Every finding on record at Vernon Health & Rehabilitation

Based on record review and interview, the facility failed to consistently notify the nurse practitioner or physician of a resident's weight gain per order for 1 of 5 residents reviewed for unnecessary medications. (Resident 3) Finding includes: Resident 3's clinical record was reviewed on 12/17/25 at 10:48 a.m. Diagnoses included atherosclerotic heart disease of the native coronary artery with angina pectoris (buildup of plaque in the heart's arteries), chronic atrial fibrillation (irregular heartbeat), acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, cardiomegaly (enlarged heart), ischemic cardiomyopathy (weakened and enlarged heart caused by lack of blood flow), edema, and stage 3 chronic kidney disease. Current orders included bumetanide (diuretic) 2 mg twice a day (8/28/25), metolazone (diuretic) 2.5 mg every Monday (11/10/25), and daily weight in the morning - notify the Nurse Practitioner (NP) for 3-pound weight gain in 24-hour period or 5 pounds in 48 hours (7/22/25). A current care plan, initiated on 5/13/25, indicated the resident had altered cardiovascular status related to cardiomegaly, atherosclerotic heart disease of native coronary artery without angina pectoris, combined heart failure, and shortness of breath. Interventions included daily weight and notify MD/NP of 3-pound weight gain over one day or 5-pound weight gain over 3 days (5/13/25). The resident's medication administration records for November 2025 and December 2025 indicated the following: The resident had a weight gain of 5.6 pounds on 11/6/25, a 4.2-pound weight gain on 11/13/25, a 4-pound weight gain on 11/15/25, a 10-pound weight gain on 11/17/25, a 7.8-pound weight gain on 12/6/25, and a 3-pound weight gain on 12/8/25. The resident's clinical record lacked physician/NP notification of the weight gains on those days. During an interview, on 12/19/25 at 10:27 a.m., LPN 12 indicated when the resident's orders had parameters which included calling the NP or physician, then the notification of the NP or physician should be completed and documented in the progress notes if the parameters were met. During an interview, on 12/19/25 at 2:53 p.m., LPN 7 indicated if a resident had a weight gain and the physician or NP notification was ordered, then the NP/physician would be notified and the notification would be placed in the resident's progress notes. During an interview, on 12/19/25 at 3:00 p.m., RN 11 indicated if a resident had a weight gain and the physician or NP should be notified, typically the notification would be placed in the progress notes. For some orders with parameters the software would require documentation if the parameters were/were not met depending on the order. During an interview, on 12/19/25 at 4:11 p.m., the DON and the Corporate Nurse Consultant indicated they were unable to find physician/NP notification as ordered of the resident's weight gain on several days during November and December 2025. A current facility policy, last reviewed 7/1/21 and provided by the Administrator on 12/19/25 at 4:30 p.m., titled Notification of Changes, indicated the following: The facility shall promptly notify the resident and/or the resident's representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring and promote the resident's right to make choices about treatment and care preferences.Document the notification and record any new orders in the resident's medical record. 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, related to medications not being administered via ordered route for 2 observed medication administration opportunities of 34, resulting in a medication error rate of 5.88%.Findings include:During a medication administration observation, on 12/19/25 at 8:08 a.m., the following was observed:LPN 7 prepared aspirin 81 milligrams (mg) and ferrous sulfate (iron) 325 mg for Resident 17. Both medications were removed from medication cards and placed into a plastic sleeve to be crushed. Both medications were crushed by a pill crusher then mixed with vanilla pudding before administering the mixture orally to Resident 17.Resident 17's current physician orders included aspirin 81 mg daily via gastrostomy tube ([g- tube], a tube placed directly into the stomach for feedings, medications, nutrients, etc) and ferrous sulfate 325 mg daily via g-tube.During an interview, on 12/19/25 at 8:13 a.m., LPN 7 indicated Resident 17 did not have an order to give medications orally. Both medications should have been administered via her g-tube.On 12/19/25 at 9:49 a.m., the DON indicated Resident 17 had always been given crushed medications orally. Resident 17 previously had an order to crush medications and give orally but that order had been discontinued. The two medications should have been administered via Resident 17's g-tube per physician orders.A current facility policy, dated 6/22/22, titled Medication Administration, provided by the Corporate Consultant, on 12/19/25 at 9:08 a.m., indicated the following: .Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. 10. Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, right documentation 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to remove discontinued medications from the Kalor Court medication cart for 2 of 15 residents' medications contained in the medication cart. (Resident 10 and Resident 26) Findings include: During an observation, on 12/16/25 at 10:51 a.m., of the Kalor Court medication cart with LPN 13, an undated and opened bottle of GenTeal Tears (eye drops) with a pharmacy sent date of 6/20/25 and instructions to instill two drops a day to both eyes four times a day for Resident 10 was in the top right-hand drawer of the medication cart. An undated opened bottle of Blink Tears (eye drops) with a pharmacy sent date of 10/22/25 and instructions to instill two drops into right eye every six hours for two days was in the top right-hand drawer of the medication cart for Resident 26. The bottle did not have a change of directions sticker or writing on it. At the same time as the observation, LPN 13 indicated when the last dose of the eye drops was given, they should have been discarded. 1. Resident 10's clinical record was reviewed on 12/17/25 at 11:21 a.m. Current orders did not include GenTeal Tears. The resident had two previous orders for GenTeal Tears which included GenTeal Tears - Instill two drops in both eyes four times a day for dry eyes, started 5/9/25 and discontinued 6/20/25 and GenTeal Tears - Instill two drops in both eyes four times a day for dry eyes, started 6/21/25 and discontinued 7/10/25.2. Resident 26's clinical record was reviewed on 12/17/25 at 10:56 a.m. Current orders included Artificial Tears - Instill one drop in both eyes two times a day, started 10/23/25. An order for Blink Tears - Instill 2 drops in right eye every six hours for two days was started 10/22/25 and discontinued on 10/24/25. During an interview, on 12/17/25 at 2:50 p.m., the Corporate Consultant Nurse indicated she was unable to locate a current order for Resident 10's GenTeal eye drops. Resident 26's Blink Tears could have been used for his Artificial Tears order as they were the same drops. The pharmacy removed discontinued and expired medications from the cart and should have removed them when the pharmacy had observed the cart a few weeks ago. During an interview, on 12/19/25 at 2:27 p.m., LPN 12 indicated when an order for medication including eye drops changed, a sticker could be placed on the medication label to indicate the change in orders, and the medication could continue to be used. With a big change, such as the eye drops where it went from one eye to both eyes and the times changed, she would have waited for the new medication from the pharmacy. The order on the medication administration record should match the order on the medication. During an interview, on 12/19/25 at 2:47 p.m., LPN 7 indicated if an eye drop was ordered for a few days, then completed, she would discard medication in the drug buster. If the order was changed, she would put it on the alert charting and put a sticker on the label that said the order changed. During an interview, on 12/19/25 at 2:54 p.m., RN 11 indicated once an eye drop order was discontinued, the eye drops should be removed from the medication cart. Typically, the nurse that administered the last ordered drop removed the eye drops from the cart. If the order was changed, that should be caught during the triple checks with medication administration, and the eye drop should not be given unless the order matched the order on the medication administration record. A current, undated facility policy, provided by the Administrator on 12/19/25 at 4:30 p.m., titled Destruction of Unused Drugs, indicated the following: .Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. 3.1-25(o)

Based on observation and interview, the facility failed to ensure food was served under safe sanitary conditions during meal service regarding food handling for 1 of 35 residents who received meals orally. (Resident 37) Findings include:During a lunch service observation, on 12/15/25 at 12:31 p.m., the following was observed. CNA 14 touched a piece of bread inside a storage bag. With her bare hands, she reached into the storage bag and pulled the bread out with her bare hands before placing it on Resident 37's plate. She then proceeded to butter the bread before she picked the bread up with her bare hands, folded it in half, and handed it to Resident 37. Resident 37 took a bite out of the bread before placing it down on his plate.During an interview, on 12/15/25 at 12:48 p.m., CNA 14 indicated she did not recall pulling the bread from the plastic bag with her bare hands. She probably touched the bread with her bare hands when she folded it in half and handed it to the resident.On 12/19/25 at 9:05 a.m., the Corporate Consultant indicated the facility had already started in-servicing staff members regarding proper food handling. Written education with CNA 14 was completed.On 12/19/25 at 9:08 a.m., the DON indicated staff members should not be touching food with their bare hands. Staff should wear gloves before touching food.A current facility policy, dated 2/27/25, titled Serving a Meal, provided by the Administrator, on 12/17/25 at 9:30 a.m., indicated the following: .6. Avoid handling actual unwrapped food items with bare hands. Be careful to handle wrapping/packaging instead of the food/condiment when opening. In the rare instance that this is necessary, gloves must be worn 3.1-21(i)(3)

Based on interview and record review, the facility failed to offer eligible residents and/or the residents' representatives the current pneumococcal immunization according to the Centers for Disease Control and Prevention (CDC) guidelines for 2 of 5 residents reviewed for immunizations. (Resident 2 and Resident 7). Findings include: 1. Resident 2's clinical record was reviewed on 12/17/25 at 9:12 a.m. Diagnoses included tracheostomy status, heart failure, obstructive sleep apnea, chronic pulmonary edema, and emphysema. Current orders included Vaccines - May receive vaccines as scheduled as recommended per CDC, per responsible part consent unless contraindicated (4/30/25); Change Trach Shiley 8 cuffless and as needed once a day on the first day of the month (5/1/25); Albuterol nebulizer 0.083% inhale orally twice a day (5/11/25); and Ipratropium solution 0.02% inhale orally via nebulizer twice a day (5/11/25). Resident 2's immunization record was reviewed. A pneumococcal vaccination, Prevnar 13 (PCV13), was given on 12/11/23. The record lacked consent or declination for a Prevar 20 (PCV20) or PCV21 as recommended by the CDC. 2. Resident 7's clinical record was reviewed on 12/17/25 at 3:10 p.m. Diagnoses included shortness of breath, chronic kidney disease, stage 4 (severe), and type 2 diabetes mellitus. Resident 7's immunization record was reviewed. The resident received, prior to facility admission, a PCV13 on 9/4/18 and a Pneumovax 23 (PPSV23) on 11/28/18. A pneumonia vaccination consent which indicated two types of vaccines were used to prevent pneumococcal disease, the PCV13 and the PPSV23, was signed on 11/19/25 by the resident's representative and indicated the resident had already received the pneumococcal vaccine on 11/28/18. The record lacked consent or declination for a PCV20 or PCV21 as recommended by the CDC. During an interview, on 12/19/25 at 4:03 p.m., the ADON/Infection Preventionist indicated Resident 2 and Resident 7 had not been offered that PCV20 or PCV21 as far as she knew. She indicated she would check the previous electronic medical record software to see if it had been offered at some time. During an interview, on 12/19/25 at 4:11 p.m., the DON and the Corporate Consultant Nurse indicated they were unable to find consents or declinations of the PCV20 or PCV21. According to the CDC website, the Morbidity and Mortality Weekly Report for 1/9/25 article Expanded Recommendations for the Use of Pneumococcal Conjugate Vaccines Among Adults Aged > 50 Years: Recommendations of the Advisory Committee on Immunizations Practices - United States, 2024, accessed on 12/19/25, adults aged greater than or equal to [AGE] years of age and have received the PCV 13 at any age and the PPSV23 at age less than 65 years then a single does of PCV21 or PCV20 greater than or equal to 5 years after the last pneumococcal vaccine dose is recommended. The guidance for adults aged 19 to [AGE] years of age with chronic medical conditions which include alcoholism, chronic heart disease, including congestive heart failure and cardiomyopathies, chronic liver disease, chronic lung disease (chronic obstructive pulmonary disease, emphysema, and asthma), cigarette smoking, or diabetes mellitus, is to receive the PCV 21 or PCV 20 one year or greater after receiving the PCV 13 dose. A current facility policy, dated 4/1/21, provided by the Administrator on 12/15/25 with entrance conference paperwork, with no title, indicated the following POLICY: All residents will be offered pneumococcal vaccines to aid in prevention pneumonia/pneumococcal infections.Administration of pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 3.1-13(a)

Based on interview and record review, the facility failed to administer medications according to physician order for 1 of 3 residents reviewed for medication administration. (Resident B) Findings include:Resident B's closed clinical record was reviewed on 8/25/25 at 10:44 a.m. Diagnoses included spastic quadriplegic cerebral palsy, dysphagia, and scoliosis. Current orders during the resident's stay included diazepam 2.5 milligram (mg) four times a day. A June 2025 Medication Administration Record (MAR) indicated he received four doses of diazepam on 6/7/25.A June 2025 narcotic count sheet indicated the medication was not removed for his 6/7/25 morning and noon doses. During an interview, on 8/25/25 at 4:25 p.m., the ADON indicated it showed the medication was documented as administered on the MAR but was not signed out on the controlled medication log. Staff should double check the medication, dispense the medication from the medication card, mark that the medication was prepped on the MAR, give the medication, and then mark that the medication administered on the MAR. During an interview, on 8/25/25 at 4:33 p.m., the Administrator indicated that the diazepam was signed off as administered on the MAR but was not signed out on the narcotic count sheet. Looking at both sheets, it appeared the medication was not administered to Resident B.A current facility policy, titled Medication Administration, provided by the Administrator on 8/25/25 at 4:14 p.m., indicated the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 20. Sign MAR after administered. 21. If medication is a controlled substance, sign narcotic sheet.This citation relates to Intake 1753947.3.1-37(a)

Based on record review and interview, the facility failed to ensure the resident's representative was notified in writing of the transfer/discharge appeal rights for 1 of 3 hospitalization s. (Resident D) Findings include: Resident D's clinical record was reviewed on 5/12/25 at 3:24 p.m. Diagnoses included cerebral palsy, fracture of left lower leg, adult failure to thrive, Cauda Equina syndrome, severe intellectual disabilities, osteoarthritis, congenital deformities of feet, and diabetes. Review of a progress note, dated 3/18/25 at 10:24 a.m., indicated the resident yelled out upon being rolled onto his left side during care. The resident's left hip had non-pitting edema, was warm to the touch, and slight green discoloration was noted. An order was received for a left hip x-ray. The resident's representative was notified. A progress note, dated 3/19/25 at 12:45 a.m., indicated x-ray results showed resident had a left hip fracture. The resident's representative was notified. A progress note, dated 3/19/25 at 2:04 a.m., indicated an order was received to send the resident to the ER for treatment and possible surgery. The clinical record lacked indication that the resident's representative was notified of the transfer/discharge appeal rights in writing for the resident's transfer to the hospital. A progress note, dated 5/4/25 at 7:30 a.m., indicated the resident had bruising and swelling was noted to his left hand, wrist and shoulder. An x-ray order was received. A message was left for the resident's representative to return the call for a status update. On 5/4/25 at 2:52 p.m., indicated the Nurse Practitioner (NP) was notified of the resident's x-ray results. An order was received to send the resident to the hospital for evaluation and treatment. The resident's representative was notified. The clinical record lacked indication that the resident's representative was notified of the transfer/discharge appeal rights in writing for the resident's transfer to the hospital. A progress note, dated 5/6/25 at 12:00 p.m., indicated Resident D was experiencing shortness of breath with the use of his accessory muscles noted. Breathing treatments were ineffective. An order was received to send the resident to the emergency room (ER) for evaluation. A call was placed for emergency transportation. A progress note, dated 5/6/25 at 12:20 p.m., indicated the Emergency Medical Technicians (EMTs) arrived to transport the resident to the ER for evaluation. The clinical record lacked indication that the resident's representative was notified of the transfer/discharge appeal rights in writing for the resident's transfer to the hospital. During an interview, on 5/13/25 at 2:37 p.m., the Social Services Director indicated the nurses were responsible for the transfer form for hospital discharges. During an interview, on 5/13/25 at 2:59 p.m., LPN 6 and LPN 8 each indicated they discussed the facility bed hold policy during resident transfers or discharges with the resident's representative. They did not discuss appeal rights information with the residents or their representatives. During an interview, on 5/14/25 at 9:08 a.m., the DON indicated she did not inform the resident or their representative of their appeal rights during transfers or discharges. She only discussed the bed hold policy. During an interview, on 5/14/25 at 10:05 a.m., the Regional Nurse Consultant indicated she was unable to locate any information where Resident D's representative was notified of their appeal rights. A current facility policy, dated 11/15, titled Discharge, provided by the Regional Nurse Consultant on 5/14/25 at 10:35 a.m., indicated the following: .Hospital Transfer: 5. Prepare a transfer form, send with the resident. 7. Document in the nursing notes the condition of the patient, disposition of residents belongings and medications, notification to all parties of the discharge This citation relates to Complaint IN00458788. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to follow physician orders regarding continuation of care for residents transported to day programs with medications for 2 of 3 residents reviewed for day services (Resident B and C). Findings include: During an interview, on 5/12/25 at 9:14 a.m., LPN 6 indicated the Social Services Director informed her of Resident B and Resident C's school schedules. LPN 6 was unsure if the school had received their medications, but sent Resident C to school anyway without checking on 5/6/25. The school immediately called the facility to have Resident C picked up, as he was not approved to attend at that time. During an interview, on 5/12/25 at 10:36 a.m., the DON indicated all documents were sent to the school before the residents could attend. She ordered the school their own medication supply, but it wasn't delivered at this time. Staff sent Resident C to school one day before his care plan was approved or medications were delivered. During an interview, on 5/12/25 at 11:05 a.m., the Administrator indicated Resident B was sent to school and the school called requesting the resident be picked up. The facility did not realize Resident B was not approved to start school at that time. During an interview, on 5/12/25 at 11:10 a.m., CNA 4 indicated Resident B was sent to school on 5/7/25. The school called shortly after and needed him picked up. She transported him from the school back to the facility. During an interview, on 5/12/25 at 11:44 a.m., the Social Services Director indicated Resident C was sent to school without the school having his medication on hand. To her knowledge, Resident B was never sent to school. Once the school received their medication, both residents could attend school. Review of electronic mail (e-mail) correspondence dated 5/5/25 at 2:26 p.m. and provided by the Administrator on 5/12/25 at 1:13 p.m., indicated the school nurse informed the facility both residents could not attend until the school received their rescue medications and their care plans have been approved. 1. Resident B's clinical record was reviewed on 5/12/25 at 11:30 a.m. Diagnoses included epilepsy (seizures), convulsions (violent, involuntary muscle movement and spasm), lack of coordination, and contracture of right ankle. Current orders included attending day services outside the facility with medications, Trileptal (anti-seizure) nine milliliters (mL) twice a day, diazepam (anti-convulsant) 10 milligram (mg) as needed for seizure activity, and Topamax (anti-convulsant) 75 mg twice a day. A current care plan, initiated 4/24/25, indicated the resident was at risk for seizure and injury related to epilepsy. Interventions included medications as ordered. A progress note, dated 5/1/25 at 12:39 p.m., indicated Social Services was in the process of enrolling Resident B into school. 2. Resident C's clinical record was reviewed on 5/13/25 at 10:57 a.m. Diagnoses included autism, epilepsy, and anxiety. Current orders included attending day services outside the facility with medications, clobazam (anti-seizure) 20 mg daily, Valtoco (anti-seizure) 10 mg nasal liquid as needed for seizure, Rufinamide (anti-seizure) 600 mg twice a day, and Felbamate (anti-seizure) 400 mg three times a day. A 4/22/25, quarterly, Minimum Data Set (MDS) assessment, indicated Resident C had an active diagnosis of epilepsy. A current care plan, initiated 3/18/25, indicated the resident was at risk for seizures and injury related to epilepsy. Interventions included medications as ordered. On 5/14/25 at 9:11 a.m., RN 7 indicated she sent Resident B to school. There was miscommunication between herself and the DON on which resident was approved to attend school. The school immediately called to have Resident B picked up as the school did not have his care plan approved or his medications. On 5/14/25 at 10:05 a.m., the Regional Nurse Consultant indicated the facility did not have a policy regarding residents attending school outside the facility. A current facility policy, dated 6/202, titled Physician Orders, provided by the Regional Nurse Consultant, on 5/14/25 at 10:35 a.m., indicated the following: .It is the policy of this facility to provide resident centered care that meets psychosocial, physical, and emotional needs and concerns of the resident This citation relates to Complaint IN00459066. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide adequate supervision and intervention to prevent physical resident-to-resident abuse for 4 of 4 residents reviewed for resident-to-resident abuse (Resident 19, Resident 21, Resident 43, and Resident 44). Findings include: 1. During an observation, on 10/15/24 at 9:15 a.m., Resident 43 stood up from her wheelchair, grabbed the nurses' desk to steady herself, her foot caught behind the wheelchair pedal, and she continued to lean forward to attempt to ambulate toward facility visitors. CNA 10 attempted to assist the resident to sit down in the wheelchair. Resident 43 declined and continued to ambulate toward the visitors with the assistance of CNA 10. Resident 43 reached out and attempted to grab a visitor's drink. CNA 10 redirected the resident by offering her a soda if she would sit down in the wheelchair. The resident agreed. During an observation, on 10/16/24 at 9:03 a.m., Resident 43 sat in her wheelchair beside the nurses' station near the administrator's office and facility's front entrance doors. During an observation, on 10/16/24 at 1:35 p.m., the resident sat in her wheelchair at the doorway of the administrator's office and facility's front entrance doors. During an observation, on 10/18/24 at 8:50 a.m., the resident sat in her wheelchair beside the nurses' station near the administrator's office. During an observation, on 10/18/24 at 12:11 p.m., the resident sat in her wheelchair beside the nurses' station. During an observation, on 10/18/24 at 1:00 p.m., the resident reached out and grabbed at Activity Aide 13 during lunch. Activity Aide 13 indicated she would sit with Resident 43 during the meal. Resident 43's clinical record was reviewed on 10/17/24 at 3:59 p.m. Diagnoses included spastic quadriplegic cerebral palsy, post-traumatic stress disorder, depression, adjustment disorder with mixed anxiety and depressed mood, hallucinations, generalized anxiety disorder, and suspected adult sexual abuse. The current physician's orders included venlafaxine extended release (antidepressant) 37.5 milligrams (mg) daily, alprazolam (antianxiety) 0.5 mg every 8 hours, and ziprasidone (antipsychotic) 40 mg twice a day. A quarterly Minimum Data Set (MDS) assessment, completed on 4/26/24, indicated the resident was unable to complete the interview to determine cognitive status. The resident had long and short-term memory impairment, and her cognitive decision making skills were severely impaired. She had hallucinations. She exhibited physical symptoms directed at others 1 to 3 days of the assessment period. She exhibited other behavioral symptoms not directed toward others daily. A quarterly Minimum Data Set (MDS) assessment, completed on 7/24/24, indicated the resident was unable to complete the interview to determine cognitive status. The resident had long and short-term memory impairment, and her cognitive decision making skills were severely impaired. She had hallucinations. She exhibited other behavior symptoms not directed toward others 4 to 6 days of the assessment period but not daily. A care plan for verbal aggression indicated the resident would sometimes use curse words (initiated 5/8/24 and last revised/reviewed 10/15/24). Interventions included encourage resident to use positive language, redirect conversation, and redirect to different activity such as a movie. Interventions were initiated 5/8/24 and last revised/reviewed 10/15/24. A care plan for a target behavior for putting up her middle finger to others was initiated on 5/8/24 and last revised/reviewed on 10/15/24. Interventions included encourage resident to not be inappropriate, engage in conversation, and redirect to an activity such as a movie or jukebox. Interventions were initiated 5/8/24 and last revised/reviewed 10/15/24. A care plan for a target behavior of self-injurious behavior (SIB), initiated on 9/11/23 and last revised/reviewed on 9/3/24, indicated the resident sometimes hit herself. Interventions included offer a snack or drink, offer a movie, and redirect to a baby doll or musical device. Interventions were initiated 9/11/23 and last revised/reviewed 9/3/24. A care plan for food seeking, initiated on 9/9/23 and last revised/reviewed on 9/3/24, indicated the resident would sometimes try to take food from others. Interventions included direct attention to a sensory device like her dolls or telephone, offer snacks frequently, and offer to sing with her. Interventions were initiated on 9/9/23 and last revised/reviewed on 9/3/24. A care plan for the behavior of inappropriate sexual comments was initiated on 5/25/23 and last revised/reviewed on 9/3/24. Interventions included change conversation, educate on appropriateness, and offer snack. Interventions were initiated on 5/25/23 and last revised/reviewed on 9/3/24. A care plan for post traumatic stress disorder was initiated on 5/8/24 and last revised/reviewed on 9/3/24. Interventions included ensure immediate safety and that of others, gently redirect or reorient as needed, and observe for stressors in the environment and provide a quiet, non-stimulating environment. Interventions were initiated on 5/8/23 and last revised/reviewed on 9/3/24. A care plan for a target behavior of aggression as evidenced by hitting, biting, and scratching was initiated on 5/5/23 and last revised/reviewed on 10/11/24. Interventions included 15-minute checks for 72 hours (initiated 10/11/24), redirect resident away from nurses' station when appropriate or needed (initiated 1/5/24), educate resident she could hurt someone (initiated 9/15/23), offer snack, coffee, or soda (initiated 5/8/23), give cool down period (initiated 5/5/23), and play music (initiated 5/5/23). Interventions were last /revised/reviewed on 10/11/24. A progress note, dated 1/5/24 at 3:41 p.m., indicated Resident 43 made contact with another resident. A resident-to-resident investigation for 1/5/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated Resident 43 made contact with Resident 21 in the face with an open hand as she approached Resident 21. Both residents were in their wheelchairs. The contact resulted in a small scratch on Resident 21's face. A progress note, dated 2/6/24 at 4:08 p.m., indicated the resident made contact with another resident with a slight pat to the face. A resident-to-resident investigation for 2/6/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated Resident 43 made slight contact with Resident 19's nose with an open hand. The investigation determined the actions of Resident 43 were not intended to harm Resident 19. The staff indicated Resident 43's behavior of lightly tapping the nose was common when expressing feeling of friendship. A progress note, dated 2/9/24 at 9:50 a.m., indicated the resident shook her finger aggressively towards another resident. She was removed from the situation by the staff. A progress note, dated 2/14/24 at 6:55 p.m., indicated the resident had a verbal altercation with another resident. She was moved to a safe area. A progress note, dated 3/6/24 at 4:53 p.m., indicated the resident made contact with another resident. A resident-to-resident investigation for 3/6/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated Resident 21 was witnessed to have a small mark on her forehead and a small scratch on her nose. Resident 43 was witnessed to be sitting beside Resident 21. Staff witnessed no contact between the residents. A progress note, dated 3/27/24 at 7:01 a.m., indicated Resident 43 approached the provider and requested a hug while the provider was in a male resident's room. The staff reminded the resident it was not appropriate to enter the male resident's room, and the provider would exit when finished. The resident expressed verbal frustration and cursed at the provider. A progress note, dated 4/12/24 at 9:05 a.m., indicated an aggressive outburst was reported to the provider. The resident threw a carton of feeding at another resident for pointing at her. A progress note, dated 4/16/24 at 4:09 p.m., indicated contact was made by another resident with Resident 43. The other resident put Resident 43 in a headlock and was biting her. A resident-to-resident investigation for 4/16/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated Resident 43 approached Resident 21. Resident 21 grabbed Resident 43's hair and made contact with Resident 43. A progress note, dated 5/2/24 at 4:42 p.m., indicated contact was made by another resident. Resident 43 had a small red mark on her left cheek. A resident-to-resident investigation for 5/2/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated Resident 43 sat at the nurses' station in her wheelchair when Resident 21 grabbed Resident 43's hair and attempted to bite Resident 43's left check. Small red area noted to Resident 43's left cheek. Resident 21 was moved to a different hall to prevent future incidents between the two residents. A progress note, dated 5/3/24 at 6:47 p.m., indicated Resident 43 was cursing at another resident in the hallway. She flipped her middle finger up at the other resident. Resident 43 was assisted to her room. A progress note, dated 5/6/24 at 5:53 p.m., indicated Resident 43 took another resident's soda off his tray. She flipped her middle finger up at the other residents in the dining room without provocation. A progress note, dated 5/8/24 at 6:45 p.m., indicated Resident 43 went over to another resident's table, took the resident's plate, held it up to her mouth, and licked the plate. When staff attempted to intervene Resident 43 cursed, yelled, and flipped her middle finger up at the staff. A progress note, dated 7/16/24 at 6:09 p.m., indicated Resident 43 threw her shoe at another resident. She smacked herself then blamed the other resident for hitting her. A progress note, dated 8/25/24 at 10:47 a.m., indicated Resident 43 put herself on the floor from her wheelchair multiple times. She was difficult to redirect. She shook her fist and flipped her middle finger up numerous times at other residents. A progress note, dated 8/25/24 at 10:02 p.m., indicated Resident 43 made contact with another resident. A resident-to-resident investigation for 8/25/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated the CNA heard a commotion in the hallway between Resident 19 and Resident 43. Resident 19 had scratches on her upper extremities. Resident 43 was placed on 15-minute checks and was moved to another hall. A resident-to-resident investigation for 10/11/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated Resident 43 was at the front entrance doors when Resident 44 crouched down in front of her face and asked where she was going. Resident 43 made contact with Resident 44's nose with an open hand. Resident 44 made contact with Resident 43's face with an open hand. Resident 44 had a small open area to the bridge of his nose from his glasses. During an interview, on 10/21/24 at 12:43 p.m., the Social Services Director (SSD) indicated Resident 43 was redirected often with coffee and food. When Resident 43 would go to the unit in the back hall she had to be closely monitored because Resident 19 and Resident 21 do not get along with her (Resident 43). During an interview, on 10/21/24 at 2:55 p.m., Certified Nurse Assistant (CNA) 8 indicated she was uncertain what the specific interventions were for Resident 43 as she had been recently hired. She said she would look them up on the care plan to see Resident 43's behaviors and triggers. During an interview, on 10/21/24 at 3:07 p.m., LPN 14 indicated Resident 43 was mostly verbal. She would make eye contact with the resident and tell her what she was doing was not appropriate. If the resident was really upset, she would remove her from the situation and talk to the resident on the resident's level. During an interview, on 10/21/24 at 4:19 p.m., the DON indicated Resident 43 had been doing much better since she had moved to the front hall. The incident on 10/11/24 was the first one that had occurred since the move. 2. During an observation, on 10/21/24 at 3:37 p.m., Resident 21 wheeled herself out of the Director of Nursing (DON)'s office. She was smiling as she moved her arms spastically. Resident 21's clinical record was reviewed on 10/21/24 at 9:04 a.m. Diagnoses included spastic quadriplegic cerebral palsy, profound intellectual disabilities, and mixed receptive-expressive language disorder. A quarterly MDS assessment, completed 8/21/24, indicated the resident was rarely or never understood and rarely or never understood others. Her cognitive decision-making skills were severely impaired. She exhibited physical behavioral symptoms directed at other 1 to 3 days during the assessment period and other behavioral symptoms not directed at others 4 to 6 days, but less than daily during the assessment period. A care plan for behavioral symptoms indicated the resident could only propel her wheelchair by using her left hand on the wheels of her chair. The resident leaned side to side, was very spastic and would inadvertently bump into others with her head/mouth. The resident would move her wheelchair in front of people walking in the halls and block doors. The resident had a behavior of unsafe wheelchair mobility. The care plan was initiated 5/31/16 and last revised/reviewed on 9/12/24. Interventions included educate the resident their behavior was unsafe, redirect to an activity, and report any behaviors to the nurse. All interventions were initiated on 6/3/16 and last revised/reviewed on 9/12/24. A care plan for aggression indicated the resident would bite or reach out and grab/hit others or bite them. The care plan was initiated on 6/3/16 and last revised/reviewed on 10/3/24. Interventions included encourage therapeutic rest following any outside activity as needed (initiated 9/6/18), educate it was not nice to hit others (initiated 4/21/17), and promptly respond to her to decrease her behavior of grabbing/hitting/biting when she wanted attention (initiated 6/3/16). All interventions were last revised/reviewed on 10/3/24. A progress note, dated 1/5/24 at 3:47 p.m., indicated the resident had contact with another resident. A red scratch on her left cheek from the contact was 4 cm (centimeters) long by 0.1 cm wide. A progress note, dated 3/6/24 at 8:38 p.m., indicated the resident was in an altercation with another resident earlier in the day resulting in pink marks to the resident's right check and above the right eye. A progress note, dated 4/16/24 at 3:59 p.m., indicated the resident made contact to another resident. There was no documentation regarding injury. A progress note, dated 5/2/24 at 4:29 p.m., indicated the resident made contact with another resident. There was no documentation regarding injury. 3. During an observation, on 10/17/24 at 6:03 p.m., Resident 19 smiled at staff and wheeled herself down the hallway to the dining room and back to her room. Resident 19's clinical record was reviewed on 10/21/24 at 11:01 a.m. Diagnoses included severe intellectual disabilities, impulse disorder, and oppositional defiant disorder. An annual MDS assessment, completed on 9/9/24, indicated the resident rarely or never understood others and was rarely or never understood by others. Her cognitive skills for decision making were severely impaired. A progress note, dated 2/6/24 at 4:14 p.m., indicated contact was made by another resident. The resident was smiling and no injuries were identified. A progress note, dated 8/25/24 at 10:11 p.m., indicated the resident made contact with another resident. Multiple surface level scratches were noted to face, chest and left thigh. 4. During an observation, on 10/15/24 at 11:27 a.m., Resident 44 ambulated down the hallway with his cane smiling at other residents and staff members. During an observation, on 10/17/24 at 4:28 p.m., Resident 44 sat outside the facility's front entrance, smiled, and indicated he was enjoying the weather. Resident 44's clinical record was reviewed on 10/21/24 at 10:22 a.m. Diagnoses included anxiety disorder, major depressive disorder, and visual hallucinations. A quarterly MDS assessment, completed 8/26/24, indicated the resident was cognitively intact. He exhibited no behaviors. A resident-to-resident investigation for 10/11/24, provided by the Administrator on 10/18/24 at 1:12 p.m., indicated Resident 43 was at the front entrance doors when Resident 44 crouched down in front of her face and asked where she was going. Resident 43 made contact with Resident 44's nose with an open hand. Resident 44 made contact with Resident 43's face with an open hand. Resident 44 had a small open area to the bridge of his nose from his glasses. During an interview, on 10/18/24 at 4:32 p.m., the Administrator indicated she had been in her office right in the immediate vicinity of Resident 43's and Resident 44's resident-to-resident interaction. The interaction had happened very quickly without warning. During an interview, on 10/21/24 at 4:19 p.m., the DON indicated she believed Resident 44 bent down and was in Resident 44's face causing her to react out of fight or flight mode when she hit him. She believed he also reacted instinctively when he hit her back. A facility policy, dated 3/5/24, provided by the Administrator on 10/15/24 at 11:32 a.m., titled Abuse and Neglect Policy, indicated .All residents will be protected from harm 3.1-27(a)

Based on record review and interview, the facility failed to provide an arbitration agreement that granted the resident or their representative the right to rescind the agreement within 30 days of signing it for 3 of 3 current residents reviewed who were admitted after 2/1/24 (Resident 26, Resident 44, and Resident 97). Findings include: During an interview conducted in conjunction with the entrance conference on 10/15/24 at 9:37 a.m., the Administrator indicated the facility offered arbitration agreements in the admission agreement packet. The sample admission agreement packet, provided as indicated above, was reviewed on 10/21/24 at 2:39 p.m. The admission/arbitration agreement packet lacked mention of the resident's or resident's representative's right to rescind the arbitration agreement within 30 days of signing the agreement. 1. Resident 44's 2/25/24, Admission Agreement document indicated section 8.7 addressed an agreement not to elect a trial by jury of any fact trialable by a jury. The resident initialed agree. The form lacked mention of the resident's or resident's representative's right to rescind the agreement within 30 days of signing the agreement. 2. Resident 97's 10/14/24, Admission Agreement document indicated section 8.7 addressed an agreement not to elect a trial by jury of any fact trialable by a jury. The resident's representative initialed agree. The form lacked mention of the resident's or resident's representative's right to rescind the agreement within 30 days of signing the agreement. 3. Resident 26's 8/15/24, Admission Agreement document indicated section 8.7 addressed an agreement not to elect a trial by jury of any fact trialable by a jury. The resident's representative initialed agree. The form lacked mention of the resident's or resident's representative's right to rescind the agreement within 30 days of signing the agreement. During an interview, on 10/21/24 at 2:50 p.m., the Administrator indicated the Social Services Director (SSD) went over the arbitration agreement during the admission process and explained the resident/resident's representative could change their minds about arbitration within 30 days of signing the agreement. During an interview, on 10/21/24 at 2:57 p.m., the SSD indicated she explained during the admission process what arbitration was and the resident/resident's representative could change their minds about arbitration within 30 days if they changed their mind. She did not know where the admission/arbitration agreement indicated the resident could rescind the arbitration agreement. During an interview, on 10/21/24 at 3:32 p.m., the Administrator indicated the admission agreement containing the arbitration agreement lacked mention of the ability for the resident/resident's representative to rescind the arbitration agreement within 30 days of signing the agreement. During an interview, on 10/21/24 at 3:50 p.m., the Administrator indicated the facility did not have a policy on arbitration.

Based on observation, record review, and interview, the facility failed to ensure privacy was provided during incontinence care for 2 of 3 residents reviewed for dignity (Resident 38 and Resident 39). Findings include. 1. During a random observation, on 10/17/24 at 1:29 p.m., Resident 39 was visible from the room door window as a new brief was applied by CNA 6. The resident's privacy curtain had not been pulled. During an interview, on 10/17/24 at 1:46 p.m., Certified Nurse Assistent (CNA) 6 indicated she would typically pull the curtain around the resident for privacy during care. She was in a hurry and had not done so for Resident 39. Resident 39's clinical record was reviewed on 10/21/24 at 4:48 p.m. Diagnoses included need for personal assistance with care. A quarterly Minimum Data Set (MDS) assessment, completed on 9/18/24, indicated Resident 39 was dependent on the staff for upper and lower body dressing, toileting hygiene, personal hygiene, and for rolling left to right. 2. During a random observation, on 10/17/24 at 1:36 p.m., CNA 6 assisted Resident 38 in his wheelchair to his room. She pulled the privacy curtain of the first bed beside the door to nearly the edge of the first bed. Resident 38's foot of the bed including his feet were fully visible from the door window. His privacy curtain was not pulled around him. He was visible to the occupant of the first bed and the occupant of the bed against the wall throughout his incontinence care. During an interview, on 10/17/24 at 1:46 p.m., CNA 6 indicated she had pulled the curtain near the door so Resident 38 could not be seen from the door. She had not pulled the privacy curtain around him to provide him with privacy from the other residents in the room. Resident 38's clinical record was reviewed on 10/21/24 at 4:41 p.m. Diagnoses included need for assistance with personal care. A quarterly MDS assessment, completed on 9/16/24, indicated Resident 38 was dependent on the staff for upper and lower body dressing, toileting hygiene, personal hygiene, and for rolling left to right. During an interview, on 10/21/24 at 2:47 p.m., CNA 7 indicated the privacy curtain should be pulled around a resident when care was provided for said resident. During an interview, on 10/21/24 at 2:55 p.m., CNA 8 indicated she would pull the privacy curtain around the resident when performing resident care. During an interview, on 10/21/24 at 3:38 p.m., the Director of Nursing (DON) indicated privacy should be provided when resident care was done. During an interview, on 10/21/24 at 4:19 p.m., the DON indicated the facility did not have a policy on providing privacy during resident care. 3.1-3(t)

Based on interview and record review, the facility failed to ensure interventions were implemented as ordered for a resident experiencing an acute medical decline for 1 of 2 residents reviewed for hospitalization s (Resident 18) Findings include: Resident 18's clinical record was reviewed on 10/17/24 at 3:44 p.m. Diagnoses included spastic quadriplegic cerebral palsy, severe intellectual disabilities, idiopathic epilepsy and epileptic syndromes, hyperglycemia (elevated blood sugar), and chronic kidney disease. A care plan, revised on 10/15/24 at 4:01 p.m., indicated the resident was unable to independently change positions, feed self, toilet self, or transfer self. He was dependent on staff for all needs to be met with routine, anticipatory care. A revision of his care plan, dated 9/17/24 at 12:47, included the addition of enhanced barrier precautions (EBP) because he had an indwelling device (suprapubic catheter) which placed him at higher risk for infection. Lab results, dated 10/10/24, indicated the resident's blood glucose level was 456 mg/dL (milligrams per deciliter). (Normal blood glucose levels run between 70 mg/dL and 100 mg/dL.) On 10/10/24, at 1:50 p.m., a nurse practitioner's note indicated an order for 10 units of Novolog insulin (a rapid acting insulin), 10 units daily of Lantus insulin ( a long-acting insulin), and a hemoglobin A1C (HbgA1c) to be performed one week later (measures average glucose levels for the previous 3 months). The NP indicated the resident's low sodium level was likely related to elevated blood sugars. The plan was to follow glucose levels closely and get repeat labs in a week. A review of lab results in the clinical record between 10/10/24 and 10/20/24 indicated no HbgA1c had been performed. A progress note, dated 10/11/24 at 1:53 a.m., indicated nursing checked Resident 18's blood glucose due to issues from earlier in the day. (The issues were not specified). The NP was notified of a blood glucose of 330 mg/dL. The NP advised the nurse to recheck blood glucose at 4:00 a.m. There was no documentation in the resident's clinical record to indicate the blood glucose level was obtained at 4:00 a.m. on 10/11/24, as ordered. Vital signs on 10/11/24, at 10:30 a.m., indicated the resident's blood glucose was now 502 mg/dL. A progress note, dated 10/20/24, at 1:29 p.m., indicated the resident's blood glucose was 373 mg/dL. His respiratory rate was 32 (per minute) and heart rate was 122 beats per minute (bpm). His oxygen saturation was 87% on room air. He required 4 liters of oxygen via nasal cannula to maintain an oxygen saturation of 91%. The NP ordered a stat CBC (complete blood count), with differential, a stat BMP (basic metabolic panel), a stat magnesium level, a stat chest x-ray, a stat UA (urinalysis), an additional 15 units of Novolog, and 2 grams IM (intramuscular injection) of Rocephin (antibiotic). The note indicated the Rocephin was pulled from the emergency drug kit at that time. A progress note, dated 10/20/2024 at 1:47 p.m., indicated the resident's oxygen saturation was 86%. A breathing treatment was administered at that time. His heart rate was 121 bpm, respiratory rate was 28 bpm and shallow, and breath sounds were clear but diminished on the left side. Slight rhonchi (gurgling or bubbling sounds) were heard on the right side. After the breathing treatment, his heart rate was 125 bpm, respirations were 32 bpm and shallow, breath sounds were unchanged. He was placed on 4 liters of oxygen via nasal cannula, resulting in an oxygen saturation of 91%, heart rate of 125 bpm, and respirations had increased to 40 bpm, still shallow. Nursing was to continue to monitor. On 10/20/24, at 2:23 p.m., a progress note indicated the resident's supplemental oxygen had to be increased to 5 liters because his oxygen saturation levels had decreased to 90%. His respiratory rate continued at 40 bpm. The resident would continue to be monitored. On 10/20/24 at 2:25 p.m., a progress note indicated the nurse called the resident's representative to give an update on the resident's status. The representative requested the resident be sent out to a local hospital to be evaluated. The note indicated, as of the time of departure, the Rocephin had not been administered. On 10/20/24, at 11:41 p.m., a progress note indicated the nursing facility received a call from the local hospital. The resident had to be intubated (a breathing tube was inserted into the resident's airway) and was transferred to a larger, regional hospital. During an interview with LPN 5 on 10/21/24 at 3:47 p.m., she indicated the regional hospital had called with an update. The resident was intubated and was septic (a life threatening condition involving the body's response to an infection). During an interview with the NP on 10/21/24 at 2:26 p.m., she indicated when she talked to nursing on 10/20/24 at 1:21 p.m., she asked the LPN 5 to get the resident's vital signs, which indicated Resident 18 was meeting sepsis criteria. Prior to this, she had only had his glucose levels reported to her. She ordered 2 grams of Rocephin to be administered immediately. At 2:32 p.m., the nurse called to tell the NP the Rocephin had not been given because the nurse could not find a 1-inch needle with which to administer the antibiotic. The NP told LPN 5 at that time how critical it was for antibiotics to be administered at the first signs of sepsis. The risk of sepsis increased 10% every hour without antibiotics. During an interview with the Director of Nursing (DON), on 10/21/24 at 3:54 p.m., she indicated she had received a report from the regional hospital. The resident was septic and had a urinary tract infection (UTI). The resident had a history of declining rapidly when sick. During an interview with LPN 5, on 10/21/24 at 4:54 p.m., she indicated she called the NP at 7:00 a.m. on 10/20/24 to tell her the resident's blood glucose was high. At 9:30 a.m., she called the NP with blood glucose levels. At 1:30 p.m., she contacted the NP and received orders for insulin, stat labs, chest x-ray, and 2 grams of Rocephin. She could not find a 1-inch needle to administer the Rocephin. When she told the NP that she had not given the Rocephin, the NP was fine with it. LPN 5 had been busy with other needs, residents, and tasks on the unit. The resident did not appear to be in distress. LPN 5 had been monitoring and reporting the resident's vitals regularly since first contacting the NP at 7:00 a.m. on 10/20/24. The resident had a history of declining rapidly when sick. Resident 18's hospital progress notes, dated 10/20/24 indicated the resident was seen by intensivist services for septic shock. The resident was transferred from his facility to the emergency department with complaints of decreased level of consciousness and hyperglycemia (high blood glucose). In the emergency department, he was found to have signs of sepsis including tachycardia (elevated heart rate), hypotension (low blood pressure), and elevated lactic acid levels. Due to his decreased mentation, he was eventually intubated for airway protection and hypoxia (low oxygen levels). A current facility policy, provided by the DON on 10/22/24 at 10:27 a.m., titled Change In A Resident's Condition or Status, indicated the following: .6) The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure staff were qualified to perform GJ-tube care for 1 of 1 residents reviewed for feeding tubes. (Resident 42) Findings include: A clinical record review for Resident 42 was performed on 10/16/24 at 11:06 a.m. Diagnoses included anoxic brain damage, gastrostomy malfunction, lack of expected normal physiological development in childhood, artificial openings of the gastrointestinal tract, and a disorder of the autonomic nervous system which caused sympathetic storming (a condition which can occur with patients with severe brain injuries). Physician orders, dated 7/22/24, indicated the resident was to receive Pedia-Sure Enteral Formula through his gastrojejunostomy (GJ-tube). (A GJ-tube is a means of delivering food to someone who cannot eat by mouth.) The order specified 620 mils (milliliters)of Pedia-Sure combined with 340 mils of Pedialyte. The pump was to run at 42 ml/hour for 23 hours per day. The bag of formula was to be changed every 24 hours. A care plan, revised on 9/12/24 at 1:36 p.m., indicated the resident was at risk for gastrointestinal complications related to gastrostomy, jejunostomy, and enteral feeding. On 10/16/24, at 2:09 p.m., QMA 12 was observed providing GJ-tube care for Resident 42. QMA 12 transferred the resident from his play pen to his crib. During the observation, QMA 12 indicated she had already prepared his bag of formula and would be switching the old bag out with the new bag. She detached the tubing connected to GJ-tube and checked the placement of the tube by flushing it with 10 mils of normal tap water. The tube was not flushing properly and took some time to begin to flow. The QMA indicated she was not concerned with the slow draining of the syringe. Once the tube was flushing properly, she attached the tubing connected to the new bag of formula and discarded the old bag and tubing. She indicated, at that time, it was her practice to date the new bag of formula before hanging it or attaching it to the resident. A review of Resident 42's MAR (medication administration record) was performed on 10/17/24 at 9:36 a.m. The following dates indicate the days in October 2024 when QMA 12 hung and attached a new bag of formula for Resident 42: 10/10/24, 10/16/24, and 10/17/24. These dates were documented under the order for the enteral feeding bag to be changed every 24 hours. During an interview with LPN 5 on 10/17/24 at 10:57 p.m., she indicated QMAs were allowed to spike the enteral feeding bags and program the pump for Resident 42. During an interview with the DON on 10/18/24 at 4:03 p.m., she indicated QMAs could clean around the GJ-tube site, but could not hang a new bag of formula, nor attach the new tubing to the GJ-tube site. A current facility document, titled QMA Orientation, provided by the Administrator on 10/18/24 at 12:15 p.m., indicated QMAs were not oriented to hang enteral feeds or change the tubing accompanying a new bag.

Based on record review and interview, the facility failed to ensure shift to shift narcotic count and reconciliation was completed for 2 of 5 carts reviewed for medication reconciliation. (Kalor Hall and [NAME] Hall) Findings include: 1. During a medication storage observation of the Kalor Hall medication cart, on 10/21/24 at 1:21 p.m., accompanied by LPN 4, the Narcotic Sheet Log/ Tracking Form was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card, liquid, and/or bottle count: 10/8 on day shift and night shift 10/9 on day shift and night shift 10/10 on day shift 10/11 on day shift October 2024- lacked a shift-to-shift narcotic reconciliation signatures: 10/12 on day shift and night shift 10/15 on day shift 10/18 on day shift During an interview, at the time of the observation, LPN 4 indicated the narcotic count was completed by the oncoming nurse and offgoing nurse during shift change. 2. During a medication storage observation of the [NAME] Hall medication cart, on 10/21/24 at 1:21 p.m., accompanied by LPN 4, the Narcotic Sheet Log/ Tracking Form was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card, liquid, and/or bottle count: 10/11 on day shift and night shift 10/14 on night shift October 2024- lacked a shift-to-shift narcotic reconciliation signatures: 10/16 on night shift During an interview, at the time of the observation, LPN 4 indicated the narcotic count was completed by the oncoming nurse and offgoing nurse during shift change. During an interview, on 10/18/24 03:37 p.m., the DON indicated staff was to complete the narcotic sheet log after every shift. A current facility policy, titled Controlled Medication Storage, provided by the DON on 10/18/24 at 3:37 p.m., indicated the following: . At change of custody, a physical inventory of all controlled medications is conducted by 2 licensed/ certified personnel and is documented 3.1- 25(b)(3)

Based on observation, interview, and record review, the facility failed to ensure monitoring of vital signs parameters as ordered for 1 of 1 residents randomly reviewed for parameters during medication administration. (Resident 27) Findings include: Resident 27's clinical record was reviewed on 10/21/24 at 8:35 a.m. Diagnoses included autistic disorder, essential hypertension (high blood pressure), hypothyroidism due to medicaments and other exogenous substances, and iron deficiency anemia. Current orders included atenolol (antihypertensive) 25 milligram (mg) tablet once daily with parameters of holding the medication if systolic blood pressure (top number) was less than 110 millimeters of mercury (mmHg) and/or heart rate was less than 55. A Medication Administration Report (MAR) for October 2024 indicated the resident received atenolol without obtaining blood pressure or pulse as follows: on 10/1, 10/2, 10/3, 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16. 10/17, 10/18, 10/19, 10/20, and 10/21. During a medication administration observation, on 10/21/24 at 8:17 a.m., LPN 4 was observed administering atenolol 25 mg without obtaining Resident 27's vital signs before administration. During an interview, on 10/21/24 at 8:34 a.m., LPN 4 indicated she did not check resident's blood pressure or heart rate before administering his atenolol. During an interview, on 10/21/24 at 9:22 a.m., the DON indicated vital signs were not completed before the administration of atenolol. Staff should be following the physician's order. During an interview, on 10/21/24 at 10:03 a.m., the MDS Coordinator indicated the need to check the medication parameters before administering the medication per physician orders. Review of a current facility policy, titled Medication Administration, provided by the DON on 10/21/24 at 9:28 a.m., indicated the following: .Medications are administered in accordance with written orders of the physician/prescriber 3.1-48(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% related to medications not being administered according to orders for 2 of 36 opportunities of medication administration, resulting in a medication error rate of 5.56%. Findings include: During a medication administration observation, on 10/21/24 at 8:17 a.m., Licensed Practical Nurse (LPN) 4 was observed preparing mediations for Resident 27. The following was observed: LPN 4 prepared atenolol (high blood pressure) 25 milligram (mg) daily with parameters of holding the medication if systolic blood pressure was less than 110 millimeters of mercury (mmHg) and/or heart rate less than 55. Blood pressure and pulse were not obtained before administering the medication. LPN 4 prepared levothyroxine (hypothyroidism) 88 micrograms (mcg) daily. The medication was administered with eleven other medications, including but not limited to, famotidine (antacid) 20 mg twice daily, and ferrous sulfate (iron supplement) 325 mg daily. During an interview, on 10/21/24 at 8:34 a.m., LPN 4 indicated she did not check the resident's blood pressure or heart rate before administering the atenolol. During an interview, on 10/21/24 at 9:49 a.m., LPN 5 indicated the need to check the physician's orders before administering medications. It would show under the physician's order if there were any medication parameters. Levothyroxine should be administered separately. During an interview, on 10/21/24 at 9:56 a.m., the Director of Nursing (DON) indicated the facility did not have an order to administer levothyroxine with other medications. During an interview, on 10/21/24 at 10:03 a.m., the MDS Coordinator indicated any medication parameters were in the physician's order. If the levothyroxine medication did not specify directions, one would go off the preference of the resident. During an interview, on 10/21/24 at 10:24 a.m., the DON indicated medication administration times were reviewed as part of the pharmacy medication reconciliation review. Resident 27's medications were reviewed in August, September, and October 2024 without any recommendations. Review of a current facility policy, titled Medication Administration, provided by the DON on 10/21/24 at 9:28 a.m., indicated the following: .Medications are administered in accordance with written orders of the physician/prescriber The National Institute of Medicine, Medline Plus document titled Levothyroxine, dated 2/15/2019, was retrieved on 10/21/24 from https://medlineplus.gov/druginfo/meds/a682461.html. The guidance included: .if you take ferrous sulfate (iron supplement), take it at least 4 hours before or 4 hours after you take levothyroxine 3.1-48(c)(1)

Based on interview and record review, the facility failed to ensure residents received medications per physician orders for 5 of 6 residents reviewed for medication administration. (Residents E, F, H, J, and K) Findings include: 1. The clinical record for Resident E was reviewed on 9/10/24 at 11:50 a.m. Diagnoses included spastic quadriplegic cerebral palsy, profound intellectual disabilities, dysphagia, anemia, idiopathic epilepsy and epileptic syndromes with status epilepticus, neuromuscular dysfunction of bladder, aphasia, rheumatoid arthritis with rheumatoid factor of multiple sites, respiratory disorder, pain, and gastro-esophageal reflux disease. The clinical record indicated the following orders: baclofen (muscle relaxant) 10 mg three times daily (dated 6/3/24) and ferrous sulfate (iron supplement) 325 mg three times daily (dated 6/3/24). A care plan, dated 8/8/24, indicated Resident E was at risk for excessive tiredness, shortness of breath, and cold intolerance due to anemia. An intervention dated 8/8/24, indicated Supplement as ordered. A care plan, dated 2/3/17, indicated the resident had an order for baclofen for spasticity related to their Cerebral Palsy diagnosis. An intervention, dated 2/3/17, indicated to give mediations as ordered. A progress note, dated 9/7/24 at 3:58 a.m., indicated the resident's noon medications were found in the top drawer of the medication cart. Review of the August 2024 Medication Administration Record (MAR) indicated the medication was documented as given. 2. The clinical record for Resident F was reviewed on 9/10/24 at 12:46 p.m. Diagnoses included spastic quadriplegic cerebral palsy, severe intellectual disabilities, idiopathic epilepsy and epileptic syndromes, dysphagia, iodine-deficiency related thyroid disorders and allied conditions, chronic kidney disease, aphasia, Autistic disorder, and hypomagnesemia. The clinical record indicated the following orders: magnesium oxide (magnesium supplement)500 mg three times daily (dated 7/22/24), midodrine (anti-hypotensive)10 mg three times daily per gastric tube (dated 2/4/24), and valporate (anti-convulsant) 250 mg/5 milliliters (ml) give 10 ml three times daily per gastric tube (dated 10/24/23). A care plan, dated 5/7/24, indicated the resident had diagnosis of hypomagnesemia, and was at risk for muscle spasms, nausea, vomiting, fatigue, and seizures. An intervention, dated 5/7/24, indicated supplements as ordered. A care plan, dated 5/28/21, indicated Resident F was at risk for complications associated with hypernatremia, recent acute kidney failure and metabolic encephalopathy. An intervention, dated 6/7/21, indicated for medication or treatment as ordered. A care plan, dated 5/28/21, indicated the resident had altered respiratory status as evidenced by recent bilateral pulmonary embolis, acute respiratory failure, and aspiration pneumonia. An intervention, dated 6/7/21, indicated to medicate as ordered. A care plan, dated 11/1/15, indicated the resident had epilepsy. An intervention, dated 6/21/18, indicated to give medications as ordered for seizures and notify physician. A progress note, dated 9/7/24 at 3:55 a.m., indicated the noon medications were found in the top drawer of the medication cart. Review of the August 2024 MAR indicated the medication was documented as given. 3. The clinical record for Resident H was reviewed on 9/10/24 at 1:06 p.m. Diagnoses included tuberous sclerosis, profound intellectual disabilities, contracture, generalized idiopathic epilepsy and epileptic syndromes with status epilepticus, gastro-esophageal reflux disease, dysphagia, hypothyroidism, aphasia, benign neoplasm of kidney, hypomagnesemia, hypo-osmolality and hyponatremia, pain, and dyspnea. The clinical record indicated the following orders: carbamazepine (anticonvulsant) 300 mg three times daily (dated 7/20/20) and magnesium (magnesium supplement) oxide 400 mg three times daily (dated 3/26/24). A care plan, dated 3/26/24, indicated Resident H had a diagnosis of hypomagnesemia and was at risk for muscle spasm, muscle cramps, fatigue and weakness. An intervention, dated 3/26/24, indicated to medicate as ordered. A care plan, dated 1/8/13, indicated the resident had a diagnosis of epilepsy with the potential for adverse effects related to acute episodes. An intervention, dated 6/20/13, indicated to administer medications as ordered and assess for signs and symptoms of toxicity. A progress note, dated 9/7/24 at 4:01 a.m., indicated the noon medications were found in the top drawer of the medication cart. Review of the August 2024 MAR indicated the medication was documented as given. 4. The clinical record for Resident J was reviewed on 9/10/24 at 1:10 p.m Diagnoses included spastic quadriplegic cerebral palsy, profound intellectual disabilities, dysphagia, gastro-esophageal reflux disease, gastrostomy status, adult failure to thrive, idiopathic epilepsy and epileptic syndromes with status epilepticus, aphasia, contracture, right knee and autistic disorder. The clinical record indicated the following orders: baclofen 10 mg three times daily (dated 5/26/22) and valporic acid 250 mg/5 ml give 5 ml three times daily per gastric tube (dated 5/26/22). A care plan, dated 4/20/22, indicated Resident J had seizure and was at risk for complications and injury related to seizure disorder. An intervention, dated 4/25/24, indicated to medicate as ordered. A care plan, dated 11/9/18, indicated the resident had the potential for discomfort related to the diagnosis of spastic quadriplegic cerebral palsy. An intervention, dated 11/9/18, indicated to give medications as ordered. A care plan, dated 3/14/16, indicated the resident had spastic quadriplegic cerebral palsy and contractures of arms and legs. The resident took baclofen to reduce spasticity. An intervention, dated 3/15/16, indicated to administer medications as ordered. A progress note, dated 9/7/24 at 3:46 a.m., indicated the noon medications were found in the top drawer of the medication cart. Review of the August 2024 MAR indicated the medication was documented as given. 5. The clinical record for Resident K was reviewed on 9/10/24 at 1:15 p.m. Diagnoses included spastic quadriplegic cerebral palsy, severe intellectual disabilities, impulse disorder, epilepsy, unspecified without status epilepticus, dysphagia, aphasia, pain, and respiratory disorder. The clinical record indicated the following order: baclofen 10 mg per gastric tube 3 times daily (dated 7/20/20). A care plan, dated 11/29/12, indicated the resident had epilepsy and the potential for adverse effects related to acute episodes, and medication usage. An intervention, dated 11/12/15, indicated to administer medications as ordered by physician for seizure activity and assess for symptoms of toxicity. A progress note, dated 9/7/24 at 3:49 a.m., indicated the noon medications were found in the top drawer of the medication cart. Review of the August 2024 MAR indicated the medication was documented as given. During an interview on 9/9/24 at 3:09 p.m. the DON indicated, on 9/6/24 between 11:00 a.m. and 1:00 p.m., Residents E, F, H, J, and K were not administered medications. The DON indicated the nurse on duty was an agency nurse. The medications were found by the night shift nurse in the top drawer of the medication cart. During an interview on 9/10/24 at 1:22 p.m., the Administrator and the DON indicated, according to the Medication Administration policy, refusal of a medication would also be applied to not being administered. Any missed or refused medication should be documented as such in the electronic MAR. A current policy, dated 6/17/21, titled Medication Administration was provided by the Administrator on 9/10/24 at 12:00 p.m. The policy indicated the following: Procedure: 12. If resident refuses medication, document refusal and based on plan of care notify physician. This citation relates to Complaint IN00441262. 3.1-13(m)(1)

Based on interview and record review, the facility failed ensure a resident's medication was available for administration for 1 of 6 residents reviewed for medication availability. (Resident G) Findings include: During an interview on 9/9/24 at 3:09 p.m., the DON indicated the facility had experienced two incidents of medication errors within the past 30 days. The DON provided a list of 6 residents who had medication errors within the past 30 days. Resident G (whose name was on the list) had not been administered a dose of diazepam 15 mg on 9/7/24 between 5:30 a.m. and 9:30 a.m. The facility had failed to secure a refill prescription, and the pharmacy could not refill the medication without a prescription from the provider. The DON indicated staff had attempted to call the Nurse Practitioner (NP) to get a renewed prescription for the medication with no response. The staff then called the alternate NP, with no response. After staff were unable to reach the NP, they called the DON. The DON instructed them to call the NP again and if no response inform her (DON). The staff were able to reach the NP and the prescription for the medication was sent to pharmacy. The clinical record for Resident G was reviewed on 9/10/24 at 12:12 p.m. Diagnoses included spastic quadriplegic cerebral palsy, cardiomegaly, apraxia, heart failure, dysphagia, gastrostomy status, asthma, severe intellectual disabilities, Cauda Equina Syndrome, aphasia, abnormal posture, gastro-esophageal reflux disease, and anxiety disorder. A current, 5/5/22 physician order indicated diazepam (anti-anxiety) 15 mg was to be administered per gastric tube twice daily (once in am and once in pm). A care plan, dated 3/20/20, indicated the resident had anxiety as evidenced by shortness of breath. The resident had a diagnosis of dysphasia and would sometimes not be able to swallow, causing anxiety. The resident received an antianxiety medication. An intervention, dated 6/8/21, indicated Medication as ordered. A care plan, dated 2/28/12, indicated the resident had cerebral palsy with the upper and lower extremity impairments and spasticity. The medication regimen included an anti-anxiety medication. An intervention, dated 7/1/16, indicated to give medications as ordered. During an interview on 9/10/24 at 1:22 p.m., the DON indicated it was the responsibility of all nurses to reorder medications as needed. All nurses were to be mindful of when medications needed to be reordered from pharmacy and alert management if there were an issue. A current policy, dated 6/17/21, titled Medication Administration was provided by the Administrator on 9/10/24 at 12:00 p.m. The policy indicated the following: Purpose: Medications are administered as prescribed in accordance with manufacture's specifications, good nursing principles and practices and only by persons legally authorized to d so. Procedure: 2. Medications are administered in accordance with written orders of the physician/prescriber. This citation relates to Complaint IN00441262. 3.1-25(g)(3)

Based on observation, interview and record review, the facility failed ensure a resident's controlled substances were accounted for and were being reconciled during shift change for 1 of 3 residents reviewed for medication storage and availability. (Resident B) Findings include: Resident B's clinical record was reviewed on 7/17/24 at 1:41 p.m. Diagnoses include anoxic brain damage, cognitive communication deficit, history of disorder of muscle, unspecified-hypertonia, other muscle spasm, other seizures, and familial dysautonomia ([NAME]-Day). His medication orders included lorazepam (treat anxiety) 0.4 ml (milliliter) as needed with neurostorming episodes (4/12/24) and diazepam (treat muscle spasms) 1 ml as needed 30 minutes after Tylenol (pain reliever), if not effective (7/12/24). A quarterly Minimum Data Set (MDS) assessment, dated 6/5/24, indicated he was rarely/never understood. A pharmacy packing slip, with RN 6's signature and dated 3/21/24, indicated 60 mls of diazepam was delivered to the facility for Resident B. During a controlled substance reconciliation on the Kalor hall medication cart with LPN 21, on 7/17/24 at 12:03 p.m., a narcotic sheet log/tracking form for oncoming and off going nurses for the month of July was reviewed. The log/tracking form indicated the date and time, total number of controlled substance cards, liquid and bottles, and how many count sheets were added or removed. Of the 35 shift changes, 19 cards had a total documented. There were no counts of liquids or bottles documented for the 35 shift changes. LPN 21 indicated the shift change form was made up by the previous DON and they had never completed the total liquid or the total bottles on the sheet when counting, but probably should. A narcotic count form indicated there were 60 mls of diazepam confirmed with RN 6's signature, dated 3/21/24. Handwritten on the form indicated the bottle was sent to an appointment on 4/23/24 and on 7/12/24 there were 45 mls remaining in the bottle. A narcotic count form indicated there were 28.4 mls of lorazepam. Handwritten on the form indicated there should be 28.4 mls and on 7/12/24 there were 22 mls remaining in the bottle. There were three of four times 0.4 mls were signed out but the remaining amount of mls left in the bottle were not recorded on the form. An ambulatory visit summary note from the neurologist, dated 3/21/24, indicated for neurostorming, they recommended to first assess for any noxious stimuli, administer Tylenol 140 mg and wait 30 minutes, and if not resolved, give diazepam 1 mg (which would be sent to pharmacy). A nurses note, dated 3/21/24 at 5:01 p.m., indicated Resident B had a new order to increase his Keppra (treat seizures) and a new order for diazepam and gabapentin (treat neuropathy) to be clarified during business hours. A nurses note, dated 3/26/24 at 7:20 p.m., new order for Keppra dose to be increased to 150 mg (1.5 mls) and diazepam 1 mg (milligram) for neurostorming, if Tylenol not effective after 30 minutes. A nurses note, dated 4/23/24 at 6:12 a.m., indicated Resident B was out for an appointment, accompanied by RN 6. A review of the facility investigation, on 7/17/24 at 10:55 a.m., contained a handwritten statement by RN 6, dated 7/12/24 at 12:00 p.m., that indicated RN 6 and LPN 7 completed the narcotic count. The narcotic count for the pills in punch cards were correct, however, Resident B's liquid diazepam count was incorrect. RN 6 told LPN 7 to put the bottle aside and that she would talk to the nurse on call when she returned that evening for her shift, then RN 6 left the facility. RN 6 indicated the last time she counted the diazepam with any other nurse was unknown. During an interview with the Administrator, on 7/17/24 at 2:37 p.m., she indicated when RN 6 and LPN 7 completed a narcotic count, the diazepam had a discrepancy. LPN 7 wanted to figure it out and felt RN 6 was being rude. RN 6 was upset and left. RN 6 told her that she she couldn't tell her the last time she counted the narcotic liquids. RN 6 had accepted the delivery of the diazepam and put it in the narcotic box, but did not put the order in the electronic health record. The bottle of diazepam should have been unsealed, and shouldn't have been given, because there was not an order for it. The facility wasn't sure when the diazepam actually disappeared, whether it was that night or over an undetermined amount of time. During an interview with LPN 7, on 7/17/24 at 2:50 p.m., she indicated she attempted to get report and count the narcotics with RN 6. There was supposed to be 60 mls of Resident B's diazepam, but there were only 45 mls in the bottle. She asked RN 6 if she gave it and just forgot to sign it out. She asked RN 6 to contact her supervisor, because she didn't want to be responsible for the narcotic count not being correct. RN 6 indicated to her that she wasn't going to address or deal with it at that time and left the keys in the keyhole of the cart. LPN 7 reported RN 6's behavior and the incorrect count of the diazepam to LPN 14, who contacted the on-call nurse. There was a bottle of lorazepam in the refrigerator and LPN 7 counted that with LPN 14. The lorazepam amount was also incorrect. LPN 14 again called the on-call nurse. The amount given was not subtracted on the narcotic count sheet for the lorazepam. There was supposed to be 28 mls and there were only 22 mls in the bottle. During an interview with the Administrator, on 7/17/24 at 3:09 p.m., she indicated the facility was still looking into the missing amount of lorazepam for Resident B. During an interview with the MDS Coordinator, on 7/17/24 at 3:12 p.m., she indicated at shift change the nurses should be filling out the total liquid and the total bottles to keep track of the controlled substances. A current facility policy, titled Controlled Medication Storage, provided by the Administrator, on 7/17/24 at 3:09 p.m., indicated the following: .Purpose: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations .4. At the change of custody, a physical inventory of all controlled medications is conducted by 2 licensed/certified personnel and is documented This citation relates to Complaint IN00438619. 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview, and record review, the facility failed to ensure residents were receiving dental services for 3 of 3 residents reviewed for mouth care. (Residents C, Resident E and Resident F) Findings include: 1. Resident C's clinical record was reviewed on 7/17/24 at 4:15 p.m. Diagnoses include spastic quadriplegic cerebral palsy, profound intellectual disabilities, dysphagia, oropharyngeal phase, aphasia, and posteruptive color changes of dental hard tissues. His orders included he may be seen by podiatrist, dentist, optometrist, psychiatrist, psychologist and an audiologist as needed (PRN). A significant change Minimum Data Set (MDS) assessment, dated 7/3/24, indicated he was severely cognitively impaired. He was dependent on staff for oral hygiene. He had obvious or likely cavity or broken teeth. His dental care plan indicated he was at risk for chewing complications related to posteruptive color changes of dental hard tissues, encounter for dental examination and cleaning without abnormal findings (2/2/22). His interventions included assist with oral care as needed (2/2/22) and dental referral as needed (2/2/22). His last dental note from, dated 5/6/22, indicated adult prophylaxis was performed, which included his teeth were hand scaled and polished. A toothette swab was used. A fluoride varnish was applied. His next visit would include mouth swab and prophylaxis. There was no indication in the clinical record that Resident C had seen a dentist since 5/6/22. 2. Resident E's clinical record was reviewed on 7/18/24 at 12:22 p.m. Diagnoses included spastic quadriplegic cerebral palsy, profound intellectual disabilities, dysphagia, oropharyngeal phase, aphasia, and posteruptive color changes of dental hard tissues. Her orders included she may be seen by podiatrist, dentist, optometrist, psychiatrist, psychologist, and an audiologist as needed. A quarterly MDS assessment, dated 4/30/24, indicated BIMS 99. She was dependent on staff for oral hygiene. Her dental care plan indicated she needed assistance to complete dental care and she had a diagnosis of posteruptive color changes of dental hard tissues (2/1/17). Her interventions included assist as needed to brush teeth and gums (2/17/17) and assist to attend dental appointments (2/17/17). Her last dental note, dated 3/23/22, indicated she had plaque calculus stains and inflammation recession bleeding gingivitis. She needed sedation for Full Mouth Debridement (FMD) please. The next dental visit would include FMD. There was no indication in the clinical record that Resident E had seen a dentist since 3/23/22. 3. Resident F's clinical record was reviewed on 7/18/24 at 2:10 p.m. Diagnoses included spastic quadriplegic cerebral palsy, profound intellectual disabilities, dysphagia, oropharyngeal phase, aphasia, and posteruptive color changes of dental hard tissues. His orders include he may be seen by podiatrist, dentist, optometrist, psychiatrist, psychologist, and an audiologist PRN. A quarterly MDS assessment, dated 6/5/24, indicated he was rarely/never understood. He was dependent on staff for oral hygiene. His dental care plan indicated he needed assistance to complete dental care. He had a diagnosis of post eruptive color changes of dental tissue (2/1/17). His interventions included assist as needed to complete dental care every shift (2/17/17) and assist to attend dental appointments (2/17/17). His last dental note, dated 5/6/22, indicated adult prophylaxis was performed which included a Cavitron (an ultraxonic scaling system used to clean teeth) used to scale, polished and toothette swab. His next visit would include mouth swab and to schedule annual periodic oral evaluation with the dentist. There was no indication in the clinical record that Resident F had seen a dentist since 5/6/22. During an interview with the Social Service Director (SSD) on 7/18/24 at 10:50 a.m., she indicated the new dental services for the facility, which took over the beginning of 2023, was responsible for reaching out to the residents and resident representatives to get them enrolled for dental services. It was brought to her attention by a family member that dental services had not been offered, so the SSD completed an audit and found half of the residents were not enrolled. She contacted the new dental services, and was currently assisting with the enrollment process. The previous dental services had taken care of everything. She trusted the new dental was taking care of everything and she had not completed audits to make sure the residents were receiving dental services. A current facility policy, titled Dental Services (including dentures), provided by the Administrator on 7/18/24 at 11:58 a.m., indicated the following: .Purpose: Ensure a resident obtains needed dental services .1. The facility will assist residents in obtaining routine and emergency dental care This citation relates to Complaints IN00437378 and IN00437511. 3.1-24(a)

Based on record review and interview, the facility failed to ensure adequate supervision and interventions to prevent a fall for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident Y falling from her bed and acquiring a femur fracture. Findings include: Resident Y's clinical record was reviewed on 10/04/21 at 11:04 a.m. Diagnoses included, but were not limited to, spastic quadriplegic [CONDITION(S)], profound intellectual disabilities, [CONDITION(S)], generalized idiopathic [CONDITION(S)] and epileptic syndromes, not intractable, with [CONDITION(S)], and [CONDITION(S)]. An annual Minimum Data Set (MDS) assessment, dated 6/30/2021, indicated the resident was severely cognitively impaired. She required full staff performance of two persons for bed mobility, transfers, dressing, and toilet use. The resident's current physician orders included, but were not limited to, [MEDICATION(S)] 10 mg daily, [MEDICATION(S)] 500 mg twice daily, [MEDICATION(S)] 300 mg daily, [MEDICATION(S)] 2 mg twice daily, bed in low position at all times except during care, bedside safety mats to both sides, check placement of bed bolsters twice a day, apply seatbelt when in wheelchair to promote proper hip positioning due to the diagnosis of [CONDITION(S)] with seizures, and transfer with two person assist with sheet. A health care plan, initiated on 4/09/10, indicated the resident was at risk for falls related to dependence for activities of daily living (ADLs) and care, bilateral, upper and lower extremity impairments/contractures and [CONDITION(S)]. A health care plan, initiated on 10/19/16, indicated the resident was unable to independently change position while in bed, feed self, toilet self or transfer self due to having [CONDITION(S)], intellectual disability and being dependent for all needs met with routine anticipatory care. An intervention, dated 7/02/21, indicated total assistance was to be provided by two staff members for bed mobility. The point of care history indicated the assistance of one person was used for bed mobility for 102 of 122 times from 7/03/21 through 9/20/21. The fall event report, dated 9/20/21 at 11:30 a.m., indicated the CNA was performing morning cares and had the resident positioned on her side when the resident started to go over the side of the bed. The CNA was holding onto the resident, but the resident slipped from the CNA's hands immediately prior to the resident's left side making contact with the floor. The CNA indicated the resident did not hit her head. The report indicated no injury was noted. A progress note on 9/23/21 at 10:20 a.m. indicated the resident's left knee and thigh were swollen and warm to touch. The Nurse Practitioner (NP) was notified and ordered an X-ray of the left leg and hip. The radiology report from 9/23/21 indicated the resident had an acute fracture involving the left distal femoral condyle with moderate displacement. A witness statement by CNA 22, on 9/20/21, provided by the Administrator on 10/04/21 at 10:59 a.m. indicated she had turned the resident onto her side. The resident rolled off the bed onto the floor. A witness statement by LPN 33, on 9/20/21, provided by the Administrator on 10/04/21 at 10:59 a.m., indicated she was called to the resident's room because the resident was lying on the floor mat on the right side of the bed. She indicated the resident was not exhibiting signs or symptoms of pain, and resident's range of motion was unchanged. The resident was transferred back to bed. During an interview on 10/04/21 at 12:32 p.m., CNA 22 indicated she turned the resident on her side, and the resident slipped over the bed bolsters. She had her hands on the resident the entire time, but she was unable to prevent the resident from sliding over the bolster and falling to the floor mat on the floor. She tried to ease the resident to the floor. She did not know the resident required assistance of two persons when she performed care for the resident. She indicated residents' assistance requirements information was available on the kiosk on the unit, but it does not always work well. This Federal Tag relates to Complaint IN 953. 3.1-45(a)

Based on interview and record review, the facility failed to transfer a resident in accordance with the plan of care for 1 of 3 residents reviewed for accidents. This deficient practice resulted in a fracture, hospitalization and surgery. (Resident B) Findings include: Review of an Indiana State Department of Health (ISDH) reportable, dated 3/8/20 at 11:01 p.m., provided by the Administrator on 3/12/20 at 9:26 a.m., indicated Resident B was noted to have swelling to his right hip. The hip was warm to touch with evidence of pain. An X-ray was obtained on 3/8/20, which indicated a fractured right femur. The resident was sent to the emergency room (ER) for evaluation and treatment. Review of the facilities internal investigation, provided by the Administrator, indicated the following time line of events related to 3/8/20: a. Qualified Medication Aide (QMA) 1 indicated he worked on 3/7/20 night shift. As he walked past Resident B's room, he noted the resident to be on the floor beside his bed on his mat. He went to find the nurse, but found CNA 2. CNA 2 indicated the resident was care-planned to crawl on the floor and that they could just place him back in bed. CNA 2 grabbed the resident's upper body and QMA 1 grabbed his legs and they lifted him back into bed. Licensed Practical Nurse 3 was made aware the resident had fallen/crawled out of his bed. b. A follow-up statement by CNA 2, dated 3/11/20, indicated she knew they did not have to use the mechanical lift for a resident who was under 50 lbs. She indicated to her he was a child and QMA 1, who was the charge (nurse)on the hall, assisted the resident back into bed. c. The first interview statement, provided by CNA 4, dated 3/9/20, indicated on 3/7/20 while doing a bed check around 4:00 a.m., the resident had urinated. She indicated that was when she noticed something wrong with his leg. She did not observe the resident in pain. d. A second interview, dated 3/9/20, indicated CNA 4 changed Resident B's brief at 4:18 a.m. on 3/8/20. She noticed the change and reported it to LPN 3. CNA 4 then left following the completion of her shift. She returned on 3/8/20 around 5:00 p.m. and did her rounds between 6:00 p.m. and 6:30 p.m. and noticed the resident's right leg/hip still looked the same from earlier that morning. The resident was fussy and crying. She stopped and notified the nurse. There were two additional aide in the room. CNA 5 went to get the nurse and they stayed with the resident. LPN 3 came to the room and noted swelling and redness. LPN 6 then came into the room and stated the leg was warm to the touch. e. A third interview by CNA 4, indicated she reported Resident B's leg looked wrong and he was being fussy. Both LPN 3 and CNA 4 thought he was fussy because of the enema he had received earlier. When she saw him again at 6:30 p.m. his leg was the same so we got the nurse. f. A statement by LPN 3 indicated on 3/8/20 at approximately 4:15 a.m., she went to see if the resident had any results from his enema. The CNA came in and asked her if she could check him because he was fussy. The resident was awake, but fussy. He grimaced when she palpated his abdomen. CNA 4 asked her how his legs looked, so she went back into the room and did not observe any abnormality or discoloration. During a shift round at 4:30 a.m., the resident was resting with his eyes closed. She came back into work at 5:00 p.m. and between 6:00 p.m. and 6:30 p.m., she was called to his room. Several staff were at the bedside, then went to get his nurse. LPN 6 came in and did an assessment and found his leg to be swollen and warm. She notified the physician who ordered an X-ray. g. A second interview with LPN 3 was related to any action taken after the resident was found on his mat on 3/7/20. She indicated she was told later in the shift that the resident was found on his mat beside his bed and CNA 2 picked him up and put him back to bed. LPN 3 saw the resident several times and did not notice anything out of the ordinary. She did a gastrointestinal assessment on him towards the end of her shift. After assessing the resident, CNA 4 asked her if his legs looked right. She went back in and the resident was in him normal frog-like position and nothing appeared to be unusual. h. On 3/8/20, LPN 7 provided a statement that indicated a CNA reported to her the resident was crying. The resident was assessed for discomfort and found to have a temperature of 99.9 Fahrenheit (F). She did give the resident bolus (method of tube feeding) and he acted his normal self. During the last bolus, the resident did kick the Asepto (instrument for introducing fluid) out of her hand. i. A second interview on 3/8/20, indicated LPN 7 worked the day shift on 3/7/20 and 3/8/20. On 3/8/20, CNA 8 came to her and said the resident was fussy during care. Tylenol was given for discomfort. LPN 7 indicated she received report from QMA 1 that morning and he reported nothing to her regarding any abnormalities for Resident B. j. An interview with CNA 8 on 3/10/20, indicated she was the resident's aide for both 3/7/20 and 3/8/20 from 5:00 a.m. until 1:30 p.m. On 3/8/20, between 9:00 a.m. and 10:00 a.m., she gave the resident a bed bath and only dressed him on the top because he had been crying. She left him in bed and then told LPN 7 he was crying. The nurse reported to her between 11:00 a.m - 11:30 a.m., the resident had a temperature. CNA 8 went back in to check on the resident between 12:30 p.m. - 1:00 p.m. and noted he was acting as though he did not feel good, but he was not crying. She indicated it was unusual for the resident to cry. The clinical record for Resident B was reviewed on 3/11/20 at 10:20 a.m. [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 1/31/20, indicated the resident rarely or never understood. The resident required two-person assistance for transfers. The resident was dependent on staff for all care. A current care plan, dated 10/21/16, indicated the resident was unable to independently change position while in bed, feed self, toilet self or transfer self due to non-weight bearing. An intervention was implemented on 10/21/16 to use a mechanical lift during transfers. Resident B weighed 74.4 lbs. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. A radiology report, dated 3/8/20 at 11:04 p.m., indicated the resident had an acute fracture with displacement of the proximal femoral shaft. A bone fragment and soft tissue swelling was also noted. The report was called to the facility at 8:00 p.m. An emergency room (ER) report, dated 3/9/20 at 1:50 a.m., indicated a CNA checked on the resident and noted him holding his leg in a different position than normal. An x-ray indicated an acute fracture. The resident did not appear to be in acute distress and no other bruising was noted on the resident. A second x-ray was done 3/9/20 and indicated an offset [MEDICAL CONDITION] with some angulation and butterfly fragments. The report indicated the fracture was likely related to osteopenia. The resident was evaluated and sent to a larger hospital for treatment. A progress note, dated 3/10/20 at 11:30 a.m., indicated the resident had surgical repair on 3/9/20. During a telephone interview on 3/12/20 at 2:04 p.m., CNA 4 indicate when she saw the resident's leg around 6:30 p.m., she immediately got LPN 3. QMA 1 was the nurse on that hall, but she was always told to go to the nurse. She indicated LPN 7 did not receive any information in morning report from QMA 1 or LPN 3. During a telephone interview on 3/12/20 at 2:28 p.m., LPN 7 indicated she did not receive any information from the morning report she received from QMA 1 on 3/8/20. During a telephone interview on 3/12/20 at 2:36 p.m., QMA 1 indicated he was walking down the hall with a tray and saw Resident B on the floor, on his mat. CNA 2 assisted him in picking the resident up off the floor and putting him back in bed. He grabbed the resident's trunk and CNA 2 grabbed his upper half. CNA 4 did not tell him anything about the resident having a problem with his leg. He was unaware the resident required the use of a mechanical lift. Two attempts were made to contact the following staff with no return phone call; CNA 2, LPN 3, or CNA 8. During an interview on 3/13/20 at 12:13 p.m., the Administrator indicated she had received a message from Child Protective Services (CPS) the resident's fracture was due to osteopenia and would be returning to the facility at an unknown date. Review of a current facility policy, dated 8/14/19, titled MECHANICAL LIFT, which was provided by the Administrator on 3/13/20 at 11:44 a.m., indicated the following; Purpose: Transfer a dependent resident safely. Procedure: 1. Confirm mechanical lift to be used. 2. Place sling under resident .8. Slowly lower resident into bed or chair This Federal tag relates to Complaint IN 902. 3.1-45(a)(2)

A. Based on observation, interview and record review, the facility failed to provide treatment and services to prevent and care for pressure ulcers for 3 of 7 residents with pressure ulcers. (Residents 41, 8, and 65) This resulted in progression of one pressure ulcer to a Stage 3 wound with tunneling, undermining and infection. (Resident 41). Findings include: 1. On 11/9/18 at 8:46 a.m., CNA 10 was providing care to another resident. She indicated she would next be going to get Resident 41 cleaned up for the day. During an observation on 11/9/18 at 9:10 a.m., CNA 10 raised the night gown from Resident 41's back. There was a saturated dressing on her back. The linens had a salad plate size, dried, serosanguinous drainage on them. The CNA indicated she did not want to change her linens until the dressing was changed and left to get the nurse. During a wound care observation on 11/9/18 at 9:22 a.m., LPN 11 brought in the supplies to change the wound dressing. She placed a trash bag on the bed side table and washed her hands for less than 10 seconds. She removed the old dressing and a large, open wound was exposed. During a wound care observation on 11/9/18 at 9:30 a.m., the DON indicated she had looked at the wound the previous night and they were going to refer the resident to the wound clinic. They were waiting on a call back from the physician. At 9:31 a.m., The DON measured the wound and indicated the resident had 0.5 cm tunneling at 2:00 through 3:00. At 11:00, she had 1.3 cm of tunneling. From 4:00 through 7:00, the resident had 0.3 cm of tunneling. She indicated the resident also had undermining. The DON removed her gloves and washed her hands for less than 2 seconds. The wound was left open to air. During wound care observation with LPN 11 and CNA 10 on 11/9/18 at 10:50 a.m., CNA 10 assisted to hold Resident 41 during care. LPN 11 donned gloves and then removed gloves and exited the room to retrieve wound cleanser. At 10:53 a.m., LPN 11 came back into the room and washed her hands for less than 10 seconds. She set up her supplies without washing the over bed table. She donned gloves and picked up several 4 x 4 gauze pads and wet the gauze pads with wound cleanser. She inserted one gauze pad into the wound. She then took another gauze pad and blotted around the wound. LPN 11 removed her gloves and washed her hands less than 5 seconds. She donned gloves, open and applied skin prep (protective film) to the peri-wound. She removed her gloves, pulled out her scissors from her pocket and donned gloves. She did not wash her hands or use hand sanitizer gel. She then opened the Medi-Honey (medicated dressing) and cut approximately a 1.5 cm x 1.5 cm size of the dressing with the unclean scissors. LPN 11 again trimmed the dressing and placed into the wound. She removed her gloves, applied sanitizer gel and signed the dressing. She then donned gloves and applied the dressing over the wound. LPN 11 did not speak to the resident throughout the wound care observation. At 11:00 a.m., LPN 11 removed her gloves and washed her hands for less than 5 seconds. During a second wound care observation on 11/13/18 at 3:39 p.m., RN 12 had already donned gloves and table set up with supplies. LPN 13 had the resident on her left side assisting to hold during the care. RN 12 sprayed wound wash into the wound and then took a 4 x 4 gauze pad and pushed inside the wound. He took a second 4 x 4 gauze pad and blotted in and over the wound. He removed his gloves, washed his hands and donned new gloves. He then cut a strip of [MEDICATION NAME] and used a cotton tip applicator to pack the gauze into the wound. He applied skin prep to the peri-wound and fanned dry with the packed of dressing. He then applied the foam dressing over the wound. He described the wound as full thickness loss and adipose exposed (fat). After he cleaned the wound, he no longer saw the slough that was present. The wound had a large amount of drainage with tunneling and undermining. RN 12 indicated if it were pressure, it would be a stage 4. The clinical record for Resident 41 was reviewed on 11/9/18 at 8:10 a.m. [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 9/7/18, indicated the resident was severely cognitively impaired. She required two person assistance with bed mobility, transfers, dressing and hygiene. She was incontinent of bowel and bladder. A health care plan, dated 6/11/18, indicated the resident had an abrasion to the right upper back. Interventions included to see approaches under skin integrity. Another health care plan, dated 3/29/11 and revised 6/11/18, indicated the resident was at risk for pressure ulcers related to decreased mobility and dependence for Activities of Daily Living (ADL). Interventions included, but were not limited to, cushion to wheelchair, pressure reducing mattress, report any signs of skin breakdown, turn and reposition. A Braden scale (for predicting pressure sores), dated 6/13/18, indicated the resident was at high risk for developing pressure ulcers. Treatments in place included pressure reducing device for the bed and wheelchair. A progress note, dated 6/25/18, indicated a specialized seating company was in to assess the resident's wheelchair for adjustment. The company recommended an overlay foam to the back of the wheelchair to build up the seatback, as well as, new lateral supports and armrests. The company was to secure the payment and return to the facility on [DATE]. A present equipment assessment, dated 6/25/18, indicated her current wheelchair .need to provide increased pressure relief to R (right) rib area reoccurring issue. An observation report, dated 7/6/18, indicated the resident had a wound to the right side of her back that measured 3.4 cm x 1.8 cm. A Braden scale, dated 7/11/18, indicated the resident was at high risk for developing pressure ulcers. Treatments in place included pressure ulcer care, turn and reposition, nutrition intervention and pressure reducing device for the bed and wheelchair. An observation report, dated 7/26/18, indicated the resident had a wound to the right side of her back that measured 2.5 cm x 1.0 cm x less than 0.1 cm. The wound had a small amount of serous (thin, watery) drainage. On 8/9/18, an observation report indicated the wound to the upper right back that measured 2.5 x 1.1 x less than 0.1 cm. The wound had serosanguinous (thin, watery, pale red to pink) drainage. A new order was received on 8/9/18 to apply Opticell Ag (absorbent dressing) to the right upper back wound. The dressing was to be changed daily and as needed. An observation report, dated 8/16/18, indicated the wound to the right back measured 2.5 cm x 1.2 cm x less than 0.1 cm. The wound had a moderate amount of serous drainage. A quotation was received from the specialized seating company on 8/17/18. The physician signed the agreement for payment of equipment update on 8/22/18 and again on 9/19/18. A prior authorization request for the expense of the updated wheelchair was submitted to the resident's payor source on 8/22/18. On the product description, the physician indicated the foam overlay was required to provide additional pressure management to the right rib and [MEDICATION NAME] area. He indicated it was a recurring issue. On 8/23/18, the observation report indicated the wound measured 2.0 cm x 1.5 cm x less than 0.1 cm. The wound had a moderate amount of serosanguinous drainage. On 8/30/18, the observation report indicated the wound measured 2.0 cm x 2.0 cm with a moderate amount of serosanguinous drainage. An observation report, dated 9/6/18, indicated the wound to the right back measured 2.0 cm x 2.0 cm. The wound had a small amount of serosanguinous drainage. A physician order, dated 9/6/18, indicated to apply Puracol Ag (wound dressing) to wound on back and cover with a foam dressing. The dressing was to be changed daily and as needed. An observation report, dated 9/13/18, indicated the wound to the right back measured 2.0 cm x 2.0 cm. The wound had a large amount of serosanguinous drainage. A physician order, dated 9/14/18, indicated to apply Puracol Ag (wound dressing) to wound on back and cover with a foam dressing. The dressing was to be changed twice weekly and as needed. An observation report, dated 9/21/18, indicated the wound to the right back measured 1.8 cm x 2.0 cm. The wound had a moderate amount of serosanguinous drainage. An observation report, dated 9/27/18, indicated the wound to the right back measured 2.0 cm x 1.7 cm. The wound had a large amount of serosanguinous drainage. A physician order, dated 9/27/18 and discontinued 10/18/18, indicated to apply Gold Dust (product interacts with the wound drainage) and cover with a non-adherent dressing. The dressing was to be changed twice weekly. An observation report, dated 10/4/18, indicated the wound to the right back measured 2.2 cm x 2.5 cm x 0.7 cm. The wound had a large amount of serosanguinous drainage. An observation report, dated 10/11/18, indicated the wound to the right back measured 2.0 cm x 3.0 cm x 0.9 cm. The wound had a large amount of serosanguinous drainage. An observation report, dated 1018/18, indicated the wound to the right back measured 2.5 cm x 3.0 cm x 0.7 cm. The wound had a large amount of serosanguinous drainage. The wound had odor and macerated surrounding tissue. A progress note, dated 10/18/18 at 8:41 a.m., indicated the physician was notified related to stalled wound healing and new orders were received. A physician order, dated 10/18/18 and discontinued 11/2/18, indicated to cleanse wound and place Opticell AG (antibacterial dressing) over wound and covered with a bordered foam dressing. The dressing was to be changed every Sunday, Tuesday and Thursday. A dietary progress note, dated 10/18/18, indicated and area to the upper back was being treated and the resident was receiving [MEDICATION NAME] (supplement for wound healing) twice daily. A delivery ticket indicated the equipment for the wheelchair was delivered on 10/24/18. An observation report, dated 10/25/18, indicated the wound to the right back measured 4.7 cm x 5.0 cm 1.0 cm. The wound had a moderate amount of purulent drainage and odor. The surrounding tissue had redness noted. An infection report, dated 10/27/18, indicated the resident was on antibiotics for an infection with an onset date of 10/26/18. She was currently receiving [MEDICATION NAME] (antibiotic) 500 mg daily for 10 days. An Inter-Disciplinary Team (IDT) note, dated 10/30/18, indicated the resident was noted to have a change in condition to the wound on her back. The wound had purulent drainage and foul odor noted On 11/1/18, a non-pressure wound report indicated the resident had a 3.5 cm x 3.8 cm x 1.0 cm wound to the left upper back. The wound did not have any tunneling or undermining. The wound had a large amount of serosanguineous drainage. The wound bed had 75% granulation tissue and 25% slough. A physician order, dated 11/2/18 and discontinued 11/9/18, indicated to cleanse wound and place Medi-Honey (medicated dressing) over wound and cover with bordered foam dressing. The dressing was to be changed every Sunday, Tuesday and Thursday. A physical therapy evaluation, dated 11/2/18, indicated Clinical Impressions: Current wound is stage 3 with yellow slough. Staff has her rolled onto her left side while in bed to prevent pressure to the area A progress note, dated 11/6/18, indicated the resident was referred to the wound clinic for treatment related to a wound on the upper right back. On 11/8/18, a Braden scale indicated the resident at high risk for developing pressure ulcers. Interventions included, but were not limited to, application of non-surgical dressing and application of ointments and/or medications. A new order was received on 11/9/18 to cleanse the open are with wound cleanse, allow to dry and pack loosely with [MEDICATION NAME] strip. The wound was then to be covered with a bordered foam dressing and changed daily. On 11/9/18 at 9:27 a.m., the DON indicated she had just observed the wound a few days ago and they were aware the wound was not an abrasion and they were going to change it to a pressure wound in the documentation. The have faxed an order to the wound clinic. She needed to have her orders changed, but it has not been done yet. They were working on getting a new mattress for her. On 11/9/18 at 9:55 a.m., LPN 11 indicated she last saw the wound on 11/4/18 and it was open at that time. During an interview on 11/9/18 at 2:13 p.m., the DON indicated the resident had not been seen by the wound clinic. She looked at the wound last night (11/8/18) but just pulled the dressing down and did not look at the wound. On 11/13/18 at 9:59 a.m, the DON indicated at this point it has not been staged as a pressure ulcer. Nothing has been documented under the wound tab. During an interview on 11/13/18 at 12:20 p.m., RN 12 indicated nothing indicated it was a pressure wound. He felt the wound was not healing and he could see the base of the wound. The clinical record lacked any information as to why the seating company did not return on 7/16/18 or follow up related to the pressure relieving equipment for the wheelchair from 6/25/18. 2. On 11/8/18 at 8:14 a.m., Resident 8 was in bed. She was observed to have a [MEDICAL CONDITION] (trach), with a washcloth tucked partially under her mist collar. During a wound observation, on 11/9/18 at 3:34 p.m., LPN 31 moved the resident'[MEDICAL CONDITION] and foam pad to the side, revealing an open area to the left side of her neck. The foam pad was observed to have visible red drainage to it. LPN 31 indicated the resident had previously had a wound in the same area, which could go from closed one day and open the next day. During a wound care observation, on 11/9/18 at 4:35 p.m., accompanied by the DON and LPN 31, the following was observed: Resident 38 was seated in her wheelchair at the end of Resident 8's bed, with the privacy curtain left open, allowing both residents to be in direct sight of each other and the bathroom doorway left open, allowing a view to the adjacent room. The DON cleansed the resident's wound with wound wash and gauze, causing her to startle. The DON washed her hands for less than 10 seconds, donned gloves, and applied a foam dressing over the wound. The DON loosened the resident'[MEDICAL CONDITION], indicating it was digging into the resident's neck. She indicated, at that point, she would say the wound was a stage 1 or 2 pressure ulcer; she confirmed it was open and measured 1 centimeter (cm) long (L) x 1.5 cm width (W). She removed her gloves and washed her hands for less than five seconds. On 11/13/18 at 12:14 p.m., she was in her wheelchair in her room. A foam dressing was visible to the left side of neck, tucked under her [MEDICAL CONDITION] collar, partially covering her neck wound. A washcloth was tucked partially under her mist collar. On 11/13/18 at 12:48 p.m., during a wound observation with the Wound Nurse, he moved the resident's head to expose the left side of her neck and removed a foam wound dressing. He did not speak to her or alert her prior to providing care. The wound to her neck was approximately the size of a marble and bright red in color, with a dark red area in the shape of the foam dressing surrounding it. He indicated the green elastic from her mist collar needed to be kept off of her neck due to it contributing to irritation of the area around her neck. Previous preventative measures for her neck were to keep a foam dressing over the previous wound site every three days. Review of Resident 8's clinical record was completed on 11/8/18 at 2:15 p.m. [DIAGNOSES REDACTED]. She had a current physician's orders [REDACTED]. A 11/9/18 physician's orders [REDACTED]. A 10/29/18, quarterly, Minimum Data Set (MDS) assessment indicated she was rarely/never understood and rarely/never understood others. She was totally dependent on others for ADLs and mobility. She was at risk for pressure ulcers. She had a current care plan problem, revised on 10/18/18, of risk for pressure ulcers related to decreased mobility, dependence for ADLs and care, bilateral upper and lower extremity contractures, incontinence, [DEVICE], [MEDICAL CONDITION], and disease processes. There were no interventions specific to her [MEDICAL CONDITION] collar. She had a current 11/10/18 care plan problem of impaired skin integrity as evidenced by open area to back of neck. Interventions included document skin condition, treatments or medications per order, notify family and physician, and observe area for infection. An 8/29/18 Braden (Pressure ulcer risk) assessment indicated she was at high risk of developing pressure ulcers. A 11/9/18 Braden assessment indicated she was at high risk of developing risk pressure ulcers. A 10/18/18 progress note indicated an area to her posterior neck had been assessed and was noted to be intact. A physician order [REDACTED]. An 11/9/18 Event progress note indicated an open area was noted to the back of her neck, under the preventative dressing. The wound measured 1.0 cm L x 1.5 cm W. The note indicated it was related to friction from the resident rubbing her head back and forth against [MEDICAL CONDITION]. An 11/9/18 late entry note for 10/18/18 indicated her neck had been observed periodically and no open areas were noted. Review of a BATHING AND SKIN ASSESSMENTS REPORT, used during a Skin Sweep dated 11/12/18 and provided by the DON on 11/13/18 at 8:30 a.m., indicated Resident 8 had no open areas noted. During an interview, on 11/13/18 at 10:04 a.m., the DON indicated a facility-wide skin sweep had been completed on 11/12/18 in the evening. One of the other nurses had completed the skin assessment form, which incorrectly indicated no open areas, and the DON had completed an additional form on 11/12/18, which documented the open area being present. Review of an additional BATHING AND SKIN ASSESSMENTS REPORT, dated 11/12/18 and provided by the DON on 11/13/18 at 3:17 p.m., indicated Resident 8 had an open area to the back of her neck. 3. During an interview, on 11/13/18 at 10:04 a.m., the DON indicated a skin sweep involving all residents of the facility had been completed on the evening of 11/12/18, resulting in two residents being noted to have previously undiscovered pressure ulcers, including Resident 65. During a wound care observation, on 11/13/18 at 1:10 p.m., wearing gloves, the Wound Nurse pulled down Resident 65's brief, exposing a beefy red open area to his right groin, approximately the size of a small marble. The Wound Nurse indicated the wound was probably caused by his brief and was a stage 2 pressure ulcer. Wearing the same gloves, he washed the over bed table, opened a tube of [MEDICATION NAME] (skin protectant) ointment and placed a small amount into a medication cup, and then opened two packages of gauze pads. He removed the gloves, washed his hands, and donned another pair of gloves. He sprayed wound spray directly on the resident's groin and peri-area, causing him to startle. He proceeded to apply the [MEDICATION NAME] to the wound and replaced his brief. Review of Resident 65's clinical record was completed on 11/13/18 at 12:03 p.m. [DIAGNOSES REDACTED]. He had a current, 11/13/18, physician's orders [REDACTED]. Review of his treatment administration record indicated the medication was first administered on 11/13/18. Review of a Non-Pressure Wound progress note, dated 11/13/18 at 8:21 a.m., indicated a superficial open area to right groin 0.9 x 1.1, non-intact blister. Review of a Skin Ulceration progress note, dated 11/13/18 at 8:30 a.m., indicated he had a superficial open area to his right upper thigh measuring 0.9 cm L x 1.1 cm W, related to friction caused by his incontinence brief. Review of a progress note, dated 11/13/18 at 10:27 a.m., indicated he had an open area to his right upper thigh. The physician and resident's guardian were notified. During an interview, on 11/13/18 at 3:07 p.m., the DON indicated the pressure ulcer had been discovered during the skin sweep on 11/12/18, but the physician had not been notified because the area needed to be verified by the DON, since she did not participate in the entire skin sweep. The other nurse completing the skin assessment during the sweep felt the area did not need treatment, but then the DON thought maybe it should and forwarded the assessment form to an additional nurse, who notified the doctor to get an order. She wasn't aware there was a treatment ordered for the wound, and she had not yet observed it herself. Review of a current facility policy, Skin and Wound Care Management Program, dated 2/1/18 and provided by the DON on 11/13/18 at 10:24 a.m., indicated it was the facility's intent that residents do not develop pressure ulcers unless clinically unavoidable and the facility was to care and services consistent with professional standards of practice to: promote the prevention, promote the healing, and prevent the development of additional pressure ulcers. Ulcers identified as pressure were to be documented in Wound Management. A person-centered careplan and point of care profile was to be developed to prevent or treat skin breakdown. The Interdisciplinary Team was to ensure planned interventions and treatments were carried out as written in the care plan. Review of a current facility policy, HANDWASHING AND USE OF GLOVES, dated 12/27/16 and provided by the DON on 11/13/18 at 10:24 a.m., indicated hand hygiene was the single most important measure of preventing the spread of infections. Hand hygiene was to be performed before and after resident care and after handling contaminated articles. Handwashing was to include, but was not limited to, vigorously rotating hands to ensure friction was applied with soapy water between fingers and back of the hands, at least 15-20 seconds, with the focus on cleaning hands at the right times. Hand hygiene was to be performed after removing gloves. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure residents were free from abuse in the form of verbal, physical and intimidation for 4 of 4 residents reviewed for abuse. (Resident's B, C, D and E). This deficient practice had the potential to affect 65 cognitively impaired residents residing on 3 of 3 hallways. The immediate jeopardy began on 8/30/18 when CNA 2 provided care in an intimidating, physically and verbally abusive manner to Residents C and D and was intimidating and verbally abusive to Residents B and E. The Vice President of Operations was notified of the immediate jeopardy on 9/5/18 at 10:36 a.m. Findings include: 1. Review of an Indiana Department of Health (ISDH) reportable, with an alleged event date of 8/30/18 at 9:15 a.m., indicated CNA 1 reported a concern to the Administrator related to an allegation of verbal abuse. CNA 1 reported she was providing resident care with CNA 2 on 8/30/18. CNA 1 indicated she could not stand the way CNA 2 treated the residents. A follow up investigation, dated 8/31/18, indicated an expanded investigation revealed allegations of rough handling potentially constituting physical abuse. An internal event investigation completed by the Administrator, Social Service Director (SSD) and Director of Nursing (DON) , indicated on 8/30/18 at 9:27 a.m., CNA 1 was interviewed and indicated CNA 2 . was king of yanking (Resident D) around and calling her a d--- a--. Resident D was placed on the toilet while CNA 2 was being rough with her. Resident D had gotten bowel movement on the toilet and her shirt. CNA 2 got mad and yanked her up off the toilet and yanked her shirt off and then said If I could rip this shirt in in f------ half I would, I'm so p-----. CNA 2 started assisting Resident B. CNA 2 got Resident B's clothes and went over and stated get up here w/(with) your nasty a--. After finishing with Resident B the nurse told the CNA's to assist Resident C who was walking down the hall wet. The nurse and CNA 1 assisted him to his bed, then CNA 2 and I started to provide him care. CNA 2 then put his hand down by his bottom and then she jerked his hand away and said get your fingers out of your nasty a--. Resident B's roommate laughed and she said shut up (Resident E), your (sic) ugly too. Resident C was assisted into his recliner chair and CNA 2 still proceeded to be rough. CNA 2 then said to Resident C I wish your head would have hit that night stand. CNA 1 then washed her hands and told CNA 2 she was going to talk to the Administrator. CNA 2 was suspended pending an investigation. An internal event investigation completed by the Administrator, SSD, and DON, on 8/30/18 at 9:51 a.m. indicated CNA 2 was asked if anything out of the ordinary happened that morning. CNA 2 indicated No. CNA 2 was then asked if she was having a bad morning or was rough with any of the residents. She stated she was frustrated that morning and she did call (Resident C) ugly. The DON indicated to CNA 2 that was verbal abuse. (CNA 2) stated I know and I'm sorry. CNA 2 admitted she did curse while she was on the floor. A second facility interview completed on 8/31/18 at 6:00 p.m. with CNA 1, indicated she and CNA 2 began providing care to residents at 8:15 a.m. At approximately 9:05 a.m. she left the hall to notify the Administrator of the allegations of abuse. During a telephone interview on 9/4/18 at 2:54 p.m., CNA 1 indicated she had worked at the facility for almost two years and was currently on suspension. She indicated her story related to the events were the same as in her provided statement. She felt she did not delay in reporting since it happened to all four residents within minutes. She indicated she had no prior concerns related to CNA 2 before 8/30/18. During an interview on 9/5/18 at 8:41 a.m., CNA 6 indicated she had reported a previous concern related to CNA 2 to the Administrator for swatting back at a resident. Attempts were made to contact CNA 2 on 9/5/18 at 8:48 a.m. and 9/5/18 at 9:25 a.m. No return call was received. Review of an Abuse, Neglect, and Misappropriation of Property policy indicated CNA 2 signed she understood the policy on 1/19/18. On 9/5/18 at 12:21 p.m., the SSD indicated CNA 2 worked all three halls, which included cognitively impaired residents. A list provided indicated there was 65 cognitively impaired residents on the three halls. 2a. The clinical record for Resident B was reviewed on 9/4/18 at 3:37 p.m. [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set (MDS) assessment, dated 8/22/18, indicated the resident was severely cognitively impaired. She required two person assistance for bed mobility, transfers and dressing. A current health care plan, dated 8/25/18, indicated the resident had impaired decision making skill related to profound intellectual disability. Interventions included, but were not limited to, inform the physician of any change of condition and limit choices. Another health care plan, dated 9/1/18, indicated to observe her psychosocial well-being related to an allegation of verbal abuse. Interventions included, but were not limited to, observe for signs and symptoms of distress such as crying or emotional outbursts. An allegation of abuse event, dated 8/30/18 at 9:30 a.m., indicated a full skin assessment was completed with no abnormalities noted. The resident exhibited no signs or symptoms of pain for discomfort. b. The clinical record for Resident C was reviewed on 9/4/18 at 4:18 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 8/22/18, indicated the resident was severely cognitively impaired. He required two person assistance for bed mobility and transfers. A current health care plan, dated 8/24/16, indicated the resident was non-verbal related to profound intellectual disability. Interventions included, but were not limited to, staff to anticipate care needs. Another health care plan, dated 9/1/18, indicated to observe his psychosocial well-being related to an allegation of verbal abuse. Interventions included, but were not limited to, observe for signs and symptoms of distress such as crying or emotional outbursts. An allegation of abuse event, dated 8/30/18 at 2:44 p.m., indicated a full skin assessment was completed with no abnormalities noted. The resident exhibited no signs or symptoms of pain for discomfort. c. The clinical record for Resident D was reviewed on 9/4/18 at 4:28 p.m. [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 8/17/18, indicated the resident was severely cognitively impaired. She required one person assistance for bed mobility, transfers and dressing. A current health care plan, dated 9/1/17 and revised 8/23/18, indicated the resident participated in Functional Maintenance Program for grooming and toileting due to [MEDICAL CONDITION]. Interventions included, but were not limited to, staff to toilet with morning care, before meals, after meals and before bed. Another health care plan, dated 9/1/18, indicated to observe her psychosocial well-being related to an allegation of verbal abuse. Interventions included, but were not limited to, observe for signs and symptoms of distress such as crying or emotional outbursts. An allegation of abuse event, dated 8/30/18 at 9:30 p.m., indicated a full skin assessment was completed with no abnormalities noted. The resident exhibited no signs or symptoms of pain for discomfort. d. The clinical record for Resident E was reviewed on 9/4/18 at 4:37 p.m. [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 7/17/18, indicated the resident was severely cognitively impaired. He required two person assistance for transfers. A current health care plan, dated 7/10/17 and revised 7/26/18, indicated the resident had profound intellectual disability. Interventions included, but were not limited to, encourage him to respond to his environment and increase his interaction. Another health care plan, dated 9/1/18, indicated to observe his psychosocial well-being related to an allegation of verbal abuse. Interventions included, but were not limited to, observe for signs and symptoms of distress such as crying or emotional outbursts. An allegation of abuse event, dated 8/30/18 at 9:30 p.m., indicated a full skin assessment was completed with no abnormalities noted. The resident exhibited no signs or symptoms of pain for discomfort. Review of a current facility policy, dated 6/25/17, titled FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION, which was provided by the Administrator on 9/4/18 at 12:56 p.m., indicated the following: Purpose: To prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Procedure: 1. The facility shall conduct an investigation of any alleged or suspected abuse, neglect 2. The Executive Director is responsible for oversight of abuse prohibition standard. Screening: Each facility will follow any and all state specific requirements 1. Pre-employee screening will be completed on all employees, to include: Criminal History Check; Background Check; Reference Check from previous employers; Professional licensure, Protection: 1. All residents will be protected from harm. 2. All allegations involving staff will necessitate suspension pending investigation. Reporting and Response: 1. Allegations will be reported to the Executive Director immediately. 2. The facility will report all alleged violations and substantiated incidents to the state agency and to all other agencies as required 3. The facility and/or staff will report suspicion of a crime to local authorities and/or agencies as required. The Immediate Jeopardy (IJ) that began on 8/30/18 was removed on 9/6/18 when interviews with staff confirmed the facility had begun inservicing staff on abuse and the reporting process and making staff observations. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced and monitoring was ongoing. This Federal tag relates to Complaint IN 579. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure that a staff member who had knowledge of an incident of physical and verbal abuse and intimidation, immediately reported those concerns to the facility Administrator for 4 of 6 residents reviewed for abuse (Resident's B, C, D and E). This deficient practice had the potential to affect 65 cognitively impaired residents residing on 3 of 3 hallways. The immediate jeopardy began on 8/30/18 when CNA 1 failed to immediately report the the Administrator when CNA 2 was both physical and verbally abusive to Resident's C and D and was verbally abusive to Resident's B and E. The Vice President of Operations was notified of the immediate jeopardy on 9/6/18 at 11:37 a.m. Findings include: 1. Review of an Indiana Department of Health (ISDH) reportable with an alleged event, 8/30/18 at 9:15 a.m., indicated CNA 1 reported a concern to the Administrator related to an allegation of verbal abuse. CNA 1 reported she was providing resident care with CNA 2 on 8/30/18. CNA 1 indicated she could not stand the way CNA 2 treated the residents. A follow up investigation, dated 8/31/18, indicated an expanded investigation revealed allegations of rough handling potentially constituting physical abuse. An internal event investigation completed by the Administrator, Social Service Director (SSD) and Director of Nursing (DON) , indicated on 8/30/18 at 9:27 a.m., CNA 1 was interviewed and indicated CNA 2 . was king of yanking (Resident D) around and calling her a d--- a--. Resident D was placed on the toilet while CNA 2 was being rough with her. Resident D had gotten bowel movement on the toilet and her shirt. CNA 2 got mad and yanked her up off the toilet and yanked her shirt off and then said If I could rip this shirt in in f------ half I would, I'm so p-----. CNA 2 started assisting Resident B. CNA 2 got Resident B's clothes and went over and stated get up here w/(with) your nasty a--. After finishing with Resident B the nurse told the CNA's to assist Resident C who was walking down the hall wet. The nurse and CNA 1 assisted him to his bed, then CNA 2 and I started to provide him care. CNA 2 then put his hand down by his bottom and then she jerked his hand away and said get your fingers out of your nasty a--. Resident B's roommate laughed and she said shut up (Resident E), your (sic) ugly too. Resident C was assisted into his recliner chair and CNA 2 still proceeded to be rough. CNA 2 then said to Resident C I wish your head would have hit that night stand. CNA 1 then washed her hands and told CNA 2 she was going to talk to the Administrator. CNA 2 was suspended pending an investigation. An internal event investigation completed by the Administrator, SSD, and DON, on 8/30/18 at 9:51 a.m., indicated CNA 2 was asked if anything out of the ordinary happened that morning. CNA 2 indicated No. CNA 2 was then asked if she was having a bad morning or was rough with any of the residents. She stated she was frustrated that morning and she did call (Resident C) ugly. The DON indicated to CNA 2 that was verbal abuse. (CNA 2) stated I know and I'm sorry. CNA 2 admitted she did curse while she was on the floor. During a second facility interview completed on 8/31/18 at 6:00 p.m. with CNA 1, she indicated her and CNA 2 began providing care to residents at 8:15 a.m. At approximately 9:05 a.m. she left the hall to notify the Administrator of the allegations of abuse. On 9/1/18 at 7:30 p.m., the Vice President of Operations contacted CNA 1 by phone. CNA 1 was asked why she waited so long to report the incident and indicated .Everything happened so fast and the residents needed assisted and I just didn't think about it like that CNA 1 was asked if she recalled telling CNA 2 that she should not talk like that in front of the residents or to take a break? CNA 1 indicated .No, I didn't. As soon as I walked out of that room I started crying I was trying to not make a scene As soon as we got done assisting them with being soaked in pee, that's exactly what I did. I walked out of the room, I went up to (Administrator's) office .was in morning meeting. I asked .to get her for me CNA 1 exited the facility on 8/30/18 at 1:05 p.m. Review of the facilities internal investigation, the Administrator provided a time line of events from 8/30/18. The time line included the following: Time Line 9:10 AM .in the conference Room (sic) for Morning (sic) Meeting (sic) .stated that (CNA 1) needed to speak to me. 9:11 am .(CNA 1) said she needed to tell me what happened 9:15 am .(CNA 1) started talking to explain what had happened, I ask her to stop .ask (CNA 2) to come to the front reception area. 9:27 am .told (CNA 1) we needed to take her formal statement 9:51 am .(CNA 2) had been waiting We took her statement. .11:30 AM .(SSD) to complete Resident (sic) Interviews (sic) with all interviewable During a telephone interview on 9/4/18 at 2:54 p.m., CNA 1 indicated she had worked at the facility for almost two years and was currently on suspension. She indicated her story related to the events were the same as in her provided statement. She felt she did not delay in reporting since it happened to all four residents within minutes. Review of an Abaqus (on-line training program), titled, Preventing, Recognizing, and Reporting Abuse, CNA 1 signed she understood the policy on 12/31/17. 2a. The clinical record for Resident B was reviewed on 9/4/18 at 3:37 p.m. [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set (MDS) assessment, dated 8/22/18, indicated the resident was severely cognitively impaired. She required two person assistance for bed mobility, transfers and dressing. b. The clinical record for Resident C was reviewed on 9/4/18 at 4:18 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 8/22/18, indicated the resident was severely cognitively impaired. He required two person assistance for bed mobility and transfers. c. The clinical record for Resident D was reviewed on 9/4/18 at 4:28 p.m. [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 8/17/18, indicated the resident was severely cognitively impaired. She required one person assistance for bed mobility, transfers and dressing. d. The clinical record for Resident E was reviewed on 9/4/18 at 4:37 p.m. [DIAGNOSES REDACTED]. The most recent annual MDS assessment, dated 7/17/18, indicated the resident was severely cognitively impaired. He required two person assistance for transfers. Review of a current facility policy, dated 6/25/17, titled FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION, which was provided by the Administrator on 9/4/18 at 12:56 p.m., indicated the following: Purpose: To prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property . .Training: 1. All new and current employees will receive training and reinforcement that will identify all aspects of abuse prohibition; at the time of employment with their initial .on-going in-service programs 2. Each new employee will be informed of his or her responsibility to immediately report any violations or alleged violations to the Executive Director Protection: 1. All residents will be protected from harm. 2. All allegations involving staff will necessitate suspension pending investigation. Reporting and Response: 1. Allegations will be reported to the Executive Director immediately. 2. The facility will report all alleged violations and substantiated incidents to the state agency and to all other agencies as required 3. The facility and/or staff will report suspicion of a crime to local authorities and/or agencies as required. The Immediate Jeopardy (IJ) that began on 8/30/18 was removed on 9/6/18 when interviews with staff confirmed the facility had begun inservicing staff on abuse and the reporting process and making staff observations. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced and monitoring was ongoing. This Federal tag relates to Complaint IN 579. 3.1-28(c)

Based on observation, record review and interview the facility failed to prevent the development and worsening of pressure ulcers for 1 of 1 resident observed for wounds. (Resident 58) This deficient practice resulted in unstageable pressure ulcers developing and worsening over a period of four months. Findings include: 1. On 5/15/18 at 9:54 a.m., Resident 58 was observed lying flat on his back on a low air loss mattress, heels were laying on the bed and the bed bolster was not in place. On 5/11/18 at 1:16 p.m., he was sitting in the recliner. His calves were lying flat on the recliner and heels were hanging off of the foot rest. On 5/14/18 at 9:04 a.m., he was sitting in the recliner. His calves were lying flat on the recliner and heels were hanging off of the foot rest. On 5/14/18 at 12:59 p.m., he was observed lying flat on his back on a low air loss mattress, heels were laying on the bed and the bed bolster was in the bed under his knees. On 5/15/18 9:29 a.m., he was observed lying flat on his back on a low air loss mattress, his heels were touching the bed and the ball of his right foot just below the toes was touching the foot board, the bolster was on the bed, but not in the correct place. On 5/14/18 at 12:34 p.m., Resident 58's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 58 had a quarterly Minimum Data Set assessment (MDS) on 3/28/18 which indicated the resident was cognitively intact. The MDS indicated the resident was at risk for pressure ulcers but lacked information of the wounds present. A Braden evaluation was completed on 1/18/2018 and indicated the resident was a moderate risk for skin breakdown. Wound notes, dated 2/1/2018, indicated the right heel had a new unstageable pressure ulcer which measured 3.8 cm (centimeters) x 4.0 cm., with no undermining, no tunneling, no drainage, no odor, tender, and no indication as to the cause of the wound. The unstageable pressure was acquired in the facility. Wound notes, dated 2/1/2018, indicated the left heel had a new unstageable pressure ulcer and measured 3.7 cm. x 3.0 cm., with no undermining, no tunneling, no drainage, no wound odor, condition of surrounding tissue is tender, no indication as to the cause of the wound. The unstageable pressure was acquired in the facility. A review of the Wound Clinic Notes, dated 18, indicated the right heel was a 5.0 cm x 4.5 cm. x 0.5 cm, unable to stage pressure ulcer and left heel was a 6.0 cm x 3.5 cm. x 0.6 cm., unable to stage pressure ulcer. The treatment plan indicated Hydragaurd (cream to help resist moisture loss) to bilateral legs, santyl (enzymatic [MEDICATION NAME] ointment) to all wounds, cover with oil [MEDICATION NAME] dressing and cover with gauze. Roll gauze from toes to ankle bilateral legs, change daily and keep heels floated at all times with wedge pillow. A review of the Wound Clinic Notes, 5/4/2018, indicated the right heel was a 4.1 cm x 3.7 cm. x 0.5 cm., unable to stage pressure ulcer and left heel was a 5.0 cm. x 3.5 cm. x 0.1 cm., unable to stage pressure ulcer. There was a new open pocket above right heel ulcer from 10 o'clock to 1 o'clock which was 2.1 cm deep. Packed with silver alginate then silver alginate placed over wound bed. The treatment plan indicated santyl to all wounds, cover with oil [MEDICATION NAME] dressing and cover with gauze. Pack tunnel on right heel loosely with silver alginate rope. Roll gauze from toes to ankle bilateral legs. Change daily. Keep heels floated at all times with wedge pillow. During an interview on 5/14/18 at 1:10 p.m., Licensed Practical Nurse (LPN) 25 indicated the bolster on the bed was to keep the residents heels off of the bed. The LPN then went to the residents' room and verified that the bolster was not placed where it was to be placed in order to keep the heels floated. During an interview on 5/14/18 at 4:18 p.m., the Director of Nursing (DON) indicated that the bolster for residents heels being floated should have been on the skin care plan and was not and if it was not on the care plan it was not being carried over to the Point of Care screen that the Certified Nurses' Aides (CNA) utilize. During a dressing change observation and interview on 5/15/18 at 1:30 p.m., RN 24 indicated that the area tunneling on the right heel was new on the last visit to the Wound Clinic on 5/4/18. He indicated the resident was to have his heels floated at all times both while up and while in bed. A current, 2/1/2018, facility policy titled Skin and Wound Care Management Program provided by the Director of Nursing on 5/15/18 at 4:15 p.m. indicated the following: Purpose: The intent of this requirement is that the resident does not develop pressure ulcers/injuries (PU/PI) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote prevention of pressure ulcer /injury development . .Assessment .Nursing will complete the Braden's Observation upon .development of a new wound to evaluate risk for skin breakdown . .Implementation The Interdisciplinary Team ensures that planned interventions .are carried out as written in the plan of care No further information was provided at time of exit. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure staff immediately reported an allegation of physical and verbal abuse and involuntary seclusion to the administrator and failed to investigate the allegation of abuse for 1 of 7 reviewed for abuse (Resident B). This deficient practice had to potential to affect 84 of 84 residents residing in the facility. The immediate jeopardy began on 10/1/2017 when CNA 2 indicated she had observed physical and verbal abuse and involuntary seclusion from a staff member toward a cognitively impaired dependent resident and failed to report that abuse to the Administrator. The Administrator was notified of the immediate jeopardy on 10/12/2017 at 2:10 p.m. Findings include: The clinical record review for Resident B began on 10/11/2017 at 1:12 p.m. His [DIAGNOSES REDACTED]. Resident B had a current health care plan, dated 2/2/10 and revised 10/12/17, which indicated he would communicate to the best of his ability, but would often scream out when he had a basic need. Interventions included, but were not limited to, Assess my needs if I scream .Read me my mail .Visit me regularly to provide support Resident B had current health care plan, dated 2/2/10, which indicated he was non-verbal and unable to relay his needs. He was dependent on others for all activities of daily living. Interventions included, but were not limited to, Talk to me while providing and preparing to provide my care. During an interview on 10/12/17 at 9:10 a.m., CNA 2 indicated on 10/1/17, CNA 10 was in the dining room feeding a resident. Resident B had been yelling loudly throughout lunch. She indicated CNA 10 got up from the the table and walked over to the table where Resident B was seated. She indicated CNA 10 then stated to Resident B you are pissing me off. CNA 2 indicated she saw CNA 10 make contact with Resident B's mouth, hard enough to make a pop sound. CNA 2 indicated Resident B's face turned red and he was moving side to side. She indicated CNA 10 removed Resident B from the dining room. She then placed Resident B at the 300 Hall nurses' station, in his wheelchair, with his face towards the door. She indicated there was no staff person at the nurses' station at the time. CNA 2 indicated CNA 10 returned to the dining room to assist other residents, left again and took Resident B to his room. CNA 2 indicated she went to check on Resident B in his room and found him in the doorway, between the bathroom and the bedroom, with the curtain pulled to his face. Resident B was still seated in his wheelchair. She moved Resident B to the side of his bed, then reported the incident to LPN 11. CNA 2 indicated she checked on Resident B a short time later and found him again facing the wall in the closet of his room. She indicated she moved him back to the side of his bed. CNA 2 indicated she again checked on Resident B and found him in his closet, facing the wall. She indicated Resident B was visually upset and yelling. She indicated she reported the incident to LPN 11 after she saw CNA 10 slap Resident B, as well as, each time after being placed in his room. She indicated LPN 11 reported all the incidents to LPN 12. LPN 12 was the charge nurse on 10/1/17. She indicated LPN 11 did walk up to the front of the building to talk to LPN 12, but did not see her talk to her initially. CNA 2 indicated LPN 12 was present when she told LPN 11 about finding Resident B in his room. She indicated LPN 12 instructed LPN 11 to say something to CNA 10. She indicated at one point, she heard CNA 10 say she had put Resident B in a time-out. During an interview on 10/12/17 at 9:49 a.m., CNA 5 indicated she worked on 10/1/17 and saw Resident B removed from the dining room by CNA 10 because he was screaming. She indicated CNA 10 was pushing Resident B towards his room. During an interview on 10/12/17 at 1:29 p.m., CNA 6 indicated she did not see or hear anything in the dining room on 10/1/17. She indicated several residents were yelling at the time. During an interview on 10/13/17 at 9:45 a.m., CNA 7 did not see or hear anything on 10/1/17. During an interview on 10/13/17 at 10:38 a.m., the Social Service Director (SSD) indicated Resident B was unable to propel his wheelchair. During an interview on 10/13/17 at 12:34 p.m., CNA 4 indicated she did not hear or see anything on 10/1/17. She indicated she did not hear anything until she returned to work on 10/2/17. During a telephone interview on 10/12/17 at 9:58 a.m., CNA 10 indicated she did come to the facility on [DATE] for an in-service. She indicated when she came in, co-workers were saying to her that she had slapped Resident B during lunch. She indicated the Administrator said she had not heard anything about the incident and to not worry about it. She indicated she then received a call at home on 10/7/17 from the Administrator, who indicated she had been placed on suspension pending an investigation of the abuse allegation. During an interview on 10/12/17 at 10:19 a.m., the Administrator indicated she had an in-service on 10/3/17 related to abuse and neglect. She indicated CNA 10 came to her after and told her that she was hearing people talk about her. The Administrator indicated she told CNA 10 to not worry about gossip. The Administrator indicated at no time was there mention of CNA 10 hitting a resident. She indicated the Director of Nursing (DON) did call into the facility on [DATE] and talk to both LPN 11 and LPN 12. She indicated the DON was only told there was conflict between CNA 10 and CNA 2. Review of an Indiana State Department of Health Incident Report, dated 10/7/17, indicated CNA 2 reported an allegation to RN 3 that she observed CNA 10 slap Resident B in the mouth while in the dining room. RN 3 completed a head to toe assessment of Resident B on 10/7/17 and notified the Administrator immediately. Review of CNA 10's work summary log, indicated she worked in the facility on 10/1/17, 10/3/17, 10/4/17, 10/5/17 and 10/6/17. An Abuse Prevention policy, dated 6/21/17, indicated CNA 2 signed that she had read the facility policy on abuse prevention and reporting. CNA 10 completed Prevention, Recognizing, and Reporting Abuse on 1/10/17. LPN 11 was no longer employed by the facility. There were multiple unsuccessful attempts made to reach LPN 11. A current facility policy, dated 5/17/17, titled Abuse, Neglect and Exploitation, provided by the Administrator on 10/12/17 at 1:00 p.m., indicated the following: Purpose: Prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property. .Training: .2. Each new employee will be informed of his or her responsibility to immediately report any violations or alleged violations to their supervisor and facility Executive Director/Administrator Identification: 1. Staff will immediately report any suspicious event that may constitute abuse, neglect, exploitation or misappropriation. .3. The facility will report the allegation to the State Agency in accordance with state law. Investigation: 1. The facility will conduct an internal investigation and report the results .state law. 2. The facility will thoroughly investigate all alleged violations and take appropriate actions. Protection: 1. All residents will be protected from harm The immediate jeopardy that began on 10/1/2017 was removed on 10/13/17 when the facility reeducated staff regarding abuse and following the abuse policy, but the non-compliance remained at no actual harm, but potential for minimal harm because system monitoring had not been completed. This Federal Tag relates to complaint IN 727. 3.1-28(b) 3.1-28(c)

Based on observation, interview and record review the facility failed to manage Gastrostomy status for 1 of 3 residents reviewed with tube feedings. This deficient practice resulted in hospitalization s and significant weight loss for the resident. (Resident 57) Findings include: Record review for Resident 57 began on 8/14/17 at 1:30 p.m., indicated the resident was admitted [DATE] with diagnosed including: [DIAGNOSES REDACTED]. A review of an MDS (Minimal Data Set) assessment, dated 3/21/17, indicated the resident was admitted with a feeding tube. A care plan, dated 4/10/17, indicated the resident had dementia and was at risk for weight loss, dehydration, choking and the resident had a gastric tube to supplement her oral intake . Interventions included, but were not limited to, assist with feedings, give diet as ordered, give gastric tube feedings as ordered and observe for signs and symptoms of dehydration. An additional focus area was added to care plan on 5/31/17, this indicated Resident feeding tube had been dislodged, intervention included but were not limited to: check tube for proper placement, notify physician and re-insert feeding tube. Review a of nurses note, dated 3/22/17, indicated the resident's [DEVICE] (feeding tube) was found by CNA (certified nursing assistant) on the floor in the resident's room. Facility staff placed a 16F urinary catheter in place of the [DEVICE]. Record review of the hospital record, indicated the resident was admitted to hospital on [DATE]. During this admission the hospital staff removed the 16F urinary catheter and replaced it with a Gastostomy tube on 4/14/17. The resident's admitting [DIAGNOSES REDACTED]. Physician note, dated 4/13/17 at 2249 (10:49 p.m.), indicated the resident was at the hospital with concerns of [MEDICAL CONDITION], because abd (abdominal) wall peri-peg [MEDICAL CONDITION]. Past medical history did not indicate a history of any previous [MEDICAL CONDITION]. Review of nurses note, dated 4/26/17 at 7:03 p.m., indicated the resident was readmitted to the facility. Review of nurses notes from 4/26/17 thru 5/14/17 indicated the resident had emesis (vomiting) at the following dates and times: 5/10/17 at 9:54 p.m. 5/11/17 at 2:14 p.m. 5/11/17 at 2:17 p.m. 5/14/17 at 8:02 a.m. 5/14 /17 at 10:00 a.m. 5/14/17 at 12:46 p.m. Review of a hospital record, dated 5/14/17, indicated Resident was evaluated and admitted with diagnoses included, but not limited to, ulcer, acid reflux and gastrostomy status. No nurse note completed as to when Resident returned to facility. Review of hospital record, dated 5/20/17, indicated the resident was evaluated and admitted with diagnosed including: [DIAGNOSES REDACTED]. History of present illness in this physician note indicated there was some blistering [MEDICAL CONDITION]/[MEDICAL CONDITION] around the PEG tube (gastrostomy tube). Resident was discharged from hospital and returned to facility on 5/24/17. Review of a nurses note, dated 5/31/17 at 7:20 p.m., indicate the resident's [DEVICE] was found on the floor in her room. It was replaced with a 20F urinary catheter. Review of a nurses note, dated 7/5/17, indicated the urinary catheter, which was being used as a gastrostomy tube, became dislodged and it was replaced with a new 20 french urinary catheter. Review of a nurses note, dated 7/6/17 at 6:30 p.m., indicated the Foley catheter was removed and a Mic-key button (feeding tube device) placed. Review of the Resident's weights from 3/17/17 thru 8/14/17 were as listed below: 3/17/17 100 pounds 4/6/17 94 pounds which is a 6% weight loss 5/7/17 89 pounds which is an 11% weight loss 6/9/17 91 pounds which is a 9% weight loss 7/11/17 89 pounds which is an 11% weight loss 7/26/17 86 pounds which is a 14% weight loss 8/14/17 93 pounds which is a 7% weight loss Resident had a 14% weight loss in approximately 4 months. An interview with Employee 28, on 8/14/17 at 2:49 p.m., indicated replacing a gastrostomy tube with a Foley catheter was normal practice at the facility. She confirmed the resident had a Foley catheter placed from 3/22/17 thru 4/12/17 instead of a gastrostomy tube. An interview with the Administrator, on 8/15/17 at 10:33 a.m., indicated replacing a gastrostomy tube with a urinary catheter is used for only a short term need until a new gastrostomy tube can be placed, but it should not be used for long periods of time. An interview with the DON, on 8/15/17 at 11:15 a.m., indicated she thought the resident had a history of [REDACTED]. During a record review with the DON present, the resident had no [DIAGNOSES REDACTED]. The DON indicated the resident had a long history of pulling out the gastrostomy tube in the facility and prior to admission as reported by previous facility. Review of dietician note, dated 4/7/17, indicated acknowledgment of the resident's weight loss and recommended to increase the tube feeding. Dietician note, dated 4/26/17, indicated the resident has had an 8% weight loss in 30 days. Dietician note, dated 5/11/17, indicated the resident's family member requested a high calorie supplement to promote weight gain for the resident. Dietician note, dated 6/22/17, indicated the Nurse Practitioner described the resident as well-nourished, and her weight appears to be stable. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer for a resident with a known risk for skin breakdown for 1 of 1 residents reviewed for pressure ulcers (Resident 43). Findings include: During a wound observation, accompanied by the DON, beginning on 8/11/17 at 9:12 a.m., Resident 43 had an intact reddened area, approximately the size of a small paperclip, to his left second toe. A bright red area, approximately the size of a small paper clip, with a small amount of scabbing was observed to his right second toe, and a small reddened area, the size of a pea was observed between the two toes. On both of his feet, his great toe curled over the top of his second toe. The DON indicated, at the time of the observation, his pressure wound was on the top of his right second toe. When his right hip was observed, a 2 inch (in.) x 2 in [MEDICATION NAME] dressing, dated 8/10 was present to his right hip. At 9:15 a.m., the DON and LPN 32 indicated there were 4 in. x 4 in. [MEDICATION NAME] dressings available in the storage room, and did not know why a smaller dressing was applied to his hip. Review of the clinical record began on 8/10/17 at 8:51 a.m. [DIAGNOSES REDACTED]. A 7/4/17, quarterly, Minimum Data Set (MDS) assessment indicated he was moderately cognitively impaired, totally dependant on others for ADLs and mobility, and was non-ambulatory. He had current physician's orders [REDACTED]. Apply spacer to left foot between first and second toe to decrease pressure from 2nd dorsal toe when out of bed (from 10/5/16 - 8/10/17). Hold right shoe, loose fitting slipper only, until area to digit 2 of right foot healed. Tube foam sleeve 1st toe bilateral feet for protection of 2nd toe lesion (due to 1st toe pressure) daily until healed (from 2/15/17-8/10/17). Beginning 8/10/17, apply [MEDICATION NAME] (a foam dressing) to 2nd digit on right and left foot for protection daily. Apply [MEDICATION NAME] (a wound dressing) 4 x 4 to fragile right hip every 3 days for prevention (beginning 8/18/16). He had a current care plan problem, initiated 10/10/16, for My toes overlap each other causing sore areas on my toes. Interventions included to apply a toe separator between the first and second toes of his left foot and to complete treatments as ordered. There was no mention of interventions for his right foot. He had a current care plan problem, initiated 5/12/17, of impaired skin integrity due to an open area to the 2nd digits of his right and left foot. The care plan indicated the area occurred following a marathon he had attended with a family member, which caused his feet to bounce in his wheelchair. Interventions included to complete his treatment as ordered, wear puffy slippers to the next race, and notify family of occurrence on 5/12/17. Review of a Non-Pressure Wound assessment, dated 12/4/16, indicated he had an abrasion to the second digit of his right foot, caused by Toes perpetually touch d/t (due to) contractures. The documentation provided by the facility indicated the wound was still present as of 2/9/17, but there was no further indication of when it resolved. A Pressure Wound Documentation note, dated 5/12/17, indicated a stage 2 pressure ulcer was present to his second toe on his right foot, measuring 1.1 cm x 1 cm. No depth was indicated on the assessment. An Acquired Pressure/Non-Pressure Skin Impairment assessment, dated 5/12/17, indicated the root cause of the pressure ulcer was his toes cross over and lay on each other. A Non-Pressure Wound Documentation note, dated 5/31/17, indicated the area was an abrasion, measuring 0.2 cm x 0.2 cm, with undetermined depth, as the area was scabbed over. A Pressure Wound Documentation note, dated 6/7/17, indicated the area was a suspected deep tissue injury (defined on the document as purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear), measuring 0.2 cm x 0.2 cm with undetermined depth. A Pressure Wound Documentation note, dated 6/14/17, indicated the area was unstageable (defined on the document as having necrotic (dead/dying) or slough (yellow or cream colored dead tissue) tissue covering or preventing adequate staging of the pressure ulcer). The wound measured 0.2 centimeters (cm) x 0.2 cm, with depth undetermined. A Pressure Wound Documentation note, dated 8/9/17, indicated he had an unstageable pressure wound remaining to his second digit on his right foot. An 8/10/17 progress note indicated he had a 0.3 x 0.3 cm x depth undetermined, area of emaceration (sic) to his 2nd digit on his left foot. During an interview, on 8/11/17 at 9:54 a.m., the DON indicated he had developed the pressure ulcer to his right foot after attending a race with his family. She indicated his shoes had caused the area to develop from wearing his shoes. A 5/12/17 Care Conference note indicated he had participated in a marathon with a family member, and the area was possibly caused by friction during running. A Leave of Absence (LOA) document, dated 5/5/17, indicated Resident 43 had left the facility for an overnight visit through 5/6/17. There was no assessment upon his return to the facility. During an interview, on 8/14/17 at 10:40 a.m., the DON indicated she could not answer why the wound observed on 5/12/17 had been attributed to his LOA six days prior. During an interview, on 8/15/17 at 2:07 p.m., CNA 33 indicated she was not aware of Resident 43 having any special interventions for his feet in May, nor at the current time. 3.1-40(a)(1)

Based on interview and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to a resident who quested a full code status and was found unresponsive without respirations or a heart beat. This deficient practice affected 1 of 3 residents reviewed who requested CPR and had the potential to affect 45 of 81 residents in the facility who were considered a full code status and would require CPR. The immediate jeopardy began on [DATE] when the facility staff failed to initiate CPR to a full code resident found unresponsive without respirations and pulse. The Administrator was notified of the immediate jeopardy on [DATE] at 1:18 p.m. The immediate jeopardy was removed and the deficient practice corrected, on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: Resident #B's record was reviewed on [DATE] at 10:30 a.m. [DIAGNOSES REDACTED]. Review of the clinical record indicated Resident B had a form titled, Resuscitative and Life Prolonging Procedures, dated [DATE], and signed by the resident's legal representatives. Review of a nursing progress note, dated [DATE], indicated Resident B was a full code and status had been verified on the face sheet and physician's re-write order's. Review of the nursing note, dated [DATE] at 12:25 a.m., indicated Resident B was found unresponsive with no pulse. The nursing note lacked any indication CPR had been initiated. Review of the physician orders [REDACTED]. Review of a care plan, dated [DATE], titled Communication indicated the resident was nonverbal and could not make his needs or wants known. The resident was unable to answer yes/no questions and relied on staff to provide anticipatory care. Interventions included, but were not limited to, staff will ensure that I am having my needs met. Review of a care plan dated [DATE] titled Code Status indicated Resident B's parents would make his life decisions and he was a full code. Interventions included, but were not limited to, staff would ensure that Resident B's parents wishes were to be honored. Review of the facility investigation indicated the following: CNA #1 indicated she last saw Resident B between 10:00 p.m. and 10:15 p.m. Resident B had shown no signs of distress. CNA #2 indicated she was making her rounds around midnight and got to Resident B's room. She noted his color did not look right and called for the nurse. LPN #3's written statement was as follows: I was in another residents room and (name of CNA #2) came and got me. We walked into (Resident B's name) room he was pale. I checked his respirations and felt that he was cold. Got vital machine to check O2 (oxygen). It wouldn't read. While I was doing this (name of CNA #2) went to get (name of LPN #4). (name of LPN #4) came in and asked if I checked his O2 and said check his heart rate. I went to get stethocope (sic). I came back and check (sic) heart rate with stethoscope (sic) and didn't hear one. (name of LPN #4) checked with my stethocope (sic). (name of LPN #4) said we need (sic) to call doctor, DON (Director of Nursing), ED (Executive Director) and family. The last time I saw (name of Resident B) was during med pass 5:,[DATE]:30 p.m. (name of Resident B) seemed fine then. (name of LPN #4) nor I went to check to look at code status. LPN #3 later added she did not check the code status because the resident had been dead a while and he was cold. LPN #4's written statement indicated she was called to Resident B's room. I walked into the room (name of LPN #3) was there at bedside (sic). I asked what happened (name of LPN #3) said (name of CNA #2) found him like this. I told her to check for heart rate (sic). (name of LPN #3) checked said she didn't hear a heartbeat. (name of LPN #3) asked what all do I do now. I told her to call DON, ED, family and doctor and funeral home. I went to desk and made (name of LPN #3) a list of things to do. I did not check code status. I did not check because I thought (name of LPN #3) already did. I did not attempt CPR because (name of LPN #3) didn't seem emergent. I thought code status was already checked and (name of Resident B) was a DNR (Do Not Resuscitate) code status. It has not been my practice to check another nurse's patients code status. During an interview on [DATE] at 11:31 a.m., the DON indicated she and the ADON (Assistant Director of Nursing) read all the nursing progress notes to review care. She indicated she had been behind in the reading of the nursing notes and did not read about the [DATE] incident until [DATE]. She indicated she questioned LPN #3 regarding her actions during the incident and asked if she had initiated CPR. She stated LPN #3 did not initiate CPR for Resident B. Second and third shift do a walking report at 11:00 p.m. and the first round bed check has to be done by 1:00 a.m. CNA #2 said she found him at midnight. The DON indicated resident code status are indicated by a colored banner on the electronic chart: green for full code and red for DNR. Review of a memorandum from the corporate Regional Director of Clinical Services, dated [DATE], indicated the following: . The essential message is that in our environment, it is all or nothing. Even if a resident is found pulseless and breathless with rigor, CPR must be initiated if the code status is full code. At no time is a nurse at liberty to make a judgement call and not do CPR. EMS will make that determination when they arrive. Staff must clearly know where to find a resident's code status in Matrix (computer based documentation system) and respond accordingly. LPN #3 and LPN #4's signature on an inservice sign in sheet dated [DATE] indicated both nurses had read and understood the policy. Review of a current policy, dated [DATE], titled Cardiopulmonary Resuscitation (CPR) Do Not Initiate Cardiopulmonary Resuscitation (DNR) Informed Consent indicated the following: Purpose: To support and provide the right for each resident to formulate a resuscitation advance directive. Procedure: 1. Social Services Director/designee and \or Licensed Nurse will review resuscitation options and document self determination preferences from the resident or the legal representative. (Utilize INTERACT resource tool for Education on CPR for Residents and Families) 2. Resuscitation options will be a Full Code (CPR) or Do Not Resuscitate. 3. Review will include that the facility will provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a DNR order. 4. The decision for Full Code (CPR) or DNR will be documented in the medical record. 5. A physician order [REDACTED]. 6. If a resident or legal representative wishes to change their resuscitation status, the discussion should be documented in the medical record and physician order [REDACTED]. 7. State specific regulations will be followed as applicable. Staff should initiate CPR when [MEDICAL CONDITION] occurs on: 1)residents (sic) who have requested CPR 2)residents (sic) who have not formulated an advance directive . The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by February 16, 2017 after the facility implemented a systemic plan that included the following actions: provided education for all nurses on CPR guidelines and expectations and location of the code status in the medical record, reviewed the code status for all residents and validated the CPR certification of all nursing staff. This Federal tag relates to Complaint IN 558 3XXX,[DATE](a)(3)

Based on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a resident's increased body temperature (Resident B). The immediate jeopardy began on 3/13/16 when the facility failed to notify the physician of an elevated temperature of 103.9 degrees Fahrenheit (F). The Executive Director, Director of Nursing and Regional Director were notified of the immediate jeopardy on 3/31/16 at 12:00 p.m. The Immediate Jeopardy was removed 4/1/16 when the facility developed and implemented a systematic plan of correction. Findings include: During record review on 3/29/16 at 9:55 a.m., the clinical record indicated Resident B was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE], indicated Resident B was unable to complete the Brief Interview Mental Status (BIMS). Resident B was severely cognitively impaired. During review of a progress note dated 3/13/16 at 6:45 p.m., RN #1 noted a fever. The note indicated the nurse gave 600 milligrams of [MEDICATION NAME]. On 3/14/16 at 6:00 a.m., LPN #2 indicated the resident was resting in bed, moaning. He had an elevated temperature and [MEDICATION NAME] was given. Review of the vital signs record, on 3/13/16 at 6:04 p.m., Resident B had an elevated temperature of 103.9 degrees Fahrenheit (F). A progress note dated 3/14/16 at 11:57 a.m., LPN #2 indicated an elevated temperature and tylenol given. A progress note on 3/14/16 at 4:16 p.m., LPN #2 indicated an elevated temperature of 100 degrees F. A progress note dated 3/14/16 at 5:03 p.m., indicated LPN #2 notified Md of increase temps. The physician responded to monitor the resident at this time. A progress note dated 3/14/16 at 7:00 p.m., RN #1 indicated an elevated temperature of 102.5 F. [MEDICATION NAME] was given. RN #1 noted the abdomen to be slightly firm and tender to palpation, resident is expelling gas. A note dated 3/14/16 at 8:02 p.m., RN #1 indicated an elevated temperature of 100.2 F, but indicated the resident continued to have abdominal tenderness with palpation. A progress note dated 3/15/16 at 12:52 p.m., indicated resident was afebrile (temperature not elevated) with hypoactive bowel sounds and discomfort with palpation. A progress note dated 3/15/16 at 1:29 p.m., indicated the physician was notified of the residents vital signs and abdominal tenderness. No specific numbers were indicated. A progress note dated 3/15/16 at 2:49 p.m., RN #4 indicated a new order for Resident B to have the following: chest x-ray, Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and 2 sets of blood cultures done 15 minutes apart. The order indicated the chest x-ray would be done tonight. A progress note dated 3/15/16 at 5:00 p.m., LPN #3 indicated may have labs drawn 3/16/16 in the AM per (name of physician). A progress note dated 3/16/16 at 1:58 a.m., LPN #5 indicated the breath sounds had rhonchi (low-pitched) breath sounds. A progress note dated 3/16/16 at 8:30 a.m., indicated CBC, BMP and blood cultures drawn per hosp lab from left hand this am. 15 minutes later 2nd set of blood cultures drawn from right hand. A note dated 3/16/16 at 12:27 p.m., indicated the Director of Nursing (DON) informed the physician of the chest x-ray results. The x-ray indicated a right perihilar infiltrate. The physician was also notified of the CBC and BMP results. A new order was received on 3/16/16 at 3:48 p.m. The order indicated to start Bactrim DS (antibiotic) 800mg/160mg, 1 tablet twice daily for 10 days and [MEDICATION NAME] (antibiotic) 500 mg daily for 10 days. The family was notified of the order. A progress note dated 3/17/16 at 2:06 a.m., LPN #5 indicated Dr. (name of physician) notified of culture results. Review of laboratory blood culture results, dated 3/16/16, indicated a preliminary result of Streptococcus A. Interview with LPN #5 indicated she had faxed the report and not actually spoken to the doctor. A progress note dated 3/17/16 at 7:30 a.m., indicated the DON spoke to the physician about the positive blood culture, related to isolation precautions. A note on 3/17/16 at 8:40 a.m., indicated Resident B was observed between the floor and the bed, crawling as per normal Resident B was observed to have the following abrasions: 4.5 cm x 5.0 cm to the right temple and a 2 cm x 2 cm to right ankle. Emesis was on his clothing and bedding. LPN #3 indicated BrSo (breath sounds) are clear and BoSo (bowel sounds) active in all four quadrants. At 9:00 a.m., the physician was notified in person of the resident's vital signs and went to assess the resident. The order was given to send the resident to the local hospital. Resident B was transported to the hospital on [DATE] at 9:15 a.m. Review of an Event Report, dated 3/13/16 at 6:45 p.m., LPN #5 noted a temperature of 103.8 degrees F. The report indicated the event started on 3/13/16 at 6:03 p.m. The report indicated Physician Notified: Yes Date/Time: 3/14/16 at 12:51 AM. During an interview on 3/31/16 at 9:20 a.m., the physician indicated she was not notified of an elevated temperature of 103.9. She indicated she was notified of a temperature on Monday from her nurse. The physician's nurse, LPN #6, indicated she had received a text message from LPN #2 on 3/14/16 at 9:57 a.m., indicating Resident B had a temperature in the 100 range and had vomited his narcotic medication. The physician indicated she was informed on Tuesday (3/15/16) the resident had abdominal tenderness, but with positive bowel sounds. She received no update on Wednesday(3/16/16). She indicated on Thursday (3/17/16), she had received a fax at 2:35 a.m., indicating a positive blood culture. The report only indicated the resident had Gram Positive Cocci (GPC). She indicated she had spoken to the DON prior to her 8:00 a.m. meeting. She indicated the DON was concerned about the blood culture containing streptococcus pyogenes (strep A). The physician indicated she was not aware of the recent culture results. She indicated she immediately contacted her nurse and gave an order for [REDACTED]. During an interview on 3/31/16 at 9:20 a.m., LPN #6 indicated she wrote the order on a sticky note and gave to LPN #3. The note indicated an order for [REDACTED].>During review of the chart, no order for the [MEDICATION NAME] was found. The physician indicated she arrived at the facility at 9:00 a.m. on 3/17/16 and went straight to Resident B's room. She indicated he was listless on his bed and had breathing rapid at about 45 breaths per minute. His hands were cyanotic and cold. His heart rate was between 135-145 beats per minute. She indicated she could tell from the doorway that he was acutely ill. She told the staff to send him to the hospital. She indicated the staff was going to call the local fire department for transfer, but she insisted it was an emergency and to call 911. She indicated there was no sense of urgency from staff. She indicated she had her phone on her 24 hours per day and staff could also call her nurse. She indicated she often received faxes at her home, but would leave early and get home late. She was also not wakened by a fax, but would never sleep through a phone call. During an interview on 3/31/16 at 12:13 p.m., LPN #3 indicated she was told by the DON to not write the order for the [MEDICATION NAME] because the resident had already been transferred. She indicated she did receive the order from the physician's nurse. She indicated when the blood cultures were ordered, there was no one in the facility that could draw the blood and the facility did not have the supplies to draw a blood culture. During an interview on 3/31/16 at 1:06 p.m., the DON indicated she did talk to the physician on Thursday. The DON indicated the facility did not have the supplies to draw the blood culture at that time and she was the only person who could draw the cultures. The DON indicated she spoke to the physician because she was concerned that she, herself, may need [MEDICATION NAME] antibiotics. She indicated the physician did seem surprised to hear the culture grew strep A. Review of a fax confirmation dated 3/14/16 at 1:04 a.m., provided by the DON on 3/31/16 at 2:51 p.m., indicated LPN #5 faxed the elevated temperature at 1:04 a.m. 7 hours after the noted temperature of 103.8 F. During an interview on 3/31/16 at 2:52 p.m., LPN #5 indicated the resident did have a temperature over 103.0 degrees F. She indicated she created the Situation Background Assessment Recommendation (SBAR) on 3/14/16 at 12:46 a.m. She indicated she faxed the SBAR to the physician, but did not hear back from her. She indicated she told the charge nurse, but could not remember who it was. She indicated she did not find any additional attempts to contact the physician. She indicated Resident B had been coughing the previous day and that everyone had been sick. She stated she monitored his vital signs throughout the night, but did not document any of them. She indicated the fax number she sent the report to was listed as the physicians' home fax machine. She indicated she was unaware of the time frame for calling physicians' or vital sign parameters. Review of the Subject, Objective, Assessment and Plan (SOAP) note, dated 3/17/16 at 8:55 a.m., the physician indicated positive for group A strep. PCN ([MEDICATION NAME]) G 2m units IV q4h was ordered as soon as possible. When (name of resident) was seen this morning, he appeared acutely ill. He was tachypneic and [MEDICAL CONDITION]. Review of a current facility policy, dated 9/10/13 and titled Notification of Change provided by the DON on 3/29/16 at 8:50 a.m., indicated the following: Purpose: Communicate to the resident, physician and resident's legal representative or interested family member when a change in condition occurs. Notification occurs when: An accident A significant change in the residents physical mental or psychosocial status (i.e. deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) A need to alter treatment A decision to transfer Procedure: 1. Assess resident's change in condition 2. Notify physician of condition change. .5. Follow up nursing assessments continues until condition has stabilized. An Immediate Jeopardy was identified on 3/31/16 at 12:00 p.m. The IJ began on 3/31/16 when the facility failed to provide timely communication related abnormal vital signs to the physician. The Immediate Jeopardy was removed on 4/1/16 when the facility implemented a plan of action to correct the deficiency. The corrective action included the following: 1. The physician must be immediately notified of any significant change in the resident's physical, mental, or psychosocial status. 2. An SBAR will be thoroughly completed which will include the detailed information communicated to the physician including vital signs, mental status, functional status, respiratory status, GI/abdominal status, labs, etc. 3. All attempts to notify the physician will be documented in the medical record. 4. The physician will be contacted via telephone using the facility phone. No communication regarding orders or changes of condition will take place with the physician via fax, email or text messaging. In the event the nurse is unable to reach the physician in a timely manner, the Executive Director and Director of Nursing/designee with be contacted. During an interview on 4/1/16 at 10:12 a.m., the Administrator indicated the DON had updated all nursing staff on notification of change and only contacting the physician directly by telephone. She indicated the numbers had been posted at the nursing station and each person had to sign the form indicating they understood the change. She indicated the DON started inservicing the nursing staff shortly after noon on 3/31/16. She indicated the DON provided each nurse with a policy to notify the physician of any change. Each staff person was to date and sign the form. The nursing staff was also provided with the facility policy for Notification of Change. Nursing staff on duty were interviewed on 4/1/16 to confirm each understood the changes in the policy. Staff interviewed included LPN# 11, LPN # 10, RN # 9, RN # 4, LPN # 7, and RN #8. Each staff person was aware of the inservice and changes made to machine compliance. This Federal tag relates to Complaint IN 359. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure the physician was notified in a timely manner of a resident's increased body temperature. This failure resulted in a delay in medical care, hospitalization and death (Resident B). The immediate jeopardy began on 3/13/16 when the facility failed to notify the physician of an elevated temperature of 103.9 degrees Fahrenheit (F). The Executive Director, Director of Nursing and Regional Director were notified of the immediate jeopardy on 3/31/16 at 12:00 p.m. The Immediate Jeopardy was removed 4/1/16 when the facility developed and implemented a systematic plan of correction. Findings include: During record review on 3/29/16 at 9:55 a.m., the clinical record indicated Resident B was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE], indicated Resident B was unable to complete the Brief Interview Mental Status (BIMS). Resident B was severely cognitively impaired. During review of a progress note dated 3/13/16 at 6:45 p.m., RN #1 noted a fever. The note indicated the nurse gave 600 milligrams of [MEDICATION NAME]. On 3/14/16 at 6:00 a.m., LPN #2 indicated the resident was resting in bed, moaning. He had an elevated temperature and [MEDICATION NAME] was given. Review of the vital signs record, on 3/13/16 at 6:04 p.m., Resident B had an elevated temperature of 103.9 degrees Fahrenheit (F). A progress note dated 3/14/16 at 11:57 a.m., LPN #2 indicated an elevated temperature and tylenol given. A progress note on 3/14/16 at 4:16 p.m., LPN #2 indicated an elevated temperature of 100 degrees F. A progress note dated 3/14/16 at 5:03 p.m., indicated LPN #2 notified Md of increase temps. The physician responded to monitor the resident at this time. A progress note dated 3/14/16 at 7:00 p.m., RN #1 indicated an elevated temperature of 102.5 F. [MEDICATION NAME] was given. RN #1 noted the abdomen to be slightly firm and tender to palpation, resident is expelling gas. A note dated 3/14/16 at 8:02 p.m., RN #1 indicated an elevated temperature of 100.2 F, but indicated the resident continued to have abdominal tenderness with palpation. A progress note dated 3/15/16 at 12:52 p.m., indicated resident was afebrile (temperature not elevated) with hypoactive bowel sounds and discomfort with palpation. A progress note dated 3/15/16 at 1:29 p.m., indicated the physician was notified of the residents vital signs and abdominal tenderness. No specific numbers were indicated. A progress note dated 3/15/16 at 2:49 p.m., RN #4 indicated a new order for Resident B to have the following: chest x-ray, Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and 2 sets of blood cultures done 15 minutes apart. The order indicated the chest x-ray would be done tonight. A progress note dated 3/15/16 at 5:00 p.m., LPN #3 indicated may have labs drawn 3/16/16 in the AM per (name of physician). A progress note dated 3/16/16 at 1:58 a.m., LPN #5 indicated the breath sounds had rhonchi (low-pitched) breath sounds. A progress note dated 3/16/16 at 8:30 a.m., indicated CBC, BMP and blood cultures drawn per hosp lab from left hand this am. 15 minutes later 2nd set of blood cultures drawn from right hand. A note dated 3/16/16 at 12:27 p.m., indicated the Director of Nursing (DON) informed the physician of the chest x-ray results. The x-ray indicated a right perihilar infiltrate. The physician was also notified of the CBC and BMP results. A new order was received on 3/16/16 at 3:48 p.m. The order indicated to start Bactrim DS (antibiotic) 800mg/160mg, 1 tablet twice daily for 10 days and [MEDICATION NAME] (antibiotic) 500 mg daily for 10 days. The family was notified of the order. A progress note dated 3/17/16 at 2:06 a.m., LPN #5 indicated Dr. (name of physician) notified of culture results. Review of laboratory blood culture results, dated 3/16/16, indicated a preliminary result of Streptococcus A. Interview with LPN #5 indicated she had faxed the report and not actually spoken to the doctor. A progress note dated 3/17/16 at 7:30 a.m., indicated the DON spoke to the physician about the positive blood culture, related to isolation precautions. A note on 3/17/16 at 8:40 a.m., indicated Resident B was observed between the floor and the bed, crawling as per normal Resident B was observed to have the following abrasions: 4.5 cm x 5.0 cm to the right temple and a 2 cm x 2 cm to right ankle. Emesis was on his clothing and bedding. LPN #3 indicated BrSo (breath sounds) are clear and BoSo (bowel sounds) active in all four quadrants. At 9:00 a.m., the physician was notified in person of the resident's vital signs and went to assess the resident. The order was given to send the resident to the local hospital. Resident B was transported to the hospital on [DATE] at 9:15 a.m. Review of an Event Report, dated 3/13/16 at 6:45 p.m., LPN #5 noted a temperature of 103.8 degrees F. The report indicated the event started on 3/13/16 at 6:03 p.m. The report indicated Physician Notified: Yes Date/Time: 3/14/16 at 12:51 AM. During an interview on 3/31/16 at 9:20 a.m., the physician indicated she was not notified of an elevated temperature of 103.9. She indicated she was notified of a temperature on Monday from her nurse. The physician's nurse, LPN #6, indicated she had received a text message from LPN #2 on 3/14/16 at 9:57 a.m., indicating Resident B had a temperature in the 100 range and had vomited his narcotic medication. The physician indicated she was informed on Tuesday (3/15/16) the resident had abdominal tenderness, but with positive bowel sounds. She received no update on Wednesday(3/16/16). She indicated on Thursday (3/17/16), she had received a fax at 2:35 a.m., indicating a positive blood culture. The report only indicated the resident had Gram Positive Cocci (GPC). She indicated she had spoken to the DON prior to her 8:00 a.m. meeting. She indicated the DON was concerned about the blood culture containing streptococcus pyogenes (strep A). The physician indicated she was not aware of the recent culture results. She indicated she immediately contacted her nurse and gave an order for [REDACTED]. During an interview on 3/31/16 at 9:20 a.m., LPN #6 indicated she wrote the order on a sticky note and gave to LPN #3. The note indicated an order for [REDACTED].>During review of the chart, no order for the [MEDICATION NAME] was found. The physician indicated she arrived at the facility at 9:00 a.m. on 3/17/16 and went straight to Resident B's room. She indicated he was listless on his bed and had breathing rapid at about 45 breaths per minute. His hands were cyanotic and cold. His heart rate was between 135-145 beats per minute. She indicated she could tell from the doorway that he was acutely ill. She told the staff to send him to the hospital. She indicated the staff was going to call the local fire department for transfer, but she insisted it was an emergency and to call 911. She indicated there was no sense of urgency from staff. She indicated she had her phone on her 24 hours per day and staff could also call her nurse. She indicated she often received faxes at her home, but would leave early and get home late. She was also not wakened by a fax, but would never sleep through a phone call. During an interview on 3/31/16 at 12:13 p.m., LPN #3 indicated she was told by the DON to not write the order for the [MEDICATION NAME] because the resident had already been transferred. She indicated she did receive the order from the physician's nurse. She indicated when the blood cultures were ordered, there was no one in the facility that could draw the blood and the facility did not have the supplies to draw a blood culture. During an interview on 3/31/16 at 1:06 p.m., the DON indicated she did talk to the physician on Thursday. The DON indicated the facility did not have the supplies to draw the blood culture at that time and she was the only person who could draw the cultures. The DON indicated she spoke to the physician because she was concerned that she, herself, may need [MEDICATION NAME] antibiotics. She indicated the physician did seem surprised to hear the culture grew strep A. Review of a fax confirmation dated 3/14/16 at 1:04 a.m., provided by the DON on 3/31/16 at 2:51 p.m., indicated LPN #5 faxed the elevated temperature at 1:04 a.m. 7 hours after the noted temperature of 103.8 F. During an interview on 3/31/16 at 2:52 p.m., LPN #5 indicated the resident did have a temperature over 103.0 degrees F. She indicated she created the Situation Background Assessment Recommendation (SBAR) on 3/14/16 at 12:46 a.m. She indicated she faxed the SBAR to the physician, but did not hear back from her. She indicated she told the charge nurse, but could not remember who it was. She indicated she did not find any additional attempts to contact the physician. She indicated Resident B had been coughing the previous day and that everyone had been sick. She stated she monitored his vital signs throughout the night, but did not document any of them. She indicated the fax number she sent the report to was listed as the physicians' home fax machine. She indicated she was unaware of the time frame for calling physicians' or vital sign parameters. Review of the Subject, Objective, Assessment and Plan (SOAP) note, dated 3/17/16 at 8:55 a.m., the physician indicated positive for group A strep. PCN ([MEDICATION NAME]) G 2m units IV q4h was ordered as soon as possible. When (name of resident) was seen this morning, he appeared acutely ill. He was tachypneic and [MEDICAL CONDITION]. Review of a current facility policy, dated 8/8/13 and titled ABUSE, NEGLECT, AND MISAPPROPRIATION OF PROPERTY provided by the DON on 3/29/16 at 8:50 a.m., indicated the following: Purpose: Prevent abuse, neglect and misappropriation of property. Procedure: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property of residents. .Training: .3. Staff members will identity and assess . .E. Neglect, the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. .Protection: 1. All residents will be protected from harm. Review of another facility policy, dated 9/10/13 and titled Notification of Change provided by the DON on 3/29/16 at 8:50 a.m., indicated the following: Purpose: Communicate to the resident, physician and resident's legal representative or interested family member when a change in condition occurs. Notification occurs when: An accident A significant change in the residents physical mental or psychosocial status (i.e. deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) A need to alter treatment A decision to transfer Procedure: 1. Assess resident's change in condition 2. Notify physician of condition change. .5. Follow up nursing assessments continues until condition has stabilized. An Immediate Jeopardy was identified on 3/31/16 at 12:00 p.m. The IJ began on 3/31/16 when the facility failed to provide timely communication related abnormal vital signs to the physician. The Immediate Jeopardy was removed on 4/1/16 when the facility implemented a plan of action to correct the deficiency. The corrective action included the following: 1. The physician must be immediately notified of any significant change in the resident's physical, mental, or psychosocial status. 2. An SBAR will be thoroughly completed which will include the detailed information communicated to the physician including vital signs, mental status, functional status, respiratory status, GI/abdominal status, labs, etc. 3. All attempts to notify the physician will be documented in the medical record. 4. The physician will be contacted via telephone using the facility phone. No communication regarding orders or changes of condition will take place with the physician via fax, email or text messaging. In the event the nurse is unable to reach the physician in a timely manner, the Executive Director and Director of Nursing/designee with be contacted. During an interview on 4/1/16 at 10:12 a.m., the Administrator indicated the DON had updated all nursing staff on notification of change and only contacting the physician directly by telephone. She indicated the numbers have been posted at each person had to sign the form indicating they understood the change. She indicated the DON started inservicing the nursing staff shortly after noon on 3/31/16. She indicated the DON provided each nurse with a policy to notify the physician of any change. Each staff person was to date and sign the form. The nursing staff was also provided with the facility policy for Notification of Change. Nursing staff on duty were interviewed on 4/1/16 to confirm each understood the changes in the policy. Staff interviewed included LPN# 11, LPN # 10, RN # 9, RN # 4, LPN # 7, and RN #8. Each staff person was aware of the inservice and changes made to machine compliance. This Federal tag relates to Complaint IN 359. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a shoulder harness and seat belt were in place to prevent falls for 1 of 3 residents reviewed for accidents (Resident B). Findings include: The clinical record of Resident B was reviewed on 3/10/16 at 9:30 a.m. The record indicated the resident's [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set, dated dated [DATE], indicated Resident B was severely cognitively impaired. Resident B was dependent on two staff persons for transfers with a mechanical lift. A nursing note, dated 3/6/16 at 10:57 a.m., indicated Resident B fell out of his wheelchair and had broken off his two front teeth. Resident B also sustained a laceration to his lower lip. Resident B was sent to a local hospital. A nursing note, dated 3/6/16 at 4:25 p.m., indicated Resident B received 3 stitches to the inner aspect of his lower lip, as well as, 3 stitches to the outer aspect of his lower lip. A current Care Plan, dated 12/20/13 and revised 3/7/16, indicated Resident B had a problem related to fall risk. The interventions included, but were not limited to, Apply my shoulder harness .when I am in my chair. Another Care Plan, dated 7/5/13 and revised 3/7/16, indicated a problem related to devices and limited mobility. Interventions included, but were not limited to, Transfer me to my adapted wheelchair daily as tolerated with a mechanical lift. A CNA assignment sheet for Resident B indicated the following: transfers to gait trainer from w/c (wheelchair) with assist x 2; all other transfers via hoyer lift Review of an Event Investigation, dated 3/8/16, provided by the Director of Nursing (DON) on 3/11/16 at 9:25 a.m., indicated CNA #1 had transferred Resident B to his wheelchair. The CNA turned her back and Resident B fell forward and out of the wheelchair. CNA #1 indicated in the report should have buckled his seatbelt before turning away. Review of the Certified Nursing Assistant Orientation Checklist, CNA #1 completed orientation on 2/16/16. CNA #1 also completed the Transfer Training Mechanical Lift checklist on 2/16/16. During an interview on 3/10/16 at 11:00 a.m., the DON indicated CNA #1 transferred Resident B from the Hoyer lift to his wheelchair alone. She indicated the CNA should have had another person assist her with the transfer and strapped him in. Review of a current facility policy, dated 1/22/12, and titled MECHANICAL LIFT provided by DON on 3/11/16 at 9:25 a.m. indicated the following: PURPOSE: Transfer a dependent resident safely. Procedure: .7. Continue raising As applicable one person guide sling and reassure resident while other person pushes and directs movement of lift base. No additional policies were provided during the exit conference. This Federal tag relates to Complaint IN 073. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide turning and care for the prevention of pressure sores for 2 of 3 residents reviewed for pressure sores. This failure resulted in the development of pressure sores for the two residents. (Resident #34 and #55) Findings include: 1. On 5/19/14, Resident #34 was observed on his back, in the bed, at 9:00 a.m., 10:00 a.m.,11:00 a.m. and in his wheelchair at 12:10 p.m., 1:15 p.m. and 2:30 p.m. On 5/20/14 Resident #34 was observed on his back, in the bed at 9:15 a.m., 10:30 a.m., 11:25 a.m., 1:15 p.m., and 2:15 p.m. On 5/21/14 Resident #34 was observed on his back in bed at 8:00 a.m., 9:00 a.m., and 10:00 a.m. On 5/21/14 at 10:30 a.m., the personal care of Resident #34 was observed. A yellow and brown stain was observed on the resident's bottom sheet and bed pad. CNA #6 was interviewed on 5/21/14 at 11:00 a.m. During the interview, the CNA indicated she had not checked on Resident #34 since all shift, which began at 6:00 a.m. The CNA indicated she did not know when the third shift had changed the resident. On 5/21/14 at 11:00 a.m. 1:15 p.m., 3:00 p.m., and 3:30 p.m., Resident #34 was observed in the room in the wheelchair. On 5/21/14 at 7:30 p.m., Resident #34 was observed in bed. CNA #7 was interviewed. During the interview, CNA #7 indicated Resident #34 was in the wheelchair at the beginning of her shift at 2:00 p.m. The CNA indicated she changed the resident's brief at 4:00 p.m. The clinical record of Resident #34 was reviewed on 5/21/14 at 9:05 a.m. The record indicated the resident's [DIAGNOSES REDACTED]. A telephone order, dated 5/11/14, indicated " Cleanse area on R (right) side of back with wound cleanser. Cover with [MEDICATION NAME] Gentle BID (two times a day) x 7 days then re-eval." A telephone order, dated 5/16/14, indicated "Cleanse R back with wound cleanser. Apply skin prep. Apply moisturized puracell AG (silver). Cut to fit inside wound bed. Cover with [MEDICATION NAME] Gentle. Change Q (every) 3 days and PRN (as needed) X 7 days then re-eval." A nurse note, dated 5/19/14, at 11:00 p.m. indicated, "...Area to R back remains red, moist, no drng (drainage). Surrounding skin P/W/D (pink/warm/dry). No inflammation no foul odor, Area cleansed and TX applied per order. Tol (tolerated) well." The Braden Scale, an assessment to indicate a resident's risk to develop pressure ulcers was completed on 9/4/13, 11/25/13, 1/31/14, and 5/2/14. All assessment scores indicated Resident #34 was at high risk for the development of pressure sores. The Pressure Wound Flowsheet, dated 5/11/14, indicated a Stage Two pressure sore on the right side of Resident #34's back. The Flow sheet indicated the area measured 2.5 cm (centimeters) by 1 cm. The Episodic Care Plan, dated 5/11/14, indicated "Impaired skin integrity d/t (due to) loss of skin integrity as evidenced by: healed old wound, fragile skin R (right) back, partly open." The Episodic Care Plan Interventions included,"... Nurse to monitor for signs of infection at least daily. 2- Nurse to administer medication as directed. 3- Monitor resident's position at least every 2 hours to prevent adverse effects on skin related position. 4- Encourage fluid intake to promote hydration. 5- Nurse to document skin condition assessments and interventions implemented at least every shift. Nurse will notify physician and family with significant change." The Care Plan, dated 3/19/13, indicated "Potential for Alteration in Skin Integrity". The Care Plan Interventions included, "check my brief every two hours and change as needed and reposition me... Provide peri care (perineal care) with every incontinent episode..." 2. On 5/19/14, Resident #55 attended the community based workshop all day, in his wheelchair. On 5/20/14 Resident #55 was observed on his back, in the bed at 9:05 a.m., 10:15 a.m., 11:20 a.m., 1:10 p.m., and 2:20 p.m. CNA # 7 was interviewed on 5/20/14 at 1:00 p.m. During the interview the CNA indicated two CNAs were scheduled to care for 25 residents. The CNA indicated she reported to work at 6:00 a.m., and started getting those residents up who were scheduled to go out to workshop. She had to stop to serve lunch, then get more residents up. The CNA indicated she did not take her own lunch. She indicated she did not have time to do anymore than get residents up as the Care Plan indicated. The clinical record of Resident #55 was reviewed on 5/20/14 at 3:45 p.m. The record indicated the resident's [DIAGNOSES REDACTED]. The Braden Scale, an assessment used by the facility to indicate the resident's risk for the development of pressure sores was completed on 9/27/13, 12/21/13 and 3/17/14. All three assessments indicated Resident #55 was at risk for the development of pressure sores. The Pressure Wound Flow Sheet, dated 4/4/14, a stage two pressure sore on the left side of the resident's back. The draining pressure ulcer measured 1.5 cm (centimeters) by 1.0 cm. A nurse note, dated 4/21/14 at 3:00 a.m., indicated "Area to L (left) back remains unintact. Sm (small) bloody drg (drainage) noted. Cleansed and treatment applied." A nurse note, dated 4/25/14 at 3:00 a.m., indicated, "Area to back evaluated, two areas evolved into 1 area, 5 cm X 1.5 cm, New treatment orders." The Care Plan, dated 2/4/2010, indicated, " I am at risk for skin breakdown due to incontinence of bowel and bladder..." The Care Plan Interventions included: "1. Assess skin daily and document any abnormalities. 2. Check and change every two hours and prn (as needed). 3. Turn and reposition every two hours when in bed..." The CNA assignment sheets indicated Resident #55 was dependent on staff for all care. 3.1-40(a)(2)