Lisinopril (hypertension medication) 40 milligrams daily- Metformin (a diabetic medication) 500 milligrams 2 tablets twice daily- Sodium Chloride (a supplement for low sodium level) 1 gram 2 tablets three times daily- Vital Advanced Formula 1.2 tube feeding 65 milliliters per hour continuously with a 25 milliliter per hour water flush.Physician Orders for Resident B were written on 1/6/2026 for the following medications:levetiracetam, sodium chloride, glargine (Lantus) insulin, Metformin, aspirin, hydrochlorothiazide, lisinopril, Jardiance and the water tube feeding flushes.There were no admission orders found in the Resident B's record prior to 1/6/26, despite having arrived to the facility on 1/4/26. A Medication Administration Record (MAR), dated January 2026, indicated glargine (morning dose), levetiracetam (afternoon dose) and metformin (evening dose) were administered on 1/6/2026. Aspirin, hydrochlorothiazide, Jardiance and lisinopril had an initial administration date of 1/7/2026. There were no other medications documented as given from 1/4-1/7/26.A Medication Administration Record (MAR), dated January 2026, indicated Jevity 1.2 per gastric tube at 85 milliliters per hour for 20 hours three times daily and 35 milliliters of water for 20 hours began on 1/7/2026 at 2:00 P.M. The MAR did not have any documentation of any tube feeding or water flushes having been administered from admission on [DATE] until 1/7/26.There was no documentation anywhere in the record that indicated the resident received any fluids or nutritional feedings from 1/4-1/7/26.A Care Plan, initiated on 1/6/2026, indicated Resident B had the potential for altered nutritional status related to problems for cerebral infarction, hypo-osmolarity, hyponatremia, diabetes mellitus type 2 and aphasia with interventions not limited to: receive/tolerate diet as ordered and remain free from of signs of dehydration.A Care Plan, initiated on 1/6/2026 and revised on 1/7/2026, indicated Resident B required tube feeding related to dysphagia. The goal was for Resident B to maintain adequate nutrition and hydration and remain free from complications. Interventions included, but were not limited to: administer flushes per medical provider's order, administer medications via tube per orders, provide tube feeding per medical provider orders and monitor intake of enteral tube feedings.There were no care plans for Resident B initiated prior to 1/6/26.A Nursing Progress Note, dated 1/8/2026 at 6:22 A.M., indicated the nurse had gone into Resident B's room to administer Resident B's medications and Resident B was observed to be sweaty, had an oxygen saturation level of 85 percent on room air, the nurse was unable to obtain a blood pressure and Resident B's blood sugar monitor indicated HI (high, unable to register blood sugar due the blood sugar exceeded the blood sugar monitor limit). The nurse called 911 to send Resident B to the emergency room for evaluation and treatment.A 72-hour Nursing Assessment had been completed on 1/7/2026 at 5:55 P.M. There were no other Nursing Assessments completed after Resident B's admission to the facility on 1/4/2026.An emergency room Urgent Care Note, dated 1/8/2026, indicated Resident B presented to the emergency department for evaluation of a fever, altered mental status, decreased responsiveness and blood sugar level. Laboratory tests results i the emergency room indicated a blood sugar level of 954 milligrams per deciliter (mg/dL), a blood urea nitrogen of 97 mg/dL, a creatinine level of 1.43 mg/dL, a sodium level of 150 millimoles per liter (mmol/L), a calcium level of 11 mg/dL and a hemoglobin level of 16.2 grams per deciliter (g/dL). Resident B had been admitted to the flexible acuity unit (step-down unit of critical care unit) for a hyperosmolar hyperglycemic state (a critical, often fatal, complication from type 2 diabetes defined by severe hyperglycemia, extreme dehydration and high serum osmolality without significant ketoacidosis), hypernatremia, extreme volume depletion and acute kidney injury.A Hospital Discharge summary, dated [DATE], indicated Resident B discharged from the hospital on 1/18/2026 (10 day hospitalization) to another rehabilitation facility on hospice (end of life palliative care) services.During an interview, on 2/6/2026 at 10:05 A.M., RN 2 indicated Resident B had been admitted to the facility on the weekend. When she audited Resident B's admission orders the following Monday, she noted the medication, tube feeding and hydration orders had not been initiated upon Resident B's admission. RN 2 indicated the medical record did not have any documentation that the medication, tube feeding or hydration had been administered during the time period of 1/4/2026-1/6/2026. She indicated Resident B should not have waited that long to have the physician orders implemented.A policy was provided, on 2/6/2026 at 11:54 A.M., by the Regional Director of Clinical Services. A current policy titled, admission Evaluation, indicated, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. A systemic evaluation is completed by a licensed nurse upon admission/readmission to assist in determining the most effective and appropriate care needs of each resident admitted to the center.1. Complete the admission Initial UDA and appropriately triggered assessments electronically as as feasible but within 24 hours.2. Prioritize resident needs with appropriate interventions to include but not limited to: a. Meet immediate physical needs including assessment for pain.g. Complete medication reconciliation. h. Consider last meal eaten and provide hydration.A document, titled, admission Audit, was provided by the Regional Director of Clinical Services, on 2/8/2026 at 3:36 P.M. The audit tool indicated, .admission Progress Notes: Complete a progress note every shift for 72-hours, including vital signs and assessment of resident condition and interventions in place.The immediate jeopardy was removed and corrected on 2/7/2026 when the facility staff was in-serviced regarding enteral general nutrition guidelines, laboratory and radiological services, notification of change of conditions, admission evaluations, blood glucose point of care testing, physician orders, clinical morning meeting and admission audits, a house-wide clinical assessment of all residents completed, a review of all new resident admissions in the past two weeks and audits were implemented regarding newly admitted residents. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because the facility needed to continue audits to ensure ongoing compliance.This citation is related to Intake 2713578. 3.1-37(a)

Based on record review and interview, the facility failed to obtain physician ordered laboratory tests, including a urinalysis for 1 of 3 residents reviewed for laboratory service. (Resident C) This deficient practice resulted in a required hospitalization for uremic encephalopathy, hyperkalemia, acute kidney injury and acute hypoxic respiratory failure with pneumonia. Finding includes:The record review for Resident C was completed on 2/4/2026 at 1:19 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, atrial fibrillation and congestive heart failure.A Quarterly Minimum Data Set (MDS) assessment, dated 11/28/2025, indicated Resident C was cognitively intact, required substantial assistance for toileting hygiene and had an indwelling urinary catheter.A Physician's Order, dated 12/16/2025, indicated the supplement potassium chloride crystals extended-release tablet 20 milliequivalents one tablet daily was to be given for hypokalemia. This order decreased the previous order of two tablets dailyA Nursing Progress Note, on 12/23/2025 at 3:38 P.M., indicated Resident C had been refusing to eat or drink and there was a concern for dehydration. A new order for laboratory work had been obtained.A Physician's Order, dated 12/23/2025, indicated laboratory work for a complete blood count with differential, a comprehensive metabolic panel and a b-peptide natriuretic peptide for heart failure and follow-up of heart failure, follow up of leukocytosis and to rule out significant dehydration.A Nurse Practitioner Encounter Note, on 12/26/2025 at 1:00 A.M., indicated a Telehealth visit had occurred due to Resident C's increased confusion. The note indicated Resident C had been reported by a Certified Nursing Assistant (CNA) to have been hard to awaken and Resident C's eyes had rolled. The nurse on shift reported Resident C had been hard to wake up. However, Resident C was back to her baseline during the examination and no longer seemed drowsy. The note indicated that it had been possible that Resident C had been woken from a sleep and had been hard to wake up from his sleep. The nurse had reported a decreased urinary output and an order for a urinalysis test and an order to push oral fluids was placed. A Physician's Order, dated 12/26/2025, indicted to obtain a urinalysis with reflux and culture STAT (immediately) for decreased urinary output.A Nursing Progress Note, on 12/27/2025 at 5:17 A.M., indicated a urinalysis specimen had been obtained at 4:30 A.M. and placed in the refrigerator on the 100 hall (awaiting laboratory services pick up)A Skilled Nursing Assessment, on 1/1/2026 at 12:30 P.M., indicated Resident C was lethargic, but responded to verbal stimuli. In addition, he had swallowing difficulties and had been observed holding food in his mouth/cheeks or residual food in the mouth after meals. All assessments prior to this assessment had documentation of Resident C indicated he was alert and oriented times three (oriented to person, place and time).A Nurse Practitioner Encounter, on 1/2/2026 at 1:00 A.M. and documented as a late entry on 1/2/2026 at 7:18 P.M., indicated Resident C had been seen for a monthly follow-up and chronic disease management. Resident C had been examined in his room and appeared lethargic and barely responsive. Resident C's blood pressure was 82/59 mm/Hg (millimeters per mercury) with a oxygen saturation of 88 percent on room air. Resident C had not responded verbally. It was not clear to the nurse practitioner if this condition was new or a sudden chronic change. An examination of Resident C indicated his mucosal membranes were dry and he had applesauce with medication in his mouth. Resident C was tachypneic, hypoxic with diminished breath sounds. Resident C had been thought to be in acute respiratory failure with hypoxia and referred to the emergency department for emergent diagnostics and treatment.A Skilled Nursing Assessment, on 1/2/2026 at 9:59 A.M., indicated Resident C had been confused and disoriented with edema present.A Nursing Progress Note, on 1/2/2026 at 11:50 A.M., indicated the nurse went to administer medications to Resident C without any concern. Resident C had been observed to be upset and interested to engage verbally with others. The nurse encouraged fluids. The note indicated Resident C had refused his medication around 10:00 A.M. and the nurse had notified the nurse practitioner around 11:00 A.M. that Resident C had been observed to have declined. The nurse and nurse practitioner immediately assessed Resident C. Resident C's blood pressure was 81/61 and oxygen saturations had fluctuated between 88-92 percent and oxygen was applied with the head of the bed elevated. These intervention had been effective. Resident C had been observed to be non-verbal with an increase in altered mental status. Resident C moaned and groaned when moved, but able to move his head with verbal stimuli. Edema had been observed to his bilateral lower extremities, general weakness and difficulty swallowing. 911 was called to transport the resident to the hospital.A Hospital History and Physical, on 1/2/2026 at 4:37 P.M., indicated Resident C had presented to the emergency department earlier today for a decreased level of consciousness. Laboratory results were remarkable for an elevated [NAME] Blood Cell count of 28,000 cells/mcL, a critically elevated potassium level of 7.2 mEq/L, a severely elevated BUN 110 mg/dL and creatinine 3.8 mg/dL level and a urinalysis positive for a urinary tract infection. Diagnoses included, but were not limited to: uremic encephalopathy, acute hypoxic respiratory failure, acute kidney injury, hyperkalemia and pneumonia. Resident C was admitted to the intensive care unit of the acute care facility.During an interview, on 2/5/2026 at 2:20 P.M., the Director of Nursing indicated the ordered laboratory work had not been entered into the laboratory portal to be drawn. She indicated the urinalysis had been collected, but was never picked up by the laboratory. She indicated the laboratory tests that were ordered should have been completed.A policy was provided, on 2/6/2026 at 11:54 A.M., by the Regional Director of Clinical Services. A current policy titled, Laboratory and Radiological Services and Results Reporting, indicated, .The purpose of this policy is to provide guidance for reporting of results from laboratory, radiology, and other diagnostic services to the ordering practitioner. The facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. There are clinical and psychological risks when laboratory, radiology, or other diagnostic services are not performed in a timely manner or the results of these services are not reported and acted upon quickly. Delays may adversely affect a resident's diagnosis, treatment, assessment, and intervention.This citation relates to Intake 27135783.1-49(a)

Based on record review and interview, the facility failed to ensure nursing staff who participated in cardiopulmonary resuscitation (CPR) were current in their CPR training and certification for 1 of 3 residents reviewed for cardiopulmonary resuscitation, (Resident E). Finding includes: Resident E's clinical record was reviewed on [DATE] at 10:00 A.M. Diagnoses included but were not limited to pericardial effusion (fluid around the heart), breast cancer, heart valve insufficiency, and hypertension. A nursing progress note dated [DATE] at 1:13 P.M., indicated Certified Nursing Assistant (CNA)11 and CNA 12 went to Resident E's room to provide care and noted the resident had increased difficulty breathing so the CNAs notified the nurse. Licensed Practical Nurse (LPN) 1, indicated upon arrival and initial assessment the resident was unresponsive, without a pulse and respirations. She began CPR, and Emergency Services was called. An untitled document dated [DATE] at 1:20 P.M., was provided by the Director of Nursing on [DATE] at 9:45 A.M. The Director of Nursing indicated the document was a record of the CPR response documentation and time-line that was assembled by the staff following the CPR event. The Director of nursing indicated the times were approximate. The document indicated LPN 1 announced CPR at 12:47 P.M., and connected the Automated External Defibrillator (AED) at 12:49 P.M. RN 4 opened the resident's airway at 12:48 P.M. and began chest compressions at 12:49 P.M., and continued until Emergency Medical Services (EMS) arrived at 12:53 P.M. Resident E was transferred to the local emergency room by EMS at 1:20 P.M. During an interview on [DATE] at 10:50 A.M., RN 4 indicated on [DATE], after performing CPR on Resident E, she went online to obtain her CPR certification. RN 4 indicated her CPR certification was not current at the time she had provided CPR to Resident E. During an interview on [DATE] at 10:53 A.M., LPN 1 indicated her CPR certification had lapsed before performing CPR on Resident E. LPN 1 indicated after performing CPR on Resident E on [DATE], she went online to obtain a current CPR certification. On [DATE] at 10:14 A.M., the Director on Nursing provided an undated policy titled, Cardiopulmonary Resuscitation (CPR), and indicated it was the facility's current policy. The policy indicated the facility would follow current American Heart Association (AHA) guidelines regarding CPR to ensure staff present were properly trained/certified in CPR. This citation relates to Complaint IN00458543. 3.1-35(g)(1)

Based on observation, interview and record review, the facility failed to store and serve food in a sanitary manner in the pantries, dining rooms, and kitchen. This had the potential to affect 81 of 81 residents who consumed food from the kitchen, pantries and dining room. Findings include: 1. During the initial kitchen tour with dietary aide 2 on 3/23/2025 at from 10:00 A.M. - 10:30 A.M., the following was observed: -the reach-in freezer had an unsealed and undated bag of [NAME] fish and potato patties, unsealed boxes of chicken patties, biscuits, cinnamon rolls, frozen cookie dough, pretzels, 2 boxes of dinner rolls, and an employee's bottle of water. - the refrigerator had opened unsealed bags of mozzarella cheese and parmesan cheese, an undated package of hot dogs, celery and an undated pan of broccoli/cauliflower mix. -the dry goods room had an undated package of elbow noodles, an open package of hamburger buns and an open container of powdered milk. During an interview at 10:10 A.M. the dietary aide indicated all food should be dated and properly sealed and no employee beverages should be stored in the freezer. 2. During a return trip to the kitchen on 3/23/2025 at 11:05 A.M., the following was observed: -A soup bowl was noted lying on top of the brown sugar and powdered sugar in the bins. -Seven spice lids were open on a shelf and a bottle of Dawn dishwashing soap was stored next to the spices. During an interview on 3/23/2025 at 11:10 A.M., the Dietary Manager indicated there should not have been any bowls in the bins, the lids to the spices should have been closed and the dish soap should not have been on that shelf with the spices. 3. During an observation of meal service in the Main Dining Room on 3/23/2025 at 12:15 P.M., the following was observed: -Punch and lemonade pitchers were on a cart with the lids off. -CNAs served the beverages from the pitchers without the lids. -CNA served meal plates with their thumb on the eating surface of the dinner plates. During an interview on 3/23/2025 at 12:41 P.M., CNA 13 indicated he should have served the meal plate with his thumb/hand underneath the plates and the beverage pitchers should have had lids on them. 4. During an observation of the Memory Care's Pantry refrigerator on 3/24/2025 at 9:27 A.M., the following was observed: -Four containers of fruit/cottage cheese, an opened container of sour cream and bag of shredded cheese were unlabeled. During an interview on 3/24/2025 at 9:27 A.M., the Mobile Dietary Manager indicated the items should have been labeled with a name and date. On 3/24/2025 at 9:07 A.M., the ED provided a policy titled, Safe Handling for Foods from Visitors, revised on 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .4. Label foods with the resident name and the current date . And a policy titled, Food Storage: Cold Foods,revised 2/2023. The policy indicated .5. All foods will be stored and wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . And a policy titled, Food Storage: Dry Goods, revised 2/2023. The policy indicated .5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage area will be neat, arranged for easy identification, and date marked as appropriate . 3.1-21(3)

Based on interview and record review, the facility failed to provide written notification of a transfer/discharge to the resident or resident's representative for 3 of 3 residents reviewed for hospitalization. (Residents H, L and M) Findings include: 1. A record review was completed on 3/24/2025 at 10:14 A.M. for Resident H. Diagnoses included, but were not limited to, schizophrenia. A Quarterly Minimum Data Set (MDS) assessment, dated 1/29/2025, indicated Resident H's cognition was intact. A discharge order, dated 1/7/2025, indicated transfer resident to the hospital for severe symptoms that cannot be controlled otherwise. During an interview on 3/24/2025 at 1:18 P.M., Resident H indicated he was admitted to a psychiatric hospital on 1/7/2025 and did not receive written notification of the transfer/discharge. A Nurses Progress Note, dated 1/7/2025, indicated Resident H had alerted staff he was in danger of harming himself or others, had not slept in days and was talking to himself. He also made threatening gestures toward staff. A physician's order was received to send the resident to (name of local hospital) for an evaluation. During an interview on 3/25/2025 at 9:25 A.M., LPN 7 indicated the transfer/discharge documentation was to be documented in the document section of the clinical record and the Medical Records staff scanned the documentation into the record Documents for Resident H's transfer to the hospital, on 1/7/2025, could not be located in his clinical record. During an interview on 3/25/2025 at 9:25 A.M., the Divisional Director of Risk Management indicated there was no signed transfer/discharge notice in the clinical record for the 1/7/2025 hospitalization and the facility should have provided the transfer/discharge notice to the resident. 2. During an interview on 3/23/2025 at 2:08 P.M., Resident M indicated he was hospitalized for urinary retention on 2/21/2025. A record review was completed on 03/25/2025 9:30 A.M. for Resident M. Diagnoses included, but were not limited to, inflammatory polyneuropathy and urinary retention. A Medicare 5 Day Minimum Data Set (MDS) assessment, dated 3/3/2025, indicated Resident M's cognition was moderately impaired. A Nurses Progress note indicated Resident M had been transferred to the hospital on 2/21/2025. The Notice of Transfer/Discharge documentation/form could not be located in the clinical record. During an interview on 3/25/2025 at 9:25 A.M., LPN 7 indicated the transfer/discharge documentation was supposed to be located in the document section of the clinical record and the Medical Records staff scanned them in the record. During an interview on 3/25/2025 at 9:25 A.M., the Divisional Director of Risk Management indicated there was no signed transfer/discharge notice in the clinical record for the 2/21/2025 hospitalization and the facility should have provided the transfer/discharge notice to the resident.3. The clinical record for Resident L was reviewed on 3/25/2025 at 10:15 A.M. The resident's diagnoses included, but were no limited to: multiple sclerosis, adult failure to thrive, chronic pain syndrome, hypertension, repeated falls, bipolar disorder, anxiety, cannabis use and borderline personality disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 3/11/2025, indicated the resident was cognitively intact. A Nursing Note, dated 11/10/2024, indicated Resident L was transferred to (name of local hospital). The note also indicated Resident L was her own representative. A Nursing admission Evaluation, dated 11/23/2024, indicated Resident L had been re-admitted back to the facility on [DATE] at 2:30 P.M. During an interview, on 3/25/2025 at 1:51 P.M., the Social Service Designee (SSD) indicated she was unable to find a signed bed hold notice or a signed transfer/discharge notice in Resident L's electronic chart. During an interview, on 3/25/2025 at 2:09 P.M., the Divisional Director of Risk Management indicated there was no signed bed hold and no signed transfer notice in Resident L's chart for the 11/9/2024 through 11/23/2024 hospitalization. She indicated the facility had not provided the resident with a written transfer policy or a bed hold policy prior to or immediately after the resident's transfer from the facility. During an interview, on 3/25/2025 at 3:02 P.M., Resident L indicated the staff had not provided any paperwork for her to sign prior to her hospitalization in November 2024. On 3/25/2025 at 2:35 P.M., the Divisional Director of Risk Management provided a policy titled, Transfer and Discharge Policy, undated and indicated the policy was the one currently used by the facility. The policy indicated .present the Acute Transfer Letter to the resident prior to the transfer unless the resident is incapable of understanding due to cognitive impairment or unless the transfer is an emergency . This citation relates to complaint IN00452428. 3.1-12(a)(6)(i)

Based on interview and record review, the facility failed to provide the facility's Bed Hold Policy to the resident or resident representative for 3 of 3 residents reviewed for hospitalization. (Residents H, L and M) Findings include: 1. A record review was completed on 3/24/2025 at 10:14 A.M. for Resident H. Diagnoses included, but were not limited to, schizophrenia. A Quarterly Minimum Data Set (MDS) assessment, dated 1/29/2025, indicated Resident H's cognition was intact. A discharge order, dated 1/7/2025, indicated transfer resident to the hospital for severe symptoms that cannot be controlled otherwise. During an interview on 3/24/2025 at 1:18 P.M., Resident H indicated he was admitted to a psychiatric hospital on 1/7/2025 and had not received a copy of the facility's Bed Hold Policy. A Nurses Progress Noted, dated 1/7/2025, indicated Resident H had alerted staff he was in danger of harming himself or others, had not slept in days and was talking to himself. He also made threatening gestures toward staff. A physician order was received to send the resident to (name of local hospital) for an evaluation. During an interview on 3/25/2025 at 9:25 A.M., LPN 7 indicated a copy of the Bed Hold Policy issue to Resident H would be located in the document section of the clinical record. The copy of the Bed Hold Policy would have been scanned into the electronic record by the Medical Records staff. Documents pertaining to Resident H's transfer to the hospital could not be located in the clinical record. During an interview on 3/25/2025 at 9:25 A.M., the Divisional Director of Risk Management indicated there was no copy of the facility's Bed Hold Policy in the clinical record for the 1/7/2025 hospitalization and the facility should have provided a copy of the facility's Bed Hold Policy to the resident. 2. During an interview on 3/23/2025 at 2:08 P.M., Resident M indicated he was hospitalized for urinary retention on 2/21/2025. A record review was completed on 03/25/2025 9:30 A.M. for Resident M. Diagnoses included, but were not limited to, inflammatory polyneuropathy and urinary retention. A Medicare 5 Day Minimum Data Set (MDS) assessment, dated 3/3/2025, indicated Resident M's cognition was moderately impaired. A Nurses Progress Noted indicated Resident M was transferred to the hospital on 2/21/2025. A copy of the facility's Bed Hold Policy could not be found in the clinical record. During an interview on 3/25/2025 at 9:25 A.M., LPN 7 indicated copy of the facility's Bed Hold Policy would have been scanned into the electronic clinical reord by the Medical Records staff. During an interview on 3/25/2025 at 9:25 A.M., the Divisional Director of Risk Management indicated there was no copy of the facility's Bed Hold Policy in the clinical record for Resident M's 2/21/2025 hospitalization and the facility should have provided a copy of the facility's Bed Hold Policy to the resident. 3. The clinical record of Resident L was reviewed on 3/25/2025 at 10:15 A.M. The resident's diagnoses included, but were no limited to: multiple sclerosis, adult failure to thrive, chronic pain syndrome, hypertension, repeated falls, bipolar disorder, anxiety, cannabis use and borderline personality disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 3/11/2025, indicated the resident was cognitively intact. A Nursing Note, dated 11/10/2024, indicated Resident L was transferred to (name of local hospital) and indicated Resident L was her own representative. A Nursing admission Evaluation, dated 11/23/2024, indicated Resident L had been re-admitted back to the facility on [DATE] at 2:30 P.M. During an interview, on 3/25/2025 at 1:51 P.M., the Social Service Designee (SSD) indicated she was unable to locate a signed bed hold notice or a signed transfer notice in Resident L's electronic record. During an interview, on 3/25/2025 at 2:09 P.M., the Divisional Director of Risk Management indicated there was no signed bed hold and no signed transfer notice in Resident L's chart for the 11/9/2024 through 11/23/2024 hospitalization. She indicated the facility had not provided the resident with a written transfer policy or a bed hold policy prior to or immediately after the resident's transfer from the facility. During an interview, on 3/25/2025 at 3:02 P.M., Resident L indicated the staff had not provided any paperwork for her to sign prior to her hospitalization in November of 2024. On 3/25/2025 at 2:35 P.M., the Director of Nursing (DON) provided a policy titled, Bed Hold Policy, undated and indicated the policy was the one currently used by the facility. The policy indicated .the bed hold authorization form may be signed prior to the patient leaving the building, or within 24 hours .in the event a resident returns to the hospital .the nurse or designee will present the Acute Transfer Letter at time of transfer with a copy going with the resident . This citation relates to complaint IN00452428. 3.1-12(a)(26)

Based on observation, interview and record review, the facility failed to change the dressings of residents who had a peripherally inserted central catheter (PICC) line for 3 of 3 residents whose PICC lines were reviewed. (Residents B, D and C) Findings include: 1. During an observation on 3/24/2025 at 3:02 P.M., Resident B's PICC line dressing was dated, 3/14/2025 and was rolled up with the insertion site exposed. Resident B indicated the dressing had not been changed in over a week. During an interview on 3/24/2025 at 3:05 P.M., LPN 6 indicated the PICC line dressing should not be rolled up and the dressing should have been changed after seven days. Resident B's record review was completed on, 3/25/2025 at 8:30 A.M. Diagnoses included, but were not limited to: subacute osteomyelitis of the left ankle and foot, Type 1 diabetes mellitus, methicillin-resistant staphylococcus aureus, below-knee amputation of right leg. An Admission Minimum Data Set (MDS) assessment, dated 3/11/2025, indicated Resident B had intact cognition. A current Physician's order, dated 3/14/2025, indicated Resident B's PICC line dressing was to be changed every Friday on day shift (6:00 A.M.-2:00 P.M.). A current Care Plan, initiated on 3/5/2025, indicated Resident B was on intravenous (IV) antibiotics for treatment of osteomyelitis. The goal for the Care Plan was to be free of infection at insertion site. Interventions included, but were not limited to: visually inspect IV site each shift. Resident B's record lacked the documentation he had refused any dressing changes. 47419 2. A record review was completed on 3/25/2025 at 2:45 P.M. for Resident D. Diagnoses included, but were not limited to, pneumonia. An Admission Minimum Data Set (MDS) assessment, dated 3/8/2025, indicated Resident D's cognition was intact. A Physician Order, dated 3/14/2025, indicated the PICC line dressing was to be changed once weekly, on Fridays. During an observation on 3/24/2025 at 11:07 A.M., the dressing for a peripherally inserted central catheter (PICC), a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart, in Resident 76's left upper arm, was peeled up along all edges of the transparent dressing and was dated 3/3/2025. During an interview on 3/24/2025 at 11:07 A.M., the Unit Manager indicated the dressing should have been changed every week. 49229 3. During an observation, on 3/24/2025 at 10:08 A.M., Resident C had a PICC (peripherally-inserted central catheter) (a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart and used for long-term intravenous access for medications, fluids, or blood draws, and can stay in place for weeks or months) visible to his right upper arm with a dressing dated 3/14 which was peeling up slightly at the very base of the dressing. During an interview, on 3/24/2025 at 11:06 A.M., LPN 6 indicated Resident C's PICC dressing should have been changed weekly. During an observation and interview, on 3/25/2025 on 11:34 A.M., observed Resident C's right upper arm without the presence of a PICC or a dressing, the inside of Resident C's right upper arm had a quarter-sized purple/green bruise without a hematoma or drainage. Resident C indicated his PICC was removed yesterday. The clinical record of Resident C was reviewed on 3/26/2025 at 1:25 P.M. The resident's diagnoses included, but were no limited to: cerebral ischemia, cerebral amyloid angiopathy, morbid obesity, chronic kidney disease, systolic and diastolic congestive heart failure, venous insuffiency, chronic venous hypertension, obstructive sleep apnea, ischemic cardiomyopathy, paroxysmal atrial fibrillation, occlusion and stenosis of bilateral carotid arteries, ventral hernia, spinal stenosis and diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/2025, indicated Resident C was cognitively intact. The MDS assessment indicated the resident had been receiving IV medications. A Physician Order, dated 1/29/2025, indicated the PICC line site dressing was to be changed weekly on Fridays. A current Care Plan, revised on 2/10/2025, indicated Resident C had received intravenous antibiotics due to osteomyelitis (bone infection). Interventions included but were not limited to: change the dressing weekly for the PICC line. During an interview, on 3/28/2025 at 9:00 A.M., LPN 7 indicated in the chart that everything in the electronic medical record would turn green when all tasks and medications were completed. LPN indicated there was a QMA (qualified medication aide) on the hall on 3/21/2025 and the QMA had clicked on the PICC dressing change without having done the PICC dressing change yet. LPN 7 had then charted the PICC dressing change task in error due to being in a different mindset with the QMA on the hall. On 3/28/2025 at 1:00 P.M., the Administrator provided a policy, Pharmscript Infusion Intravenous Access Line Maintenance Protocol, dated 2/7/2020 and indicated the policy was the one currently used by the facility. The policy indicated .PICC dressing changes on admission or 24 hours post-insertion, then weekly and as needed . This citation relates to complaint IN00455837. 3.1-47(a)(2)

Based on record review and interview, the facility failed to provide medications to residents as ordered by the Physician for 4 of 6 residents whose medications were reviewed. In addition, the facility failed to appropriately store medications in 1 of 3 Medication Carts reviewed. (Residents F, N, O, C & 100 Hall Medication Cart ) Findings include: 1. Resident F's record review was complete on [DATE] at 10:10 A.M. Diagnoses included, but were not limited to: Parkinson's disease, anxiety disorder, insomnia, history of myocardial infarction and major depressive disorder. A current Physician's order, dated [DATE], indicated Resident F was to receive the following mediations: - 0.4 milligram (mg)/hour transdermal nitroglycerin patch (treats chest pain) every morning. -20 mg of omeprazole (treats heartburn) every morning. A current Physician's order, dated [DATE], indicated Resident F was to receive 50 mg of trazodone (sleep aid) at bedtime. A [DATE] Medication Administration Record (MAR) indicated Resident F had not received the 0.4 mg nitroglycerin patch or the 50 mg of omeprazole on [DATE] and he had not received his trazodone on [DATE]. Resident F's record lacked the documentation he had refused his medications or a Physician had been notified that he had missed doses of his medications. 2. Resident N's record review was completed on [DATE] at 11:30 A.M. Diagnoses included, but were not limited to: dementia with psychotic disturbance, major depressive disorder, generalized anxiety disorder and anorexia. Current Physician's orders for Resident N included orders for the following medications: - 7.5 mg milligrams (mg) of mirtazapine (appetite stimulant) at bedtime. - 10 mg of melatonin (sleep aid) at bedtime. A [DATE] Medication Administration Record (MAR) indicated Resident N had not received 7.5 mg of mirtazapine or 10 mg of melatonin on ,d+[DATE], ,d+[DATE] or [DATE]. Resident N's record lacked the documentation she had refused her medications or a Physician had been notified that she had missed doses of her medications. 3. Resident O's record review was complete on [DATE] at 1:30 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 with diabetic neuropathy, cerebral palsy, hypertension, and dementia. Current Physician's orders for Resident O included orders for the following medications: - 5 units of insulin glargine at bedtime. - 5 milligrams (mg) of terazosin (controls high blood pressure) at bedtime. - 2 to 10 units of Novolog (insulin) daily at 4:00 P.M., depending on her blood sugar test results. A [DATE] Medication Administration Record (MAR) indicated Resident O had not received 5 units of insulin glargine or 5 mg of terazosin on ,d+[DATE] or [DATE], and she had not received her 4:00 P.M. dose of novolog on [DATE]. Resident O's record lacked the documentation she had refused her medications or a Physician had been notified that she had missed doses of her medications. During an interview on [DATE] at 1:13 P.M., the Director of Nursing (DON) indicated she believed all the medications had been given but the staff had forgotten to sign off on the administration. She indicated staff should sign off on the medication after it was given. 49229 3. The clinical record of Resident C was reviewed on [DATE] at 1:25 P.M. The resident's diagnoses included, but were no limited to: cerebral ischemia, cerebral amyloid angiopathy, morbid obesity, chronic kidney disease, systolic and diastolic congestive heart failure, venous insuffiency, chronic venous hypertension, obstructive sleep apnea, ischemic cardiomyopathy, paroxysmal atrial fibrillation, occlusion and stenosis of bilateral carotid arteries, ventral hernia, spinal stenosis and diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident C was cognitively intact. The MDS assessment indicated the resident had received insulin, anticoagulants, diuretic and an anticonvulsant. Physician Orders for Resident C, included but were not limited to: -Atorvastatin Calcium Oral Tablet 80 MG (milligram) (Atorvastatin Calcium) -Give 1 tablet by mouth at bedtime, -Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/mL (milliliter) (Insulin Glargine) - Inject 10 units subcutaneously at bedtime, - Insulin Lispro Injection Solution 100 unit/mL (Insulin Lispro) - Inject subcutaneously before meals with sliding scale, - Santyl External Ointment 250 unit/Gm(gram) (Collagenase) - Apply to rIght lower extremity topically every evening shift for wound care. Cleanse wound to right lateral inferior lower leg with normal saline, pat dry, spread a santyl nickel thick on adaptic and place on wound, cover with ABD pads and wrap with Kerlix, secure with tape and apply TubiGrip G daily until healed, - Ertapenem Sodium Injection Solution reconstituted 1 gram IV (intravenously) in the morning, and - Vancomycin Hydrochloride Intravenous Solution 1000 mg/ 250 mL 1 gram every day. The [DATE] Medication Administration Record for Resident C indicated the following missed medications and treatments: -Atorvastatin Calcium Oral Tablet 80 mg on ,d+[DATE] - Ertapenem Sodium 1 gram on ,d+[DATE] and ,d+[DATE] - Lantus SoloStar Subcutaneous Solution Pen-injector 10 units at bedtime on ,d+[DATE], ,d+[DATE] and ,d+[DATE] - Santyl External Ointment 250 unit/G on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] - Vancomycin Hydrochloride Intravenous Solution 1000 mg/ 250 mL 1 gram: on ,d+[DATE]. During an interview, on [DATE] at 1:14 P.M., the Director of Nursing (DON) indicated she believed the missing and undocumented medications and treatments on the Medication Administration Records had been given. The DON indicated the medications and treatments should have been signed off only after it had been given or completed. 44111 4. On [DATE] at 10:37 A.M., a medication storage observation was completed with QMA 12 on the 100 Hall cart, cart one and the following was observed: -Two opened bottles of eye drops not in a pharmacy labeled container sitting on top of a packages of nicotine patches and in with a box of antibiotic oral medication. On [DATE] at 10:45 A.M., a medication storage observation was completed with QMA 12 on the 100 Hall cart, cart two and the following was observed: -An open bottle of eye drops undated and not in a pharmacy labeled container. -An open Humalog pen with an open date of [DATE]. During an interview on [DATE] at 10:55 A.M., QMA 12 indicated eye drops should not have been mixed with other types of medication and it should have been in a pharmacy labeled container. She indicated that the insulin pen was used to administer insulin that morning and should not have been used since it was expired. On [DATE] at 1:10 P.M., the DON provided a policy titled, Storage of Medication, ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated .1. The provider pharmacy dispenses medication in container that meet regulatory requirements, including standards set forth by the United States Pharmacopoeia (USP) Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original container. 4. Orally administered medication are stored separately from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye mediations are stored separately per facility policy. 6. The nurse will check the expiration date of each medication before administering it. 7. No expired medication will be administered to a resident . On [DATE] at 3:12 P.M., the ED provided a policy titled, Medication Administration, undated, and indicated the policy was the one currently used by the facility. The policy indicated . I. Procedure: dd. Medications will be charted when given. IV. Documentation a. Documentation of medication will be current for medication administration. b. Documentation will follow accepted standards of nursing practice . This citation relates to complaints IN00452428 and IN00455837. 3XXX,d+[DATE](g)(1)(o) 3XXX,d+[DATE](b)(3)

Based on observation, record review and interview, the facility failed to ensure accurate documentation of PICC (peripherally-inserted central catheter) dressing changes for 3 of 3 residents reviewed. (Residents C, D and B) Findings include: 1. During an observation, on 3/24/2025 at 10:08 A.M., Resident C had a PICC line to his right upper arm with a dressing, dated 3/14/25, peeling up slightly at the very base. The clinical record of Resident C was reviewed on 3/26/2025 at 1:25 P.M. The resident's diagnoses included, but were not limited to: cerebral ischemia, cerebral amyloid angiopathy, morbid obesity, chronic kidney disease, systolic and diastolic congestive heart failure, venous insuffiency, chronic venous hypertension, obstructive sleep apnea, ischemic cardiomyopathy, paroxysmal atrial fibrillation, occlusion and stenosis of bilateral carotid arteries, ventral hernia, spinal stenosis and diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/2025, indicated Resident C was cognitively intact. The MDS assessment indicated the resident had been receiving insulin, anticoagulants, diuretic, an anticonvulsant and IV(intravenous) medications. A Physician Order, dated 1/29/2025, indicated the PICC line site dressing change was to be done weekly on Fridays. The March Treatment Administration Record 2025 indicated the PICC line dressing change was completed on 3/21/2025 but Resident C's PICC line dressing was dated 3/14. During an interview, on 3/24/2025 at 11:06 A.M., LPN 6 indicated Resident C's PICC line dressing should have been changed weekly. During an interview, on 3/28/2025 at 9:00 A.M., LPN 7 indicated in the chart that everything in the electronic medical record would have turned green when all tasks and medications were completed. LPN 7 indicated there was a QMA (qualified medication aide) on the hall on 3/21/2025 and LPN 7 indicated she may have clicked on the PICC dressing change without having done the PICC dressing change yet. LPN 7 had charted the PICC dressing change in error due to being in a different mindset with the QMA on the hall. During an interview, on 3/28/2025 at 1:14 P.M., the Director of Nursing (DON) indicated the medications or treatments should have been signed off only after they had been given or completed. 47419 2. During an observation of Resident D's peripherally inserted central catheter (PICC), a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart, on 3/24/2025 at 11:07 A.M., the date on the dressing over the insertion site was 3/3/2025. During an interview on 3/24/2025 at 11:07 A.M., the Unit Manager indicated the PICC line dressing should have been changed weekly. Documentation on the Treatment Administration Record (TAR) indicated the dressing was changed on 3/14/2025 and 3/21/2025. During an interview on 3/27/2025 at 9:59 A.M., LPN 8 indicated the dressing should have been changed on 3/14/2025 and she was not sure how her initials had been documented on the TAR as having chnaged the dressing. LPN 8 indicated she must have documented it accidentally. During an interview on /28/2025 at 11:23 A.M., LPN 4 indicated PICC line dressings should be changed weekly. His initials on the TAR on 3/21/2025 was more than likely because he had passed it off to the next shift but he should not have signed off that he had xompleted the dressing change. 48145 3. During an observation on 3/24/2025 at 3:02 P.M., Resident B's PICC dressing was dated, 3/14/2025 and was rolled up with the insertion site exposed. Resident B indicated the dressing had not been changed in over a week. During an interview on 3/24/2025 at 3:05 P.M., LPN 6 indicated the PICC dressing should not be rolled up and the dressing should have been changed after seven days. Resident B's record review was completed on, 3/25/2025 at 8:30 A.M. Diagnoses included, but were not limited to: subacute osteomyelitis of the left ankle and foot, Type 1 diabetes mellitus, methicillin-resistant staphylococcus aureus, below-knee amputation of right leg. A current Physician's order, dated 3/14/2025, indicated Resident B's PICC dressing was to be changed every Friday on day shift (6:00 A.M.-2:00 P.M.). A current Care Plan, dated 3/5/2025, indicated Resident B was on intravenous (IV) antibiotics for the treatment of osteomyelitis. The goal was to be free of infection at the insertion site. Interventions included, but were not limited to: visually inspect IV site each shift. Resident B's March 2025 Medication Administration Record (MAR), indicated LPN 7 had changed the PICC dressing on 3/21/2025. Resident B's record lacked the documentation he had refused any dressing changes. During an interview on 3/28/2025 at 8:58 A.M., LPN 7 indicated it was her initials on Resident B's PICC dressing change for 3/21/2025 on March 2025's MAR. She indicated the process for signing off on a task was to mark the task complete in the Electronic Medical Record after the task was completed and she had made a mistake by signing off on the PICC dressing change when the task had not been completed. On 3/28/2025 at 2:30 P.M., the Director of Nursing (DON) provided an undated policy, titled, Clinical Documentation Standards and identified it as the policy currently used by the facility. The policy indicated, . Nurses will follow the basic standard of practice for documentation including, but not limited to providing a timely and accurate account of resident information in the medical record . b. The nurse is expected to: i. Document accurately and truthfully to the best of his/her knowledge This citation relates to complaint IN00455837. 3.1-50 (a)(2)

Based on observation, interview, and record review the facility failed to follow the standards of practice for infection control for 1 of 1 resident reviewed for tracheostomy care (Resident 3), for 2 of 3 residents reviewed for PICC line care (Residents B and 76) and 2 residents observed for mediction administration. (Resident K and 13) Findings include: 1. During an observation on 3/24/2025 at 9:27 A.M. Resident 3's tracheostomy stoma dressing was dirty with yellowish/brown stains and was not dated. A record review was completed on 3/25/2025 09:53 A.M. for Resident 3. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and tracheostomy. A Quarterly Minimum Data Set MDS) assessment, dated 1/10/2025, indicated Resident 3's cognition was intact and received tracheostomy care. Physician Orders included, but were not limited to, an order on 3/13/2025 to cleanse the tracheostomy site with normal saline, pat dry, apply gauze and secure with tape until healed. A current Care Plan revised on 8/8/2024, indicated the tracheostomy was discontinued and care to the stoma was to be done per physician orders. During an observation of tracheostomy stoma care and dressing change on 3/25/2025 at 1:38 P.M., LPN 8 used proper infection control measures to cleanse and dress the site but put the old dressing in the the Resident 3's trash. She did not take the trash out of the room and dispose of it properly. During an interview on 3/25/2025 at 1:45 P.M., LPN 8 indicated she should have removed the trash and put it in the soiled utility room's Biohazard box. 2. During an observation on 3/24/2025 at 11:07 A.M., the dressing for a peripherally inserted central catheter (PICC), a thin, flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart, in Resident 76's left upper arm, was peeled up along all edges of the transparent dressing and was dated 3/3/2025. A record review was completed on 3/25/2025 at 2:45 P.M. for Resident 76. Diagnoses included, but were not limited to, pneumonia. An Admission Minimum Data Set (MDS) assessment, dated 3/8/2025, indicated Resident 76's cognition was intact. A Physician Order, dated 3/14/2025, indicated the PICC line dressing should be changed once weekly on Friday. During an interview on 3/24/2025 at 11:07 A.M., the Unit Manager indicated the dressing should have been changed every week. 48145 3. During an observation on 3/24/2025 at 3:02 P.M., Resident B's PICC dressing was dated, 3/14/2025, and was rolled up with the insertion site exposed. Resident B indicated the dressing had not been changed in over a week. During an interview on 3/24/2025 at 3:05 P.M., LPN 6 indicated the PICC dressing should not be rolled up and the dressing should have been changed after seven days. Resident B's record review was completed on, 3/25/2025 at 8:30 A.M. Diagnoses included, but were not limited to: subacute osteomyelitis of the left ankle and foot, Type 1 diabetes mellitus, methicillin-resistant staphylococcus aureus, below-knee amputation of right leg. An Admission Minimum Data Set (MDS) assessment, dated 3/11/2025, indicated Resident B had intact cognition. A current Physician's order, dated 3/14/2025, indicated Resident B's PICC dressing was to be changed every day shift (6:00 A.M.-2:00 P.M.) on Fridays. A current Care Plan, dated 3/5/2025, indicated Resident B was on intravenous (IV) antibiotics for treatment of osteomyelitis. The goal for the Care Plan was to be free of infection at insertion site. Interventions included, but were not limited to: visually inspect IV site each shift. Resident B's record lacked the documentation he had refused any dressing changes. 44111 4. During an observation of medication administration of eye drops on 3/24/2025 at 9:58 A.M., for Resident K, LPN 4 donned gloves and entered the room with oral medication and eye drops. The eye drops were placed on the bedside table without a barrier. LPN 4, with gloved hands, handed Resident K nine oral medications one at a time. LPN 4, with same gloved hands, then wiped crust away from both of Resident K ' s eyes and then applied the eye drops without washing her hands or changing her gloves. During an interview on 3/24/2025 at 10:08 A.M., LPN 4 indicated he should have sanitized his hands before donning the gloves and should not have used the same gloves after administering oral medication and wiping of the eyes to administer eye drops. LPN 4 indicated he should have brought the eye drops into the room in the pharmacy provided bag. 5. During an observation on 3/24/2025 at 10:16 A.M., LPN 4 took a glucometer that was just used by Resident 13 with ungloved hands, cleaned it with a Sani-wipe and did not wash his hands afterwards. During an interview on 3/24/2025 at 10:17 A.M., LPN 4 indicated he should have washed his hands prior to disinfecting glucometer, put on gloves and then performed hand hygiene after glove removal. 6. During an observation on 3/24/2025 at 11:20 A.M., LPN 6 placed a glucometer on the bedside table without a barrier and did not perform hand hygiene after removing her gloves after administering insulin. During an interview on 3/24/2025 at 11:23 A.M., LPN 6 indicated she should have placed a barrier under the glucometer and performed hand hygiene after glove removal. On 3/24/2025 at 12:38 P.M., the ED provided a policy titled, Eye Drop Administration, dated 9/2018, and indicated the policy was the one currently used by the facility. The policy indicated . 4. Remove the cap, taking care to avoid touching the dropper tip. Place the cap on the barrier or a clean, dry surface. 13. Remove and dispose of gloves. Discard any barrier used for carrying or storing the medication and supplies. Wash hands thoroughly with antimicrobial soap and water or facility-approved hand sanitizer . And a policy titled, Blood Sugar Monitoring, dated 2018. The policy indicated .d. Turn on machine and place on a hard surface, with a clean barrier under device. f. (v)Remove gloves and perform hand hygiene . And a policy titled, Standard Precautions.3/2016. The policy indicated .II, When to perform hand hygiene B. Before and after direct contact with a resident's skin. C. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings. G. After glove removal . And policy titled, Blood Glucose Point of Care Testing, dated 2018. The policy indicated, .Clean and Store Equipment a. Place a clean barrier under glucometer until disinfected. c. Perform hand hygiene prior to disinfecting. d. [NAME] gloves. e. Perform cleaning and disinfection procedure. f. Remove gloves and perform hand hygiene . On 3/28/2025 at 1:00 P.M., the Administrator provided a policy, Pharmscript Infusion Intravenous Access Line Maintenance Protocol, dated 2/7/2020 and indicated the policy was the one currently used by the facility. The policy indicated .PICC dressing changes on admission or 24 hours post-insertion, then weekly and as needed . 3.1-18(l)

Based on interviews and record review, the facility failed to ensure a resident's choice of code status was documented consistently in the medical record for 1 of 3 residents reviewed for code status (Resident 70). Finding includes: During an interview, on [DATE] at 2:02 P.M., LPN 7 indicated Resident 70 was a full code. During an interview, on [DATE] at 10:00 A.M., the Social Service Designee (SSD) indicated Resident 70 was his own representative, had not been deemed incompetent and was capable of making his own legal decisions. The SSD indicated Resident 70 had reported to her he wanted to be a full code. The clinical record of Resident 70 was reviewed on [DATE] at 9:27 A.M. The resident's diagnoses included but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side, chronic obstructive pulmonary disease, cerebrovascular disease, hypertension, other reflux and obstructive uropathy, dysarthria, and dysphagia. A Quarterly Minimum Data Set assessment, dated [DATE], indicated Resident 70 was cognitively intact. A Physician Order, dated [DATE], indicated Resident 70 had a CPR status (a life-saving emergency procedure used when someone's breathing or heartbeat has stopped, combining chest compressions and rescue breaths to restore blood circulation and oxygenation). A current Care Plan, dated [DATE], indicated Resident 70 had a full code status. A POST (Physician Orders for Scope of Treatment) form (a medical order form that documents a patient's treatment preference as medical orders that can be easily understood and enacted by health care providers), dated [DATE], indicated Resident 70 had a status of Do Not Attempt Resuscitation (no life-sustaining measures if a person's heart or breathing stops). Resident 70's code status was unclear in the medical record. \ On [DATE] at 1:00 P.M., the Administrator provided a policy titled,Cardiopulmonary Resuscitation (CPR), undated, and indicated the policy was the one currently used by the facility. The policy indicated .facility staff should verify the presence .the resident's wishes with regard to CPR, upon admission .if the resident's wishes are different than the admission orders .facility staff should document the resident's wishes in the medical record . 3XXX,d+[DATE](l)(5)

Based on observation, interview and record review, the facility failed to ensure showers, hair care and/or nail care were provided for 2 of 6 residents. (Resident L- showers and hair care, Resident K- nail care) Findings include: 1. During an observation and interview, on 3/23/2025 at 1:51 P.M., Resident L indicated she could not recall the last shower she had been offered and had had bed baths only. She indicated the last bed bath she had received was given about a week ago. Resident L had a mass of hair that was matted. The matted hair was the size of a softball and was located at her back of her head. Resident L indicated she had only been offered disposable shower caps in regards to shampooing and does not remember the last time her hair was washed in a shower or was brushed. During an observation and interview, on 3/25/2025 at 9:14 A.M., Resident L indicated she still had not had a shower. The back of Resident L's hair still had a softball-sized hair matt present. During an interview, on 3/25/2025 at 11:10 A.M., CNA 9 indicated she had frequently offered her residents daily bed baths due to the bed bound status of many of the facility's residents. CNA 9 indicated she provided a disposable hair shampoo bonnet,as well as hair care, after a resident's bed bath. CNA 9 indicated she had attempted to brush out Resident L's hair matts 2 days ago but the resident's hair had become tangled again within a few days. During an observation and interview, on 3/26/2025 at 9:58 A.M., Resident L was observed with uncombed hair with a visible, large softball-sized tangled hair matt in the posterior of her head. The resident indicated she could not remember the last time had staff assisted her with brushing her hair. During an interview, on 3/26/2025 at 10:10 A.M., CNA 10 indicated she had showered residents twice a week unless the resident's care plan dictated the resident was to be cleaned more frequently. During an interview, on 3/26/2025 at 11:22 A.M., the Divisional Director of Risk Management indicated Resident L was showered and had her hair brushed and braided. During an interview, on 3/26/2025 at 3:33 P.M., CNA 11 indicated she bathed her residents twice a week and it included a disposable shampoo cap and nail care if the resident was not diabetic. The clinical record of Resident L was reviewed on 3/25/2025 at 10:15 A.M. The resident's diagnoses included, but were no limited to: multiple sclerosis, adult failure to thrive, chronic pain syndrome, hypertension, repeated falls, bipolar disorder, anxiety, cannabis use and borderline personality disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 3/11/2025, indicated the resident was cognitively intact, was dependent for showering and/or bathing and required substantial assistance for personal hygiene. A current Care Plan, revised 3/17/2025, indicated Resident L had an Activity of Daily Living (ADL) Self-Care Performance deficit. Interventions included, but were not limited to: shower/bathe- Resident L was dependent with two or more helpers to do all the effort of the task and personal hygiene- Resident L required substantial assistance for more than half the effort of the task. The shower documentation, dated 2/13/2025 thru 3/27/2025, indicated Resident L was only documented as having received showers on the following dates: -2/13/2025, 2/21/2025, 3/4/2025, 3/7/2025, 3/10/2025, 3/14/2025, 3/21/2025 and 3/25/2025. Resident L had not received 5 of the scheduled 13 showers during the time frame. It was unclear why Resident L had not received hair care to prevent her hair from becoming matted. 47419 2. A record review was completed on 3/27/2025 at 10:22 A.M. for Resident 22. Diagnoses included, but were not limited to dementia. An Annual Minimum Data Set (MDS) assessment, dated 1/20/2025, indicated Resident 22's cognition was severely impaired and was dependent for shower/bathing needs. A current Care Plan, revised on 1/22/2025, indicated Resident 22 was dependent for shower/bathing and staff performed all care tasks. Observations on 3/23/2025 at 12:11 P.M., 3/25/2025 at 9:16 A.M., and 3/27/2025 at 1:45 P.M., indicated Resident 22's toenails were very long and had grown past the end of her toes. During an interview on 3/27/2025 at 1:48 P.M. CNA 14 indicated a shower included washing a resident's hair with shampoo, washing their body, drying their body, applying lotion, got dressing the reisdent. She indicated nail care was included in the showering process. CNA 14 indicated Resident 22 had received a shower twice a week and if she refused, they re-approached the resident and reported the refusal to the nurse. During an interview on 3/27/2025 at 1:52 P.M., LPN 8 indicated the nurse was responsible for trimming toenails and if a podiatrist was needed, they let the Social Worker know to add the resident to the list for the podiatry visit. During an interview on 3/27/2025 at 2:11 P.M., the Social Worker Designee indicated the nursing staff let her know who needed to see the podiatrist. She indicated the nusing staff had not reported that Resident 22 needed to be seen by the podiatrist. On 3/28/2025 at 1:10 P.M., the Director of Nursing (DON) provided an undated policy title, Foot Care and indicated it was the policy currently used by the facility. The policy indicated, . Foot care is often performed in conjunction with shower/bathing . In some residents, foot care including trimming of nails should only be performed by a professional 3.1-38(a)(3)(A) 3.1-38(a)(3)(B)

Based on observation, interview, and record review the facility failed to ensure freedom from verbal abuse for 2 of 8 residents reviewed (Resident F and Resident G). Findings include: 1) A complaint filed with the Indiana Department of Health, dated 1/13/25 indicated Resident G filed a grievance alleging Licensed Practical Nurse (LPN) 5 had been rude and used foul language to Resident F during a medication pass. The report indicated Resident F asked LPN 5 to bring her some water to take her medication when the nurse entered the room with her pills. LPN 5 grabbed the pills from her bedside table and indicated Resident F should let her know when she wanted to take her pills. She indicated Resident F could not have a breathing treatment because her heart rate was too high. Resident F told LPN 5 her heart rate might not be so high if LPN 5 was not being a b****. The complainant indicated LPN 5 closed the door, and then reopened it, put her head in the doorway, called Resident F a b**** and closed the door. The complainant indicated the Administrator rewrote the grievance, changing what had been originally stated. Resident F's record was reviewed on 1/29/25 at 1:20 PM. Diagnoses included chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. Resident F's current Minimum Data Set (MDS) indicated Resident F's Basic interview for Mental Status (BIMS) score was 15 (cognitively intact). In an interview, on 1/29/25 at 1:27 PM, Resident F indicated a few weeks ago, she had requested a breathing treatment from LPN 5. LPN 5 obtained a heart rate by a pulse oximeter device and informed Resident F her heart rate was too high to receive a breathing treatment. Resident F indicated LPN 5 was rude during the interaction and it upset her. Resident 5 indicated the next day, LPN 5 came to give her medicine, did not bring fresh water and indicated Resident F should use the water that was at her bedside. Resident F indicated to LPN 5 the water had been sitting since the day before and she wanted some fresh water to take her medicine. LPN 5 indicated Resident F was being difficult with her because she asked for fresh water. The resident indicated LPN 5 took her medicine cup away from her, indicated she would come back when she was ready to take her medicine and did not provide her with any fresh water. Resident F indicated she requested a breathing treatment and LPN 5 told her she could not have it due to her heart rate being too high. She indicated LPN 5's tone and body language were rude, causing her to become angry. Resident F indicated she told LPN 5 her heart rate would not be high if the nurse weren't being a b****. Resident F indicated LPN 5 stormed out of the room and closed the door. A few seconds later LPN 5 opened the door, peeked her head in and indicated Resident F was a b****. Resident F indicated she did not see LPN 5 for a long time after the occurrence. She indicated LPN 5 was her nurse last night for the first time in a while. She indicated LPN 5 poked her hard with her finger in the left shoulder to awaken her when it was time to take her medicine. She indicated the poking was painful due to LPN 5's long fingernails. She indicated LPN 5 was rude and standoffish during the encounter. She indicated she felt intimidated by LPN 5 and was afraid she would not receive her medicine when LPN 5 was working. Progress notes dated 12/30/24 at 7:59 AM indicated social services visited Resident F and assessed her for psychosocial distress. Progress notes dated 1/1/25 at 8:01 AM indicated social services visited Resident F and assessed for psychosocial distress. Progress notes dated 1/2/25 at 11:24 AM indicated social services visited Resident F and assessed for psychosocial distress. During a confidential interview on 1/28/25 at 6:28 PM, Employee 2 indicated they were aware of an occurrence of Nurse 5 calling Resident F a b****. They indicated Resident F reported LPN 5 to management. The staff were not interviewed or aware of any interviews being done to investigate the matter. Employee 2 indicated calling a resident a b**** was a form of verbal abuse. During a confidential interview on 1/29/25 at 1:05 PM, Employee 6 indicated Resident F came to them a few weeks ago and asked to file a grievance. Resident F told them a nurse passing her meds became rude after Resident F had asked for water with her pills and a breathing treatment. Resident F said she was denied the breathing treatment because her heart rate was too high. Resident F then told the nurse it might not be so high if she was not being a b****. Employee 6 indicated LPN 5 left the room closing the door, then reopened the door, told Resident F she was a b**** and closed the door again. Employee 6 indicated they presented the grievance to the Administrator immediately. Employee 6 indicated they normally were assigned to interview residents in the area and check for any psychosocial effects when such allegations were made. Employee 6 indicated they were not assigned to do any additional interviews in this instance. She indicated calling a resident a b**** was an example of verbal abuse. She indicated psychosocial assessment visits are generally provided for three days or more if indicated after an occurrence of abuse. In a confidential interview on 1/29/25 at 1:24 PM, Employee 7 indicated they witnessed a grievance being filled out with Resident F. They indicated the grievance stated LPN 5 had cursed at Resident F. 2) During an interview on 1/29/24 at 1:31 PM, Resident G indicated she had witnessed LPN 5 being rude to Resident F on a few occasions. She indicated she recalled an occasion where Resident F and LPN 5 had an argument over medicine. She indicated she heard Resident F call LPN 5 a b****, then LPN 5 returned to the room and called Resident F a b****. She indicated residents used that word on occasion, but staff should not be addressing residents like that. She indicated the incident made her uncomfortable. A record review conducted on 1/29/25 at 1:22 PM indicated Resident G had diagnoses including heart failure and hypertension. Resident G's current MDS indicated her BIMS score was 15 (cognitively intact). A document titled Concern Form, dated 1/2/25, provided by the Social Services Director on 1/29/25 at 1:16 PM indicated Resident F reported LPN 5 was rude to her and she, the resident, cursed at the nurse. The response section of the form indicated the Administrator spoke at length with the nurse regarding the incident. The form indicated the nurse was counseled on her attitude and approach with residents and peers. The form indicated the nurse denied cursing and no one reported hearing the nurse curse. The form was signed by the Administrator and dated 12/31/25. In an interview, on 1/29/25 at 1:36 PM, the Administrator indicated she had interviewed Resident F about her interaction with LPN 5, the resident indicated LPN 5 seemed annoyed and used a rude tone with her, but did not mention the nurse had called her a b****. The Administrator indicated she notified her supervisors and followed corporate guidance. She indicated she did not report the abuse allegation to the department of health because she did not view the interaction as possible abuse. She indicated she did not conduct an investigation or interview staff or other residents about the allegations. She indicated she had interviewed LPN 5 and the nurse denied using foul language. The Administrator indicated she had no further statements or interviews of residents or employees available for review. The Administrator did not provide an explanation of the need to question the nurse about cursing if it was not in the allegation, or the signature date on the concern form occurring before the date of the concern. A current policy titled Abuse and Neglect and Misappropriation Property, undated, provided by the Administrator on 1/28/25 at 1:58 PM indicated use of foul language directed at a resident constituted verbal abuse. This citation is related to complaint IN00451234. 3.1-27(a)(b)

Based on observation, interview, and record review the facility failed to ensure an occurrence of verbal abuse was reported to the Department of Health for 1 of 8 residents reviewed (Resident F). Findings include: A complaint filed with the Indiana Department of Health, dated 1/13/25, indicated Resident G filed a grievance alleging Licensed Practical Nurse (LPN) 5 had been rude and used foul language to Resident F during a medication pass. The report indicated Resident F asked LPN 5 to bring her some water to take her medication when she entered the room with her pills. LPN 5 grabbed the pills from the resident's bedside table and indicated Resident F should let her know when she wanted to take her pills. The nurse indicated Resident F could not have a breathing treatment because her heart rate was too high. Resident F told LPN 5 her heart rate might not be so high if LPN 5 was not being a b****. The complainant indicated LPN 5 closed the door, then reopened it, put her head in the doorway, called Resident F a b**** and closed the door. The complainant indicated the Administrator rewrote the grievance, changing what had been originally stated. Resident F's record was reviewed on 1/29/25 at 1:20 PM. Diagnoses included chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. Resident F's current Minimum Data Set (MDS) indicated Resident F's Basic interview for Mental Status (BIMS) score was 15 (cognitively intact). Survey report system documents submitted by the facility for December 2024 and January 2025, provided by the Administrator on 1/28/25 at 1:40 PM, did not include a report of an allegation of verbal abuse against Resident F had been reported. During a confidential interview, on 1/28/25 at 6:28 PM, Employee 2 indicated they were aware of an occurrence of Nurse 5 calling Resident F a b****. They indicated Resident F reported LPN 5 to management. Employee 2 indicated they were not interviewed or aware of any interviews being done to investigate the matter. They indicated calling a resident a b**** is a form of verbal abuse. During a confidential interview, on 1/29/25 at 1:05 PM, Employee 6 indicated Resident F came to them and asked to file a grievance. They indicated Resident F told them a nurse passing her meds became rude after Resident F had asked for water with her pills and a breathing treatment. She indicated Resident F said she was denied the breathing treatment because her heart rate was too high. Resident F then told the nurse it might not be so high if she was not being a b****. She indicated LPN 5 left the room closing the door, then reopened the door, told Resident F she was a b**** and closed the door again. Employee 6 indicated they presented the grievance to the Administrator immediately. Employee 6 indicated they normally were assigned to interview residents in the area and check for any psychosocial effects when such allegations were made. They indicated they were not assigned to do any additional interviews in this instance. They indicated calling a resident a b**** was an example of verbal abuse. In a confidential interview, on 1/29/25 at 1:24 PM, Employee 7 indicated they witnessed a grievance being filled out with Resident F. She indicated the grievance stated LPN 5 had cursed at Resident F. In an interview, on 1/29/25 at 1:27 PM, Resident F indicated she had requested a breathing treatment from LPN 5. LPN 5 obtained a heart rate by a pulse oximeter device and informed Resident F her heart rate was too high to receive a breathing treatment. Resident F indicated LPN 5 was rude during the interaction and it upset her. Resident 5 indicated the next day, LPN 5 came to give her medicine, did not bring fresh water and indicated the should use the water that was at Resident F's bedside. Resident F indicated to LPN 5 the water had been sitting since the day before and she wanted some fresh water to take her medicine. LPN 5 indicated Resident F was being difficult with her because she asked for fresh water. The resident indicated LPN 5 took her medicine cup away from her and indicated she would come back when she was ready to take her medicine and did not provide her with any fresh water. Resident F indicated she requested a breathing treatment and LPN 5 told her she could not have it due to her heart rate being too high. She indicated LPN 5's tone and body language were rude, causing her to become angry. Resident F indicated she told LPN 5 her heart rate would not be high if she weren't being a b****. Resident F indicated LPN 5 stormed out of the room and closed the door. A few seconds later, LPN 5 opened the door, peeked her head in and indicated Resident F was a b****. Resident F indicated she did not see LPN 5 for a long time after the occurrence. She indicated LPN 5 was her nurse last night for the first time in a while. She indicated LPN 5 poked her hard with her finger in the left shoulder to awaken her when it was time to take her medicine. She indicated the poking was painful due to LPN 5's long fingernails. She indicated LPN 5 was rude and standoffish during the encounter. She indicated she felt intimidated by LPN 5 and was afraid she would not receive her medicine when LPN 5 was working. A document titled Concern Form, dated 1/2/25, provided by the Social Services Director on 1/29/25 at 1:16 PM indicated Resident F reported a nurse was rude to her and she, the resident cursed at the nurse. The response section of the form indicated the Administrator spoke at length with the nurse regarding the incident. The form indicated the nurse was counseled on her attitude and approach with residents and peers. The form indicated the nurse denied cursing and no one reported hearing the nurse curse. The form was signed by the Administrator and dated 12/31/24. In an interview on 1/29/25 at 1:36 PM, the Administrator indicated she had interviewed Resident F about her interaction with LPN 5, she indicated LPN 5 had seemed annoyed and used a rude tone with her, but did not mention the nurse had called her a b****. She indicated she notified her supervisors and followed corporate guidance. She indicated she did not report the abuse allegation to the department of health because she did not view the interaction as possible abuse. She indicated she did not conduct an investigation or interview staff or other residents about the allegations. She indicated she had interviewed LPN 5, and she denied using foul language. The Administrator indicated she had no further statements or interviews of residents or employees available for review. The Administrator did not provide an explanation of the need to question the nurse about cursing if it was not in the allegation or the signature date occurring before the date of the concern. The Administrator indicated upon receiving an allegation of abuse, the employee should be suspended, the Department of Health should be notified, and the Administrator should begin an investigation. A current policy titled Abuse, Neglect and Misappropriation of Property, undated, provided by the Administrator on 1/28/25 at 1:58 PM indicated use of foul language directed at a resident constituted verbal abuse. The policy indicated required notification of agencies, the physician and resident representative should be completed in a timely manner. This citation is related to complaint IN00451234. 3.1-28(c)

Based on observation, interview, and record review the facility failed to ensure an allegation of verbal abuse was investigated for 2 of 8 residents reviewed (Resident F, Resident G). Findings include: 1) A complaint filed with the Indiana Department of Health indicated Resident G filed a grievance alleging Licensed Practical Nurse (LPN) 5 had been rude and used foul language to Resident F during a medication pass. Resident F asked LPN 5 to bring her some water to take her medication when she entered the room with her pills. LPN 5 grabbed the pills from her bedside table and indicated Resident F should let her know when she wanted to take her pills. She indicated Resident F could not have a breathing treatment because her heart rate was too high. Resident F told LPN 5 her heart rate might not be so high if LPN 5 was not being a b****. The complainant indicated LPN 5 closed the door, then reopened it, put her head in the doorway, called Resident F a b**** and closed the door. The complainant indicated the Administrator rewrote the grievance, changing what had been originally stated. Resident F's record was reviewed on 1/29/25 at 1:20 PM. Diagnoses included chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. Resident F's current Minimum Data Set (MDS) indicated Resident F's Basic interview for Mental Status (BIMS) score was 15 (cognitively intact). During a confidential interview, on 1/28/25 at 6:28 PM, Employee 2 indicated they were aware of an occurrence of Nurse 5 calling Resident F a b****. The employee indicated Resident F reported LPN 5 to management, and they were not interviewed or aware of any interviews being done to investigate the matter. They indicated calling a resident a b**** is a form of verbal abuse. During a confidential interview, on 1/29/25 at 1:05 PM, Employee 6 indicated Resident F came to them and asked to file a grievance. They indicated Resident F told them a nurse passing her meds became rude after Resident F had asked for water with her pills and a breathing treatment. She indicated Resident F said she was denied the breathing treatment because her heart rate was too high. Resident F then told the nurse it might not be so high if she was not being a b****. She indicated LPN 5 left the room closing the door, then reopened the door, told Resident F she was a b**** and closed the door again. Employee 6 indicated they presented the grievance to the Administrator immediately. Employee 6 indicated they normally were assigned to interview residents in the area and check for any psychosocial effects when such allegations were made. They indicated they were not assigned to do any additional interviews in this instance. They indicated calling a resident a b**** was an example of verbal abuse. In a confidential interview, on 1/29/25 at 1:24 PM, Employee 7 indicated they witnessed a grievance being filled out with Resident F. She indicated the grievance stated LPN 5 had cursed at Resident F. In an interview, on 1/29/25 at 1:27 PM, Resident F indicated she had requested a breathing treatment from LPN 5. LPN 5 obtained a heart rate by a pulse oximeter device and informed Resident F her heart rate was too high to receive a breathing treatment. Resident F indicated LPN 5 was rude during the interaction and it upset her. Resident 5 indicated the next day, LPN 5 came to give her medicine and did not bring fresh water and indicated she should use the water that was at Resident F's bedside. Resident F indicated to LPN 5 the water had been sitting since the day before and she wanted some fresh water to take her medicine. LPN 5 indicated Resident F was being difficult with her because she asked for fresh water. She indicated LPN 5 took her medicine cup away from her, indicated she would come back when she was ready to take her medicine and did not provide her with any fresh water. Resident F indicated she requested a breathing treatment and LPN 5 told her she could not have it due to her heart rate being too high. She indicated LPN 5's tone and body language were rude, causing her to become angry. Resident F indicated she told LPN 5 her heart rate would not be high if she weren't being a b****. Resident F indicated LPN 5 stormed out of the room and closed the door. A few seconds later LPN 5 opened the door, peeked her head in and indicated Resident F was a b****. Resident F indicated she did not see LPN 5 for a long time after the occurrence. She indicated LPN 5 was her nurse last night for the first time in a while. She indicated LPN 5 poked her hard with her finger in the left shoulder to awaken her when it was time to take her medicine. She indicated the poking was painful due to LPN 5's long fingernails. She indicated LPN 5 was rude and standoffish during the encounter She indicated she felt intimidated by LPN 5 and was afraid she would not receive her medicine when LPN 5 was working. 2) During an interview, on 1/29/24 at 1:31 PM, Resident G indicated she had witnessed LPN 5 being rude to Resident F on a few occasions. She indicated she recalled an occasion where Resident F and LPN 5 had an argument over medicine She indicated she heard Resident F call LPN 5 a b****, and LPN 5 returned to the room indicating Resident F was a b****. She indicated residents used that word on occasion, but staff should not be addressing residents like that. She indicated the incident made her uncomfortable. A record review conducted on 1/29/25 at 1:22 PM indicated Resident G had diagnoses including heart failure and hypertension. Resident G's current MDS indicated her BIMS score was 15 (cognitively intact). A document titled Concern Form, dated 1/2/25, provided by the Social Services Director on 1/29/25 at 1:16 PM indicated Resident F reported a nurse was rude to her and she cursed at the nurse. The response section of the form indicated the Administrator spoke at length with the nurse regarding the incident. The form indicated the nurse was counseled on her attitude and approach with residents and peers. The form indicated the nurse denied cursing and no one reported hearing the nurse curse. The form was signed by the Administrator and dated 12/31/24. In an interview, on 1/29/25 at 1:36 PM, the Administrator indicated she had interviewed Resident F. about her interaction with LPN 5. She indicated LPN 5 had seemed annoyed and used a rude tone with her, but did not mention the nurse had called her a b****. She indicated she notified her supervisors and followed corporate guidance. She indicated she did not report the abuse allegation to the department of health because she did not view the interaction as possible abuse She indicated she did not conduct an investigation or interview staff or other residents about the allegations. She indicated she had interviewed LPN 5 and she denied using foul language. The Administrator indicated she had no further statements or interviews of residents or employees available for review The Administrator did not provide an explanation of the need to question the nurse about cursing if it was not in the allegation or the signature date occurring before the date of the concern. A current policy titled Abuse, Neglect and Misappropriation of Property, undated, provided by the Administrator on 1/28/25 at 1:58 PM indicated use of foul language directed at a resident constituted verbal abuse. The policy indicated each occurrence of abuse should be investigated timely. The policy indicated the Administrator was responsible for directing the investigation. This citation is related to complaint IN00451234. 3.1-28(d)

Based on observation, interview, and record review the facility failed to ensure assessment, education and care planning were accurately recorded pertaining to smoking for 1 of 4 residents reviewed (Resident D). Findings include: A complaint addendum filed with the Department of Health, dated 1/16/25, indicated some residents had been smoking in their rooms the previous night. The complainant indicated the Administrator had told the nursing staff on duty not to document the indoor smoking in the residents' charts. The complainant also alleged the Administrator instructed the department heads and corporate staff present in the morning meeting the following day not to chart anything about the indoor smoking. During an observation, on 1/29/24 at 1:45 PM, Resident D was observed in the smoking area with a lit cigarette smoking An unidentified staff member was supervising several residents in the smoking area at the time. During an interview ,on 1/29/25 at 1:46 PM, Resident D indicated he smoked at the designated times posted inside the door with a staff member present.He indicated some residents smoked independently and some needed to be supervised. He indicated he did not know why he had to be supervised. Resident D's record was reviewed on 1/29/24 at 11:22 AM. Diagnoses included chronic obstructive pulmonary disease and shortness of breath. Resident D's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). Resident D's current care plan titled .uses nicotine products .Resident is a supervised smoker .indicated the resident had a problem of using cigarettes, with a goal date of 4/22/25. Interventions included educating the resident to use the smoking area to smoke, and the resident is an independent smoker. A smoking assessment dated [DATE] indicated Resident D used cigarettes and was independent with smoking. A smoking assessment dated [DATE] indicated Resident D used cigarettes and required supervision to smoke cigarettes. No changes in diagnoses, cognition, vision, dexterity, frequency or safety were indicated on the form to validate the change in status. No progress notes between 1/15/24 and 1/21/24 pertaining to smoking were available for review. In an interview, on 1/28/25 at 10:12 AM, the Director of Nursing indicated Resident D, and another resident were caught smoking in their rooms on a very cold day because they were angry about not being able to go outside and smoke. In an interview, on 1/28/25 at 11:13 AM, the Administrator indicated she was aware of a different resident having an occurrence of indoor smoking but was not aware of any others. In a confidential interview, on 1/29/25 at 1:05 PM Employee 6 indicated they were aware of a few residents who reportedly smoked in their rooms on a very cold day when they were not allowed to go outside due to the low temperatures. Employee 6 indicated a new smoking assessment was done to indicate Resident D now required supervision due to smoking indoors. They indicated the Administrator announced in the morning meeting that staff were not allowed to document the occurrences of indoor smoking. They indicated upon a violation of the smoking policy, staff should stop the resident from smoking in an unsafe area, educate them on the policy and safety standards, remove the smoking materials from their possession, perform a new smoking assessment and update the care plan. All the events should be documented and reported to the physician and representative. A current policy titled Resident/Patient smoking dated 3/25/16 provided by the Administrator on 1/28/25 at 1:58 PM indicated smoking supervision changes were made by the interdisciplinary team recommendations. The policy indicated staff should document the reason for the need to change, update the care plan and document resident and family notification. The policy also indicated smoking should only occur in designated areas. This citation is related to complaint IN00451234. 3.1-45 (a)(2)

Based on observation, interview and record review, the facility failed to store food and maintain equipment in a sanitary manner related to foods not sealed tightly, mold in a refrigerator, cookware with chipped Teflon and a resident's personal water container with mold (Resident G). This deficient practice had the potential to affect 84 of 84 residents who received meals out of the kitchen. Findings include: 1. During an interview on 4/18/2024 at 11:32 A.M., Resident G indicated he had a plastic water container that he used to use, but the water from the bathroom where the staff would get the water from turned his straw black. Resident G indicated staff had never washed it. He had stopped them from using it and had a water pitcher staff would put ice in now. A plastic clear water jug with a plastic ringed straw sitting in the container was observed on the resident's night stand. The straw was noted to have black around the rings of the straw. A record review was completed on 4/23/2024 at 5:00 P.M. Resident G was cognitively intact. During an observation on 4/24/2024 at 9:57 A.M. the Corporate Nurse, the container was on the resident's night stand. During an interview on 4/24/2024 at 9:58 A.M., the Corporate Nurse indicated the container was dirty and should have been sanitized, and it was not dirty due to the water, but was moldy. 49994 2. On 4/17/2024 at 9:37 A.M., a kitchen tour was conducted with the Dietary Manager (DM). The following was observed: a buildup of ice on the floor of a freezer, mold on a refrigerator shelf, one dented can of pumpkin, and a bag of whipped topping and parmesan cheese not sealed appropriately. During an interview on 4/22/2024 at 10:14 A.M., the DM indicated areas should be clean and food stored and sealed properly, 3. During a follow-up tour of the kitchen on 4/22/2024 at 10:11 A.M., the following was observed: two skillets with a buildup of grease on the inside and four skillets missing Teflon. During an interview on 4/22/2024 at 10:14 A.M., the DM indicated he understood that chipped Teflon could get into the food and the skillets should be removed. On 4/18/2024 at 8:47 A.M., the Corporate Infection Prevention Nurse provided the policy titled, Environment, dated 9/2017, and indicated the policy was the one currently used by the facility. The policy indicated . Procedures: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces On 4/18/2024 at 8:47 A.M., the Corporate Infection Prevention Nurse provided the policy titled, Food Storage: Dry Goods, dated 9/2017, and indicated it was the one currently used by the facility. The policy indicated . Procedures: 5. All packaged and canned food items will be kept clean, dry, and properly sealed . On 4/18/2024 at 8:47 A.M., the Corporate Infection Prevention Nurse provided the policy titled, Food Storage: Cold Foods, dated 4/2018, and indicated it was the one currently used by the facility. The policy indicated . Procedures: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . This citation relates to Complaint IN00430346. 3.1.21(i)(3)

Based on record review, observation and interview, the facility failed to develop comprehensive/person centered care plans for residents with behaviors and dementia care, for 6 of 23 residents whose care plans were reviewed. (Residents 66, 17, 77, 5, E & F) Findings include: 1. A record review was completed on 4/22/2024 at 10:27 A. M. Resident 66's diagnoses included, but were not limited to, dementia, depression anxiety, mood disorder and psychosis. A Quarterly MDS (Minimum Data Set) assessment, dated 3/18/2024, indicated the resident was moderately cognitively impaired. A current Care Plan, dated 3/27/2023, indicated the resident was at risk for Psychosocial well-being related to: Adjustment to new admission, Anxiety, Loss of Independence, dementia with behavioral disturbances, paranoia, auditory hallucinations, anxiety, and depression. A current Care Plan, dated 4/2/2023, indicated the resident had a behavior problem related to Psychosocial issues, dementia with behavioral disturbances, auditory hallucinations, agitation, anxiety, depression, paranoia, adjustment to new facility, history of saying she is here to work; now ready to go home; history of layering her clothing; history of disorganized thoughts; history of putting clothing in room trash can; history of expressions of frustrations to others. Packs personal belongings and repeatedly asks to leave. Exit seeking behavior, asking for the door codes and a history of repeating questions. At times redirection is unsuccessful. She prefers to wear make up and likes to put it on herself. History of pulling peers hair and pushing peer. Interventions included, but were not limited to: Administer medications as ordered. Observe and document signs/symptoms, and effectiveness and side effects. Educate resident / resident representative to medication effectiveness and side effects. Approach, speak in calm manor. Behavioral health consults as needed. Communicate with resident / resident representative regarding behaviors, and treatment. Encourage active support by family / resident representatives. Encourage Resident to express feelings. Encourage resident to participate in activities of choice. Encourage to maintain as much independence and control / decision making as possible. Intervene as necessary to protect the rights and safety of others. Minimize potential for disruptive behaviors by offering tasks that divert attention. Monitor behavioral episodes, and attempt to determine underlying causes. Observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs. Offer resident activities of books, magazines, and if applicable with time and weather out side walks. Praise any indication of progress in behaviors. During an interview, on 4/22/2024 at 2:02 P.M., the Corporate Nurse indicated the care plan was not person centered and should have been. 49994 2. A clinical record review was completed on 4/19/2024, at 11:51 A.M. Resident 17's diagnoses included, but were not limited to: Cerebral palsy, Type 2 diabetes, depression, anxiety, hallucinations, and dementia. A current Care Plan, dated 8/30/2021, indicated the resident had a behavior problem related to dementia as evidence by, repetitively packing her belongings and staying in her room, sitting on the floor, believing there were bugs in her toes, picking her toenails off, yelling at people who were not there, talking to and carrying a doll. Interventions included, but were not limited to, administer medications as ordered, observe and document signs and symptoms of effectiveness and side effects of medications, educate resident and resident representative on medication, speak in a calm manor, communicate with resident regarding behaviors and treatment, encourage active support, encourage resident to express feelings, encourage resident to participate in activities, and encourage resident to maintain as much decision making as possible. During an interview, on 4/22/2024 at 1:59 P.M., the Corporate Infection Prevention Nurse indicated the care plans were not person centered and they should have been. 3. A clinical record review was completed on 4/18/2024 at 3:08 P.M. Resident 77's diagnoses included, but were not limited to: Alzheimer's, dementia, major depressive disorder, psychosis, hallucinations, and psychotic disorder with delusions. A Care Plan, dated 10/27/2023, indicated the resident had the potential to urinate and defecate on floors, become aggressive with care, a history of becoming physically and verbally aggressive, and a history of inappropriate boundaries. Interventions included but were not limited to 1:1 at all times with a staff, speak in a calm manner, intervene as necessary, minimize potential for disruptive behaviors by offering tasks that divert attention, observe and anticipate resident's needs, observe behavioral episodes and attempt to determine the underlying cause. During an interview, on 4/22/2024 at 1:59 P.M., the Corporate Infection Prevention Nurse indicated the care plans were not person centered and they should have been. 48145 4. During an interview on 4/18/2024 at 10:05 A.M., Resident 5 became frustrated when she could not remember what she had eaten for breakfast. Resident 5's frustration was eased when asked about her child. A record review was completed on 4/19/2024 at 3:15 P.M. Resident 5's diagnoses included, but were not limited to: dementia, anxiety disorder, major depressive disorder, post traumatic stress disorder, chronic pain, and delusional disorders. A current Care Plan, dated 3/14/2024, indicated Resident 5 had a behavior problem related to disease process, family dynamic, loss of independence, nursing home admission, pain and psychosocial issues. The interventions were: observe and anticipate resident's needs: thirst, food, body positioning, pain and toileting needs, and praise any indication of progress in behaviors. A current Care Plan, dated 3/21/2024, indicated Resident 5 had impaired cognitive function related to dementia. The interventions were: encourage resident to be involved in daily decision making and keep routine as consistent as possible in order to decrease confusion. During an interview on 4/22/2024 at 10:05 A.M., Qualified Medication Aide (QMA) 12 indicated Resident 5 did exhibit frustration over being confused sometimes and the staff used the resident's Care Plan to identify interventions to help her. QMA 12 was not able to identify interventions in Resident 5's Care Plan that were person-centered. An interview with the Corporate Nurse was completed on 4/22/2024 at 10:30 A.M. The Corporate Nurse indicated Resident 5 did not have person-centered interventions for the Care Plans. 5. During an observation on 4/18/2024 at 10:07 A.M., Resident E's hair was oily and she had long fingernails on both of her hands. Resident E's finger nails were dirty on her right hand. An observation of Resident E was completed on 4/19/2024 at 9:45 A.M. Resident E's hair was oily and she had long fingernails on both of her hands. Resident E's finger nails were dirty on her right hand. Resident E's record review was completed on 4/22/2024 at 9:00 A.M. Resident E's diagnoses included, but were not limited to: vascular dementia, major depressive disorder, mood disorder, anxiety disorder, cerebral vascular accident, contracture of left wrist and left hand, and contracture of muscle of left lower leg and left lower hand. A Quarterly Minimum Data Set (MDS) assessment, dated 2/17/2024, indicated Resident E had severe cognitive impairment, had rejected care 1-3 days and was dependent on staff for bathing and personal hygiene. Resident E's record included documentation she had received bed baths on 4/1/2024, 4/4/2024, 4/8/2024, 4/15/2024, and 4/18/2024, but lacked the documentation that she had refused hair or nail care during any bed baths. A current Care Plan, dated 12/1/2023, indicated Resident E had an Activities of Daily Living self care performance deficit, required assistance with Activities of Daily Living and had a history of refusing nail care from staff. The interventions included, but were not limited to: Resident E is dependent for shower or bath and helper does all of the effort, and Resident E is dependent for personal hygiene care and helper does all of the effort. During an interview on 4/19/2024 at 10:44 A.M., CNA 6 indicated hair and nail care were performed during showers and bed baths. Residents were allowed to refuse care, but staff would make three attempts to complete showers, baths, hair and nail care. CNA 6 indicated the third attempt was done with a nurse, and if the resident still rejected care, the number of attempts and refusal for care was documented on the shower sheets. During an interview on 4/19/2024 at 10:50 A.M., the Director of Nursing indicated there were no shower sheets in the shower book for Resident E. An interview with the Corporate Nurse was completed on 4/22/2024 at 10:34 A.M. The Corporate Nurse indicated Resident E did not have person-centered interventions for the Care Plan to address rejection of care. 6. During an interview on 4/19/2024 at 10:20 A.M., Resident F indicated she did not always receive two showers a week. Resident F's hair appeared dirty and a strong smell of body odor was observed during the interview. Resident F's record review was completed on 4/19/2024 at 11:23 A.M. Her diagnoses included, but were not limited to: chronic obstructive pulmonary disease, major depressive disorder, asthma, chronic respiratory failure with hypoxia, vertigo, bipolar disorder, congestive heart failure and chronic pain. An Admission Minimum Data Set (MDS) assessment, dated 3/9/2024, indicated Resident F had intact cognition and required maximal assistance for showering and personal hygiene. Documentation indicated Resident E received a shower on 4/3/2024 and 4/10/2024, but refused a shower on 4/6/2024, 4/13/2024 and 4/17/2024. A current Care Plan, dated 2/20/2024, indicated Resident F had impaired skin integrity or is at risk of altered skin integrity related to congestive heart failure, body size, and morbid obesity, and often refuses showers. The interventions included, but were not limited to: complete [NAME] at risk assessment upon admission, readmission, quarterly, and as needed and complete weekly skin checks. During an interview on 4/19/2024 at 10:44 A.M., CNA 6 indicated hair and nail care were performed during showers and bed baths. Residents were allowed to refuse care, but staff would make three attempts to complete showers, baths, hair and nail care. CNA 6 indicated the third attempt was done with a nurse, and if the resident still rejected care, the number of attempts and refusal for care was documented on the shower sheets. The shower sheets for Resident F were requested from the Director of Nursing on 4/19/2024 at 10:50 A.M., but none were provided prior to exiting the survey. An interview with the Corporate Nurse was completed on 4/22/2024 at 10:36 A.M. The Corporate Nurse indicated Resident F did not have person-centered interventions for the Care Plan to address rejection of care. On 4/22/2024 at 1:57 P.M., an undated policy was received from the Corporate Nurse, titled, Plan of Care Overview, and identified as the policy currently used by the facility. The policy indicated, .the Plan of Care, also Care Plan is written treatment provided for a resident that is resident-focused and provides for optimal personalized care . planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to their daily routines This citation relates to Complaint IN00431942. 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure a medication cart was kept locked when unattended during a random observation of the medication cart. This had the potential to affect the 22 residents residing on the memory care unit. (400 Hall Medication Cart) Finding includes: During a random observation on 4/18/2024 at 11:10 A.M., the 400 hall medication cart on the memory care unit was unlocked with no staff in the vicinity. During an interview on 4/18/2024 at 11:12 A.M., LPN 14 indicated the cart should have been locked. On 4/24/2024 at 8:37 A.M., the Corporate Nurse provided the policy titled, Storage of Medications, dated 8/2020, and indicated the policy was the one currently used by the facility. The policy indicated .Medications and biologicals are stored safely, securely, and properly . 2. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access 3.1-25(m)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for urinary tract infections, received appropriate treatment and services to prevent a worsening urinary tract infection, when the resident demonstrated signs of a urinary tract infection and when the resident's contaminated urinalysis was not repeated. (Resident C) Finding includes: On 3/30/22 at 10:00 A.M., Resident C's clinical record was reviewed. The resident's Admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of Resident C's most recent comprehensive Minimum Data Set (MDS) was a quarterly assessment dated [DATE] and indicated the following; Resident C's Brief Interview for Mental Status Score (BIMS) of 15, indicated the resident was cognitively intact. The resident required extensive assistance for transfers and toilet use, was not steady and required staff assistance for moving from seated to standing position and surface-to-surface transfers, and utilized a wheelchair for mobility. Resident C was always incontinent of bladder and frequently incontinent of bowel. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C had a fall in the last month prior to reentry, and recent surgery. The resident received surgery involving the kidneys, and ureters and was on 6 days of antibiotics in the previous 7 days. Review of the Progress Notes included, but were not limited to the following: 11/22/21 at 11:34 A.M., Nurse Practitioner (NP) Note indicated, .seen for post covid with urinary sx [symptoms] .She c/o [complains of] dyssuria off and on according to son she [has] been delusional over the weekend . 11/29/21 at 1:19 A.M., Nurses Note indicated, .resident was lowered to the ground by CNA (Certified Nursing Assistant) while she was being transferred from wheelchair to the bathroom .no injuring [sic] or complain [sic] at this time . 11/30/21 at 9:56 A.M., Nurse Practitioner Note indicated, .seen for fell ing [sic] lethargic .She fell the other day she is independent able to transfer herself. she [She's] c/o[complains of] dyssuria off and on .She is seen laying in bed and she says she [is] afraid of getting up and said she cannot take care of herself anymore or doesn't want to go back home .We will run labs . 12/2/21 at 11:30 A.M., Nurse Practitioner Note indicated, .seen for fell ing [sic] lethargic and alter mental status changes. the last few days she did more complaining abut [sic] staff she is post covid she never did mentioned [sic] what is bothering her. She had a fall and she was altos told that she was getting close to dc and since then she just laid in bed .She c/o [complained of] dyssuria off and on .She is seen laying in bed with no effort to eat or drink. She mentioned she [is] afraid of getting up and said she cannot take care of herself anymore or doesn't want to go back home. She is likely making her statement. the [The] labs order [ordered] today she refuses. She appears more pallor . 12/2/21 at 12:08 P.M., Nurses Note indicated, .Resident continues to refuse to get out of bed and not do anything for herself. Seen by the Nurse Practitioner who stated vital signs are ok but to send her out to local emergency room due to her being lethargic and altered mental status. Son notified. Resident refused her labs this A.M 12/2/21 at 7:40 P.M., Nurses Note.Resident admitted to local hospital with right femur fracture, urinary tract infection, low white blood cell count, and a possible blood clot A review of Resident C's Physical Therapy Notes indicated the following: On 11/24/21 at 9:30 A.M., Resident C .reports that she had pain and discomfort in her abdomen and when she urinates. Nursing is aware and a U/A [urinalysis] has been initiated per pt [patient] On 11/29/21 at 3:10 P.M., Resident C .required coaxing and cueing to eat this day. Pt [patient] is lethargic and confused On 11/30/21 at 3:17 P.M., Resident C .appears to be lethargic and increased confusion. Spoke with NP [Nurse Practitioner] and a U/A [urinalysis] was completed with no findings and lab work is being done to find out why patient is showing a decline On 3/30/22 at 2:23 P.M., the Director of Nursing provided Resident C's clinical record from local hospital, and it was reviewed at that time. The report indicated Resident C was admitted to the local hospital on 12/2/21 at 1:40 P.M. for altered mental status, possible [CONDITION(S)], and lethargy. Review of the resident's hospital History and Physical documentation for services provided on 12/15/22 at 4:40 P.M., indicated, .history of pyelonephritis and recurrent UTIs [urinary tract infections]. bilateral hydronephrosis and right renal hematoma and had bilateral stents placed at [local hospital] in September 2021 .presented from nursing home to ER [emergency room ] on 12/2/2021 with [CONDITION(S)] and lethargy .on 12/3/21 patient underwent IR [[MEDICATION(S)] radiology] guided nephrostograms, right nephrostomy placement, left percutaneous nephroureteral stent placement. Patient also underwent IR guided aspiration of right thigh hematoma and was continued on broad-spectrum antibiotics. Patient underwent right hip hemiarthrosplasty with placement of antibiotics spacers, right hip irrigation and debridement on 12/3/21. After procedures patient was admitted to ICU [intensive care unit] on 12/3/2021 for further management/pressor support for septic shock and required transfusion. Patient was started on CRRT [continuous renal replacement therapy]. Infectious disease consulted for E. coli bacteremia and pyelonephritis and per infectious disease recommendation patient will require 6 week of antibiotics On 3/31/22 at 10:28 A.M., the Director of Nursing provided Resident C's Urine Culture lab which was reviewed at that time. The documented collection date was 11/23/21 at 00:00 and reported dated was 11/26/21 at 10:33 A.M. The report indicated the lab results were reviewed by the Nurse Practitioner on 11/26/21 at 11:28 A.M. The report indicated, Result .MIXED PATH, PROBABLE CONTAMINATION . On 4/6/22 at 1:05 P.M., the Corporate Vice President provided a laboratory order that was reviewed at that time. The order was dated 11/30/21 at 9:44 A.M., to obtain a lab for complete blood count (CBC) and basic metabolic panel (BMP), to be drawn on 12/2/21. On 3/31/22 at 10:51 A.M., an interview with the Nurse Practitioner indicated he reviewed Resident C's urinary report on 11/26/21 and was aware the urine sample was contaminated. The NP indicated he did not assess the resident until he returned to the facility on [DATE]. The NP indicated the Physical Therapist Assistant reported the resident's condition of lethargy and increased confusion to him on 11/30/21 and so he ordered labs to be collected on 12/2/21. The NP indicated labs were collected in the facility only on Tuesdays and Thursdays, so he did not order a urinalysis to be repeated and also indicated he did not repeat the urinalysis because the resident was complaining about everything. It was my bad, we should have repeated the U/A [urinalysis].The NP indicated Resident C refused labs to be drawn on 12/2/21 so decided to send her to the emergency room because she was so lethargic and wasn't acting right. On 3/31/22 at 11:40 A.M., an interview with the Director of Nursing indicated only 1 urinalysis was collected from Resident C in November and December. The Director of Nursing indicated the residents contaminated urinalysis should have been repeated. On 4/6/22 at 12:01 P.M., a document entitled, NURSING FACILITY LABORATORY AGREEMENT, dated 9/28/2018, was provided by the Administrator and reviewed at that time. The laboratory agreement with the facility indicated, .[local laboratory] will provide STAT (life threatening situation) services 24 hours per day, 365 days per year On 4/6/22 at 1:05 P.M., a policy entitled,Laboratory and Radiological Services and Results Reporting, dated 3/22/2019 and revised on 1/18/2022, was provided by the Corporate Vice President and reviewed at that time. The policy indicated, .The facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. There are clinical and physiological risks when laboratory services are not performed in a timely manner or the results of these services are not reported and acted upon quickly. Delays may adversely affect a resident's diagnosis, treatment, assessment and interventions(SOM, 2017) . This Federal tag relates to complaint IN 068. 3.1-41(2)

Based on interview and record review, the facility failed to ensure agency staff who worked in the facility as Certified Nursing Assistants and a Licensed Practical Nurse were certified and/or licensed according to Federal and State law from 9/29/21 to 1/15/22. The facility had 18 individuals working as Certified Nursing Assistants who were not certified. The facility also had 1 individual who worked as an LPN who was not licensed. These individuals performed the functions as if they were licensed. License and certifications were not verified by the facility. This deficient practice had the potential to affect all residents who resided in the facility from [DATE] to 1/15/22. The immediate jeopardy began on 9/29/21 when the first uncertified nursing assistant began working with residents. The Administrator was notified of the immediate jeopardy on 2/11/22 at 2:25 P.M. Finding includes: During an interview, conducted with Agency Staff 1, on 2/9/22 at 2:08 P.M., she indicated she had taken a job with a local staffing agency after applying for a dietary position. The agency owner told her they needed Certified Nursing Assistants (CNA), Qualified Medication Aides (QMA), and Nurses. She told the owner she did not have training in those areas and the agency owner told her she could train her, and she was given one day of training. She indicated she guessed she should have known better but she didn't. During an interview, conducted with the Administrator of the facility, on 2/9/22 at 2:40 P.M., he indicated some of the staff from (local staffing agency) worked as CNA's, QMA's, and nurses in the facility. Agency staff 1 worked as an LPN on 12/31/21, 1/7/22, 1/8/22, 1/9/22, 1/10/22, and 1/11/22. He indicated there were other staff from the same agency that worked in the facility without licenses or certifications, but he did not say how many. When asked who was responsible for checking licenses, he indicated himself and the human resources department. He indicated the facility did not check certification or licenses immediately. The discovery came when they began preparing for F888 and doing research on Agency staff, immunizations, education, and licenses with the intent to make files for the agency staff. He Indicated this was when he discovered Agency Staff 1 did not have a nurse's license, they began looking into the other agency employees at that time. During a second interview with Agency staff 1, on 2/9/22 at 2:46 P.M., she indicated she worked at (local facility) for a couple of months as a CNA and LPN. She indicated she had passed medications at (local facility), and that mostly everyone from the staffing agency was uncertified and working as aides and QMA's, and LPN's, she alleged most staff of the agency were members of the owner's family. During a second interview, conducted with the Administrator of the facility on 2/10/22 at 4:36 P.M., he indicated he had not reported the occurrence to the State of Indiana, and he probably should have. During an interview, with the Director of Nurses (DON), on 2/11/22 at 12:27 P.M., she provided documentation that indicated Agency staff 1 worked in the capacity of a CNA on 11/23/21, 11/26/21 and in the capacity of a Licensed Practical Nurse on 11/27/21, 11/28/21, 11/30/21, 12/1/21, 12/29/21, 12,31/21, 1/3/22, 1/7/22, 1/8/22, 1/9/22, 1/10/22, and 1/11/22. A license was unable to be verified. On 11/27/21 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100 Hall from 2:00 P.M. to 10 P.M., where she administered medications and insulin to residents. On 11/28/21 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100 Hall from 6:00 A.M. to 2:00 P.M., where she administered medications and insulin to residents. On 11/30/21 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 400 Hall from 2:00 P.M. to 10: 00 P.M., where she administered medications to residents. On 12/1/21 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100 Hall from 2:00 P.M. to 10:00 P.M. where she administered medications and insulin to residents. On 12/29/21 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 300 Hall from 2:00 P.M. to 10:00 P.M. where she administered medications to residents. On 12/31/21 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100 Hall from 2:00 P.M. to 10: 00 P.M. and then 100/400 Hall from 10:00 P.M. to 6:00 A.M., where she administered medications to residents. On 1/3/22 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 200 Hall from 2:00 P.M. to 10:00 P.M., where she administered medications to residents. On 1/7, 22 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100/400 Hall from 10:00 P.M. to 6:00 A.M., where she administered medications to residents. 1/8/22 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100/400 Hall from 10:00 P.M. to 6:00 A.M., where she administered medications to residents. 1/9/22 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100/400 Hall from 10:00 P.M. to 6:00 A.M., where she administered medications to residents. 1/10/22 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100/400 Hall from 10:00 P.M. to 6:00 A.M., where she administered medications to residents. 1/11/22 Agency staff 1 worked in the capacity of a Licensed Practical Nurse on the 100/400 Hall from 10:00 P.M. to 6:00 A.M., where she administered medications to residents. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by the agency employee and facility staff and dated for 10/28/21, 10/29/21, 11/1/21, 11/3/21, 11/4/21, 11/5/21, 11/9/21,11/29/21, 12/8/21, 12/9/21, 12/15/21, 12/16/21, 12/17/21, 12/28/21, 12/29/21, 12/30/21 and indicated Agency staff 2 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by the agency employee and facility staff and dated for 10/20/21, 10/21/21, 10/23/21, 10/24/21, 10/26/21, 10/27/21, 10/28/21, 10/30/21, 10/31/21, 11/1/21, 11/3/21, 11/4/21, 11/6/21, 11/7/21,11/15, 11/16/21, 11/17/21, 11/20/21, 11/21/21, 11/22/21, 11/23/21, 11/26/21, 11/27/21, 11/28/21, 11/29/21, 11/30/21, 12/4/21, 12/5/21, 12/7/21, 12/8/21, 12/9/21, 12/11/21, 12/15/21, 12/16/21, 12/18/21, 12/19/21, 12/20/21, 12/22/21, and 12/23/21. Agency staff 3 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by the agency employee and facility staff and dated for 10/1/21,10/2/21, 10/4/21, 10/5/21, 10/14/21, 10/15/21, 10/17/21, 10/18/21, 10/19/21, 10/20/21, 10/21/21, 10/22/21, 10/24/21, 10/25/21, 10/26/21, 10/27/21, 10/28/21, 10/29/21, 10/30/21, 11/3/21, 11/4/21, and 11/5/21. Agency staff 4 worked on those dates in the capacity of a Certified Nursing Assistant. A current license could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by the agency employee and facility staff and dated for 10/1/21, 10/2/21, 10/31/21, 11/4/21, 11/5/21,11/6/21, 11/7/21, 11/14/21, 11/16/21, 11/17/21, 11/19/21, 11/20/21,11/23/21, 11/24/21, 11/25/21, 11/26/21, 11/27/21,11/30/21, 12/1/21, 12/3/21,12/4/21, 12/6/21, 12/7/21, 12/8/21, 12/9/21, 12/11/21, 12/21/21, 12/22/21, 12/23/21, 12/24,21, 12/26/21, 12/27/21, 12/28/21, and 1/22/22. Agency staff 5 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/21 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by the agency employee and facility staff and dated for 10/15/21, 10/18/21, 10/19/21, 10/20/21, 10/22/21, 10/23/21, 10/28/21, 10/29/21, 10/30/21, 11/1/21, 11/2/21, 11/3/21, 11/4/21, 11/6/21, 11/7/21, 11/22/21, 11/23/21, 11/24/21, 11/25/21, 11/27/21, 12/1/21, 12/2/21, 12/3/21, 12/4/21, 12/18/21, 12/20/21, 12/21/21, 12/22/21, 12/23/21, 12/24/21, and 12/25/21. Agency staff 6 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was unsigned by the agency employee but signed by the agency supervisor and facility employee for 12/4/21 and signed by the agency employee and facility staff on 12/7/21, 12/10/21, and 12/11/21. Agency staff 6 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by agency employee staff and facility staff and dated for 10/4/21, 10/5/21, 10/13/21,10/14/21, 10/16/21, 10/17/21, 10/18/21, 10/24/21, 11/1/21, 11/2/21, 11/3/21, 11/6/21, 11/23/21, 11/24/21, 11/25/21, 11/27/21, 12/6/21, 12/7/21, 12/8/21, and 12/9/21. Agency staff 8 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by agency employee staff and facility staff and dated for 10/20/21, 10/21/21, 10/22/21, 10/23/21, 10/30/21, 10/31/21, 11/2/21, 11/3/21, 11/4/21, 11/5/21 and 11/7/21. Agency staff 9 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by agency employee staff and facility staff and dated for 12/24/21. Agency staff 10 worked on those dates in the capacity of a Certified Nursing assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by agency employee staff and facility staff and dated for 10/19/21, 10/20/21, 10/31/21, 11/1/21, 11/4/21, 11/6/21, 11/7/21, 11/8/21, 12/7/21, 12/9/21, 12/11/21, 12/16/21, 12/17/21, 12/27/21, 12/31/21 and 1/1/22. Agency staff 11 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by agency employee staff and facility staff and dated for 10/9/21, 10/15/21, 10/16/21, 10/18/21, 10/26/21, 10/27/21, 11/3/21, 11/4/21 and 11/5/21. Agency staff 12 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M. The time sheet was signed by agency employee and facility staff and dated for 11/3/21, and 11/4/21. Agency staff 13 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M., the time sheet was signed by agency employee and facility staff and dated 9/29/21, 11/28/21, 11/29/21, 11/30/21, and 12/2/21. Agency staff 14 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M., the time sheet was signed by agency employee and facility staff and dated 11/3/21, 11/4/21 and 11/5/21. Agency employee 15 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M., the time sheet was signed by the agency employee and facility staff and dated 11/3/21, 11/4/21, 11/5/21, 11/6/21, 12/16/21, 12/17/21, 12/18/21, 12/19/21 and 12/31/21. Agency Employee 16 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M., the time sheet was signed by the agency employee and facility staff and dated 12/20/21, 12/21/21 and 12/29/21. Agency employee 17 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M., the time sheet was signed by the agency employee and facility staff and dated 10/10/21, 10/11/21, 10/12/21, 10/13/21, 10/14/21, 10/17/21, 10/30/21, 11/1/21, 11/2/21, 11/4/21 and 11/6/21. Agency employee 18 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Employee Time Sheet, provided by the DON, on 2/11/22 at 9:30 A.M., was reviewed on 2/11/22 at 12:35 P.M., the time sheet was signed by the agency employee and facility staff and dated 11/2/21 and 11/5/21. Agency employee 19 worked on those dates in the capacity of a Certified Nursing Assistant. A current certification could not be verified. An Agency Agreement/Contract, dated 8/24/21, was provided by the DON on 2/11/22 at 2:00 P.M. The policy indicated .Provider's Responsibilities: 2. Provider shall only provide personnel who meet the requirements of Customer as defined in Attachment A. d. Verification that evidence of the professional licensure identification, as applicable has been seen and examined. 4. Provider is responsible for evaluating skills and experience of its nursing personnel. Provider will match the skills and experience level of its employees to the specific needs of the customer. Customer Responsibilities: 5. Customer agrees the Provider's duty to fill assignments is subject to the availability of qualified personnel. III. Mutual Responsibilities: 1. The parties shall comply with all federal, state and local laws and regulations including but not limited to, Title [NAME] of the Civil Rights Act, The National Labor Relations Act, and the Health Insurance Portability and Accountability Act of 1996 A policy, titled .Staffing Agency Use, with a revision date of 11/22/21, was provided by the DON on 2/11/22 at 2:00 P.M. The policy indicated .The purpose of this policy is to provide guidance for using an outside agency to provide qualified and competent staff during periods when additional staff is required. The Director of Nursing (D.O.N.) will be responsible for providing safe and competent staff to fill positions with interim or agency staff. Procedure: C. The D.O.N./designee will obtain, at a minimum, basic information from the agency including name, contact information, license information including license number and type, COVID vaccination card or medical or religious exemption, previous training including HIPPA, Universal Precautions and Medication Administration Safety and any current experience. D. The facility will obtain and maintain a file on each person working in the facility as a staffing agency. F. The facility will obtain current state license verification prior to the nurse starting the shift This Federal tag relates to Complaint IN 368. 3.1-14(s)

Based on record review and interview, the facility failed to ensure medical intervention and monitoring was initiated after staff became aware an anchored urinary catheter had become dislodged for a resident with [MEDICAL CONDITION] bladder, which resulted in the resident being sent to the emergency room where a suprapubic catheter was inserted with return of 1 liter (1000 milliters) of purulent urine and requiring hospital admission on IV (intravenous) antibiotics [MEDICAL CONDITION] (an infection that gets into the blood )/bacteremia due to Escherichia Coli (a bacteria) and acute kidney injury due [MEDICAL CONDITION] for 1 of 2 residents reviewed for catheters. (Resident B) The immediate jeopardy began on 10/2/19 when Resident B's catheter became dislodged, the residents physician was not notified and no follow up was provided to prevent a UTI (urinary tract infection) from occurring and the resident [MEDICAL CONDITION] requiring hospitalization and IV antibiotics. The Administrator, Director of Nursing, and Corporate Nurse were notified of the immediate jeopardy on 10/23/19 at 5:01 P.M. The immediate jeopardy was removed, and the deficient practice was corrected on 10/10/19, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: During an interview, on 10/22/19 at 11:20 [NAME]M., LPN (Licensed Practical Nurse) 1 indicated he provided care for Resident B on 10/2/19 when it was discovered the resident's catheter was no longer anchored, the balloon usually filled to keep it in place had deflated and needed to be removed. LPN 1 then removed the catheter and immediately notified the Assistant Director of Nursing (ADON) who indicated she would follow up and take care of it. The clinical record for Resident B was reviewed on 10/22/19 at 11:00 [NAME]M [DIAGNOSES REDACTED]. An Admission Observation Tool, dated 8/27/19 at 11:37 P.M., indicated .Date and time of admission 8/27/19 14:15 (2:15 P.M.) .Bowel/Bladder 1. Indwelling catheter 16 F (french) [MEDICAL CONDITION] bladder .5. Clarity of urine per catheter .1. Amber 2. Clear A Urology Consultation, conducted while Resident B was still in a local hospital on [DATE], indicated .At this point, I would recommend indwelling Foley catheter with monthly changes. I suspect this will likely be a long -term issue .she does not appear to be a good candidate for intermittent catheterization. This could be reconsidered at a later time as long as her [MEDICAL CONDITION] bladder is not particularly spastic. At some point it may be worthwhile to consider a suprapubic tube placement, but I would like to wait until after this hospital course is resolved. Long-term , she will need periodic monitoring of her renal function and possibly ultrasounds. She will follow-up with our office in a few months as an outpatient A (local hospital) Extended Care Facility Patient/Resident Transfer Form-Physicans Orders Form , dated 8/27/19, indicated .Appt. Urology 3-4 week for catheter The clinical record lacked documentation the appointment had been set up or that she was seen by urology since her return from the hospital on [DATE]. The clinical record lacked documentation of monitoring, care planning with interventions or measuring of intake and outputs for a resident with a catheter or the physician being notified of the residents catheter being removed on 10/2/19. A Medication Administration Record, [REDACTED].Oxybutrin Chloride (a medication used to treat bladder spasms) Tablet 5 MG (milligrams). Give 1 tablet by mouth two times a day for incontinence A Progress Note, dated 10/5/19 at 4:30 P.M., indicated .Having unusual difficulty taking meds. When asked if ok, had difficulty responding. After several attempts was able to answer questions with either a yes or no .B/P (blood pressure) 75/54. Pulse 109, Resp. (respirations) 20, temp. (temperature) 98.0 A Progress Note, dated 10/5/19 at 4:45 P.M., indicated . Son is here visiting. Made him aware that resident is having a change in condition and may need to be sent out. (name of local hospital) notified of resident's condition and decision made to send there for eval (evaluation) A Progress Note, dated 10/5/19 at 5:00 P.M., indicated .911 was called and ambulance here to transport resident to hospital A Computerized [NAME]ography (CT scan), dated 10/5/19, indicated .CT Abdomen and Pelvis W-O (without) contrast (dye) .Radiology Rpt. (report): Moderate distention of urinary bladder is increased since prior study. Foley Catheter on prior CT study no longer present A (name of local hospital) [MEDICATION NAME] Progress Note, dated 10/6/19 at 1:59 P.M., indicated .Radiology Rpt; Suprapubic Tube Placement .Indication: Septic patient with [MEDICAL CONDITION], acute [MEDICAL CONDITION], and unable to obtain Foley catheter access secondary to anatomic distortion of the vagina and urethra .History: Presents with acute [MEDICAL CONDITION]. There is extensive necrotic change within the vagina and distortion of the urethral anatomy. An attempt was previously made by the gynecology service to place a Foley catheter unsuccessfully. The patient is septic and unstable at this time .Procedure: Purulent urine was obtained. The catheter was connected to gravity drainage .Approximately 1 L (liter) of purulent urine was drained A (local hospital) History and Physical, dated 10/6/19, indicated .Chief Complaint: Altered mental status .History of Present Illness: This patient was previously admitted and discharged from (local hospital) from 8/6/2019 until 8/27/2019. At that time she was treated for [REDACTED]. Her hospital course was complicated due to acute kidney injury, ileus, and [MEDICAL CONDITION] bladder. She has a permanent indwelling Foley catheter in place . Yesterday, the patient was sent to the emergency department with altered mental status .In the emergency department, her temperature was 101.2, pulse 105, respirations 20, blood pressure 129/58 .Labs drawn on 10/5/19 shows that CBC (complete blood count) has a white cell count of 20.20 (normal range is between 4000 per microliter of blood and 11,000, white blood cells elevate in response to infection) BUN (blood urea nitrogen) 64.1 (normal range is between 7 to 20 milligrams per deciliter, bun elevation can be an indicator of kidney injury) and Creatinine of 2.81 ( normal range for females is between 0.5 and 1.1 milligrams per deciliter a Creatinine above 2.0 in adults may be indicative of severe kidney impairment). Urinalysis had a specific gravity (urine concentration) of 1.020, WBC (white blood cell) greater than 100, (indicative of infection in urine) and a RBC (red blood cell) count of greater than 100 (indicative of increased blood in the urine) .Assessment: 1.[MEDICAL CONDITION] due to urinary tract infection, present on admission, probably due to chronic indwelling Foley catheter. 2 .Suprapubic 3. Acute-on-chronic kidney injury, could be due [MEDICAL CONDITION] and/or dehydration During an interview, on 10/22/19 at 11: 40 [NAME]M., the ED (Executive Director) indicated a catheter should be monitored and that the physician should have been notified when the catheter was removed. A policy, titled Catheter Care, with a revision date of 5/1/2017 was provided by the Corporate Nurse on 10/22/19 at 12:30 P.M The policy indicated .Policy: Catheter care is performed at least twice daily on residents that have indwelling catheters, for as long as the catheter is in place. CAUTI (Catheter Associated Urinary Tract Infections) is the most common adverse event associated with indwelling urinary catheters . The risk of bacteremia in residents with indwelling catheters is 3-36 times more likely than residents without an indwelling catheter A policy, titled Physician Notification for Change in Condition Reporting, with a reviewed date of 5/29/2019, was provided by the Director of Nurses on 10/21/19 and reviewed on 10/22/19 at 1: 00 P.M The policy which gave various scenarios of when a physician should be notified and in what time frame immediate versus next office day addressed urinalysis results, urine culture results, abdominal pain, fever , abrupt onset of painful urination, urinary hesitancy or retention and hematuria but gave no indication for catheters The Past Noncompliance Immediate Jeopardy began on 10/2/19. The Immediate Jeopardy was removed and the deficient practice corrected on 10/10/19 when the facility implemented the following: Nursing staff in-services related to catheter care and medical intervention, including physician notification and monitoring, signs and symptoms [MEDICAL CONDITION] and infection, and an intake and output monitoring system was implemented for all residents with urinary catheters. This Federal tag is related to Complaint IN 842 and IN 041. 3.1-41(a)(2)

Based on observation, record review and interview, the facility failed to monitor the PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) level of a resident receiving an anticoagulant drug and notify the physician of a refusal of a lab draw, which resulted in continued administration of anticoagulant drug and hospitalization secondary to uncontrolled bleeding for 1 of 1 residents. (Resident 47) This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE], when the facility failed to obtain a PT/INR blood draw on Resident 47 and failed to notify the MD of this refusal. The Executive Director was notified of the Immediate Jeopardy on [DATE] at 4:05 P.M. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A clinical record review was completed on [DATE] at 4:45 P.M., and indicated Resident 47 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident 47 had a BIMS (Brief Interview for Mental Status) score of 11, moderately cognitively impaired. During an initial observation, on [DATE] at 10:42 A.M., Resident 47 was found to have a large, tennis ball sized bruise to her left front shoulder. The bruise varied in color from yellow to deep purple. The resident indicated that the bruise occurred when her shoulder pinched in her chair. During a medication pass observation, on [DATE] at 9:35 A.M., LPN (Licensed Practical Nurse) 1 indicated that Resident 47 had been to the hospital ER (emergency room ) that morning for uncontrolled bleeding from an open area on her bottom. She indicated that Resident 47 had been treated at the facility for MASD (moisture associated skin [MEDICAL CONDITION]. Upon entering Resident 47's room, the resident was observed to be lying on her back on a fully inflated waffle cushion on top of her bed. LPN 1 indicated that Resident 47 had been back from the hospital approximately ,[DATE] minutes. LPN 1 requested the assistance of CNA 3 to remove the waffle cushion from under the resident. Upon rolling Resident 47 to the right side, bright red blood was observed under the resident, which had penetrated through the existing dressing to the resident's bottom, and onto the sheet under the resident. The bloodied area was approximately the size of a dinner plate. LPN 1 immediately applied pressure and requested CNA 3 go and get another nurse and the treatment cart. LPN 1 indicated she did not know what the resident's last INR was and did not know if an INR had been done that morning. Multiple, large bruises of various stages of healing on both of the resident's lower legs and upper thighs were observed, and varied in color from yellow to deep purple and ranged in sizes from dime size to tennis ball size. A small wound below the dressing area on the right buttock was observed. The wound was smaller than a dime, open, shaped like a crescent moon, and not actively draining any fluid. LPN 1 indicated that this was not MASD (Moisture Associated Skin [MEDICAL CONDITION]) and appeared to be a Stage 3 pressure ulcer. At 9:50 A.M., the LPN 2 entered the room to assist with care. LPN 1 removed the bloodied dressing and used a clean sterile gauze to hold pressure to the actively bleeding second wound. The second wound was a dime-sized hole at the bottom of the resident's right buttock, and was actively draining a moderate amount of bright red blood. LPN 1 held pressure for 20 minutes and indicated the bleeding had slowed. The second wound began to actively bleed again, LPN 1 held pressure once more with a clean, sterile gauze for another 7 minutes, then applied a pressure dressing. The first wound was measured by LPN 1 to be 0.8 cm in length x 0.2 cm in width, and described as a slit, with a red to pink wound bed, no drainage, no slough, no odor. LPN 1 was unable to measure the second wound due to amount of bleeding present. The physician orders [REDACTED]. The resident's target INR was ,[DATE]. Normal ranges for INR was 0XXX,[DATE].1. She received 7 mg of [MEDICATION NAME] from [DATE] to [DATE]. On [DATE], her INR was rechecked and was 1.2. On [DATE] the physician ordered an increase to 8 mg daily with a booster dose of 2 mg one time only for a total of 10 mg. On [DATE] her INR was rechecked and was 1.9. The physician ordered for the 8 mg to be continued and recheck the INR on [DATE]. On [DATE] the [MEDICATION NAME] anticoagulation record indicated she refused the INR. She received [MEDICATION NAME] 8 mg daily from [DATE] to [DATE]. The clinical record indicated no documentation of the physician being notified of resident's refusal of the INR on [DATE]. A Nurses Note, dated [DATE], at 5:55 A.M., indicated, .resident sent to ER due to bleeding heavily on her gluteal fold before returning to the facility a few hours later. An ER (emergency room ) Physician report, dated [DATE] at 6:27 A.M., indicated .70 y/o (year old) female who presents to the ED (Emergency Department) via EMS (Emergency Medical Service) from a local nursing facility for a seeping wound to her buttocks .The pt (patient) is noted to have diffuse bruising .Nursing home did not call report on this patient but it sounds like from EMS report that they sent her here for sutures for a bleeding wound A Nurses Note, dated [DATE], at 10:34 A.M., indicated she was sent back to the hospital due to continuously bleeding from the open area to her right buttock. An ER Physician Report, dated [DATE] at 11:36 A.M., indicated .Pt (patient) was sent back to the ED from the nursing home because the pt's buttock wound started to bleed again .They were concerned because the pt was laying in a large area of blood and drainage .She was just seen in the ED ,[DATE] hours ago for similar symptoms .Her workup shows .a too high to calculate INR .She was medicated here with vitamin K .Pressure was applied to her bleeding wound from her buttocks and it stopped .will admit the patient A History and Physical Report, dated [DATE] at 11:04, indicated .admitted to ICC (Intermediate Care Center, a stepdown unit from Critical Care) .with the following problems. 1. Severe [MEDICATION NAME] (impaired blood clotting disorder) .secondary to [MEDICATION NAME] administration resulting in massive bleeding .INR initially was unable to calculate with a PT ([MEDICATION NAME] time) greater than 130 seconds (reference range of 9XXX,[DATE].0) .after 4 units of fresh frozen plasma and 5 mg of vitamin K INR is 4.14 and PT is 14.2 2. Acute blood loss [MEDICAL CONDITION] .hemoglobin 12.3 (on [DATE] at noon), now 7.6 (on [DATE] at 3:03 A.M.) . During an interview, on [DATE] at 10:47 A.M., the DON (Director of Nursing) indicated if a resident refuses a lab draw the expectation is to try and retest the next day and to notify the physician. A policy was provided by the DON on [DATE] at 10:30 A.M., titled [MEDICATION NAME] Monitoring dated [DATE], and indicated this was the policy currently being used by the facility. The policy indicated, .e. All INR labs are called into the prescriber/physician office in a timely manner when received, to allow for dose adjustments before the next dose is administered A policy regarding lab refusal was requested, but one was not provided. The Immediate Jeopardy that began on [DATE] was removed on [DATE], when, through record reviews and interviews, staff had completed education regarding [MEDICATION NAME] use with residents, resident refusal of lab draws, and notifying the physician of lab draw refusal. This education included physician notification for change of condition, refusal of care and treatment, and INR deviations outside therapeutic range and/or refusal of lab will be called to physician before administering medication. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of ongoing monitoring to ensure residents are free from side effects of [MEDICATION NAME], and the need for further education. 3XXX,[DATE](a)(3)

Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent a resident admitted with a red area did not develop a wound which progressed to be unstageable pressure ulcer, and failed to assess, monitor and appropriately treat wounds once they were identified for 2 of 3 residents reviewed for pressure ulcers. (Resident E and Resident D) Findings Include: 1. A clinical review was conducted, on 2/21/19 at 2:14 P.M., for Resident E and indicated he was admitted on [DATE]. His [DIAGNOSES REDACTED]. An admission nurse assessment was completed 1/8/19 and indicated he had a red area to coccyx with no documented measurements. The skilled documentation charting, dated 1/8/19, indicated he had no skin issues on the wound observation area of the form. No follow up documentation found regarding the red area to his coccyx. The MDS (Minimum Data Set) assessment, dated 2/5/19, indicated a BIMS (Brief Interview for Mental Status) score of 3, severe cognitive impairment and indicated he had no skin issues. A care plan, dated 1/10/19, indicated a care plan for potential for skin breakdown related to impaired mobility related [MEDICAL CONDITION]. The interventions were as follows: assist to reposition frequently as he will allow; medication as ordered and monitor for adverse side effects; monitor for signs and symptoms of pain and discomfort; and nursing to continue to observe and notify physician of changes. A care plan, dated 2/20/19, indicated a care plan for actual alteration in skin integrity to coccyx: pressure. The interventions included but were not limited to the following: consult and treatment by certified wound physician; encourage frequent position changes, low air loss mattress, out of bed for meals only. The care plan indicated no care plan in place for wound to the right buttock or the right inner thigh. The TAR (Treatment Administration Record) indicated he had weekly skin assessments on 1/9/19, 1/16/19, 1/23/19, 1/30/19 and 2/6/19. No further documented weekly skin assessments. On 2/20/19 the facility began documenting daily wound assessment to coccyx. A late entry progress notes, dated 2/5/19, indicated Resident E had loose stools and his buttocks were red and a new order was obtained for house cream. No further assessment found documented for the red buttocks. A skin observation report, dated 2/1/19 - 2/11/19, indicated on 2/11/19 there was a skin area noted and the resident's nurse must be notified. No documentation found in the progress notes regarding the area that was found. On 2/13/19, an order for [REDACTED]. On 2/15/19, an order for [REDACTED]. No documentation of treatment being completed on 2/16, 17, 18, 19 or 2/20/19. A skin grid non-pressure assessment, dated 2/15/19, indicated on 2/11/19 a wound to the right thigh (rear) was first observed and it was a large boil like area. The description indicated an open area with a measurement of 2 cm (centimeter) x 2 cm and a red hard area underneath it measuring 5 cm x (by) 4 cm. The assessment described the wound as partial thickness with red, [MEDICATION NAME] occurring, with a medium amount of bloody drainage with an odor, but no signs or symptoms of infection. No further monitoring or assessment found in the clinical record for the wound on the right thigh. A progress note, dated 2/15/19, indicated a wound on the right inner thigh and the right buttocks had opened and the wound physician had been notified and a new order for Bactrim DS 1 tablet twice daily for 7 days and warm compresses. On 2/15/19 at 3:12 P.M., a low air loss mattress was observed to be on Resident E's bed and he was observed to be sitting on a pressure relieving wheelchair cushion. A skilled documentation note, dated 2/16/19, indicated an existing wound to left buttocks and described it as a superficial open area with no drainage and no odor. No further monitoring or assessment found in the clinical record for the wound on the left buttock. A wound evaluation, dated 2/18/19, conducted by the wound physician indicated an unstageable wound of the right buttock with unstageable necrosis and measured 3 cm x 3 cm. The wound was described as having thick adherent devitalized necrotic tissue 80% (percent) and 20% viable tissue and indicated the wound progress had deteriorated. The dressing treatment plan was Santyl apply once daily for 30 days. No documentation by the wound physician related to the wound on the right inner thigh was found. A skin grid non-pressure form, dated 2/20/19, indicated a rash was first observed to his coccyx, on 2/15/19. The description indicated it was a MASD (moisture associated skin damage) with a small amount of sanguineous drainage and measured 4 cm round, the skin was intact and blanchable. No further monitoring or assessment found in the clinical record related to a rash on his coccyx. A progress note, dated 2/21/19, indicated the right thigh and right buttock dressings were changed and had a moderate amount of bright red blood. The wound physician was notified and no new orders were received. During a wound observation, on 2/22/19 at 10:30 A.M., LPN (Licensed Practical Nurse) 4 measured the wound on his right lower buttock as 2 cm x 2 cm. The wound had light tan slough 80% and 20% pink tissue covering the wound. The LPN indicated she thought the wound was a stage 2 or 3 and it had gotten worse since last week. The right inner thigh wound measured at 4 cm x 1.5 cm and the LPN indicated it was a boil . It has a dark tan slough covering 80% of the wound, the wound is raised and 20% of the wound is bright purplish red in color. No rash noted to coccyx area and no wound noted to his left buttock. During a wound observation, on 2/22/19 at 3:30 P.M., the wound care physician re-evaluated the wounds to his right buttock and his right inner thigh. The right buttock wound had a large amount of bloody drainage on the dressing and dark red surrounding the wound and slightly raised. He indicated he was at the facility, on 2/18/19, and the right inner thigh wound was not present and the right buttock was a unstageable wound. During an interview, on 2/21/19 at 3:40 P.M., the DON indicated the care plan should have been in place when the open area was found, but the nurses do not update the care plans and the IDT (interdisciplinary team) would have done it after the weekend. She indicated she assessed the wound on 2/15/19 but did not document it until the 2/20/19 and the care plan was not done until 2/20/19. She indicated it should have been done at the time the wound was found. During an interview, on 2/21/19 at 4:40 P.M., the Therapy Manager indicated therapy placed a roho cushion (pressure relieving cushion) on his wheelchair on 2/15/19. During an interview, on 2/22/19 at 1:13 P.M., the DON indicated it was in error the order for cleansing the wound with normal saline, and applying [MEDICATION NAME] dressing one time a day for wound care was written for daily as it was only suppose to be done every 3 days. She indicated she had documented it in error that the TAR indicates to monitor daily the coccyx wound and it should be the buttock. She indicated the UM (Unit Manager) was responsible for ensuring weekly wound measurements were completed. During an interview, on 2/22/19 at 1:58 P.M., the Chief Nursing Officer indicated the facility should have continued to monitor Resident E's buttocks once it was red on admission. They should have assessed him weekly and documented wounds on the day they were found and then assessed them weekly. The care plan should have been updated with interventions for wound care and wounds. 2. A clinical record review was conducted on 02/21/19, at 11:53 A.M., for Resident D and indicated an admission date of [DATE]. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 12/21/18, indicated a BIMS (Brief Interview for Mental Status) score was not assessed and the staff assessment was not conducted. Heart failure, anxiety disorder, and pressure ulcers, one stage 4, were indicated as current diagnoses. The resident was receiving hospice. A care plan, dated 1/10/19, was in place related to a pressure ulcer on the right heel and has the potential for complications and had interventions that included, but were not limited to, diet as ordered, hospice services, monitor for s/s (signs and symptoms) of pain and discomfort, nursing to continue to observe and notify MD (medical doctor) of changes, off load heel, treatment as ordered, weekly and prn (as needed) skin assessment. During an interview, on 2/20/19 at 10:30 A.M., the hospice nurse indicated that the facility nurses were to be providing daily wound care for the resident, but, recently hospice had been taking over wound care because they (the hospice nurse) found the wound declined in healing and treatments were not being done. During a Hospice Care meeting, on 2/20/19 at 11:40 A.M., a hospice nurse indicated that she felt at the last Hospice care meeting on 2/6/19, things were going well. She indicated the following week, she found no wound care occurring. She indicated she found the resident's foot wound dressing adhered to the sock and wound, and the foot was resting directly on the metal bar at the end of the resident's chair. The Regional Director for the hospice agency indicated the resident's wound needed more attention than the facility was providing and it was uncommon for hospice to do daily wound care. She indicated that Hospice wanted to ensure the resident was receiving proper care. She indicated the resident was receiving good nutrition and wound healing on the part of the resident until the past two weeks when the wound was found macerated and hospice started a new treatment with Calcium Alginate. LPN 1 indicated each shift's nurse is responsible for wound care and the resident was scheduled for wound care on the second shift. She indicated the facility will provide wound care. The ED (Executive Director) indicated that he would like the resident's wound care to be provided on first shift and have the same two nurse's provide wound care for continuity of care. He indicated that he wanted hospice to inservice the two nurses on technique and requested weekly updates. The Regional Director for the hospice agency indicated that the hospice nurse is here three times per week, Monday, Wednesday, and Friday. She indicated that the facility must ensure wound care is being provided on the weekends. She indicated the wound has too much slough to stage right now. A Physician Wound Evaluation and Management Summary, dated 12/17/18, indicated the resident had a stage 4 pressure wound of the left heel. The wound size was indicated as 2.5 x 1.5 x 0.4 cm (centimeters) (L x W x D). The surface area was indicated as 3.75 cm2 (centimeters squared). Light serous exudate was indicated. 100% granulation. Wound detail indicated wound opened in area of prior stage 4 wound. Treatment plan was indicated as Collagen sheet, apply three times per week for 30 days and foam with border dressing, apply three times per week for 30 days. A Physician Wound Evaluation and Management Summary, dated 1/7/19, indicated the resident had a stage 4 pressure wound of the left heel. The wound size was indicated as 2.5 x 1.4 x 0.4 cm (centimeters) (L x W x D). The surface area was indicated as 3.50 cm2 (centimeters squared). No exudate was indicated. 100% granulation. No change in wound progress, healing. Treatment plan was indicated as Mupirocin apply twice daily for 30 days, dry protective dressing, apply twice daily for 30 days. A Physician Wound Evaluation and Management Summary, dated 1/9/19, indicated the resident had a stage 4 pressure wound of the left heel. The wound size was indicated as 2.5 x 1.4 x 0.4 cm (centimeters) (L x W x D). The surface area was indicated as 3.50 cm2 (centimeters squared). No exudate was indicated. 100% granulation. No change in wound progress, healing. Treatment plan was indicated as Mupirocin apply twice daily for 30 days, dry protective dressing, apply twice daily for 30 days. A physician order, dated 1/1/19, indicated, .daily wound assessment to left foot. Document abnormalities in progress notes A physician order, dated 1/10/19 at 10:34 P.M., indicated ' .new order from hospice, patient is no longer to be underneath facility wound doctor for wound care A physician order, dated 1/10/19, indicated .cleanse wound L heel with NS (normal saline), pat dry, cut medi-honey slightly smaller than wound bed, cover with gauze and wrap with kerlix, on time a day .start date, 1/11/19, end date 2/13/19. A physician order, dated 2/14/19, indicated, .cleanse left heel with wound wash or normal saline, pat dry, cut calcium alginate to fit in wound bed and cover with foam padded dressing daily until healed one time a day for wound . start date, 2/14/19 A TAR (treatment administration record) dated for February, 2019, indicated the resident received the ordered treatment daily, with the exception of 2/16/19 and indicated the resident had daily wound assessments, as ordered, with the exception of 2/8/19, with no abnormalities indicated. A Skin Grid Pressure note, dated 2/7/19 at 3:55 P.M., indicated the resident had an improved wound from last assessment, the wound size was indicated as 4.2 x 3 cm (L x W) with no depth indicated, stage 3. Appearance of wound bed indicated [MEDICATION NAME] tissue present. Color of wound bed was yellow and white. Serous exudate was documented as medium amount. A progress note, dated 2/6/19 at 11:04 P.M., indicated .patient c/o (complained of) increased pain in foot during care plan meeting A hospice visit note, dated 1/29/19, indicated the onset date for the left heel wound was 3/25/18. The size was 4.5 x 3 x 0.25 cm (L x W x D). The surface area was 13.5 cm2. Depth description was partial thickness. There was 75-100% granulation tissue. Small amount of purulent exudate. Less than 25% [MEDICATION NAME]. 0-25% necrotic tissue slough and eschar. No signs and symptoms of infection. Wound care provided indicated cleanse outer heel with wound cleanser, pat dry, apply medi-honey, cut smaller than wound bed, cover with gauze. Change daily and PRN. Hospice nurse to assess/measure weekly and change two times per week at scheduled visits. Facility staff to change 5 days per week and PRN .Narrative note indicated, chronic wound shows great improvement with no eschar .entire wound bed is red, beefy with no slough. A hospice visit note, dated 1/31/19, indicated the wound size was 5 x 3.5 x 0.5 (L x W x D) with a surface area of 17.5 cm2. Depth description was partial thickness. Granulation tissue was less than 75% and greater than 25%. Small amount of purulent exudate. Yellow necrotic tissue at less than 25%. Partial maceration to the surrounding tissue. Narrative note indicated, .wound at heel showing 25% eschar at left border and covered with about 25% yellow loose slough which rinses off completely .small amount of tan discharge on dressing with no malodor A hospice visit note, dated 2/12/19, indicated the wound size was 4 x 3 x 0.5 (L x W x D) with a surface area of 12 cm2. Depth description was described as full thickness. Granulation was less than 25%. Small amount of purulent exudate. No odor. Less than 25% of white necrotic tissue was present. 51-75% of total tissue was slough, 0-25% of total tissue eschar. Narrative note indicated, .pt heel was found resting on metal frame of Baroda chair .Kerlix dressing not covering wound .sock adhered completely to wound .unit manager assisted with removal of sock dressing dated 2/10/19, which is two days ago .the majority of yellow slough that had been on wound was removed with sock adherement .N.O. (new order) received, stop [MEDICATION NAME] treatment .start calcium alginate treatment daily with foam boarder dressing .treatment to be completed by the facility nursing daily and twice weekly by hospice A hospice visit note, dated 2/15/19, indicated the wound size was 7 x 5 x 0.3 (L x W x D) with a surface area of 35 cm2. Depth description was described as full thickness. Granulation was less than 25%. Moderate amount of purulent exudate. No odor. 50 to 75% of yellow necrotic tissue was present. 51-75% of total tissue was slough, 0-25% of total tissue eschar. A hospice visit note, dated 2/17/19, indicated the wound measurement was not due. Suspected deep tissue injury. Moderate amount of purulent exudate, with faint odor. Narrative notes indicated, .wound care completed on left foot, large amount of yellow/brown drainage with small amount of blood and a copious amount of slough noted A physician order, dated 2/18/19, indicated [MEDICATION NAME] (an antibiotic) tablet 500 mg (milligram), give 1 tablet by mouth one time a day for left foot wound infection for 10 days. During an interview, on 2/20/19 at 2:30 P.M., LPN 1 indicated that the resident was receiving wound care as ordered at the facility but the wound did decline. On 2/22/19 at 1:21 P.M., the DON (Executive Director) provided the Skin Care & Wound Management Overview policy, dated 7/10/2016, and indicated this was the policy currently being used by the facility. The policy indicated, .each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition .resident skin condition is also re-evaluated with change in clinical condition .skin care and wound management program includes, but is not limited to: .application of treatment protocols based on clinical best practice standards for promoting wound healing .daily monitoring of existing wounds .identification of residents at risk for development of pressure ulcers .implementation of prevention strategies to decrease the potential for developing pressure ulcers Prevention: .complete the Braden Scale on admission, weekly x 3, quarterly and with change of clinical condition to identify risk indicators .Treatment: .select and complete the appropriate form .pressure ulcer documentation .complete for all pressure ulcers . This Federal tag is related to Complaint IN 340. 3.1-40(a) 3.1-40(b)

Based on record review and interview, the facility failed to prevent sexual abuse to a female resident from a male resident with known hypersexual activity. As a result of this deficient practice a female resident reviewed for abuse was sexually assaulted while a resident of the facility. (Resident C) This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/2/18 when a resident was observed by the QMA (Qualified Medication Aide) 6 with his pants down and his hands in a female residents pants. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy on 12/5/18 at 12:29 P.M. The Immediate Jeopardy was removed on 12/9/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview, on 12/4/18 at 1:59 P.M., CNA (Certified Nurses Aide) 1 indicated on 12/2/18 around lunchtime, she found Resident B standing in a room near a bed where Resident C was lying with her eyes closed. Resident B had his pants pulled down to his hip area and his white pull up brief was exposed. CNA 1 indicated she removed Resident B from the room and assisted him to the hall railing a few rooms away from where she found him and went to get QMA (Qualified Medication Aide) 6 to assist her, when she returned with the QMA she found Resident B back in the room where Resident C was lying with her eyes closed and he was standing near the bed, the QMA asked her to go get help from the charge nurse on another hall. CNA 1 indicated she did not see anything else happen. During an interview, on 12/4/18 at 2:26 P.M., the Charge Nurse indicated she was sought out by CNA 1, to assist QMA 6 with a resident who was found in a room with another resident. The Charge Nurse indicated she was told by CNA 1 that the resident was found in the room with his pants pulled down to his hip area but that his brief was on and the other resident was asleep. The Charge Nurse reported the incident to the DON right away and told her what was told to her by CNA 1. The Charge Nurse indicated QMA 6 really didn't say much when she arrived on the unit, Resident B was no longer in the room, and the QMA was rambling so she did not listen to what she was saying. The Charge Nurse indicated the DON told her to keep the resident's separated and to report any further incidents of which none were reported to her. During an interview, on 12/4/18 at 2:30 P.M., CNA 3 indicated she worked on 12/2/18 during the time of the alleged incident involving Resident B and Resident C but she was on her lunch break when the event allegedly happened. CNA 3 was given instruction by the QMA to keep Resident B and Resident C separated at all times and to make sure that Resident B did not enter into any other resident rooms. CNA 3 was told that Resident B had touched Resident C inappropriately. During an interview, on 12/4/18 at 3:20 P.M., CNA 4 indicated she worked on 12/2/18 on the night shift. CNA 4 indicated she was given report from QMA 6 and another CNA that Resident B had sexually assaulted Resident C. .I was told that CNA 1 found him and then he was found with his fingers in Resident C's private parts. I was told to keep a close eye on Resident B and not to let him back around Resident C During an interview, on 12/4/18 at 4:15 P.M., CNA 5 indicated she worked on 12/2/18 on the evening shift. She indicated when she arrived for work that day, she was told by QMA 6 on duty that Resident B was found by CNA 1, in the room where Resident C was lying down on the bed with her eyes closed. Resident B, she was told, had his pants down and his thing hanging out and his hands were down Resident C's pants. During an interview, on 12/5/18 at 1:18 P.M., QMA 6 indicated she worked the 400 hall on 12/2/18. She was passing hall trays and was asked by CNA 1 to come to a resident room with her. Upon entering the room, she observed Resident B with his pants down, genitalia exposed, his hand down Resident C's pants, sexually assaulting her with his fingers. At this time, QMA 6 tried to separate the two residents but couldn't, so the Charge Nurse came back to the unit to help her. She told the Charge Nurse what she observed and was told to keep an eye on them. She indicated, at one point, she was alone on the unit with no other staff. She called the Charge Nurse to send her some help but was told there was no one to send. QMA 6 had given a written statement to the Charge Nurse, but no one has contacted her again regarding this incident, and she did not think the facility was doing what they were supposed to do because they did not put Resident B on a 1:1 observation or send him out for an evaluation. During an interview, on 12/4/18 at 4:30 P.M., the DON indicated that she was notified on 12/2/18 around lunch time of an incident in which Resident B was found by a CNA in the room where Resident C was lying down on a bed. The DON indicated she was told Resident B had his pants down and his brief was showing but he was removed and there had been no inappropriate touching associated with the incident. At that time, she told her staff to keep the residents separated and to keep an eye on Resident B at all times and to report it to her immediately if any further incidents occur. She did ask CNA 1, the Charge Nurse, and QMA 6 to write statements about what had occurred. The DON indicated she did not receive a statement from QMA 6 and did not interview her because she was told nothing inappropriate had happened by the Charge Nurse so she did not investigate further. On 12/4/18 at 4:40 P.M., the clinical record for Resident B was reviewed. Resident B had [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/18, indicated the resident was unable to be assessed for cognition. A emergency room Report, dated 9/11/18, indicated .Historical Data: The patient is sent here for reported concerns of hypersexual activity. The patient with a history of dementia was reportedly attempting to dry hump a hospice aide. The patient with a history extensive for dementia and behavioral disorders. The patient is unable to know name or year or why here During an interview, on 12/11/18 between 10 A.M. and 3:00 P.M., the Social Service Director indicated Resident B did not have a plan of care for the behavior of hypersexual activity as she was not made aware of his behavior at the time of admission. The Social Service Director indicated that Resident B should have had a care plan for his behaviors. On 12/4/18 at 4:45 P.M., the clinical record for Resident C was reviewed. Resident C had [DIAGNOSES REDACTED]. A Quarterly MDS, with a ARD date of 9/8/18, indicated a Brief Interview for Mental Status score of 3 which indicated Resident C was severely cognitively impaired. On 12/4/18 at 12:32 P.M., a policy titled, Indiana Abuse & Neglect & Misappropriation of Property with an effective date of 9/1/07 was provided by the Administrator of the facility. The policy was reviewed on 12/5/18 at 10: 00 A.M., and indicated the following: .It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents The Immediate Jeopardy that began on 12/2/18 was removed on 12/9/18, when the facility initiated medical evaluation, established 1 on 1 direct supervision, and implemented with family involvement data collecting for root cause analysis, but the noncompliance remains at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This Federal Tag is related to Complaint IN 823. 3.1-28(c)

Based on interview and record review, the facility failed to immediately report an allegation of resident to resident sexual abuse to the Administrator and State Agency. This deficient practice affected 2 of 2 residents reviewed for sexual abuse. (Resident B and Resident C) This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/2/18 when a resident was observed by the QMA (Qualified Medication Aide) 6 with his pants down and his hands in a female residents pants. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy on 12/5/18 at 12:29 P.M. The Immediate Jeopardy was removed on 12/9/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview, on 12/4/18 at 1:59 P.M., CNA (Certified Nurses Aide) 1 indicated on 12/2/18 around lunchtime, she found Resident B standing in a room near a bed where Resident C was lying with her eyes closed. Resident B had his pants pulled down to his hip area and his white pull up brief was exposed. CNA 1 indicated she removed Resident B from the room and assisted him to the hall railing a few rooms away from where she found him and went to get QMA 6 to assist her, when she returned with QMA 6 she found Resident B back in the room where Resident C was lying with her eyes closed and he was standing near the bed, QMA 6 asked her to go get help from the charge nurse on another hall. CNA 1 indicated she did not see anything else happen. During an interview, on 12/4/18 at 2:26 P.M., the Charge Nurse indicated she was sought out by CNA 1, to assist QMA 6 with a resident who was found in a room with another resident. The Charge Nurse indicated she was told by CNA 1 that the resident was found in the room with his pants pulled down to his hip area but that his brief was on and the other resident was asleep. The Charge Nurse reported the incident to the DON right away and told her what was told to her by CNA 1. The Charge Nurse indicated the QMA 6 really didn't say much when she arrived on the unit, Resident B was no longer in the room, and QMA 6 was rambling so she did not listen to what she was saying. The Charge Nurse indicated the DON told her to keep the resident's separated and to report any further incidents of which none were reported to her. During an interview, on 12/4/18 at 2:30 P.M., CNA 3 indicated she worked on 12/2/18 during the time of the alleged incident involving Resident B and Resident C but she was on her lunch break when the event allegedly happened. CNA 3 was given instruction by QMA 6 to keep Resident B and Resident C separated at all times and to make sure that Resident B did not enter into any other resident rooms. CNA 3 was told that Resident B had touched Resident C inappropriately. During an interview, on 12/4/18 at 3:20 P.M., CNA 4 indicated she worked on 12/2/18 on the night shift. CNA 4 indicated she was given report from QMA 6 and a fell ow CNA that Resident B had sexually assaulted Resident C. .I was told that CNA 1 found him and then he was found with his fingers in Resident C's private parts. I was told to keep a close eye on Resident B and not to let him back around Resident C During an interview, on 12/4/18 at 4:15 P.M., CNA 5 indicated she worked on 12/2/18 on the evening shift. She indicated when she arrived for work that day, she was told by the QMA 6 on duty that Resident B was found by CNA 1, in the room where Resident C was lying down on the bed with her eyes closed. Resident B, she was told, had his pants down and his thing hanging out and his hands were down Resident C's pants. During an interview, on 12/5/18 at 1:18 P.M., QMA 6 indicated she worked the 400 hall on 12/2/18. She was passing hall trays and was asked by CNA 1 to come to a resident room with her. Upon entering the room, she observed Resident B with his pants down, genitalia exposed, his hand down Resident C's pants, sexually assaulting her with his fingers. At this time, QMA 6 tried to separate the two residents but couldn't, so the Charge Nurse came back to the unit to help her. She told the Charge Nurse what she observed and was told to keep an eye on them. She indicated, at one point, she was alone on the unit with no other staff. She called the Charge Nurse to send her some help but was told there was no one to send. QMA 6 indicated she was asked to provide a written statement to the Charge Nurse and indicated she gave it to the Charge Nurse, but no one had contacted her again regarding this incident, and she did not think the facility was doing what they were supposed to do because they did not put Resident B on a 1:1 observation or send him out for an evaluation. On 12/4/18 at 4:40 P.M., the clinical record for Resident B was reviewed. Resident B had [DIAGNOSES REDACTED]. A Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/18, indicated the resident was unable to be assessed for cognition. A emergency room Report, dated 9/11/18, indicated .Historical Data: The patient is sent here for reported concerns of hypersexual activity. The patient with a history of dementia was reportedly attempting to dry hump a hospice aide. The patient with a history extensive for dementia and behavioral disorders. The patient is unable to know name or year or why here During an interview, conducted with the Social Service Director on 12/11/18, between 10 A.M. and 3: 00 P.M., the Social Service Director indicated Resident B did not have a plan of care for the behavior of hypersexual activity as she was not made aware of his behavior at the time of admission. The Social Service Director indicated that Resident B should have had a care plan for his behaviors. On 12/4/18 at 4:45 P.M., the clinical record for Resident C was reviewed. Resident C had [DIAGNOSES REDACTED]. A Quarterly MDS, with a ARD date of 9/8/18, indicated a Brief Interview for Mental Status score of 3 which indicated Resident C was severely cognitively impaired. During an interview, on 12/4/18 at 4:30 P.M., the DON indicated that she was notified on 12/2/18 around lunch time of an incident in which Resident B was found by a CNA in the room where Resident C was lying down on a bed. The DON indicated she was told Resident B had his pants down and his brief was showing but he was removed and there had been no inappropriate touching associated with the incident. At that time, she told her staff to keep the residents separated and to keep an eye on Resident B at all times and to report it to her immediately if any further incidents occur. She did ask CNA 1, the Charge Nurse, and QMA 6 to write statements about what had occurred. The DON indicated she received statements from both CNA 1 and the Charge Nurse but did not receive a statement from QMA 6 and did not interview her because she was told nothing inappropriate had happened by the Charge Nurse so she did not investigate further. On 12/4/18 at 12:32 P.M., a policy titled, Indiana Abuse & Neglect & Misappropriation of Property with an effective date of 9/1/07 was provided by the Administrator of the facility. The policy was reviewed on 12/5/18 at 10: 00 A.M., and indicated the following: .if the events that cause the allegations involve abuse and/or serious bodily injury the self-repot must be made immediately, but not later than two (2) hours after the allegation is made The Immediate Jeopardy that began on 12/2/18 was removed on 12/9/18, when the facility initiated medical evaluation, established 1 on 1 direct supervision, and implemented with family involvement data collecting for root cause analysis, but the noncompliance remains at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This Federal Tag is related to Complaint IN 823. 3.1-28(c)

Based on record review and interview, the facility failed to ensure a allegation of sexual abuse, was thoroughly investigated for 1 of 1 allegations of sexual abuse reviewed. This deficient practice affected 2 of 2 residents reviewed for sexual abuse. (Resident B and Resident C) This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 12/2/18 when a resident was observed by the QMA (Qualified Medication Aide) 6 with his pants down and his hands in a female residents pants. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy on 12/5/18 at 12:29 P.M. The Immediate Jeopardy was removed on 12/9/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview, on 12/4/18 at 1:59 P.M., CNA (Certified Nurses Aide) 1 indicated on 12/2/18 around lunchtime, she found Resident B standing in a room near a bed where Resident C was lying with her eyes closed. Resident B had his pants pulled down to his hip area and his white pull up brief was exposed. CNA 1 indicated she removed Resident B from the room and assisted him to the hall railing a few rooms away from where she found him and went to get QMA 6 to assist her, when she returned with QMA 6 she found Resident B back in the room where Resident C was lying with her eyes closed and he was standing near the bed, the QMA 6 asked her to go get help from the charge nurse on another hall. CNA 1 indicated she did not see anything else happen. During an interview, on 12/4/18 at 2:26 P.M., the Charge Nurse indicated she was sought out by CNA 1, to assist QMA 6 with a resident who was found in a room with another resident. The Charge Nurse indicated she was told by CNA 1 that the resident was found in the room with his pants pulled down to his hip area but that his brief was on and the other resident was asleep. The Charge Nurse reported the incident to the DON right away and told her what was told to her by CNA 1. The Charge Nurse indicated QMA 6 really didn't say much when she arrived on the unit, Resident B was no longer in the room, and QMA 6 was rambling so she did not listen to what she was saying. The Charge Nurse indicated the DON told her to keep the resident's separated and to report any further incidents of which none were reported to her. During an interview, on 12/4/18 at 2:30 P.M., CNA 3 indicated she worked on 12/2/18 during the time of the alleged incident involving Resident B and Resident C but she was on her lunch break when the event allegedly happened. CNA 3 was given instruction by QMA 6 to keep Resident B and Resident C separated at all times and to make sure that Resident B did not enter into any other resident rooms. CNA 3 was told that Resident B had touched Resident C inappropriately. During an interview, on 12/4/18 at 3:20 P.M., CNA 4 indicated she worked on 12/2/18 on the night shift. CNA 4 indicated she was given report from QMA 6 and a fell ow CNA that Resident B had sexually assaulted Resident C. .I was told that CNA 1 found him and then he was found with his fingers in Resident C's private parts. I was told to keep a close eye on Resident B and not to let him back around Resident C During an interview, on 12/4/18 at 4:15 P.M., CNA 5 indicated she worked on 12/2/18 on the evening shift. She indicated when she arrived for work that day, she was told by QMA 6 on duty that Resident B was found by CNA 1, in the room where Resident C was lying down on the bed with her eyes closed. Resident B, she was told, had his pants down and his thing hanging out and his hands were down Resident C's pants. During an interview, on 12/5/18 at 1:18 P.M., QMA 6 indicated she worked the 400 hall on 12/2/18. She was passing hall trays and was asked by CNA 1 to come to a resident room with her. Upon entering the room, she observed Resident B with his pants down, genitalia exposed, his hand down Resident C's pants, sexually assaulting her with his fingers. At this time, QMA 6 tried to separate the two residents but couldn't, so the Charge Nurse came back to the unit to help her. She told the Charge Nurse what she observed and was told to keep an eye on them. She indicated, at one point, she was alone on the unit with no other staff. She called the Charge Nurse to send her some help but was told there was no one to send. QMA 6 had given a written statement to the Charge Nurse, but no one has contacted her again regarding this incident, and she did not think the facility was doing what they were supposed to do because they did not put Resident B on a 1:1 observation or send him out for an evaluation. On 12/4/18 at 4:40 P.M., the clinical record for Resident B was reviewed. Resident B had [DIAGNOSES REDACTED]. A Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/18, indicated the resident was unable to be assessed for cognition. A emergency room Report, dated 9/11/18, indicated .Historical Data: The patient is sent here for reported concerns of hypersexual activity. The patient with a history of dementia was reportedly attempting to dry hump a hospice aide. The patient with a history extensive for dementia and behavioral disorders. The patient is unable to know name or year or why here During an interview, conducted with the Social Service Director on 12/11/18, between 10 A.M. and 3: 00 P.M., the Social Service Director indicated Resident B did not have a plan of care for the behavior of hypersexual activity as she was not made aware of his behavior at the time of admission. The Social Service Director indicated that Resident B should have had a care plan for his behaviors. On 12/4/18 at 4:45 P.M., the clinical record for Resident C was reviewed. Resident C had [DIAGNOSES REDACTED]. A Quarterly MDS, with a ARD date of 9/8/18, indicated a Brief Interview for Mental Status score of 3 which indicated Resident C was severely cognitively impaired. During an interview, on 12/4/18 at 4:30 P.M., the DON indicated that she was notified on 12/2/18 around lunch time of an incident in which Resident B was found by a CNA in the room where Resident C was lying down on a bed. The DON indicated she was told Resident B had his pants down and his brief was showing but he was removed and there had been no inappropriate touching associated with the incident. At that time, she told her staff to keep the residents separated and to keep an eye on Resident B at all times and to report it to her immediately if any further incidents occur. She did ask CNA 1, the Charge Nurse, and QMA 6 to write statements about what had occurred. The DON indicated she received statements from CNA 1 and the Charge Nurse but did not receive a statement from QMA 6 and did not interview her because she was told nothing inappropriate had happened by the Charge Nurse so she did not investigate further. On 12/4/18 at 12:32 P.M., a policy titled, INDIANA Abuse &Neglect & Misappropriation of Property, with an effective date of 9/1/2017, indicated 2. A Suspected Abuse .b. Initial findings will be reported to the Executive Director, the physician (except in case of misappropriation of funds/property) and the resident representative .c. The Executive Director, Director of Nursing, or designee will report immediately to the appropriate agencies, and document the time and date of that report on the investigation form .d. Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. This statement should be in writing, signed, and dated at the time it is written. Supervisors may write the statement for a person giving a statement about the incident to them and the person giving the statement must sign and date it, or a third party may witness the statements .e. Statements should include the following: i. First-hand knowledge of the incident .ii. A description of what was witnessed, seen or heard .f. Findings/conclusion of the investigation are then reported to the physician (with the exception of misappropriation of funds/property), ED and resident representative and documented on the investigation form .g. By the fifth day, the alleged abuse investigation form is completed and reviewed for completeness and accuracy by the Executive Director or designee and submitted to the state .h. Investigation files are kept in a confidential file located in the Executive Director's office .i. This file will be accessible for follow-up and state or local police review of the investigation The Immediate Jeopardy that began on 12/2/18 was removed on 12/9/18, when the facility initiated medical evaluation, established 1 on 1 direct supervision, and implemented with family involvement data collecting for root cause analysis, but the noncompliance remains at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This Federal Tag is related to Complaint IN 823. 3.1-28(c)

Based on observation, interview, and record review the facility failed to prevent the formation of three pressure wounds for 2 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in one Resident forming one stage three pressure ulcer and one unstageable pressure ulcer. The other resident formed a stage two pressure ulcer. (Residents #82 & #63) Findings include: 1. A clinical record review was conducted on 01/06/2017 at 10:08 A.M., and indicated Resident #82 was admitted on [DATE]. His [DIAGNOSES REDACTED]. Minimum Data Set Assessment ((MDS) dated [DATE] indicated Resident #82 had a BIMS (Brief Interview for Mental Status) score of 15, indicating he was cognitively aware. A WOUND CARE SPECIALIST EVALUATION form dated 12/16/2016 indicated Resident #82 was to have the following treatment: .BNZ cream applied liberally to left lower leg, wrap with kerlix then 4 layer compression wraps A physician order [REDACTED].Cleanse Left entire lower leg with NS(normal saline), pat dry, apply BNZ cream wrap with kerlix then 4 layer compression wraps using acewraps daily. one time a day for [MEDICAL CONDITION] A Weekly Pressure Ulcer BWAT Report dated 12/23/2016 indicated Resident #82 had a left ankle pressure ulcer measuring 2.0 centimeters (cm) in length and 0.9 cm in width. The form indicated the pressure ulcer was unstageable and was initially observed on 12/23/2016, as a new onset pressure ulcer. The form indicated the treatment for [REDACTED].Apply [MEDICATION NAME] covered with a dry protective dressing. No wrapping with kerlix or acewraps A WOUND CARE SPECIALIST EVALUATION form dated 12/23/2016 indicated Resident #82 had a pressure ulcer to his left anterior ankle measuring 2.0 cm in length and 0.9 cm in width. The form classified the area as an unstageable pressure ulcer. Listed on the form under ADDITIONAL INFORMATION: was .Probably from overly snug compression wraps Treatment on this form indicated for Resident #82 to have .[MEDICATION NAME]-Once Daily, Dry Protective Dressing - Once Daily A late entry nurses note dated 12/23/2016 indicated .Weekly Pressure Ulcer BWAT Report Completed. Site information: Left ankle (inner) - Presssure: Length = 2.0cm, Width = 0.9cm, - Stage Unstageable. Date of initial observation: 12/23/2016. BWAT Score = 23.0. Apply [MEDICATION NAME] covered with a dry protective dressing. No wrapping with kerlix or acewraps See assessment for more details A treatment administration record for Resident #82 indicated the physician order [REDACTED].Cleanse Left entire lower leg with NS, pat dry, apply BNZ cream wrap with kerlix then 4 layer compression wraps using acewraps daily. one time a day for [MEDICAL CONDITION] was continued through 12/26/2016, following the 12/23/2016 physician order [REDACTED]. A treatment administration record (TAR) for Resident #82 indicated his 4 layer compression wraps were initiated on 12/17/2016. The TAR indicated Resident #82 rated his pain a 5 out of 10 on a pain rating scale (0 being no pain at all and 10 being the worst pain he has ever felt) on 12/18/16 and 12/20/16, on 12/21/16 he rated his pain 4 of 10, and then from 12/23/16 through 12/25 he rated his pain a 5 out of 10. A Skin/Wound Note dated 12/29/2016 indicated: .IDT SNAR/Wound Note for rounds on 12/23/16. [MEDICAL CONDITION]/[MEDICAL CONDITION] of the LLE is healed. Unstageable Necrosis to the Left Anterior Ankle 2.0cm x 0.9cm. No drainage noted. 20% yellow necrosis with 80% granulation tissue. Apply [MEDICATION NAME] cover with a dry protective dressing daily. Unstageable DTI o fthe Left Shin 6.0cm x 1.5cm. No drainage noted. No treatment needed. Do not wrap lower extremities. Wound MD states the unstageable areas are probably from overly snug compression wraps. Resident has an open area on the penis under foreskin. Wound physician states since resident has this wound and he has a foley catheter to schedule an appointment with Dr. (local urologist). Will continue to apply [MEDICATION NAME] until appointment. Consumed Regular diet NAS (no added salt) and multivitamin. Will continue to be seen by the wound doctor. No c/o (complained of) pain or discomfort A WOUND CARE SPECIALIST EVALUATION form dated 12/30/2016 indicated Resident #82 had a left lateral ankle pressure ulcer measuring 2.4 cm in length and 1.3 cm in width. The form classified this area as unstageable. The form indicated for the treatment of [REDACTED].Dry Protective Dressing - Once Daily, Mupirocin - Once Daily, Santyl - Once Daily This form indicated a treatment order for Resident #82 to be .BNZ cream to lower leg feet and toes q (every) day. Multilayer compression wraps daily, off at night. Legs elevated at night A Weekly Pressure Ulcer BWAT Report dated 12/30/2016, indicated Resident #82's ankle pressure ulcer was measuring 2.4 cm in length and 1.3 cm in width, with the stage of the ulcer being unstageable. The form indicated the treatment for [REDACTED].Apply Santyl [MEDICATION NAME] cover with a dry protective dressing daily A treatment administration record for Resident #82 indicated .Compression wraps to BLE (bilateral lower extremities) off at night. Elevate legs at night every night shift for [MEDICAL CONDITION] The start date for this order on the treatment record was 1/4/2017, following the physician order [REDACTED]. A treatment administration record for Resident #82 indicated .Cleanse Left Anterior Ankle with NS, apply Santyl, [MEDICATION NAME] cover with a dry protective dressing daily one time a day for Wound The start date for this on the treatment record was 1/4/2017, following the physician order [REDACTED]. A late entry dated 1/4/2017 indicated Notified Dr. (wound physician) BNZ cream order to bilat feet, legs and toes and compression wraps not transcribed correctly. No new orders continue with the BNZ cream and compression wraps. Wraps off at night with bilat legs elevated at night. Resident made aware and .Dr.(wound physician) and resident notified treatment was not transcribed until 1/4/17 but continued to use prior treatment. No new orders A care plan dated 1/3/2017 indicated Resident #82 had an actual alteration in skin integrity (Pressure Ulcer). Cognitive impairment, Decreased Mobility left ankle and shin. Interventions included but were not limited to: Follow physician orders [REDACTED]. During an interview on 01/06/2017 at 12:54 P.M., the Director of Nursing (DON) indicated the pressure ulcer located on Resident #82's left ankle was caused by a compression wrap and the pressure ulcer located on Resident #82's penis was caused by the use of a catheter. During an interview on 01/06/2017 at 1:29 P.M., Resident #82 indicated he had told staff the compression wraps were too tight and were causing him pain. He indicated that he asked for staff to remove them and staff indicated to him that the physician had ordered them and they needed to stay on. Resident #82 indicated the compression wraps stayed on for 3-4 days straight, before they began to be removed at night. He further indicated that the nurses wrapped his legs themselves. When asked if he had pain during the 3-4 day period his legs were compression wrapped, he indicated his pain was a 7 out of 10(a pain rating scale where 0 is no pain at all and 10 is the worst pain he has ever felt). During an interview on 01/06/2017 at 1:56 P.M., the Corporate Nurse indicated that the staff must follow the physicians orders and would not remove the wrap unless they were ordered to do so by the physician. During an observation on 1/6/2017 at 1:40 P.M., an area a little larger than a quarter was observed to Resident #82's left ankle. The area was missing a full thickness of skin with a yellow substance around the inside of the area and in the middle of the area dark colored tissue was observed. The wound nurse indicated this area was measuring 1.9 cm in length and 1.6 cm in width. She indicated there was necrotic tissue present, along with yellow slough, and a small amount of healthy tissue. She staged this area as unstageable. During an observation on 1/6/2017 at 1:50 P.M., Resident #82 was observed to have an area on his penis measuring approximately 2.5 cm in length and 1cm in width. The area was observed to his foreskin, where there was a full thickness loss of skin observed. The area was yellow to the inner area with redness surrounding it. Unable to see full extent due to a copious amount of yellow/green discharge coming from the resident's meatus. The wound nurse indicated Resident #82's penis had yellow stuff and minimal granulation tissue. She indicated the area was unstageable. During this observation, Resident #82 indicated to the Director of Nursing (DON) that he had not been receiving catheter care to keep his catheter clean. The DON indicated that she was unaware and LPN #22 indicated that she cleans his catheter every shift. He indicated that the only time his catheter area was cleaned was when he had his catheter changed. Following the observation, LPN # 22 indicated to Resident #82 that he needs to let staff know when they are supposed to clean his catheter. A record review on 1/9/17 at 11:00 AM was conducted. A Health Status Note dated 12/14/2016 indicated there was some concern regarding Resident #82's catheter leaking and it was readjusted with a urinary output of over 800 milliliters. A Weekly Skin Alteration Report dated 12/15/2016 indicated Resident #82 had an open area to the left side of his penis/foreskin, initially occurring on 12/15/2016 and indicated the area was an abrasion. A Health Status Note dated 12/15/2016 indicated Resident #82 received a new order for PRN (as needed) Tylenol, may change foley catheter PRN, and apply [MEDICATION NAME] (an topical ointment) every shift to the open areas on Resident #82's foreskin/penis. The documentation indicated the foley catheter was changed and there was a 2.0 cm x 1.2 cm x <0.1 open are to the right side of Resident #82's foreskin/penis and a 1.1 cm x 1.7 cm x <0.1 cm open area to the right side of Resident #82's foreskin/penis. A TAR indicated Resident #82 received orders to collect a urinalysis with a culture and sensitivity Dx:(diagnoses) Green drainage every shift for Drainage until 01/09/2017. Discontinue when urinalysis is obtained. During an telephone interview on 1/10/2017 at 3:25 P.M., Dr. (facilities wound physician) indicated the area on Resident #82's penis was a pressure ulcer at a stage three and was caused by the residents foley catheter positioning. Dr.(facilities wound physician) indicated Resident #82's wound was an unstageable to his left ankle and was caused by compression ace wraps being wrapped to tight. He further indicated the contracture to the residents left ankle was a bony prominence and the ace wraps compressed it and caused a pressure ulcer to form in that area. A form was provided by the Corporate Nurse on 1/6/2017 at 2:35 P.M., titled Indwelling Catheter Care, undated, and indicated this form was currently used by the facility. The form indicated .Cleanse area well and remove all debris from the indwelling catheter at the insertion site A policy was provided by the DON on 1/16/2017 at 2:35 P.M., titled NCD Prevention and treatment of [REDACTED]. The policy indicated .The facility has a system in place to promote skin integrity, prevent pressure ulcer development/other skin alterations, promote healing of existing wounds and prevent further development of additional skin alterations. National Pressure Ulcer Advisory Panel (NPUAP) A policy was provided by the DON on 1/10/2017 at 3:11 P.M., titled Categorizing/Staging, and Measuring a Wound, dated 5/2/2016, and indicated this is the policy currently used by the facility. The policy indicated .Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stage (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover' and should not be removed 2. The following observations were made of Resident #63: On 1/5/17 at 10:01 A.M., the resident was lying in bed. On 1/5/17 at 11:15 A.M., the resident was lying in bed. On 1/6/17 at 9:54 A.M., the resident was lying in bed. On 1/6/17 at 10:07 A.M., the resident was lying in bed. LPN (Licensed Practical Nurse) #11 removed Resident #63's sock from his left foot. There was a quarter sized black area to his left heel. During an interview, on 1/6/17 at 10:11 A.M., LPN #11 indicated the wound to the resident's left heel was from lying in bed and pressure. During an interview, on 1/6/17 at 12:17 P.M., the DON (Director of Nursing) indicated the resident had a decline in condition before the wound developed and was spending more time in bed. She indicated, prior to the wound developing, the resident did not have any interventions in place for his heels. Resident #63's clinical record was reviewed on 1/5/17 at 11:05 A.M. The resident's [DIAGNOSES REDACTED]. The resident's quarterly Braden Scale (a scale used to determine pressure ulcer risk), dated 10/7/16, indicated the resident was at risk for developing pressure ulcers. The resident's quarterly MDS (Minimum Data Set) assessment, dated 10/10/16, indicated he had a severe cognitive impairment, required extensive assistance with two staff members physical assist for bed mobility and transfers, had impairments to both lower extremities, used a wheelchair for mobility and was at risk for developing pressure ulcers. There were no interventions for feet indicated on the assessment. A care plan, dated 7/12/16, indicated the resident had the potential for skin/tissue integrity problems related to incontinence episodes, history of blisters, needing assistance with turning and positioning and a history of pressure ulcers. Interventions for this included, apply skin care products as ordered, assess skin weekly and as needed, turn and reposition schedule and use positioning and pressure reducing devices. A care plan, dated 12/12/16, indicated the resident had an actual alteration in skin integrity, a pressure ulcer to the left heel. Interventions for this included, administer medications as ordered, consult the wound doctor, institute weekly pressure ulcer condition reports, monitor and evaluate food intake, monitor for signs and symptoms of infection, provide medical food supplement, RD (Registered Dietician) to monitor and evaluate nutritional intake and condition of wound and make recommendations, turn and reposition as needed and institute a back to bed schedule. The resident's current physician's orders [REDACTED]. These orders were started on 12/2/16. A progress note, dated 12/2/16, indicated, .CNA (Certified Nursing Assistant) called this nurse into the shower room to look at the resident. He had developed a purple area on his (L) (left) heel. He was seen by the wound dr (doctor) and new ordere (sic) were received for skin prep to area Q (every) shift, to float heels while in bed, and for moon boots at all times A Wound Care Specialist Evaluation, dated 12/2/16, indicated, .ETIOLOGY (QUALITY): Pressure . MDS 3.0 STAGE: Unstageable DTI . WOUND SIZE (L X W X D) (length by width by depth): 3.0 x 2.2 x Not Measurable cm (centimeters) . DRESSING: Skin Prep - Once Daily . RECOMMENDATION: Sponge Boot, Float Heels in Bed, Off-Load Wound On 1/10/17, the DON provided a policy titled NCD Prevention and treatment of [REDACTED]. The policy indicated .POLICY The facility has a system in place to promote skin integrity, prevent pressure ulcer development/other skin alterations, promote healing of existing wounds and prevent further development of additional skin alterations . PROCEDURE Prevention Steps: 1. A risk assessment is completed upon admission and at designated intervals throughout the patient's stay. a. Patients at risk for developing pressure ulcers are identified by using the Braden Scale . c. Pressure ulcer and other wound and skin related interventions are created in collaboration with the interdisciplinary team and implemented in order to identify, prevent or reduce the risk of acquiring pressure and/or non-pressure related wounds or skin issues: 2. treatment of [REDACTED]. 3. Nutritional status is addressed upon admission or when there is a change in the patient's skin status. 4. The Interdisciplinary team, patient/family collaborates to establish goals and interventions to address patient specific risk factors for the prevention of skin alteration. 5. The Interdisciplinary team and patient/family collaborates to establish goals and interventions to promote the healing of wounds and/or prevent further breakdown 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview, observation and record review, the facility failed to ensure 1 of 1 resident was provided adequate hydration resulting in multiple hospital admissions for urinary tract infections [MEDICAL CONDITION] and recurrent falls. (Resident #57) Findings include: Resident 57 clinical record was reviewed 1/6/2017 at 10:15 A.M. The resident's [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment dated [DATE] indicated resident's Brief Interview for Mental Status (BIMS) was a 3, resident required extensive assist of one with transfers, toilet use, and personal hygiene, a limited of assist of 1 for eating, and resident was always incontinent of urine and frequently incontinent of bowel. Review of urinary incontinence care plan indicated has potential for complication associated with urinary incontinence related to incontinent at times with interventions that included, but were not limited to check resident every 2-3 hours and PRN for incontinent episodes and provide incontinence /perineal care after each incontinent episode. Care plan indicated resident is on antibiotic therapy related to urinary tract infection [MEDICAL CONDITION] with inventions that included but are not limited to observe for possible side effects and administer as ordered. Care plan indicated ADL Self Care Performance deficit related to/ Alzheimer's/Dementia with interventions the include but are not limited to resident is able to hold cup, feed self, eat finger foods independently with set-up and food preparation. RESIDENT CARE SHEET last updated on 1/9/17 indicated resident was a fall risk, transfers independently, dycem to wheelchair and bed, continent for toileting, and offer toileting every 2 hours from 12 A.M. to 6 A.M., and no instructions for feeding or offering fluids. Evaluation Summary dated 8/2/2016 at 12:43 P.M. indicated bladder status evaluation was completed and resident will receive incontinence care after every incontinent episode. MEDICAL NUTRITION THERAPY ASSESSMENT dated 8/4/16 at 2:52 P.M., indicated total fluid estimated needs to be 1875 to 2250 ml and the Nutrition Monitoring and Evaluation section indicated monitoring fluid/beverage intake and food intake. Health Status Note dated 8/5/26 at 5:32 P.M., indicated .resident can make self understood as evidenced by ability to express wants and needs however more frequent reminders for toileting use is necessary . Health Status Change (SBAR) note dated 8/17/16 at 8:16 P.M., indicated that resident complain of severe abdominal pain, states that is stabbing, resident unable to walk tonight . doctor notified, ordered received to send to emergency room (ER) for evaluation and treatment. ER PHYSICIAN REPORT dated 8/17/16 at 9:51 P.M., indicated nursing home reports that resident was complaining of severe abdominal pain . Emergency Medical Service (EMS) reported that the patient was complaining of abdominal pain in route HISTORY & PHYSICAL dated 8/18/16 indicated BUN 28, Creatinine 1.09, and glucose 309, GFR (glomerular filtration rate) 49.5. Urinalysis had a specific gravity of 1.010, pH 7.0, WBC (white blood cells) 21, bacteria present and [MEDICATION NAME] positive. [DIAGNOSES REDACTED]. FALL POST INVESTIGATION dated 9/8/16 at 10:45 A.M., indicated resident had a was left unattended in therapy and fell forward out of chair landing on floor face down. Health Status Note dated 9/9/16 at 11:10 A.M. indicated new order for [MEDICATION NAME] 5/325 mg every 4 hours for moderate pain. physician progress notes [REDACTED]. Health Status Note dated 9/19/16 at 7:03 A.M., indicated labs and urinalysis order for change in mental status. Lab results dated 9/19/16 indicated BUN of 27 (normal range 9.8-20.1) and urine was positive for Citrobacter freundii (a bacterium that lives in the digestive tract). Health Status Note 9/21/16 at 3:23 P.M., indicated physician was notified, resident was asymptomatic, and no new orders at this time. Health Status Note dated 9/22/16 at 1:30 P.M. indicated res was lethargic, and very unsteady on feet. POST FALL INVESTIGATION dated 9/30/16 at 6:18 A.M., indicated resident was lowered to floor during activity during a transfer from the sofa to wheelchair by staff. Plan of Care Note dated 9/30/16 at 9:30 A.M., indicated resident referred to therapy for fall. No updates were made on care plan. POST FALL INVESTIGATION dated 10/1/16 at 10:12 A.M., indicated resident was found on left side in fetal position with hands under face. Incident Note dated 10/1/2016 at 10:45 indicated was witnessed standing when she lost her balance and fell to floor. Tab alarm was placed on resident. Health Status Note dated 10/5/16 indicated to decrease [MEDICATION NAME] ([MEDICATION NAME] used to treat hypertension that could cause orthostatic hypertension or dizziness with standing) to twice daily. POST FALL INVESTIGATION dated 10/11/16 at 4:40 A.M., indicated slid to the floor from her bed, res indicated she was to get up to go to the restroom. Care plan dated 10/11/16 indicated call light in reach of resident and encourage resident to use it for assistance and resident requires prompt responses to all requests for assistance. Health Status Note dated 10/13/16 at 4:02 P.M. indicated resident's cognition as severely impaired as evidenced by BIM score of 3. POST FALL INVESTIGATION dated 10/20/16 at 11:52 A.M., indicated resident was found sitting on floor next to roommates bed, alarm was off at time of fall. Incident Note dated 10/20/16 at 12:15 P.M., indicated tab alarm was in place but not functioning at time of fall. Health Status Note dated 10/21/16 at 11:54 A.M., indicated resident was hard to arousal and order was received to send resident to emergency room (ER). ER PHYSICIAN REPORT DATED 10/21/16 indicated nursing home record shows resident less responsive this morning and resident has had multiple falls in the past week . This patient present to ER with generalized weakness, frequent falls, and her family is frustrated. She does have a urinary tract infection [MEDICAL CONDITION]. Her family said she had a UTI last month as well and required admission. DISCHARGE SUMMARY DATED 10/22/16 indicated resident was diagnosed with [REDACTED]. Plan of Care Note dated 10/28/16 at 1:13 P.M., indicated when tab alarm sounds it causes more distress and confusion for the resident. She stands real quick to try and turn alarm off them to almost lose her balance. Then when she can't get alarm turned off the sound hurts her ears and she becomes anxious, starts yelling and loses her balance. New order to discontinue tab alarm of wheelchair. POST FALL INVESTIGATION dated 11/17/16 dates 9:55 P.M., indicated resident was found lying on left arm another resident room and resident stated she was going to the bathroom. Care plan updated 11/18/16 for large print sign outside of her door and pull tab alarm to wheelchair, check placement and function every shift Health Status Note dated 11/19/16 at 9:21 P.M. indicated resident was more lethargic. Urine results dated 11/20/16 positive for Escherichia Coli and ESBL (extended spectrum beta lactamase) positive. Lab results dated 11/22/16 indicated BUN 48.0, Creatinine was 1.23, BUN/Creatinine Ratio was 39, and GFR was 43, MCHC 31.8, PLT (platelet Count) 105. POST FALL INVESTIGATION dated 12/01/16 at 12:45 A.M., indicated resident was lying on her back in common area, she was observed standing, lost her balance and fell to the floor. No Plan of Care note present in progress notes. No updates made to care plan. Plan of Care note dated 12/22/16 at 9:06 A.M., indicated resident had fell out of bed around 10:00 P.M. 12/21, resident encouraged to wear non-skid socks and resident is non-compliant with asking for assistance or using her call light due to cognitive impairment. No Post Fall Investigation provided. POST FALL INVESTIGATION dated 12/31/16 at 4:00 A.M. indicated resident fell attempting to transfer self to wheelchair, resident indicated she was very weak. Health Status Note dated 12/31/2016 at 5:47 A.M. indicated resident was found on floor after this writer had assisted her and I stated to resident to stay in bed and pull call light if she wanted back up, CNA found resident on floor, resident stated she tried to get up by herself and was weak, we lifted her to wheelchair and tab alarm on. Plan of Care Note dated 1/2/17 at 12:33 P.M. indicated new intervention was therapy evaluation. Plan of Care Note dated 1/2/2017 at 3:33 P.M., indicated resident's temperature was 99.3, Pulse- 60, Respirations-18, Blood Pressure 103/60, and Biox-92% on room air. Blood sugar 228. Slurred speech present, resident stated she was tired. Incontinent of bladder. Plan of Care Note dated 1/3/17 at 8:55 A.M., indicated resident had a fall out of wheelchair this am around 3 A.M. as resident was rolling thru the halls per self she did not want to lay down and was witnessed falling out of wheelchair onto her belly. Resident has a pacemaker that is bad and the cardiologist is not going to replace it at this time, resident seems more weak and lethargic. MD notified of resident condition, ordered labs and Urinalysis. Will continue to encourage resident to go to bed when appearing to be sleepy. Lab results dated 1/3/16 indicated BUN 56.0 mg/dL, Creatinine 1.34 mg/dL, BUN/Creatinine Ratio 39 ml/min/m2. Urine results positive of ESBL. Plan of Care Note 1/3/2017 at 4:03 P.M., indicated resident more confused than normal, when spoken to resident just stares off . incontinent of bowel and bladder . Dr notified and order received to send resident to hospital. NURSING HOME TO HOSPITAL TRANSFER FORM dated 1/3/17 at 4:30 P.M. reason for transfer more confusion, incontinent of bowel and bladder, needing to be fed, and weakness. ER PHYSICIAN REPORT dated 1/3/17 at 5:33 P.M. indicated resident presented to ER with fever and altered mental status (AMS) present for 2 days. Resident states she does have some abdominal pain, consistent with UTI which is likely contributing to her symptoms. Lab results from hospital indicate BUN 60 mg/dL, Creatinine 1.53 mg/dL, Glucose 368, GFR 33.4 ml/min/BSA, SGOT/AST- 65 U/L, SPGT/ALT 51 U/L. Resident diagnosed with [REDACTED]. Urine positive for Escherichia Coli MDRO (multiple drug resistant organism). Health Status Note dated 1/4/17 at 11:16 P.M., indicated late entry for 1/3/17 at 9:15 P.M., resident returned from hospital. Health Status Note dated 1/4/17 at 8:34 P.M., indicated resident was found leaning on left side on the floor next to bed. Plan of Care Note dated 1/5/17 at 7:07 A.M., indicated resident had fall out of bed, resident recently diagnosed with [REDACTED]. Sensor pad applied to bed while resident remains on antibiotics . POST FALL INVESTIGATION dated 1/6/17 at 1:35 P.M. indicated resident attempted to stand, lost balance, and fell in dining room. Care plan updated 1/7/17 to check resident every 30 minute while in bed. During an observation on 01/3/2017 at 12:09 P.M., CNA #31 moved Resident #57 back to the table and the wheelchair locked so she could not move. Resident tried to move her wheelchair back and was unable so she sat and continue trying and moaning to move. During on observation on 01/3/2017 at 12:13 P.M. resident began hitting the table with her silverware. She attempted to stand up again and set her alarm off. During an observation on 01/3/2017 at 12:17 P.M., Resident #57 continues to try to get up grimacing and moaning. Staff member came up to console her asking what's wrong. Resident did not respond only tried to get up again. During observation on 01/3/2017 at 12:20 P.M., Resident #57 was served food and no toileting was offered or any other intervention. During an observation on 01/05/2017 at 10:24 A.M. Resident #57 was in activity room during morning activity, no drink present within her reach, and no staff was observed offering fluids to residents. During observation on 1/5/17 at 12:25 P.M., Resident #57 received lunch tray with set up from staff. During observation on 1/5/17 at 12:37 P.M., Resident #57 was eating her meal with her fingers, she was not touching her milk that was on the tray. No assistance provided. During observation at 1/5/17 at 12:42 P.M., staff member began to assist resident with eating and drinking. During on interview on 1/9/17 at 10:43 A.M., Dietician indicated that residents with fluid requirements are located in charting and she monitors fluid intake through meal rounds. She indicated there was not a system in place to track fluid consumption. During an interview on 1/9/17 at 10:45 A.M., CNA #31 indicated she did not know where to chart fluid intakes. During an interview on 1/9/17 at 10:50 A.M., LPN (Licensed Practical Nurse) # 32 indicated fluid intake could be charted in Medication Administration Record [REDACTED]. She indicated there were no residents on this unit that had an order to push extra fluid. During an interview on 1/9/17 at 11:27 A.M., Dietician indicated she only knows what is offered, she doesn't know what they consume unless she visualizes food trays on rounds. She presented the POC response history that indicated what percentage of meal was consumed. During an observation on 1/9/17 at 9:50 A.M., Resident #57 was in her wheelchair in her room in pajamas from the night before as indicated by CNA in room. During an interview on 1/9/17 at 1:00 P.M., CNA #31 indicated she had brought Resident #57 into dining room at 11:30 A.M. CNA indicated resident had consumed 10% of meal and drank 200 CC of red juice on tray. During an observation on 1/9/17 at 1:00 P.M., Resident #57 was sitting at dining room table with her tray in front of her. She consumed 10% of her meal and 120 cc of the red juice on her tray. During an observation on 1/9/17 at 1:20 P.M., resident #57 was moved from dining room to TV room across the hall and placed next to LPN #38. No drinks present at this time and no staff observed encouraging fluids. During on interview on 1/9/17 at 1:30 P.M., CNA #37 indicated she was full time on the dementia unit and that resident was toileted upon rising, which is before 6 A.M., after breakfast usually around 8:30 A.M., and then after lunch. She indicated that snacks were offered 2 times a day after breakfast and lunch with activity. During and observation on 1/9/17 at 1:50 P.M., CNA #31 moved Resident #57 from TV room back to dining room where activity room and placed her at table to fold clothes. No fluids were present in resident's reach and no staff observed encouraging fluids. During observation on 1/9/17 at 1:52 P.M., Resident #57 was in activity room in wheelchair with eyes shut. Her lips are dry and peeling, the skin on the back of her bilateral hands was dry and tenting, dark circles were present under eyes. She was lethargic, only opens her eyes long enough to respond. She indicated she was having abdominal pain. During observation on 1/9/17 at 2:37 P.M., Resident #57 remained in activity room sitting at table with clothes to be folded as activity present in front of her. No drink present. Resident smelled of ammonia. During an interview on 1/9/17 at 2:40 P.M., CNA #34 indicated fluids outside of meals and activities are offered to those who are up and ask for it. She indicated Resident #57 really liked cold water. During observation on 1/9/17 at 2:40 P.M., CNA #33 brought Resident #57 into bathroom, placed gloves on hands. No handwashing observed. CNA then placed resident on toilet, removed depend that had blue marking indicating it contained urine. CNA assisted resident to stand and wiped resident's periarea with toilet paper and then proceeded to use moist wash cloth from sink and dry periarea with towel. No observation of gloves being changed. During an interview on 1/9/17 at 3:50 P.M., Dietician indicated she did not know what Resident #57 was offered for lunch nor did she know how much fluid she had consumed. During an interview on 1/9/17 at 4:05 P.M., LPN #39 indicated only hydration inservice was held in July due to the summer heat. During an interview on 1/10/17 at 10:00 A.M., CNA #31 indicated Resident #57 did not eat breakfast because she was still in bed during that time, but resident did consume a peanut butter sandwich and drink 120 cc of orange juice. On 1/10/17 at 3:15 P.M. the DON provided the policy titled NCD Urinary Incontinence dated 5/31/15, and indicated the policy was the one currently used by facility. The policy indicated Policy: based on the patient's comprehensive assessment, care and treatment are provided to help the patient restore his/her highest normal function as possible and to prevent urinary tract infections . A policy titled Prevention and treatment of [REDACTED].M., Policy indicated, Rationale: UTIs . are leading causes of Healthcare Associated Infections . they are often associated with immobilty and incontinence . Prevention .18. Encourage adequate fluid intake. A procedure titled Perineal Care for the Female Resident was provided by DON on 1/10/17 at 3:15 P.M. Procedure indicated the following .4. washes hands 5. puts on gloves . 3.1-41(a)(2)

Based on record review and interviews, the facility failed to ensure the safety of a resident which resulted in a fall with hip fracture for 1 of 5 residents with a history of falls reviewed in a sample of 5. (Resident "D") Finding includes: The record of Resident "D" was reviewed on 02/26/14 at 700 a.m. Resident "D" was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission form, titled, "PATIENT NURSING EVALUATION', dated 02/04/14 at 3:20 p.m., indicated: "...Morse Fall Risk Scale:...35 (Medium Risk)..." due to "Secondary Diagnosis" and "Gait: Impaired". Under "Functional Impairment of Range of Motion" the resident was noted to have impairment to the "1. Upper extremity (shoulder, elbow, wrist, hand" and "2. Lower extremity (hip, knee, ankle, foot)." The documentation indicated this effected the (L) side as "flaccid" (no purposeful movement). Review of a 14 day MDS (Minimum Data Set: a tool to assess a resident's abilities and to facilitate resident care), dated 02/18/14, indicated the resident's BIMS (Brief Interview for Mental Status) to determine cognitive patterns, as a "10" (Moderately Impaired) on a "00-15" scale. The BIMS indicated the resident's ability to recall 3 objects described in the first question, followed by 3 new questions, as "could not recall" for 1 word and "unable without cueing" for 2 words. The MDS indicated: "Mood" as exhibiting symptom for 2-6 days for "...H. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual." The MDS indicated the resident required extensive assistance of 1 person for bed mobility and extensive assistance of 2 or more for "Toilet use-how resident uses the toilet room, commode, ...;transfers on/off toilet;..". The resident assessment for "Balance During Transitions and Walking" indicated: "...2. Not steady, only able to stabilize with staff assistance" for "...D. Moving on and off toilet." The resident was noted to have "Impairment on one side: A. Upper extremity (shoulder, elbow, wrist and hand" and "B. Lower extremity (hip, knee ankle,, foot)". Review of the record indicated the resident had incurred 3 falls in 18 days, on 02/15/14, 02/20/14 & 02/22/14. The resident's fall, on 02/22/14, resulted in a (L) hip fracture. The resident remained in a local ACF (Acute Care Facility: hospital) at the time of survey. Review of fall documentation indicated: "02/15/14 2245 (10:45 p.m.) POST FALL EVALUATION:...Unwitnessed... Resident states she attempted to stand to look for her controller to her bed. Her leg gave out. She fell to the floor. No injuries..." The resident was noted to have a history of CVA, unsteady gait, and admission in the last 30 days. The resident was reeducated regarding asking for assistance when needed. "02/20/14 2145 (9:45 p.m.) POST FALL EVALUATION: Witnessed....Resident slid off bed attempting to look on the floor for bed controller..No injury." The resident was noted to have a history of CVA, history of falls, [DIAGNOSES REDACTED], and admission in the last 30 days. A sensor pad (alarm with movement) to bed was added. "02/22/14 1:15 p.m. POST FALL EVALUATION: Unwitnessed...Injury...Severe (L) hip pain...reaching for w/c (wheelchair)...sitting on commode...sent to hospital. Will be added to falling stars (program to alert staff resident high risk for falls) when return from hospital..." The resident was noted to have a history of CVA, history of falls, and [DIAGNOSES REDACTED]. Review of the "SBAR" (Situation Background Assessment Request) report for the fall on 02/22/14, indicated: "Res (Resident) was on commode. Res found on floor...Res c/o severe (L) hip pain....Res stated she was reaching for w/c that was behind her. CNA ER (and) nurse transferred Res to bed...N.O. (New Order) to send to ER for eval (evaluation) et tx (treatment)." The SBAR review did not address staff members presence. Review of "RESIDENT PROGRESS NOTES indicated: "02/04/14 1900 (7:00 p.m.)...Bedside commode used per (by) request, she says she can't use bed pan...2 assist for transfer to BSC (bedside commode). Pt (patient is very weak...." "02/05/14 0300 (3:00 a.m.) Resident resting in bed up to BSC X (times) 7 this shift...Res has no use of (L) side extremities and is a 2 person assist...." "02/06/14 (untimed) Resident restless today, found resident adjusting bed having the bed too high in the air, found resident laying sideways X 2 in the bed. Resident place in w/c (wheel/chair) @ (at) ts time for safety measures...." "'02/10/14 0105 1:05 a.m. Resident confused...." "02/12/14...Extensive assist X2 for transfers, left side flaccid..." Review of the Care Plans for Resident "D" indicated: "02//04/14 Impaired Functional Mobility: R/T (Related/To) weakness CVA (L) side weakness. Goal: Resident will be safely transferred from bed to chair or wheelchair daily as tolerated without injury to resident or staff. Approach:...Ambulation/Mobility...Limited Assist. Extensive Assist of 2...." "02/04/14 Falls: At risk for fall related to injury as evidenced by: Fall History: 2/15/14 Fall in the last month....Related to: Disease process/condition...CVA (L) side weakness. Goal: Resident will not sustain a fall related injury by utilizing fall precautions through next review date: 05/2014. Approach: Use fall risk screen to identify risk factors...." The review of the fall care plan indicated an area to "Institute Falling Star Program," which was not marked. Review of the record indicated falling star approach was not noted except in the SBAR notes following the third fall. The record did not indicate a reevaluation of the resident's fall risks had been completed following any of the Resident's 3 falls. The DNS (Director of Nursing Services) was interviewed on 02/26/13 at 9:00 a.m. The DNS indicated the resident did not require standby assist while using the bedside commode, next to the bed. The Unit Manager was interviewed on 02/26/14, at 9:00 a.m., with the DNS. The Unit Manager indicated the resident was sitting on the bedside commode and was left unattended. The Case Manager was interviewed on 02/26/14 at 10:15 a.m. The Case Manager indicated the resident's need for assistance varied, from 1 assist to 2 assist, daily. The Case Manager indicated Resident "D" did not require standby assist despite the history of falls and the loss of movement on the (L) side. On 02/26/14 at 12:00 p.m., the DNS provided documentation from the ACF. Review of a Radiology report, dated 02/22/14 15:05 (3:05 p.m.), indicated: "comminuted intertrochantieric fracture of the left femoral neck with varus angulation" (left hip fracture). The reports indicated the resident would have an open reduction with internal fixation (hip surgery) to the (L) hip. This Federal tag relates to Complaint IN 893. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall, which resulted in a fracture. This deficiency affected 1 of 3 residents, who were reviewed for falls, in a sample of 4. (Resident #D) Findings include: On 9/26/12 at 9:10 a.m., during the orientation tour, LPN #10, indicated Resident #D had a recent fall with a fracture. The resident was observed sitting in a wheelchair in her room with a sling on her left arm. The clinical record of Resident #D was reviewed on 9/26/12 at 10:45 a.m. The MDS (Minimum Data Set) Assessment, dated 9/10/12, indicated the resident had moderate cognitive impairments and was not steady when turning or walking. The MDS indicated the resident required limited assistance of one staff person for bathing. Nursing notes indicated the following: On 9/15/12 at 10:30 a.m., "Resident was in shower room awaiting shower. She stated she was trying to get up to weigh herself and the chair moved backward & (and) she went forward. She said her chair went crazy and tried to run her over..." The note indicated the resident complained of pain in the left shoulder and left hip. The note further indicated an x-ray was to be obtained. On 9/15/12 at 2:30 p.m. "X-ray results arrived. L (left) hip is normal. L (left) shoulder is fractured at the humerus..." The note indicated the physician was notified and the resident was sent to the emergency room for evaluation. On 9/15/12 at 9:30 p.m., the resident returned from the hospital with orders for pain medication, ice to the injury and not to remove the splint on the left shoulder. The emergency room Report, dated 9/15/12, indicated the resident had sustained an acute closed fracture of the left humeral head. The care plan, initiated on 2/7/12 and dated as revised on 8/2012, indicated Resident #D was at risk for fall related injuries. Interventions, added on 9/17/12, indicated, the following: Do not leave unattended in shower room, Quarterly PT(Physical Therapy)/OT(Occupational Therapy) screen for motorized wheelchair safety, and Do not take motorized wheelchair into the shower room. The "Alleged Abuse, Neglect and Exploitation Investigation" Worksheet, signed by the Administrator on 9/24/12, indicated the resident was taken into the shower room in her motorized wheelchair. The aide left Resident #D unattended briefly while she went to get a towel or bath blanket. When the aide returned to the shower room, Resident #D was on the floor. The Summary Report of Findings indicated "Resident should not have been transported to shower room in motorized wheel chair and should not have been left unattended. This staff member,...,has been terminated." On 9/26/12 at 12 noon, the DON (Director of Nursing) was interviewed. The DON indicated the aide assignment sheet, prior to the fall, directed that the resident was not to be left unattended in the shower room. The DON indicated she did not have a written policy regarding supervision in the shower room but the facility had an unwritten policy that residents were not to be left unattended in the shower room. This finding relates to Complaint IN 627. 3.1-45(a)(2)

Based on observation, interviews and record review, the facility failed to provide supervision to prevent elopement. This deficiency affected 1 of 3 residents in a sample of 6 who was assessed at risk for eloping from the facility. (Resident F) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 12/7/10 at 4:00 p.m., and began on 11/20/10 at 18:25 p.m., (6:25 p.m.). The administrator and Director of Nursing were notified of the Immediate Jeopardy on 12/7/10 at 4:00 p.m. The immediate Jeopardy was removed on 12/9/10 at 12:15 p.m., but the facility remained out of compliance at the level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of inservicing of staff, evaluation of the alarm system by safety service technicians and monitoring of staff. Findings include: During the orientation tour, on 12/6/10 at 10:20 a.m., accompanied by RN #3, Resident F was identified as being on the secured unit and having a wanderguard alarm bracelet on due to a recent elopement. The resident was observed in bed with the bracelet in place on his ankle. The window in the room was observed to have an alarm in place which sounded when the window was opened. The clinical record of Resident F was reviewed, on 12/6/10 at 1:30 p.m., and indicated the resident had been admitted to the main area of the facility on 11/16/10 at 4:00 p.m. Nurses notes dated 11/16/10 at 4:00 p.m., indicated he had been an emergency admission from adult protective services. The admission note also indicated he was placed on 15 minute checks and his main [DIAGNOSES REDACTED]. The admission elopement assessment, dated 11/16/10, indicated he was at risk due to wandering and expressing a desire to leave. It also indicated he was cognitively impaired. Nurses notes on 11/17/10 at 5:00 a.m., and on 11/18/10 at 5:00 a.m., indicated 15 minute checks continued due to elopement risk. The 11/17/10 nurses note at 10:00 p.m., indicated he was alert with confusion. Charting for 11/19/10 at 5:00 a.m., also indicated the 15 minute checks were continuing to prevent elopement. Nurses notes, dated 11/19/10 at 10:00 p.m., indicated the resident was expressing a desire to leave the facility and the 15 minute checks were continuing. The treatment record indicated the wanderguard was checked for placement and function each shift. Nurses notes on 11/20/10 at 22:45 (10:45 p.m.) indicated the resident had been cooperative at the beginning of the shift and had a shower. The note indicated he sat on the couch by the nurse's station wearing his winter coat after the shower. The note indicated, "stated on one occasion (sic) 'I might have to bust out of here'." The note also indicated the 15 minute checks were continuing. The nurses note for the evening shift on 11/20/10 indicated at approximately 18:15 (6:15 p.m.) the south door alarm was heard and the resident was seen walking away from the door. The note indicated he then sat down in a chair and picked up a book. The nurse wrote "Res (resident) questioned by nurse if res was going to read the book and res stated, 'I do not know.' This nurse then left this site for a short amt (amount) of time, returning at 18:25 (6:25 p.m.). Resident unable to be located at this time. Grounds searched by staff. DNS (Director of Nursing Service) contacted. Daughter phoned. Police called. Administrator also contacted." The Police log was reviewed, on 12/7/10 at 9:00 a.m., and indicated the police had received the call at 19:01 (7:01 p.m.)., on 11/20/10. Nurses notes, dated 11/20/10 at 20:40 (8:40 p.m.), indicated the police had returned the resident to the facility and the resident was initially agitated, but calmed after 5 minutes. He refused an assessment but no visible injuries were visible, according to the note. During an interview with the DoN, on 12/6/10 at 2:30 p.m., she indicated the wanderguard alarm system had been checked after the police brought Resident F back and all of the alarmed doors were working correctly. The facility incident reporting form was reviewed, on 12/6/10 at 2:30 p.m., and indicated the resident had been found by police approximately 2 miles from the facility, on 11/20/10. During an interview with the Director of Nursing, on 12/6/10 at 3:00 p.m., she indicated the outside temperature on the evening of 11/20/10 had been in the 40 or above degree range and Resident F was wearing his winter coat. The area around the facility was observed, on 12/6/10 at 3:30 p.m., to be in an urban area with a busy city street to the North of the building and a housing development to the West. Nurses notes, reviewed on 12/6/10 at 2:00 p.m., and dated 11/20/10 at 10:10 p.m., after the resident's return to the facility and again on 11/21/10, (no time specified) indicated he was on 1 to 1 supervision and awaiting admission to the local psychiatric hospital. He was transferred to the psychiatric hospital on [DATE] at 6:00 p.m., after refusing food and medications 11/21/10 and 11/22/10. Resident F returned to the facility 12/2/10 and was admitted to the secured unit where he currently lives. During an interview with the Director of Nursing (DoN) on 12/7/10 at 11:30 a.m., she indicated she thought someone had turned the alarm off after Resident F followed a family member out the door. She indicated she had questioned all the staff members on duty the evening of 11/20/10, but none had admitted turning the alarm off. Review of maintenance logs, on 12/7/10 at 2:00 p.m., indicated the wanderguard system had been checked monthly and the most recent check prior to Resident F's elopement had been done on 11/1/10, with no problems found in the system. The door alarms were observed, on 12/7/10, at 9:00 a.m., with RN #4 demonstrating the key pad system for exiting the facility and the second pad which silenced the alarms. The alarm sounded when the door was pushed slightly. A sign was observed over the key pad by the exit door which instructed visitors to enter the current year to release the lock. Resident F was observed, on 12/7/10 at 9:30 a.m., with the administrator present and asked to read a sign "Code is year." He was unable to read the words and could not vocalize the current year. The facility presented a plan of correction, and revised it on 12/9/10, to indicate all residents were reviewed for elopement assessments, all wander guards were checked for placement and function and door alarms were checked for proper functioning. Window alarms were also checked and the elopement book was reviewed for accuracy. The facility determined all interventions were in place for residents assessed to be at risk for elopement. Interviews were conducted of all nursing staff at the time of the elopement as well as one visitor that was observed in the facility at that time. An investigation had been initiated immediately to determine the potential reason for the elopement. The exact origin of the event could not be determined. Two possible scenarios were determined to be the potential means of exit. One scenario being door alarm malfunction or second scenario inadequate staff response to the alarm. A plan was initiated immediately to correct each possible scenario. The Staff Development Coordinator inserviced care staff related to the policy and procedures related to residents at risk for elopement, cold alert, and alarming door safety monitoring. All doors, door alarms and wander guards were checked for proper functioning and placement. Daily audits of the wander guards and door alarms were done by the Social Service person or her designee. Weekend managers were to complete door alarm and wanderguard audits on Saturdays and Sundays. Preventative maintenance would be completed daily by maintenance director for door alarms functioning. The residents assessed as elopement risks would be provided with meaningful activities appropriate for each individual if exit seeking behavior was exhibited. Residents with new exit seeking behaviors on weekends and all shifts would be assessed by the charge nurse and the DoN or Social Service person would be notified for further intervention recommendations. Audits and performance improvement recommendations such as wanderguard placement, 15 minute checks, secure unit placement or one on one monitoring would be implemented for residents exhibiting exit seeking behaviors. An Immediate Jeopardy was identified on 12/7/10 at 4:00 p.m. The Immediate Jeopardy began on 11/20/10 at 6:25 p.m., when the resident eloped form the facility. The administrator and Director of Nursing were notified of the Immediate Jeopardy on 12/7/10 at 4:00 p.m., related to the lack of supervision to prevent elopement. The facility staff submitted a plan of action to remove the Immediate Jeopardy and the Immediate Jeopardy was removed on 12/9/10, when through interviews and observation it was determined the the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to complaint IN 787 3.1-45(a)(2)