Every finding on record at Waterford Place Health Campus

Based on interview and record review, the facility failed to ensure daily weights were obtained as ordered by the physician, admission weights were obtained in a timely matter, and the physician was notified according to the physician's order for 4 of 4 residents reviewed for quality of care. (Resident 3, 93, 10 and 94)Findings include:1. The clinical record for Resident 3 was reviewed on 1/29/26 at 1:52 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with exacerbation, heart failure, fluid overload, chronic kidney disease, and acute pulmonary edema. A physician's order, dated 12/2/25, indicated to obtain a daily weight once a day. A care plan, dated 12/3/25, indicated to obtain a weight as ordered. The Medication Administration Record (MAR), dated 12/1/25 to 12/31/25, indicated the daily weight was not obtained and documented on 12/2/25, 12/3/25, 12/6/25, 12/9/25, 12/12/25, 12/15/25, 12/24/25, 12/26/25 and 12/31/25. The MAR, dated 1/1/26 to 1/31/26, indicated the daily weight was not obtained and documented on 1/1/26, 1/8/26, 1/12/26, 1/15/26, 1/17/26, 1/18/26, 1/19/26, 1/22/26, 1/23/26, 1/24/26, 1/27/26, 1/28/26 and 1/29/26. During an interview, on 2/2/26 at 3:10 p.m., QMA 2 indicated daily weights should be completed every day, usually in the morning before breakfast. During an interview, on 2/2/26 at 3:39 p.m., the Director of Nursing (DON) indicated daily weights should be completed every day. 2. The clinical record for Resident 93 was reviewed on 1/30/26 at 10:50 a.m. The diagnoses included, but were not limited to, severe protein-calorie malnutrition, encephalopathy, pneumonia, rhabdomyolysis, atherosclerotic heart disease, ischemic cardiomyopathy, repeated falls, hypovolemic shock, and gastrostomy status. Resident 93 was admitted to the facility on [DATE]. A physician's order, dated 1/20/26, indicated to obtain an admission weight. A physician's order, dated 1/21/26, indicated to obtain an admission weight. The clinical record indicated an admission weight of 106.5 pounds was obtained on 1/26/26 at 3:40 p.m. The admission weight was not documented until 6 days after admission. During an interview, on 2/2/26 at 3:10 p.m., QMA 2 indicated admission weights should be completed as soon as the resident arrived at the facility on the day of admission. During an interview, on 2/2/26 at 3:39 p.m., the DON indicated admission weights should be completed within 24 hours of admission. Resident 93's admission weight should have been completed sooner. 3. The clinical record for Resident 10 was reviewed on 1/28/26 at 2:54 p.m. The diagnoses included, but were not limited to, diabetes mellites and a fracture of the upper and lower end of right fibula. A care plan, dated 12/28/23, indicated the resident received hypoglycemia medication and was at risk for adverse effects. Interventions included, but were not limited to, to administer medication as ordered. A physician's order, dated 8/7/25, indicated to administer Humalog insulin per the sliding scale and to call the physician for a blood sugar less than 60 or greater than 400. The clinical record indicated the resident's blood sugar was 435 on 9/19/25 at 7:09 p.m. An Interdisciplinary Team (IDT) note, dated 9/22/25 at 10:41 a.m., indicated the Nurse Practitioner was notified of the resident's elevated blood sugar. During an interview, on 1/30/26 at 2:24 p.m., the Clinical Support Nurse indicated the Director of Nursing (DON) did not notify the physician until days later, on 9/22/25. During an interview, on 2/2/26 at 3:13 p.m., RN 3 indicated when a resident had an order for sliding scale insulin the order was to be followed. When the resident's blood sugar was out of range, the Nurse Practitioner (NP) would be notified. The NP could want to add additional insulin. 4. The clinical record for Resident 94 was reviewed on 1/28/26 at 3:22 p.m. The diagnoses included, but were not limited to, history of urinary tract infection and history of cerebrovascular accident. Resident 94 was admitted to the facility on [DATE]. The clinical record indicated an admission weight of 165.0 pounds was obtained on 1/30/26 at 11:12 a.m. During an interview, on 1/30/26 at 11:24 a.m., the Medical Record Nurse indicated when a resident was admitted to the facility the nurse should obtain an admission weight within 24 hours. A current facility policy, titled Guidelines for admission Nursing Observation and Data Collection, dated as last reviewed 12/10/25 and received from the Clinical Support Nurse on 2/3/26 at 3:30 p.m., indicated .To complete and document a comprehensive assessment of the resident's current medical status, identify risk factors for additional complications or safety concerns and implement a temporary plan of care to address problem areas .The admission Observation and Data Collection form is to be completed in electronic health record by a licensed nurse .The comprehensive head to toe observation and data collection addresses each body system and shall be initiated within 12 hours and completed within 24 hours of admission A current facility policy, titled Clinical Services - Weight Monitoring, dated as last reviewed 7/3/25 and received from the Clinical Support Nurse on 2/3/26 at 3:30 p.m., indicated .The purpose of this policy is to ensure weight monitoring to promote well-being of the residents we serve and requires a multidisciplinary approach .Daily review of missing admission weights in CCM .May be reviewed by clinical leaders .Provide a list of missing weights to floor staff to obtain .Review of missing weights: Daily Weights as ordered .May be delegated to clinical leaders .Provide a list of missing monthly weights to floor staff to obtain .Review of error weights, daily, in CCM 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a catheter bag and tubing were maintained in a sanitary manner for 1 of 2 residents reviewed for catheters. (Resident 11) Findings include: During an observation, on 1/30/26 at 11:13 a.m., Resident 11's catheter was attached to the trash can next to the bed. The urine in the catheter tubing was cloudy with sediment (matter which settles to the bottom of liquid). The trash can had trash in the bottom. The clinical record for Resident 11 was reviewed on 1/28/26 at 10:22 a.m. The diagnoses included, but were not limited to, history of urinary tract infection (UTI), acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, chronic obstruction pulmonary disorder, retention of urine, and atrial fibrillation.A care plan, dated 5/30/24, indicated Resident 11 had a Foley catheter related to the diagnosis of neurogenic bladder. Interventions included, but were not limited to, observe the catheter tubing.A recently completed physician's order, dated 12/27/25, indicated to administer ciprofloxacin (an antibiotic) 500 milligrams two times a day for 14 days for a UTI.During an interview, on 1/30/26 at 11:19 a.m., the Assistant Director of Nursing (ADON) indicated the catheter bag should not be placed on the trash can. The resident had a history of urinary tract infection (UTI) and a catheter bag on the trash can contribute to infection. During an interview, on 1/30/26 at 11:21 a.m., the Medical Record Nurse indicated the catheter bag was not supposed to be on the trash can and the resident was at risk of infection.During an interview, on 1/30/26 at 11:30 a.m., Qualified Medical Assistant (QMA) 6 indicated the catheter bag should be hung on the bed rail and never on the trash can. When you hang the bag on the dirty trash can, the resident would be at risk of developing a major infection. A current facility policy, titled Urinary Catheter Care, dated as last reviewed 12/16/24 and received from the Clinical Support nurse on 2/3/26, indicated .Check the urine for unusual appearance .The urinary drainage bag should be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed when the resident had a new mental health diagnosis and was prescribed an antipsychotic medication for 1 of 3 residents reviewed for PASARR. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 1/28/26 at 12:27 p.m. The diagnoses included, but were not limited to, depression, atrial fibrillation, heart disease, vascular dementia, pseudobulbar affect, post-traumatic stress disorder (PTSD), and adjustment disorder with anxiety.A physician's order, dated 9/19/25, indicated to administer diazepam (an antianxiety medication) 2 mg (milligram) twice a day. A PASARR level I screen related to the diagnosis of anxiety disorder, and the new medication was not completed until 2/2/26 after the start of the survey.During an interview, on 2/2/26 at 3:39 p.m., the Administrator indicated when a resident had a new psychotic medication or a new mental health diagnosis added, a new level I needed to be completed. The resident did not have a new level I completed until 2/2/26 to add the diazepam. A current facility policy, titled PASARR Quick Sheet, undated and received from Clinical Support on 2/2/26 at 1:39 p.m., indicated .New Admissions: If any of the following triggers a positive response.contact the PASARR office .Individual has a severe mental illness/behavioral health (BH) diagnosis. ex. Schizophrenia, Bipolar Disorder, Major Depression Disorder, Anxiety Disorder .These diagnoses must be given by a Psych MD/ARNP and not by a PCP or some other type of treatment provider other than psychiatry 3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure infection control practices were followed for 1 of 1 randomly observed resident reviewed for infection control. (Resident 11) Findings include:During an observation, on 1/30/26 at 11:13 a.m., Resident 11's catheter was attached to the trash can next to the bed. The urine in the catheter tubing was cloudy with sediment (matter which settles to the bottom of liquid). The trash can had trash in the bottom. The clinical record for Resident 11 was reviewed on 1/28/26 at 10:22 a.m. The diagnoses included, but were not limited to, history of urinary tract infection (UTI), acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, chronic obstruction pulmonary disorder, retention of urine, and atrial fibrillation.A recently completed physician's order, dated 12/27/25, indicated to administer ciprofloxacin (an antibiotic) 500 milligrams two times a day for 14 days for a UTI.During an interview, on 1/30/26 at 11:19 a.m., the Assistant Director of Nursing (ADON) indicated the catheter bag should not be placed on the trash can. The resident had a history of urinary tract infection (UTI) and a catheter bag on the trash can contribute to infection. During an interview, on 1/30/26 at 11:21 a.m., the Medical Record Nurse indicated the catheter bag was not supposed to be on the trash can and the resident was at risk of infection.During an interview, on 1/30/26 at 11:30 a.m., Qualified Medical Assistant (QMA) 6 indicated the catheter bag should be hung on the bed rail and never on the trash can. When you hang the bag on the dirty trash can, the resident would be at risk of developing a major infection. A current facility policy, titled Infection Prevention and Control Program, not dated and received during entrance on 1/27/26, indicated .To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .monitors compliance with infection control practices and procedures 3.1-18(b)(1)

Based on observation, interview and record review, the facility failed to ensure resident rooms and hallways were maintained and kept in clean and sanitary condition for 3 of 8 rooms (room [ROOM NUMBER], 106 and 107) and 3 of 3 hallways (hallway 100, 200 and 300) reviewed for environment. Findings include: During room observations, starting on 2/10/25 at 11:18 a.m., the following were observed: a. The 100-hallway had a very strong urine and bowel movement odor. b. room [ROOM NUMBER] had a large uneven area with peeling paint and cracks on the wall next to the bathroom. c. room [ROOM NUMBER] had an unsecured outlet on the wall at the foot of the resident's bed. The outlet was pulled away from the wall with black cords plugged into the outlet. The room had a very strong urine and bowel movement odor. d. room [ROOM NUMBER] had a large basketball-size dried blood smear on the wall by the first bed near the door. The resident's sheets had dried blood on both sides of the resident. The bed by the window had two little black bugs flying around the resident and in the bathroom, there was one little black bug sitting on the toilet paper mounted on the wall. The room had a very strong urine and bowel movement odor. e. The 200-hallway had multiple mechanical lifts lined down the hall and resident wheelchairs were stored in the hallway. During an observation, on 2/12/25 at 11:05 p.m., room [ROOM NUMBER] had an unsecured outlet on the wall at the foot of the resident's bed. The outlet was pulled away from the wall and black cords were plugged into the outlet. During an observation, on 2/17/25 at 8:20 a.m., the 100-hallway had a strong urine and bowel odor. There was a very strong urine and bowel odor in rooms [ROOM NUMBERS]. During an interview, on 2/10/25 at 11:10 a.m., LPN 5 indicated he was aware the resident in room [ROOM NUMBER] had blood smeared on the wall and his sheets. The CNA was busy with another resident and had not cleaned the resident up yet. During an interview, on 2/10/25 at 11:28 a.m., the Regional Support Executive Director indicated the dialysis sewer backed up and went into room [ROOM NUMBER]'s bathroom. He indicated there were little flying bugs in the room. During an interview, on 2/12/25 at 2:13 p.m., the Maintenance Director indicated he had fixed the outlet in room [ROOM NUMBER] once before. The cover had been pulled away from the wall when the nursing staff pushed the bed against the wall and lifted the bed up and down. During an interview, on 2/13/25 at 10:59 a.m., the Regional Support Executive Director indicated the 200-hallway had multiple mechanical lifts lined down the halls. The residents' wheelchairs were stored in the hallway when the residents were in bed. The facility had no other place to store the equipment and the residents' rooms were too small to store wheelchairs. The facility did not have an environmental policy, and the facility followed the state guidelines. A current facility policy, titled Resident Rights, dated as reviewed on 12/17/24 and received from the Clinical Support nurse on 2/17/25 at 4:12 p.m., indicated .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .Our residents have a right to .be treated with dignity and respect .Personalize their apartment This citation relates to Complaint IN00450780. 3.1-19(f)(4) 3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to ensure oxygen was administered at the physician's ordered level and to obtain an order to administer oxygen for 4 of 4 residents reviewed for oxygen. (Resident 118, 51, 9 and 58) Findings include: 1. During an observation, on 2/10/25 at 12:49 p.m., Resident 118 was sitting on her recliner wearing oxygen. The oxygen concentrator was set on 0.5 liters via nasal cannula. During an observation, on 2/11/25 at 3:30 p.m., the resident was sitting on her recliner wearing oxygen. Her oxygen concentrator was set on 1 liter via nasal cannula. During an observation, on 2/14/25 at 10:20 a.m., the resident was lying in bed eating her breakfast. The resident's oxygen concentrator was set on 3 liters via nasal cannula. During an interview, on 2/14/25 at 10:25 a.m., LPN 5 indicated Resident 118's concentrator was set on 3 liters, and she was not sure of the resident's oxygen order. The clinical record for Resident 118 was reviewed on 2/12/25 at 10:01 a.m. The diagnoses included, but were not limited to, chronic obstruction pulmonary disorder (COPD), congestive heart failure (CHF), hypertension, depression, dementia, and anxiety disorder. A physician's order, dated 2/7/25, indicated to administer oxygen at 2 liters when needed. A care plan, dated 2/10/25, indicated the resident had the potential for shortness of breath while lying flat. The interventions included, but were not limited to, administer oxygen per physician's order and elevate head of bed or place in upright position when needed. A care plan, dated 2/10/25, indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory failure. The interventions included, but were not limited to, administer oxygen per physician's order and to monitor lung sounds. During an interview, on 2/13/25 at 9:50 a.m., LPN 7 indicated that when a resident wore oxygen, she would check the Medication Administration Record (MAR) and verify the liter flow the resident was ordered. When a resident was wearing oxygen without an order, she would call the physician a get the order. During an interview, on 2/14/25 at 10:36 a.m., LPN 7 indicated the resident's oxygen should be set on 2 liters. 50956 2. During an observation, on 2/10/25 at 10:43 a.m., Resident 51 was sitting in a Broda chair wearing oxygen. His oxygen concentrator was set on 3 liters per nasal cannula. The clinical record for Resident 51 was reviewed on 2/13/25 at 10:48 a.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, interstitial pulmonary disease, sick sinus syndrome, atrial fibrillation, and chronic systolic congestive heart failure. A physician's order, dated 1/9/25, indicated the resident was to receive oxygen at 2 liters continuously. A care plan, dated 1/23/25, indicated the resident had the potential for complications related to congestive heart failure. The interventions included, but were not limited to, administer oxygen according to the physician's order. A care plan, dated 1/23/25, indicated the resident had the potential for cardiovascular distress. Interventions included, but were not limited to, administer oxygen according to the physician's order. On the following dates, the resident was documented on the vitals report to have been on oxygen at 3 liters per nasal cannula: On 2/3/25 at 4:32 p.m. On 2/4/25 at 7:23 p.m. On 2/5/25 at 3:59 p.m. On 2/6/25 at 7:30 p.m. On 2/7/25 at 3:41 p.m. On 2/8/25 at 8:19 a.m. On 2/8/25 at 4:23 p.m. On 2/11/25 at 3:36 p.m. On 2/12/25 at 3:11 p.m. On 2/8/25 at 8:19 a.m., the resident was documented to be on oxygen at 1.5 liters. 3. During an observation, on 2/10/25 at 11:04 a.m., Resident 9 was lying in bed wearing oxygen. His oxygen concentrator was set on 4 liters per nasal cannula. During an observation, on 2/11/25 at 4:29 p.m., the resident was sitting up in his bed wearing oxygen. His oxygen concentrator was set on 3.5 liters per nasal cannula. The clinical record for Resident 9 was reviewed on 2/11/25 at 1:32 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, systolic (congestive) heart failure (CHF), atrial flutter, emphysema, nicotine dependence- cigarettes, and pulmonary fibrosis. A care plan, dated 1/6/25, indicated the resident had the potential for cardiovascular distress. Interventions included, but were not limited to, administer oxygen per the physician's order. A care plan, dated 1/6/25, indicated the resident had the potential for complications, functional and cognitive status decline related to respiratory disease. Interventions included, but were not limited to, administer oxygen per the physician's order. There was no physician's order for Resident 9 to receive oxygen until after the survey start date. On the following dates, the resident was documented on the vitals report to have been on the following oxygen liters: On 1/27/25 at 4:58 p.m., the resident was on 4 liters of oxygen. On 1/28/25 at 9:09 a.m., the resident was on 4 liters of oxygen. On 1/28/25 at 09:05 p.m., the resident was on 6 liters of oxygen. On 1/29/25 at 4:07 p.m., the resident was on 4 liters of oxygen. On 1/30/25 at 10:41 a.m., the resident was on 7 liters of oxygen. On 1/30/25 at 4:47 p.m., the resident was on 4 liters of oxygen. On 1/31/25 at 4:54 p.m., the resident was on 4 liters of oxygen. On 2/2/25 at 8:09 p.m., the resident was on 4 liters of oxygen. On 2/3/25 at 3:37 p.m., the resident was on 4 liters of oxygen. On 2/4/25 at 3:06 p.m., the resident was on 4 liters of oxygen. On 2/5/25 at 3:57 p.m., the resident was on 4 liters of oxygen. On 2/6/25 at 7:40 p.m., the resident was on 4 liters of oxygen. On 2/7/25 at 8:48 a.m., the resident was on 2 liters of oxygen. On 2/9/25 at 09:01 p.m., the resident was on 4 liters of oxygen. On 2/10/25 at 8:46 p.m., the resident was on 4 liters of oxygen. On 2/11/25 at 3:35 p.m., the resident was on 4 liters of oxygen. 49891 4. During an observation, on 2/10/25 at 11:07 a.m., Resident 58 was sitting in his room wearing 3.5 liters of oxygen via a nasal cannula. During an observation, on 2/11/25 at 11:02 a.m., the resident was sitting in his room wearing 3.5 liters of oxygen. The clinical record for Resident 58 was reviewed on 2/12/25 at 9:57 a.m. The diagnoses included, but were not limited to, Parkinson's disease, pneumonia, acute respiratory failure with hypoxia (low oxygen), and heart failure. There was no physician's order for Resident 58 to receive oxygen until after the survey start date. During an interview, on 2/12/25 at 10:54 a.m., LPN 8 indicated the resident now had a physician's order for 2 liters of oxygen. She would check the physician's order to verify how much oxygen to give a resident when she was adjusting the flow rate. The resident should have had an order for the oxygen administration. A current facility policy, titled Administration of Oxygen, dated 12/13/24 and provided by the Clinical Support Nurse on 2/11/25 at 4:54 p.m., indicated .Verify physician's order for the procedure .Adjust the oxygen delivery device so that .the proper flow of oxygen is administered A current facility policy, titled Guidelines for Medication Orders, dated as reviewed 12/17/24 and received by the Clinical Executive Director Support on 2/12/25 at 9:15 a.m., indicated .A current list of orders will be maintained in the electronic clinical record of each resident .Oxygen orders When recording oxygen orders specify .The rate of flow, route and rationale (i.e: 02, 2L/min per nasal cannula PRN for SOB) 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the physician's orders for a medication hold parameter was followed, hospice was notified of low blood glucose readings, and staff obtained a blood glucose reading as ordered for 3 of 3 residents reviewed for quality of care. (Resident 30, 54 and 24) Findings include: 1. The clinical record for Resident 30 was reviewed on 2/10/25 at 2:38 p.m. The diagnoses included, but were not limited to, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease and neuropathy, and nonrheumatic aortic valve stenosis. a. A physician's order, dated 1/4/25, indicated to give metoprolol tartrate (a medication used to treat high blood pressure) 25 milligrams (mg) twice a day with special instructions to hold the medication for a systolic blood pressure less than 100. A Medication Administration Record (MAR), dated 1/1/25 through 1/30/25, indicated metoprolol tartrate 25 mg was given with a recorded systolic blood pressure of less than 100 on the following dates: On 1/13/25, with a systolic blood pressure of 84. On 1/16/25, with a systolic blood pressure of 88. On 1/18/25, with a systolic blood pressure of 96. On 1/19/25, with a systolic blood pressure of 97. On 1/20/25, with a systolic blood pressure of 93. On 1/24/25, with a systolic blood pressure of 89. On 1/30/25, with a systolic blood pressure of 99. During an interview, on 2/12/25 at 10:30 a.m., LPN 5 indicated vital signs should be checked and hold parameters should be followed. b. A physician's order, dated 1/31/25, indicated to call hospice if the resident's blood glucose reading was greater than 250. A MAR, dated 1/31/25 through 2/11/25, indicated Resident 30 had the following blood glucose readings greater than 250: On 2/1/25, the resident's blood glucose reading was 256. On 2/5/25, the resident's blood glucose reading was 273. On 2/9/25, the resident's blood glucose reading was 307. There was no documentation hospice was notified of the resident's blood glucose readings greater than 250 in the medical record. During an interview, on 2/13/25 at 10:11 a.m., the Clinical Support Nurse indicated the facility did not have any documentation of hospice being notified of the elevated blood sugars and the nurse should have called the hospice provider per the order. 50956 2. The clinical record for Resident 54 was reviewed on 2/12/25 at 2:26 p.m. The diagnoses included, but were not limited to, dementia, psychotic disturbance, mood disturbance, and anxiety. A care plan, dated 11/29/23, indicated the resident had the potential for cardiovascular distress related to a diagnosis of hypertension. Interventions included, but were not limited to, administer medications as ordered and obtain vital signs as ordered. A physician's order, dated 10/24/24, indicated to give metoprolol tartrate (a medication used to treat high blood pressure) 12.5 milligrams (mg) twice a day with special instructions to hold the medication for a systolic blood pressure less than 110. A Medication Administration Record (MAR), dated 11/1/24 through 11/30/24, indicated metoprolol tartrate 12.5 mg was given with a recorded systolic blood pressure of less than 110 on the following dates: On 11/1/24, the morning dose was given with a systolic blood pressure of 105. On 11/1/24, the evening dose was given with a systolic blood pressure of 107. On 11/6/24, the morning dose was given with a systolic blood pressure of 100. On 11/12/24, the morning dose was given with a systolic blood pressure of 107. On 11/14/24, the morning dose was given with a systolic blood pressure of 104. On 11/17/24, the morning dose was given with a systolic blood pressure of 103. On 11/17/24, the evening dose was given with a systolic blood pressure of 108. On 11/18/24, the morning dose was given with a systolic blood pressure of 109. On 11/19/24, the morning dose was given with a systolic blood pressure of 100. On 11/22/24, the morning dose was given with a systolic blood pressure of 100. During an interview, on 2/12/25 at 10:30 a.m., LPN 5 indicated vital signs should be checked and hold parameters should be followed. 44598 3. The clinical record for Resident 24 was reviewed on 2/12/25 at 9:42 a.m. The diagnoses included, but were not limited to, diabetes mellitus, hypertension, and depression. A care plan, dated 4/22/21, indicated the resident was at risk for hypoglycemia and hyperglycemia related to diabetes mellitus. Interventions included, but were not limited to, monitor blood sugar, give medications as ordered, and observe the resident for signs of hypoglycemia or hyperglycemia. A physician's order, dated 5/8/22, indicated to check the resident's blood glucose reading at 4:00 a.m. to prevent hypoglycemia (low blood sugar). There was no documentation in Resident 24's Electric Health Record the 4:00 a.m. blood glucose readings were obtained, or the physician was notified the order was not completed. During an interview, on 2/14/25 at 12:00 p.m., the Clinical Support Nurse indicated the nurse entered the physician's order wrong and the 4 a.m. blood glucose reading was never obtained and recorded as ordered. During an interview, on 2/17/25 at 11:43 a.m., LPN 8 indicated when a physician gave a verbal order she would repeat the order back to the physician, go straight to the computer, and enter the order into the computer. The management team verified the new orders and made sure they were entered into the computer correctly. During an interview, on 2/17/25 at 12:25 p.m., RN 9 indicated verbal orders needed to be entered into the computer and the pharmacy made aware of the new orders. The management team reviewed the orders to ensure they were checked twice. During an interview, on 2/17/25 at 12:35 p.m., the Director of Nursing indicated he did not look at the residents' orders on the Medication Administration Record (MAR). The only reason he would check the orders was if the residents' blood glucose readings were triggered high or low. The facility did not have a policy for blood glucose monitoring. A current facility policy, titled Guidelines for Medication Orders, dated as reviewed 12/17/24 and received by the Clinical Executive Director Support on 2/12/25 at 9:15 a.m., indicated .A current list of orders will be maintained in the electronic clinical record of each resident .Standing orders .The admitting nurse shall review the standing order list with the physician when verifying admission orders .The physician shall inform the admitting nurse if any of the standing orders should be eliminated, modified and/or other standing orders added for the specific resident .Standing orders shall be in the medical record with the other physicians orders 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident who resided on the memory care unit was provided with preferred activities while in isolation for Covid-19 for 1 of 4 residents reviewed for activities. (Resident 45) Finding includes: During an observation, on 1/3/24 at 10:37 a.m., Resident 45 was lying in bed, in her room, and her eyes were closed. There was no music playing and no reading material noted on the resident's bedside table. During an observation, on 1/4/24 at 10:21 a.m., Resident 45 was lying in bed and her eyes were closed. There was no music playing and the television was not on. During an interview, on 1/4/24 at 11:20 a.m., CRCA (Certified Resident Care Assistant) 3 indicated the television in the resident's room did not work. The resident would watch television in the common area when she was not in isolation. During an observation, on 1/4/24 at 2:47 p.m., the resident was lying in bed, her eyes were opened. There was no music, the television was not on, and there were no books on the resident's side of the room. The record for Resident 45 was reviewed on 1/5/24 at 10:17 a.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, cognitive communication deficit, and anxiety disorder. An activity care plan, dated 1/2/24, indicated the resident had a history of enjoying Scripture, pet therapy, and exercise. The resident would positively respond to one-to-one activities of interest at least 6 times per week. The approaches included, but were not limited to, it was important to be around animals, and important to do things with groups of people. The group activities meaningful to the resident included pet therapy, religious, and exercise. A progress note, dated 12/26/23 at 5:06 a.m., indicated the resident was positive for Covid-19 and was placed into droplet isolation. A progress note, dated 12/28/23 at 4:11 a.m., indicated the resident continued in isolation. A progress note, dated 1/1/24 at 10:28 a.m., indicated the resident remained in isolation. A progress note, dated 1/5/24 at 8:43 a.m., indicated an order was obtained to discontinue the isolation. During an observation and interview, on 1/8/24 at 11:07 a.m., the Legacy Unit Manager indicated she did not know where the remote was for the resident's television. The Unit Manager was able to turn on the television without using the remote control. During an interview, on 1/8/24 at 11:03 a.m., Life Enrichment Staff 4 indicated documentation showed the resident did not participate in activities on December 25, December 26, December 27, December 29, December 31, January 2, January 3, or January 4. During an interview, on 1/8/24 at 11:16 a.m., the Life Enrichment Clinical Support indicated the staff would go in the isolation room based on the resident's care plan and the family input. They would provide some type of independent activity if the resident was capable such as coloring pencils. The visits should have been charted in the electronic health record. The staff was not great at charting check-in visits with the residents in isolation. The Life Enrichment Team was new, and they still needed education. She could not show what activities Resident 45 participated in while in isolation since there was no documentation of the activities in the electronic health record. A Daily Rhythms Activity Protocol, not dated and received from the Life Enrichment Clinical Support on 1/8/24 at 11:39 a.m., indicated .Through research and experience, we have learned that those living with the challenges of Alzheimer's disease and related forms of dementia benefit from a structured, predictable daily program of activities. Benefits of such a program include improved sleeping patterns, decreased depression, lower anxiety levels, fewer falls A current policy, titled Program Components/Standards, dated 6/3/2016 and received from the Life Enrichment Clinical Support on 1/8/24 at 11:48 a.m., indicated .The Life Enrichment Department designs program which are meaningful, diverse, stimulating, and consistent with the needs, preferences, and abilities of each individual resident/patient .Programs are designed to provide opportunities for each resident/patient to meet their social, physical, cognitive, and emotional needs and recreation interests .The Life Enrichment Director will ensure that the life enrichment program contains the following programming standards/programming components . Intellectual/Cognitive Programs .Social Programs .encourage interaction with others .Dementia Programs .Programs that stimulate the 5 senses help to promote resident connection A current policy, titled Resident Rights-Life Enrichment, dated 6/3/2016 and received from the Life Enrichment Clinical Support on 1/8/24 at 11:56 a.m., indicated .Special care must be taken to assure the ongoing preservation of the rights of each resident in the provision of Life Enrichment services .All residents will be informed of opportunities, and provided assistance as needed, to participate in Campus and community opportunities of their choice 3.1-33(a)

Based on interview and record review, the facility failed to identify a weight loss, notify the physician, and implement interventions for 1 of 3 residents reviewed for nutrition. (Resident 12) Finding includes: The record for Resident 12 was reviewed on 1/5/24 at 12:18 p.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, type 2 diabetes mellitus, adult failure to thrive, anxiety, and major depressive disorder. A physician's note, dated 4/3/23 at 6:04 p.m., indicated the resident tested positive for Covid-19 on 3/30/23. If the resident had signs of dehydration an intravenous line should be considered for fluid resuscitation. The resident was to be monitored for falls, increased thirst, urination, weight loss, constipation, and diarrhea. The resident had the following weights: a. On 3/1/23, the weight was 114.4 pounds. b. On 4/7/23, the weight was 106.8 pounds which was a 6.64% weight loss in 37 days. The Electronic Health Record (EHR) did not include notification to the physician of the weight loss, a nutrition note, or interventions in place for the weight loss. During an interview, on 1/8/24 at 4:08 p.m., the Clinical Support Nurse indicated the facility should have notified the physician of the significant weight change and document the significant weight loss was noted. A current policy, titled Guidelines for Weight Tracking, dated as revised on 1/16/2021 and received from the Clinical Support Nurse on 1/8/24 at 4:45 p.m., indicated .To ensure resident weight is monitored for weight gain and/or loss to prevent complications from arising from compromised nutrition/hydration .Unless otherwise indicated or ordered by the physician the resident will have their weight taken and recorded monthly .The facility dietitian or representative will review the resident's nutritional status, usual body weight and current weight to implement a nutritional program when warranted .The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days 3.1-46(a)(1)

Based on interview and record review, the facility failed to follow the physician's order to call the provider and complete a re-check for low blood sugars for 1 of 1 resident reviewed for quality of care related to insulin. (Resident 1) Finding includes: During an interview, on 1/2/24 at 3:05 p.m., Resident 1 indicated she had to go to the hospital for high blood sugars in the past. The record for Resident 1 was reviewed on 1/4/24 at 12:02 p.m. Diagnoses included, but were not limited to, type 2 diabetes with history of ketoacidosis (uncontrolled production of ketones) without coma, peripheral vascular disease, iron deficient anemia, and cognitive communication deficit. A physician's order, with a start date of 10/27/22 and an end date of 9/19/23, indicated the resident received insulin lispro (short acting insulin) per sliding scale 3 times per day. If the blood sugar was less than 70, call the MD. A current physician's order, dated 3/2/2020, indicated for blood sugars between 50-69, give a 15-gram carbohydrate oral feeding, wait 15 minutes, and recheck the blood sugar. If less than 70, than repeat the 15-gram carbohydrate 4 times a day as needed. A blood sugar log indicated the following: a. On 5/24/23 at 9:35 a.m., the blood sugar was 69. There was no documentation there was a call to the provider or a 15-minute re-check was completed. b. On 5/31/23 at 10:04 a.m., the blood sugar was 53. There was no documentation there was a call to the provider or a 15-minute re-check was completed. c. On 7/5/23 at 10:00 a.m., the blood sugar was 63. There was no documentation there was a call to the provider or a 15-minute re-check was completed. d. On 7/29/23 at 8:14 a.m., the blood sugar was 54. There was no documentation there was a call to the provider or a 15-minute re-check was completed. e. On 8/6/23 at 8:06 a.m., the blood sugar was 59. There was no documentation there was a call to the provider completed. f. On 8/21/23 at 5:33 a.m., the blood sugar was 53. There was no documentation there was a call to the provider or a 15-minute re-check was completed. g. On 8/24/23 at 3:40 a.m., the blood sugar was 55. There was no documentation there was a call to the provider or a 15-minute re-check was completed. h. On 9/4/23 at 3:35 a.m., the blood sugar was 55. There was no documentation there was a call to the provider or a 15-minute re-check was completed. i. On 9/5/23 at 3:26 a.m., the blood sugar reading indicated Low. There was no documentation a 15-minute re-check was completed. j. On 9/8/23 at 8:43 a.m., the blood sugar was 67. There was no documentation there was a call to the provider or a 15-minute re-check was completed. During an interview, on 1/4/24 at 4:11 p.m., the DHS (Director of Health Services) indicated they could not find any notification or re-checks for the low blood sugars and there should have been provider notification and re-checks completed. There was no policy for blood sugar monitoring provided by exit. 3.1-37(a)

Based on record review and interview, the facility failed to ensure there was documentation to show the resident or resident's representative made the choice about the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 2 of 3 residents reviewed for beneficiary notification. (Resident 27 and 315) Findings include: 1. The Notice of Medicare Non-Coverage (NOMNC) for Resident 27 indicated rehabilitation services would end on 12/26/23. The SNF ABN form, for Resident 27, indicated the resident no longer required skilled services but wanted to continue to reside in the SNF. Medicare would not pay for the stay at the facility since the resident did not require daily skilled care. The resident had three options to choose and was to choose only one option. The options included the resident wanted the services to continue and to bill Medicare for an official decision on payment, the resident wanted to continue the services and do not bill Medicare, or the resident did not want the services. The facility could not choose the option for the resident. The resident/representative signed the form, on 12/21/23, and did not choose an option. The Electronic Health Record (EHR) did not have a note to include the facility talked to the resident or representative about which option was chosen. 2. The Notice of Medicare Non-Coverage (NOMNC) for Resident 315 indicated rehabilitation services would end on 12/22/23. The SNF ABN form, for Resident 315, indicated the resident no longer required skilled services but wanted to continue to reside in the SNF. Medicare would not pay for the stay at the facility since the resident did not require daily skilled care. The resident had three options to choose and was to choose only one option. The options included the resident wanted the services to continue and to bill to Medicare for an official decision on payment, the resident wanted to continue the services and do not bill Medicare, or the resident did not want the services. The facility could not choose the option for the resident. The resident/representative signed the form, on 12/20/23, and did not choose an option. The EHR did not have a note to include the facility talked to the resident or representative about which option was chosen. During the interview, on 1/8/24 at 1048 a.m., the Social Services Director indicated it was an oversight and she did not verify the resident chose an option on the SNFABN form. She did not document in the EHR which option the resident or representative wanted. During an interview, on 1/9/24 at 2:59 p.m., the Social Services Director indicated the facility did not have a policy on SNF ABN forms. 3.1-4(f)(3)

Based on observation, interview and record review, the facility failed to ensure a resident at risk for development of pressure ulcers received the necessary care, treatment, and services, consistent with professional standards of practice, to prevent a pressure ulcer and promote healing for 1 of 1 resident reviewed for pressure ulcers. (Resident 23) Resident 23 had developed two pressure ulcers at the facility and the wound was discovered as a stage 2 and unstageable. Finding includes: During the initial tour of the facility, on 11/14/22 at 11:30 a.m., Resident 23 was observed sitting, in her bed, with the head of the bed elevated. A low air loss mattress was on the resident's bed. The resident's heels were directly on the mattress. Resident 23 indicated she had a wound on her buttocks which she acquired while in the facility and it caused her pain when she sat to long in one position. She needed help from the staff to reposition due to weakness. During an observation, on 11/14/22 at 2:43 p.m., Resident 23 was observed lying on her back, in bed, with the head of the bed elevated and her heels flat on the mattress. During an observation, on 11/15/22 at 9:16 a.m., Resident 23 was observed lying on her back, in bed, with the head of the bed elevated and her heels flat on the mattress. During a wound observation, on 11/15/22 at 10:30 a.m., the foam dressing for Resident 23's pressure wound on the left buttocks was removed. The wound appeared unstageable with tan colored slough on more than 50 percent of the wound bed. The foam dressing had a scant amount of light red colored discharge. Resident 23 reported pain when she was lying in certain positions or for long periods of time. During an observation, on 11/16/22 at 10:30 a.m., Resident 23 was observed lying on her back, in bed, with the head of the bed elevated to a 30-degree angle with her legs slightly elevated. No pillows were observed under her legs or heels to float. At 10:56 a.m., a nurse walked into the room and changed the television channel for Resident 23. No staff asked or assisted her to reposition or float her heels. During an observation, on 11/16/22 at 1:47 p.m., Resident 23 was observed seated, in her wheelchair, with a pressure reducing cushion in place. Her head was down to the right side, and her arms were resting on her inner thighs. Her left ankle was positioned on the inside corner of the left footrest. During an observation, on 11/17/22 at 10:58 a.m., to 11:08 a.m., Resident 23 was observed seated, in her wheelchair, with a pressure reducing cushion in place. She was watching television. She indicated she had not been up to the toilet or repositioned by staff for a while. Her buttock on the left side was very achy. The record for Resident 23 was reviewed on 11/17/22 at 3:15 p.m. Diagnosis included, but were not limited to, diabetes, chronic kidney disease, muscle weakness, respiratory failure, hypertension, coronary artery disease, and unsteadiness on her feet. An Occupational Therapy Evaluation and Treatment, dated 9/21/22, indicated Resident 23 had impairment in both her right and left arms. A Care Area Assessment (CAA), dated 9/27/22, indicated Resident 23 required extensive assistance for bed mobility, transfers, dressing, toileting, and grooming. She was completely dependent on staff for locomotion, balance during transition, and did not have a pressure ulcer or injury upon admission. The CAA indicated Resident 23 had risk factors related to immobility, incontinence, and poor nutrition. She required a special mattress or seat cushion. A nurse progress note, dated 9/20/22 at 10:44 p.m., indicated Resident 23 had admitted to the facility and had preventative dressings to the resident's coccyx. The progress note lacked indication she had skin breakdown or pressure wounds upon admission to the facility. A physician's progress note, dated 9/21/22 at 9:24 a.m., indicated Resident 23 had thrush in the groin area but no skin break down on the buttocks. A nurse practitioner's progress note, dated 9/29/22 at 7:27 p.m., indicated Resident 23's skin was normal. A nurse practitioner's progress note, dated 10/6/22 at 8:27 p.m., indicated Resident 23 was uncomfortable when she was in bed for a long period of time and increased discomfort when she was in bed at night. Her skin was normal, and she was comfortable in her wheelchair. A nurse progress note, dated 10/14/22 at 4:59 p.m., indicated Resident 23 had an open pressure wound to her left upper buttocks which measured 4.5 centimeters (cm) by 4.0 cm in size. Her surrounding skin was reddened and blanchable. She complained of pain and discomfort in the area. The wound was cleansed with wound cleanser, patted dry, and a foam dressing was applied. She was repositioned and given Tylenol for discomfort. The progress note lacked indication the provider was notified. The progress note did not indicate what stage the presssure wound was. A wound care assessment, dated 10/16/22 at 11:05 a.m., indicated treatment orders of wound gel and a foam dressing every three days and as needed. A low air loss alternating mattress was ordered. A nurse practitioner's progress note, dated 10/18/22 at 7:59 p.m., indicated Resident 23's was seen for osteoarthritis, pressure ulcer, and chronic obstructive pulmonary disease. Her pressure ulcer dressing was clean, dry, and intact but lacked indication the provider visualized the pressure wound. A Physical Therapy Discharge Summary, dated 10/7/22, indicated Resident 23 was dependent on staff for transfers, and to sit to stand. She required substantial/maximal assistance to roll left and right. A Care Plan, dated 10/17/22, indicated Resident 23 had a pressure ulcer to the left buttock and indicated the following: a. Administer analgesics per physician's order. b. Assess and record the condition of the skin surrounding the pressure ulcer. c. Encourage fluids. d. Observe and report signs of infection, localized pain, redness, swelling, tenderness, drainage, odor, and fever. e. Observe for and report signs of pain related to pressure ulcer. f. Obtain a dietary consult. g. Pressure reducing cushion to chair. h. Pressure reducing mattress. i. Provide diet, supplements, vitamins, and minerals as ordered. j. Treatment per physician orders and notify if treatment is not effective. k. Weekly skin assessment, measurement, and observation of the pressure ulcer and record. A Wound Management Report, dated 10/16/22 at 10:55 a.m., indicated Resident 23 had an unstageable deep tissue pressure wound which measured five (5) centimeters (cm) by 5 cm with a depth of 0.1 cm located on her left buttock. The wound had a light amount of serosanguinous drainage with well-defined edges. The surrounding wound was described as erythema (redness) and blanchable. The wound was not present upon entry or admission to the facility. A Wound Management Report, dated 10/17/22 at 10:43 a.m., indicated Resident 23 had a stage two pressure wound which measured 0.6 cm by 0.6 cm with no depth located on her right buttock. The wound had a light amount of serosanguinous drainage with well-defined edges. The surrounding wound was described as erythema (redness) and blanchable. The wound was not present upon entry or admission to the facility. A Wound Management Report, dated 10/17/22 at 11:05 a.m., indicated Resident 23 had an unstageable deep tissue pressure wound and measured six (6) cm by 6 cm with a depth of 0.1 cm. The wound had a light amount of serous (clear, amber, thin, and watery) drainage with irregular wound edges. The surrounding wound was described as dark purple or rusty discoloration, erythema and blanchable. She had 75 percent of her wound covered with slough (necrotic tissue which needs to be removed from the wound for healing). No documentation was found in the Wound Management report for weekly wound assessments for the left deep tissue/unstageable pressure wound on the dates of 10/24/22, or 10/31/22. A Wound Management Report, dated 11/2/22 at 12:27 p.m., indicated Resident 23 had a stage two pressure wound which closed. The report indicated staff would continue to monitor for one week. A Wound Management Report, dated 11/2/22 at 12:28 p.m., indicated Resident 23 had an unstageable deep tissue pressure wound which measured four (4) cm by 3.5 cm with a depth of 0.1 cm. The wound had light amount of serous drainage with irregular wound edges. The surrounding wound was described as erythema, blanchable, and edges were well defined. She had 100 percent of her wound covered with slough. A Wound Management Report, dated 11/6/22 at 11:20 a.m., indicated Resident 23 had a unstageable deep tissue pressure wound which measured 3.6 cm by 3.6 cm with a depth of 0.2 cm. The wound had a light amount of serosanguineous drainage with well-defined wound edges. The surrounding wound was described as erythema, blanchable, and edges were well defined. She had 98 percent of her wound covered with slough. A Wound Management Report, dated 11/14/22 at 10:55 a.m., indicated Resident 23 had an unstageable deep tissue pressure wound which measured 3 cm by 3.7 cm with a depth of 1 cm. The wound had a light amount of serosanguineous drainage with well-defined wound edges. The surrounding wound was described as erythema, blanchable, and edges were well defined. She had 50 percent of her wound covered with slough. A Care Profile indicated to: a. Encourage Resident 23 to float heels while in bed. b. Encourage to turn and reposition while in bed. c. Pressure reducing cushion to wheelchair. d. Pressure reducing mattress. The Care Profile lacked indication for staff to assist with turning and repositioning. Physician orders included, but were not limited to, 1. The right gluteus pressure wound: a. On 10/16/22, wound care directed staff to observe right gluteus dressing to open area(s) every shift for draining on dressing and dislodgement. b. On 10/17/22, wound care directed staff once every five days to cleanse with wound cleanser and gauze, apply skin prep to periwound, place 1-2 mm of wound gel to wound bed and cover with foam dressing to the right gluteus. 2. The left gluteus pressure wound: a. On 9/20/22, complete weekly skin assessments on Monday. b. On 9/21/22, encourage resident to float heels while in bed. c. On 9/21/22, apply pressure reducing cushion to wheelchair. d. On 10/14/22, encourage resident to reposition every 2 hours due to worsening open area to left upper buttocks. e. On 10/16/22, wound care directed staff to observe left gluteus dressing to open area(s) every shift for draining on dressing and dislodgement. f. On 10/16/22 to 11/2/22, wound care to left gluteus to cleanse with wound cleanser and gauze, apply NO-Sting skin prep to periwound, place 1-2 mm of wound gel to wound bed and cover with foam dressing. g. On 10/17/22, apply a specialty low air loss alternating pressure mattress. h. On 11/2/22, wound care to left gluteus to cleanse with 0.125% Dakin's Solution and gauze, apply skin prep to periwound, place 2 mm layer of Santyl to wound bed and cover with foam dressing. During an interview, on 10/15/22 at 3:13 p.m., RN 5 indicated Resident 23 had a facility acquired pressure wound on her left buttocks and recently had a facility acquired pressure wound healed on her right buttock. During an interview, on 11/21/22 at 10:44 a.m., the Corporate Support Nurse indicated the pressure wounds on Resident 23 were facility acquired and were unavoidable because of the resident needing the head of the bed up at a 30-degree angle. A current policy, titled Notification of Change in Condition, not dated and received from the Director of Nursing on 11/17/22 at 2:30 p.m., indicated .To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when: A significant change in the resident's physical, mental or psychosocial status. A need to alter treatment significantly .Documentation of notification attempts should be recorded in the resident electronic health record A current policy, titled Pressure/Stasis/Diabetic Wound Guidelines, dated as revised 12/01/2021, indicated .Purpose: To provide weekly documentation of wound measurements and condition .Re-assessment/measurement weekly or with significant change in wound noting the current treatment, medical interventions provided, and comments as needed 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure residents had an appropriate diagnosis for the use of psychotropic medications and the use of multiple antipsychotics was avoided for 7 of 7 residents reviewed for psychotropic medication use. (Resident 46, 47, 55, 5, 12, 18 and 106) Findings include: 1. The record for Resident 46 was reviewed on 11/16/22 at 11:32 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, mood disorder, personality change due to known physiological condition, anxiety disorder and depressive disorder. A physician's order, dated 12/3/21, indicated valproic acid solution (an anticonvulsant) 250 mg (milligram)/5 ml (milliliter) give 5 ml by mouth twice a day for a diagnosis of a mood disorder. A care plan, dated 4/14/22, indicated the resident received an anticonvulsant medication. The medication was for the diagnosis of a mood disorder. The approaches included, but were not limited to, administer medications per the physician's order, monitor for adverse side effects of the medication, observe mood, affect, and behaviors with all hands-on care and contacts, and to titrate the medication to the lowest effective dose. A PASARR (preadmission screening and resident review), dated 12/17/21, indicated the resident had no known or suspected bipolar disorder and had a dementia diagnosis. The mental health medication listed was Lexapro (a Selective Serotonin Reuptake Inhibitor) for depression and generalized anxiety, lorazepam (benzodiazepine) for anxiety and valproic acid (an anticonvulsant medication) for seizures. There were no other mental health medications listed on the PASARR A pharmacy recommendation, dated 7/28/22, indicated the resident had been on valproic acid 250 mg twice a day since 12/2021. The resident's chart was reviewed, and the chart reflected no signs of depression and no behavioral disturbances have been documented in the progress notes in the last 30 days. To reach the minimal effective dose, consider a dose reduction to valproic acid 250 mg at bedtime. A progress note, dated 10/31/22 at 10:50 a.m., the Social Service Director (SSD) indicated the resident's mood had remained stable and continued to be social with staff and peers. There were no current psychosocial concerns. During an interview, on 11/21/22 at 11:01 a.m., the SSD indicated the facility physician normally would put the resident on valproic acid when they had a diagnosis of dementia. 2. The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A PASARR level I, dated 6/11/21, indicated the resident had diagnoses of major depressive disorder, bipolar disorder, anxiety disorder, and dementia. A physician's order, dated 7/24/22, indicated Seroquel (an antipsychotic medication) 75 mg (milligram) at bedtime for hallucinations. A diagnosis of schizoaffective disorder with hallucinations was added 7/18/2022. During an interview, on 11/21/22 at 10:51 a.m., the Social Service Director indicated Resident 47 had a diagnosis of dementia and was on Seroquel for hallucinations. 3. The record for Resident 55 was reviewed on 11/16/22 at 11:06 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, and hallucinations. A PASARR level I, indicated the resident was not on an antipsychotic medication. A diagnosis of hallucinations was added 8/2/22. A physician's order, dated 11/1/22, indicated Risperdal (an antipsychotic) 1 mg tablet at bedtime for hallucinations. During an interview, on 11/21/22 at 10:51 a.m., the Social Services Director (SSD) indicated the resident had a diagnosis of dementia. 36454 4. The record for Resident 5 was reviewed on 11/16/22 at 3:02 p.m. Diagnoses included, but were not limited to, Parkinson's disease, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, depressive episodes, and generalized anxiety disorder. A physician's order, dated 4/1/22, indicated Seroquel (an antipsychotic) 50 mg at bedtime. A physician's order, dated 12/31/22, indicated Nuplazid (an antipsychotic) 34 mg once a day. A progress note, dated 10/31/22 at 11:09 a.m., indicated the resident utilized Seroquel and Nuplazid for a diagnosis of Parkinson's with delusions. The resident continued to have distressing hallucinations on occasion. The Nursing Drug Handbook indicated Nuplazid increased the QT interval (a heart arrhythmia which causes fast, chaotic heartbeats and can cause sudden death) and use with other drugs which increased the QT interval should be avoided. The Nursing Drug Handbook indicated Seroquel can increase the QT interval and use with other medications which increase the QT interval should be avoided. The black box warning indicated the medication was not indicated for use in elderly patients with dementia related psychosis because of the risk of sudden death from cardiovascular disease. 5. The record for Resident 12 was reviewed on 11/15/22 at 4:46 p.m. Diagnoses included, but were not limited to, generalized anxiety disorder, depressive episodes, unspecified dementia with behavioral disturbance, and age-related physical debility. A physician's order, dated 9/1/2022, indicated Seroquel 50 mg once a day for unspecified dementia with behavioral disturbance. A care plan, dated 9/20/22, indicated the resident had a diagnosis of dementia with behaviors such as physical aggression with care which was treated with an antipsychotic medication. The approaches included, but were not limited to, give medications per orders, and monitor for the side effects of the medication. A social services progress note, dated 10/31/22, indicated the resident used Seroquel for a diagnosis of dementia with behaviors such as physical and verbal aggression. The resident's mood and behaviors had been stable since admission. During an interview, on 11/16/22 at 10:49 a.m., the SSD indicated the use of Seroquel with dementia for behaviors was a gray area with the diagnosis dementia. 46961 6. During an observation, on 11/14/22 at 3:39 p.m., Resident 18 was sitting, in his Broda chair, and snoring during lunch. During an observation, on 11/16/22 at 3:09 p.m., the resident was lying flat, in bed, and was snoring. During an observation, on 11/16/22 at 4:14 p.m., the resident was resting in bed, lying flat, with his eyes closed. The record for Resident 18 was reviewed on 11/16/22 at 11:39 a.m. Diagnoses included, but were not limited to, encephalopathy, urinary tract infection, Parkinson's disease, dementia in other diseases without behavioral disturbances, schizophrenia, anxiety, and depression. A care plan, dated 3/14/22, indicated the resident demonstrated physically abusive and resistive behavior toward staff during hands-on care. Interventions included, but were not limited to, approach resident in a calm manner, and explain the care process. A care plan, dated 3/14/22, indicated the resident demonstrated inappropriate behaviors by putting self on the floor mat. Interventions included, but were not limited to, assess for unmet needs, and determine cause of inappropriate behaviors. A care plan, dated 4/5/22, indicated the resident was at risk for consequences related to receiving antipsychotic medication for Parkinson with psychosis. Interventions included, but were not limited to, administer medication as ordered by physician, observe and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. Current physician's orders included, but were not limited to, Ativan (antianxiety) 1 milligram, Benadryl (antihistamine) 25 milligram, Haldol (antipsychotic) 1 milligram and Reglan (nausea and gastric medication) 10 milligram cream (ABHR cream) 1 packet topical every 4 hours. A psychiatry progress note, dated 4/17/22, indicated the resident was showing increased sexual behavior, by making sexual comments to staff. The resident had episodes of restlessness and anxiety and the primary care doctor ordered Ativan. His wife had indicated he was more tired recently and it could be the Paxil (an antidepressant). The patient was being treated for psychosis with Parkinson's disease with Seroquel 75 milligrams. No psychosis was present the day of visit. A physician's order, dated 7/18/22, indicated to add to the diagnosis of schizoaffective disorder. A psych CAR (clinically at risk) note, dated 7/30/22 at 11:24 a.m., indicated the resident had a diagnosis of schizoaffective disorder as well as psychotic disorder, however, all behaviors related to these diagnoses have resolved. No current issues with mood or behaviors. A psych CAR progress note, dated 8/24/22 at 12:19 p.m., indicated the resident received Seroquel for a diagnosis of schizoaffective disorder. Behaviors have stabilized over the last few months with fewer and fewer episodes. A progress note, dated 10/6/22, indicated new orders were received to discontinue Seroquel and lorazepam and add ABHR cream TID. During an interview, on 11/21/22 at 11:13 a.m., the Social Service Director indicated she was unable to find any documentation as to why a diagnosis of schizophrenia was added. 7. During an observation, on 11/16/22 at 11:00 a.m., Resident 106 was sitting in a recliner, in her room, with her feet elevated. She was smiling and friendly. Her daughter was in the room styling her hair. During an observation, on 11/16/22 at 4:16 p.m., the resident was resting, in the recliner, with her feet elevated and her eyes were closed. The record for Resident 106 was reviewed on 11/16/22 at 11:34 a.m. Diagnoses included, but were not limited to, encephalopathy, delusional disorders, altered mental status, and dementia with behavioral disturbances. A psych CAR note, dated 7/30/22, indicated medications, behaviors, diagnosis, and care plans were reviewed. The resident received Seroquel for delusional disorder. She had a history of delusions. She would become combative with care and would refuse hygiene and medications at times. No psychosocial concerns. A physician's order, dated 9/30/22, indicated Seroquel 50 milligrams twice daily. A diagnosis was not included with the physician's order. A behavioral progress note, dated 10/17/22, indicated the facility had requested an evaluation due to a history of delusions and hallucinations. The resident was taking Seroquel 50 milligrams twice daily. The resident was observed to be calm, cooperative, and pleasant. The resident had a Seroquel increase due to an increase in hallucinations and delusions. No delusions noted during the visit. No hallucinations had been documented or noted by patient recently. A psych CAR note, dated 10/31/22 at 10:25 a.m , indicated Seroquel was continued for the diagnosis of delusional disorder and dementia with behaviors. During an interview, on 11/16/22 at 4:23 p.m., Nurse 6 indicated the resident did not have behaviors. The use of the medication was due to dementia with behavioral disturbances. During an interview, on 11/17/22 at 10:24 a.m., the Social Service Director indicated the resident was admitted with Seroquel due to aggressive behavior and believed the resident had a gradual dose reduction. The resident had hallucinations. The diagnosis of dementia with behaviors was for the use of Seroquel. The resident may have had a urinary tract infection but was not sure if she did. During an interview, on 11/21/22 at 3:01 p.m., the Pharmacist indicated Seroquel was an antipsychotic used for psychosis, hallucinations and delusions related to dementia and agreed this was an off-label use. She would not recommend the use of antipsychotics for the diagnosis of dementia alone. The labeled use for Seroquel was schizophrenia. A recent publication of PDR.net indicated .Depakote was indicated for the treatment of bipolar disorder including mania .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Depakote in this population should be avoided if possible due to an increase in morbidity and mortality . A recent publication of PDR.net indicated .Risperdal was indicated for the treatment of schizophrenia .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Risperdal in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .Haldol (haloperidol) was indicated for the treatment of schizophrenia .the black box warning indicated antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Haldol in this population should be avoided if possible due to an increase in morbidity and mortality A current policy, titled Psychotropic Medication Usage and Gradual Dose Reduction, dated 11/15/21 and received from the Clinical Support Nurse on 11/21/22 at 2:30 p.m., indicated .residents shall receive psychotropic medications only if designated medically necessary .with appropriate diagnosis, or documentation to support usage .regular monthly review of antipsychotics in CAR (clinically at risk meetings) for continued need, appropriate diagnosis, side effects, risks and/or benefits will be conducted, to ensure the use of psychopharmacologic medications are therapeutic and remain beneficial to the resident 3.1-48(a)(1) 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure an oxygen nasal cannula was dated, failed to ensure a physician's order was followed, failed to ensure a nebulizer mask and tubing were dated, and failed to ensure a resident had an order with BIPAP (machine used to treat sleep apnea) settings for 4 of 4 residents reviewed for respiratory care. (Resident 23, 38, 61 and 18) Findings include: 1. During an observation, on 11/14/22 at 12:51 p.m., Resident 23 was seated in her bed with the head of bed elevated to 50-degrees. Her oxygen tubing was positioned to her right cheek. Her door lacked indication she was on oxygen. No date or label was found on her tubing. She indicated it felt too big and it kept falling off. During an observation, on 11/16/22 at 1:40 p.m., Resident 23 was seated in her wheelchair. Her nasal cannula was observed to be hung over her left leg. Her door lacked indication she was on oxygen. No date or label was found on her tubing. During an observation, on 11/17/22 at 10:29 a.m., Resident 23 was seated in her wheelchair drinking water. Her nasal cannula was hanging under chin. She indicated it kept falling off. Her door lacked indication she was on oxygen. No date or label was found on her tubing. During an observation, on 11/17/22 at 10:58 a.m., to 11/17/22 at 11:08 a.m., Resident 23 was seated in her wheelchair with her oxygen nasal canula under chin. Her door lacked indication she was on oxygen. No date or label was found on her tubing. During an observation, on 11/17/22 at 1:34 p.m., a housekeeper walked into Resident 23's room. Her nasal cannula was lying on her lap. Resident 23 indicated it kept falling off. Her door lacked indication she was on oxygen. No date or label was found on her tubing. Resident 23's physician orders included, but were not limited to, clean external concentrator filters every two weeks, change oxygen tubing monthly, oxygen at two liters per minute by nasal cannula continuous. A care plan, dated 10/4/22, indicated Resident 23 had a functional and cognitive decline related to respiratory disease related to the diagnosis of respiratory failure, shortness of breath, and chronic obstructive pulmonary disease. Interventions included, but were not limited to, monitor oxygen saturations by pulse oximetry as ordered, and administer oxygen per orders. 2. During an observation, on 11/14/22 at 1:01 p.m., Resident 38's oxygen concentrator and portable oxygen tank were observed in the hallway, to the right side, of the resident's door. Resident 38 was seated in his recliner, curled with his knees up, and wrapped in a blanket. His oxygen tubing was unlabeled or dated. The oxygen concentrator was set to three liters per minute. A sign hung on the door frame and indicated no smoking oxygen in use. During an observation, on 11/15/22 at 9:15 a.m., Resident 38's oxygen concentrator and portable oxygen were observed in the hallway, to the right side, of the resident's door. The oxygen tubing was unlabeled or dated and was running under the door. Resident 38 had received oxygen at three liters per minute by his nasal cannula. A sign hung on the door frame and indicated no smoking oxygen in use. During an observation, on 11/16/22 at 9:34 a.m., Resident 38's oxygen concentrator and portable oxygen were observed in the hallway, to the right side, of the resident's door. The oxygen tubing was unlabeled and was running under the door. A sign hung on the door frame and indicated no smoking oxygen in use. Resident 38's oxygen via nasal cannula was turned to 3 liters. The record for Resident 38 was reviewed on 11/16/22 at 9:21 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease with exacerbation, hypertensive heart and chronic kidney disease with heart failure, cardiomegaly, and pulmonary hypertension. Resident 38's physician orders included, but were not limited to, change oxygen tubing monthly, clean external concentrator filter every two weeks on Sunday, use oxygen at four liters per minute by nasal cannula continuously. Resident 38's care profile indicated Resident 38's oxygen concentrator was supposed to be in the hallway, and oxygen set at three liters. During an interview, on 11/16/22 at 12:18 p.m., the Director of Health Services (DHS) indicated the oxygen concentrator was set at three liters per minute and he had orders for four liters per minute. The oxygen tubing was not labeled, and it should have been. 3. During an observation, on 11/14/22 at 9:05 a.m., on Resident 61's nightstand was a nebulizer machine with clear tubing and nebulizer mask connected. The chamber of the nebulizer had a dry white residue and was uncovered and undated. During an observation, on 11/15/22 at 10:30 a.m., on Resident 61's nightstand was a nebulizer machine with clear tubing and nebulizer mask connected. The chamber of the nebulizer had a dry white residue and was uncovered and undated. During observation, on 11/16/22 at 9:45 a.m., on Resident 61's nightstand was a nebulizer machine with clear tubing and nebulizer mask connected. The chamber of the nebulizer had a dry white residue and was uncovered and undated. The record for Resident 61 was reviewed on 11/16/22 at 11:00 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (diseases which causes airflow blockage and breathing-related problems), hypoxemia (below-normal level of oxygen in your blood), and COVID-19. During an interview, on 11/16/22 at 9:45 a.m., the Corporate Nurse Support (CNS) indicated the nebulizer supplies were not covered or dated and were lying on the nightstand. The nebulizer equipment should be cleaned after each use and labeled with a date. This was an infection control issue. During an interview, on 11/18/22 at 9:09 a.m., the CNS indicated if staff noticed a resident did not have the oxygen on, they should replace it or notify the nursing staff. Staff should ensure all respiratory equipment was labeled and dated. 46961 4. The record for Resident 18 was reviewed on 11/16/22 at 11:39 a.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, history of pneumonia with covid, obstructive sleep apnea, and chronic lung disease. A physician's order, dated 1/19/2022, indicated to use the BiPap (a machine to help breathing) at night. No BiPap settings were indicated in the order. A care plan, dated 1/31/22, indicated a potential for complications due to respiratory disease related to obstructive sleep apnea and respiratory failure. Interventions included, but not were not limited to, oxygen per order, monitor lung sounds, and oxygen saturations. There was no intervention for the BiPap at night. A care plan, dated 1/31/22, indicated a potential for shortness of breath while lying flat related to obstructive sleep apnea and respiratory failure. Interventions included, but were not limited to, oxygen per physician's order, and elevate the head of the bed. There was no intervention for the BiPap at night. During an interview, on 11/16/22 at 04:57 p.m., the Corporate Nurse Consultant indicated the BiPap settings would follow the manufacturers guidelines. During an interview, on 11/17/22 at 10:50 a.m., Nurse 6 indicated the BiPap was preset, and the order did not necessarily need to include settings. The resident took the BiPap mask off and did not use it anyway. He would look in the chart to locate settings if he needed to verify them. During an interview, on 11/21/22 at 12:08 p.m., the Clinical Support Nurse indicated the policy for respiratory and medication treatment orders would cover the BiPap settings. The BiPap order was set by the respiratory therapy company. She and the new Director of Health Services indicated the order should include settings for the BiPap. There were no directions for the BiPap order in the medication or respiratory policy. No manufacturer's guidelines were received at the time of exit. A current policy, titled Respiratory Equipment, dated 12/1/21, indicated .mark water bottle with date and initials upon opening and discard after 24 hours .change oxygen cannula and tubing monthly and as necessary A facility policy, titled Administration of Oxygen, dated as revised 5/18, indicated to verify physician's orders, place the nasal cannula around the resident's ears and in the nose, place an Oxygen in Use sign outside the room entrance door, date the tubing for the date it was initiated. Tubing should be changed monthly and as needed and place the nasal cannula into the nostrils and adjust the plastic slide to position to hold in place. A facility policy, titled Respiratory Inhalation Treatments, dated as revised 5/11/16, indicated to clean the equipment and leave to air dry. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the physician was notified of a significant weight gain for 2 of 2 residents reviewed for notification. (Resident 1 and 47) Findings include: 1. The record for Resident 1 was reviewed on 11/16/22 at 10:25 a.m. Diagnoses included, but were not limited to, type 3 diabetes mellitus, hypertension, and reduced mobility. The resident had the following weights: a. On 5/13/22, the weight was 154 pounds. b. On 7/5/22, the weight was 164.4 pounds. c. On 8/2/22, the weight was 170 pounds which was a 10.39% weight gain in 81 days. A registered dietician (RD) note, dated 8/27/22 at 11:25 a.m., indicated the resident had a significant weight gain of 10.8% since admission. The note did not include the physician was notified of the significant weight gain. An RD note, dated 10/28/22 at 11:51 p.m., indicated the resident had a significant weight gain since admission. There were no new recommendations. The note did not include the physician was notified of the significant weight gain. An RD note, dated 11/16/22 at 1:20 p.m., indicated the resident triggered for a significant weight loss of 14.3% in the last 180 days. There were no new recommendations. An RD note, dated 11/20/22 at 11:51 p.m., indicated the IDT (interdisciplinary team) reviewed the resident and was noted to have a significant weight loss. There was a new order for weekly weights and the resident would be followed on clinically at risk (CAR) and by the RD as warranted. The physician was notified. The resident had a significant weight gain and not a weight loss. During an interview, on 11/21/22 at 10:42 a.m., the Clinical Support Nurse indicated there was no notification to the physician of the significant weight gain in August. The resident did not have a significant weight loss as was documented on 11/20/22 and the documentation was in error. 44598 2. The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A physician's order, dated 4/14/21, indicated the resident's diet was a Controlled Carbohydrate (CCHO) and regular liquids. Resident 47 had a 12.58% weight gain in 6 months. a. On 5/10/2022, the weight was 244.8 pounds. b. On 11/09/2022, the weight was 275.6 pounds. A dietary note, dated 5/30/22 at 12:32 p.m., indicated the resident's intake was 68% in 7 days. The dietitian was unsure of the cause of the weight gain. The physician was not notified of the resident's significant weight gain. A care plan, dated 5/27/21, indicated the resident had continued weight gain since admission. Interventions included, but were not limited to, assist with meals as needed, dietitian to re-evaluate, offer alternate food and beverages items as needed, provide diet, supplements, medications, and adaptive equipment as ordered. During an interview, on 11/21/22 at 9:12 a.m., the Director of Nursing was not aware Resident 47 gained a significant amount of weight and did not believe the residents edema was being monitored. A current policy, titled Guideline for Weight Tracking, dated as revised 1/16/21 and received from the Director of Nursing on 11/17/22 at 2:30 p.m., indicated .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .Residents will have their weight taken and recorded upon admission to establish a baseline .Unless otherwise indicated or ordered by the physician the resident will have their weight taken and recorded monthly .Residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight .The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days (unless on a planned weight loss or gain program A current policy, titled Notification of Change in Condition, not dated and received from the Director of Nursing on 11/17/22 at 2:30 p.m., indicated .To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when: A significant change in the resident's physical, mental or psychosocial status. A need to alter treatment significantly .Documentation of notification attempts should be recorded in the resident electronic health record 3.1-5(a)(2)

Based on interview and record review, the facility failed to complete a comprehensive care plan to reflect a significant change for 1 of 1 resident reviewed for hospice services. (Resident 15) Finding includes: The record for Resident 15 was reviewed on 11/21/22 at 9:30 a.m. Diagnoses included, but were not limited to, coronavirus disease (COVID-19) (an infectious disease caused by the SARS-CoV-2 virus), pneumonia, Alzheimer's disease (type of dementia which affects memory, thinking and behavior), Parkinson's disease (brain disorder which causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), ischemic heart disease (disease in the heart's major blood vessels), and pleural effusion (buildup of fluid between the tissues that line the lungs). The record indicated Resident 15 was on hospice. An Admission Minimum Data Set (MDS) assessment, dated 9/15/22, indicated she was admitted from an acute care hospital, and she was not on hospice. A physician's order, dated 9/28/22, indicated to contact Hospice for any condition change or medication change requests. A Significant Change in Status MDS assessment, dated 11/15/22, lacked indication she was on hospice. During an interview, on 11/21/22 at 9:58 a.m., the MDS Coordinator indicated the 14-day Significant change assessment for Resident 15 was not completed after she was enrolled into a hospice program. A significant change assessment should have been completed within 14 days of the change in status when Resident 15 was admitted to hospice on 9/28/22. During an interview, on 11/21/22 at 10:00 a.m., the Corporate Support MDS indicated the facility would refer to the RAI for the timing of submissions and a Significant Change in Status should have been completed within 14 days of Resident 15 starting on Hospice. The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual version 3.0, dated 10/19, indicated a Significant Change in Status Assessment must be completed by the end of the 14th calendar day following determination a significant change had occurred. 3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure a new PASARR (preadmission screening and resident review) was completed when an antipsychotic medication and new mental health diagnosis was added for 3 of 3 residents reviewed for PASARR. (Resident 12, 47 and 55) Findings include: 1. The record for Resident 12 was reviewed on 11/15/22 at 4:46 p.m. Diagnoses included, but were not limited to, anxiety disorder, depressive episodes, and unspecified dementia with behavioral disturbance. A PASARR, dated 8/30/22, indicated the resident had depression and there were no known recent or current mental health symptoms. The only medication listed was Zoloft (an antidepressant) for depression. There was no evidence of a serious behavioral health condition. If changes occurred or new information refuted the findings, a new screen must be submitted. A physician order, dated 9/1/22, indicated Seroquel (an antipsychotic) 50 mg (milligram) once a day. During an interview, on 11/16/22 at 2:19 p.m., the Clinical Support indicated the resident's PASARR, dated 8/30/22, did not include the antipsychotic medication Seroquel or a mental health diagnosis of psychosis. A new PASARR was not completed when the Seroquel was added and should have been. 44598 2. The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A PASARR level I, dated 6/11/21, indicated the resident had a diagnosis of major depressive disorder, bipolar disorder, anxiety disorder and dementia. A physician's order, dated 7/14/22, indicated Seroquel (an antipsychotic medication) 75 mg (milligram) at bedtime for hallucinations. A diagnosis of schizoaffective disorder with hallucinations was added 7/18/2022. During an interview, on 11/21/22 at 10:51 a.m., the Social Service Director indicated Resident 47 did not have a PASARR Level I completed when starting an anti-psychotic medication. The Level I should have been done when the resident started on Seroquel. 3. The record for Resident 55 was reviewed on 11/16/22 at 11:06 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, falls, hallucinations (8/2/22), and hypertension. A PASARR level I, indicated the resident was not on an antipsychotic. A physician's order, dated 11/1/22, indicated Risperdal (an antipsychotic) 1 mg tablet at bedtime for hallucinations. A diagnosis of hallucinations was added 8/2/22. During an interview, on 11/21/22 at 10:51 a.m., the Social Services Director indicated Resident 55 should have had a new PASARR Level I when Risperdal was added for hallucinations. A current policy, titled PASARR Quick Sheet, undated and received from Clinical Support on 11/16/22 at 4:58 p.m., indicated .New Admissions: If any of the following triggers a positive response, the Level I (MAP 409) will be check YES on Section I and /or II and contact the PASARR office .Individual has a severe mental illness/behavioral health (BH) diagnosis. ex. Schizophrenia, Bipolar Disorder, Major Depression Disorder, Anxiety Disorder .These diagnoses must be given by a Psych MD/ARNP and not by a PCP or some other type of treatment provider other than psychiatry .If an individual with BH has a Primary Diagnosis of Dementia from a Psychiatrist, the Level I (MAP 409) is marked NO on the Level I and a Response to Referral Form is needed .Provisional Admission to a Nursing Facility (MAP 4093) Is to be completed when an individual needs an emergent nursing facility admission from a location other than a hospital, it is completed by a nursing facility representative and individual/family, and the resident is expected to stay less than 14 days 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure a resident who was diagnosed with dementia with no previous mental health diagnosis met the criteria for a new diagnosis of schizophrenia for 1 of 6 residents reviewed for professional standards of quality. (Resident 47) Finding includes: The record for Resident 47 was reviewed on 11/16/22 at 10:22 a.m. Diagnoses included, but were not limited to, bipolar disorder, schizoaffective disorder (a disorder which affects a person's ability to think, feel and behave clearly), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), anxiety disorder, cognitive communication deficit, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. A PASARR level I, dated 6/11/21, indicated the resident had diagnoses of major depressive disorder, bipolar disorder, anxiety disorder, and dementia. A physician's order, dated 7/14/22, indicated Seroquel (an antipsychotic medication) 75 mg (milligram) at bedtime for hallucinations. A diagnosis of schizoaffective disorder with hallucinations was added 7/18/2022. During an interview, on 11/21/22 at 10:51 a.m., the Social Service Director indicated the resident started Seroquel (an antipsychotic) on 7/14/22. The resident had a diagnosis of schizoaffective disorder. A current policy, titled Psychotropic Medication Usage and Gradual Dose Reduction, revised 10/9/17 and received from Clinical Support on 11/21/22 at 2:30 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process .Efforts to reduce dosage or discontinue psychotropic medications will be ongoing, as appropriate .Reviews of medication use will be conducted by the consultant pharmacist monthly and will .Monitor psychotropic drug use in the campus to ensure that medications are not used in excessive doses or for excessive duration 3.1-35(g)(1)

Based on observation, interview and record review, the facility failed to assess and document abnormal mouth movements for 1 of 3 residents reviewed for potential medication side effects. (Resident 1) Finding includes: During an observation, on 11/14/22 at 1:39 p.m., Resident 1 was sitting up, in a chair, in her room. She continuously was moving her tongue in and out of her mouth and her tongue appeared swollen. During on observation, on 11/15/22 at 11:45 a.m., the resident was ambulating in the hallway, with her walker, and her tongue was sticking out. During an observation, on 11/16/22 at 10:34 a.m., the resident was ambulating in the hallway, with her walker, and her tongue was sticking out. During an observation, on 11/17/22 at 10:27 a.m., the resident was ambulating in the hallway, with her walker, her tongue continued to move in and out of her mouth even while the resident was talking. The record for Resident 1 was reviewed on 11/16/22 at 10:25 a.m. Diagnoses included, but were not limited to, atrial fibrillation, type 2 diabetes mellitus, pain in the right hip, reduced mobility, and stiffness of the right knee. The list of diagnoses did not include anything about the resident's tongue movements or swollen tongue. The face sheet listed the resident's allergies as chlorpromazine (an antipsychotic which can cause uncontrollable movements of any part of the body), codeine and penicillin. An admission observation, dated 5/12/22 at 3:43 p.m., indicated the resident's oral cavity had no ulcers, lesions, halitosis, dry membranes, or bleeding gums. The admission assessment did not include continuous movements of the resident's tongue or swelling of the tongue. A physician's progress note, dated 5/24/22, indicated the resident had macroglossia (an enlarged tongue). The physician note did not include the continuous movements of the tongue in and out of the mouth. The diagnoses list did not include the macroglossia. During an interview, on 11/16/22 at 10:56 a.m., the Social Service Director (SSD) indicated the resident was admitted from another facility and there was nothing in the history about the resident having any psychiatric concerns or using antipsychotics. During an interview, on 11/16/22 at 2:16 p.m., the Executive Director (ED) indicated she did not know how the facility was aware the resident had an allergy to chlorpromazine. During an interview, on 11/16/22 at 5:04 p.m., the SSD indicated she talked to the resident who denied a history of any mental health diagnosis. The resident indicated she had been placed in a state facility for several years and then a new physician came, and she was discharged . The resident did not know where she would have received chlorpromazine. During an interview, on 11/21/22 at 3:18 p.m., the Clinical Support nurse indicated when the physician would add a new diagnosis the facility should have added it to the diagnoses list on the face sheet and the macroglossia was not listed. An AIMS (abnormal involuntary movement scale) assessment would not be completed unless the resident was currently taking an antipsychotic. During an interview, on 11/21/22 at 3:52 p.m., the ADHS (Assistant Director of Health Services) indicated the continuous moving of the resident's tongue in and out of her mouth were a baseline for the resident. There was no documentation to show the resident had the mouth movements upon admission and no documentation to show if the mouth movements were the same, better, or worse. A current policy, titled Guidelines for: Abnormal Involuntary Movement Scale, dated as revised on 5/22/2018 and received from the Clinical Support Nurse on 11/16/22 at 4:58 p.m., indicated .To assess residents that have been prescribed antipsychotic medications to identify symptoms that may indicate the presence of Tardive Dyskinesia; a neurological disorder characterized by abnormal involuntary movements which may occur as an undesired side effect of dopamine blocking medications as well as other medications such as Reglan and Levsin .A licensed nurse will complete an AIMS scale assessment on all residents on antipsychotic medications and or other medications known to cause Tardive Dyskinesia .The AIMS assessment score will be communicated to the attending physician if positive for signs and or symptoms of Tardive Dyskinesia The Nursing Drug Handbook indicated chlorpromazine was indicated for the use of psychosis, mania, nausea, vomiting, intractable hiccups and tetanus. The adverse reactions included tardive dyskinesia and seizures. The nursing considerations included, but were not limited to, monitor for tardive dyskinesia which may not appear until months or years later and may persist for life despite stopping the medication. 3.1-37(a)

Based on interview and record review, the facility failed to assess a resident for the preferred time to get out of bed for 1 of 2 residents reviewed for choices. (Resident B) Finding includes: During an observation, on 11/15/22 at 11:56 a.m., Resident B was laying, in bed, in her room. During an interview, on 11/15/22 at 2:03 p.m., Resident B indicated she would like to get out of bed earlier although the staff did not usually get her up until 11:00 or 11:30 a.m. During an observation, on 11/16/22 at 10:37 a.m., the resident was still in bed and had on a hospital gown. She indicated she was waiting for the CNA to come in and get her up. During an observation, on 11/17/22 at 10:29 a.m., the resident was laying, in bed, in her room and had on a hospital gown. During an interview, on 11/17/22 at 10:34 a.m., RN 6 indicated the resident liked to get out of bed between 10:00 a.m., and 12:00 p.m. Usually it was the same staff who worked on the unit, and they just knew what time the resident wanted to get up. There was nothing in writing to indicate what time the resident preferred to get out of bed. During an observation, on 11/18/22 at 10:28 a.m., the resident was laying, in bed, in her room and was wearing a hospital gown. The record for Resident B was reviewed on 11/16/22 at 4:12 p.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, morbid obesity, body mass index 70 or greater, chronic pain, depression, mild cognitive impairment, deformity of the right ankle, and paraplegic immobility syndrome. A care plan, dated 3/30/20, indicated the resident had an impairment in functional status related to transfers and bed mobility. The approaches included, but were not limited to, the resident required assistance with transfers and bed mobility. A care plan, dated 3/30/20, indicated the resident presented with a diagnosis of depression and had symptoms of isolating, poor self-care, and poor hygiene. The approaches included, but were not limited to, monitor the resident's participation in ADLs (activities of daily living) and leisure activities. A care plan, dated 3/23/22, indicated the resident demonstrated non-compliance with physician orders and or the plan of care. The approaches included, to encourage the resident to participate in decision making by offering choices. A Profile Care Guide, dated 3/17/22, indicated the resident utilized a motorized scooter for mobility and the Maxi Move (a floor lift designed to enable a single caregiver to transfer or reposition a resident who weighs up to 500 pounds). A resident preference sheet, dated 9/15/22, indicate the resident wanted to wake up at 3:00 a.m. The preference sheet did not include the time the resident wanted to get out of bed. A current policy, titled Resident Rights Guidelines, dated as revised on 5/11/17 and received from the Clinical Support Nurse on 11/17/22 at 4:17 p.m., indicated .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus. The following is a list of rights recognized by staff .Be given the information necessary to participate in decisions which affect them both individually and corporately .Be consulted and encouraged to have input into their care plan which guides the services delivered to the resident This Federal tag relates to Complaint IN00388949. 3.1-3(u)(1)

Based on interview, and record review, the facility failed to identify changes, assess a resident's change of condition, implement interventions, and notify physicians and family of changes for a resident with [MEDICAL CONDITION] and a current urinary tract infection who had a significant weight loss, decreased fluid intake, and became confused and lethargic for 1 of 3 residents reviewed for quality care. (Resident B). Resident B was admitted to the hospital and treated for [REDACTED]. Finding includes: During an interview, on 9/1/2020 at 2:43 p.m., Resident B's family member indicated the resident was admitted to the hospital on [DATE] for dehydration. The family member indicated the resident had never looked that bad or been in that bad of shape. The family had been calling the facility daily to find out how the resident was doing and was not able to talk to the resident because she was goofy. The family then decided on 6/19/2020 to have the resident sent to the hospital for an evaluation. The record for Resident B was reviewed on 9/1/2020 at 12:06 p.m. [DIAGNOSES REDACTED]. A care plan, dated 5/18/2020, indicated the resident was at a risk for dehydration and fluid imbalance. The goal was for the resident to remain adequately hydrated and to not display signs and symptoms of dehydration. The approaches included, but were not limited to, observe for acute mental status changes, observe for and report to the RD (Registered Dietician) and MD (Medical Doctor) any decreases in intakes, observe for clinical signs of dehydration and to offer fluids with meals, medication passes, snacks and activities. A care plan, dated 5/18/2020, indicated the resident experienced episodes of incontinence. Approaches included to encourage fluids. A care plan, dated 5/18/2020, indicated the resident had stage 3 [MEDICAL CONDITION]. The approaches included, but were not limited to, monitor weight per orders. A care plan, dated 5/15/2020, indicated the resident had a potential for alteration in nutritional status related to her diagnoses, medications, fluid balance and intake. The goal included, but was not limited to, the resident was to maintain a healthy weight without any unwarranted significant weight changes and without any unfavorable nutritional outcome. The approaches included, but were not limited to, obtain weight as ordered/needed. A nursing progress, dated 6/10/2020 at 10:06 a.m., indicated an IDT (interdisciplinary team) noted the resident's UA (urinalysis) returned with positive results. There was a new order for [MEDICATION NAME] (an antibiotic) 100 mg (milligram) two times daily for 7 days. Fluids will be encouraged and monitored for effectiveness. A nursing progress note, dated 6/12/2020 at 12:03 p.m., indicated the resident had more confusion and needed a lot of coaxing to help with tasks and understanding basic instructions like eating. The resident's daughter was contacted and was told the facility would be testing for a possible stroke. The record lacked documentation of an assessment for a stroke. A nursing progress, dated 6/13/2020 at 4:37 a.m., indicated the resident was noted to sleep most of the day. A nursing progress note, dated 6/15/2020 at 10:15 a.m., indicated an IDT noted the resident had increased confusion and increased blood pressure. The NP would be notified. A nursing progress note, dated 6/15/2020 at 12:33 p.m. indicated the resident was lethargic and appeared to have a delayed swallowing. The staff encouraged fluids with limited success. A nursing progress note, dated 6/15/2020 at 5:43 p.m., indicated the resident was more alert and responsive although lethargic. The resident was reluctant to drink liquids. A nursing progress note, dated 6/15/2020 at 7:08 p.m., indicated the resident's eyes appeared lethargic and she did not respond verbally when her name was called. The resident had the following weights: 1. On 5/14/2020 at 9:41 a.m. 130 pounds. 2. On 6/9/2020 at 12:56 p.m. 114 pounds. This was a 12.31% weight loss in less than 3 weeks. 3. On 6/16/2020 107 pound at 11:14 a.m. This was a 17.69% weight loss in one month. 4. On 6/19/2020 at 12:52 p.m. 106 pounds. The progress notes, from 6/9/2020 through 6/15/2020, did not include the significant weight loss or notifications to the RD, MD, and family of the significant weight loss. An RD progress note, dated 6/16/2020 at 7:34 a.m., indicated the resident's weight was 114 pounds and was pending a re-weight due to the weight change. Lethargy was noted. Recommendations were a ST (speech therapy) evaluation and to consider medpass (nutritional supplement) 120 ml (milliliter) twice a day for additional support. A nursing progress note, dated 6/19/2020 at 3:49 p.m., indicated the new orders by the NP included but were not limited to, an IV (intravenous) of D5-45 (5% [MEDICATION NAME] and 0.45% sodium chloride) at 75 ml (milliliter) per hour continuously. A nursing progress note, dated 6/19/2020 at 4:47 p.m., indicated the resident's daughter wanted to the resident sent to the ER. The NP would be notified and the midline (IV line) and lab work would be canceled. An ER progress note, dated 6/19/2020, indicated the resident had a [DIAGNOSES REDACTED]. During an interview, on 9/1/2020 at 4:05 p.m., the Clinical Support indicated the electronic record did not include re-weights on 6/9/2020 or 6/16/2020. The significant weight changes should have been reported to the Executive Director (ED) or Director of Health Services (DHS). Then the DHS would notify the RD. Typically residents who were new admissions would be weighed weekly but it was at the MD's discretion. There was no documentation in the electronic health record of the significant weight change until 6/16/2020 and no documentation of notification to the family of the significant weight loss. During an interview, on 9/2/2020 at 2:38 p.m., MD 2 indicated the resident had a poor appetite which was age related and got dehydrated with the UTI. The resident had acute and [MEDICAL CONDITION] and went into stage 4 kidney disease while she was in the hospital. The NP (nurse practitioner) ordered an IV on June 19, 2020 after he and the NP were aware of the symptoms, but the resident went to the hospital before she received the IV. The family wanted her to go to the hospital. During an interview, on 9/2/2020 at 4:15 p.m., the ED indicated she did not see any follow up in the electronic record from the progress note, dated 6/12/2020 at 12:03 p.m., which indicated the resident's daughter was told there would be a work up for a stroke. The ED tried to contact the nurse who wrote the progress note but was unable to reach her. A current policy, titled, Guidelines for Weight Tracking, dated 5/22/2018, and received from the Clinical Support on 9/1/2020 at 3:37 p.m., indicated, .To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration .Resident will have their weight taken and recorded upon admission to establish a baseline .Residents who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight .This should be completed when the discrepancy is noted and not wait until the dietician recommends a re-weigh .The re-weigh should be documented in the medical record as well as the original weight .The physician, responsible party and dietician shall be notified of a weight variance of >5% (unless on a planned weight loss or gain program) .The facility may open and complete a .Weight/Nutrition Event for a significant weight variance of > 5% A current policy, titled Clinically at Risk Program Guidelines, reviewed on 5/23/2018 and received from the DHS on 9/2/2020 at 12:44 p.m., indicated, . committed to providing quality medical care and excellence in customer service to those entrusted to our care. Every effort will be made to identify those residents who are clinically at risk and provide proactive interventions to manage their medical needs and minimize/eliminate further decline when possible .Criteria for residents who will be followed by the CAR team .Residents who have experienced a significant weight change. Significant weight change is defined as a variance of 5% in 30 days; 7.5% in 90 days; or 10% in 180 days. Resident is to be discussed in CAR meeting until weight is stabilized for 4 weeks or weight loss is determined unavoidable/expected due to the resident's [DIAGNOSES REDACTED].For those interventions that do not require a physician's orders [REDACTED]. A current policy, titled Notification of Change in Condition, reviewed on 5/23/2020 and received from the ED on 9/2/2020 at 3:58 p.m., indicated, .To ensure appropriate individuals are notified of change in condition. The facility use inform the resident, consult with the resident's physician and if known notify the resident's legal representative when .A significant change in the resident's physical, mental or psychosocial status .Sample reasons to notify the physician immediately but not limited to .A deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications .The responsible party should be notified of change in condition or diagnostic testing results in a timely manner .Documentation of notification or notification attempts should be recorded in the resident electronic record This Federal tag relates to Complaint IN 308. 3.1-37(a)

Based on record review and interview the facility failed to ensure a resident's plan of care and physician order [REDACTED]. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 06-06-13 at 9:15 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's current plan of care, dated 03-29-13 indicated the resident had "cellulites." Interventions to this "problem" indicated "Monitor [MEDICAL CONDITION], redness, complaints of pain, red streaking at site skin, notify MD (medical doctor) of s/s (signs and symptoms) promptly, provide treatment per MD order, Provide medication per MD order." A subsequent current plan of care, originally dated 10-26-13, indicated the resident had the "potential alteration in skin integrity related to immobility, nutritional status and [MEDICAL CONDITION]." Interventions included "assess/record changes in skin status, report pertinent changes in skin status to physician, administer/monitor effectiveness of/response to preventive treatment(s) as ordered." A review of the physician orders, dated 04-16-13, indicated "cleanse both legs with soap and water - pat dry - apply [MEDICATION NAME] and cover with ABD (abdominal) pads - wrap with kerlix and secure with tape. Change every shift until healed." Subsequent order dated 05-10-13 instructed the nursing staff to discontinue the previous treatment and provide "unna boots to bilateral lower extremities - change every 3 days and as needed." On 05-20-13, the previous order was discontinued and the physician ordered the following "May do culture of wound drainage. Do CBC (complete blood count) on 05-21-13, apply optic lock to left lower leg and cover with kerlix, secure with tape every 3 days and as needed due to soilage, and apply an ABD pad to right lower leg every day and change as needed due to soilage. Cover with kerlix and secure with tape." Review of the Treatment Administration Record, for May 2013 indicated the change in treatment orders which indicated the nursing staff provided the unna boot treatment to the resident on 05-10-13, 05-14-13 (4 days), and again on 05-17-13. The nurse indicated she followed the physician order [REDACTED]. The treatment record lacked information the treatment was provided to the right lower leg which indicated the last treatment to the right lower leg occurred on 05-17-13. Review of the nurse practitioner report dated 05-20-13 as "exam" indicated "wound nurse and facility is recommending to discontinue the Unna boots and to switch treatments as well as cultures for wound drainage." The "plan" indicated "1. New order to obtain culture for wound drainage. CBC (complete blood count) scheduled for 05-21-13. Discontinue Unna boot. New order to apply (blank) to lower leg, cover with kerlix secure with tape every three days and as needed for soilage and to right lower leg apply ABD pads every day and as needed secondary to soilage and cover with kerlix." A review of the "Other Skin Impairment Assessment," indicated the initial identification of the cellulites was on 02-26-13, and was only noted on the right lower leg. Further review of the assessment indicated by 05-01-13 and on 05-08-13 the nurse was "unable to measure" and included both the right and left lower extremities. The assessment did not indicate if the area addressed was the right or left lower leg. During interview on 06-07-13 at 1:30 p.m., the Director of Health Services indicated there was no nursing skin impairment assessment for the week of 05-15-13. The "nurses notes," dated from 05-05-13 through 05-21-13 lacked documentation or assessment of the resident's wounds to the lower legs, whether the cellulites was improving or deteriorating, the resident's response to treatment or the resident's degree of pain. Review of the hospital record on 06-07-13 at 9:15 a.m. indicated the following: On 05-21-13 the resident arrived at the local area hospital emergency room and was assessed with [REDACTED]. The clinical impression [MEDICAL CONDITION], cellulites. The "Emergency Documentation" indicated "Patient seen per ERMD (emergency room medical doctor) who requested dressing to bilateral lower extremities be removed. Dressing noted to be dry and stained. Noted to have what appeared to be yellow drainage on outer dressing. Dressings were dry and foul smelling. Attempted to remove dressing on left lower extremity but dressing was so dry that it had to be soaked loose with sterile normal saline. Noted multiple layers of gauze dressing and large padded dressing to lower extremity. Dressing on right lower extremity was removed in part per (name of physician). Remainder of dressing on right lower extremity was dry and had to be soaked off with normal saline. Spoke with patient regarding the timeliness of her dressing changes at the nursing facility and she states that her dressing were not changed daily but that someone had told her "something" about changing the dressing every 3 days. The dressing were removed after considerable soaking and effort to cause patient as little pain as possible. Tissue to lower extremities was red and dry with considerable amount of devitalized tissue noted. Small area of bleeding noted to left lower extremity where dressing had adhered to the skin. Noted that patient's lower extremities were extremely painful even at rest. Tissue was very red and wrinkled in appearance." The hospital consultation physician notation, dated 05-22-13 indicated the resident "presented to the emergency room (from the nursing home) with bilateral lower extremity swelling, changes in color involving toes and very tight wrappings around both legs. She also presented with altered mental leukocytosis and laboratory results consistent with acute [MEDICAL CONDITION]. She is complaining of increased thirst and pain in her lower extremities. She has wounds and excoriations over both her lower, very bit <sic> tender, and painful to touch with trace [MEDICAL CONDITION]. The resident was also found to have multiple areas of skin breakdown or skin at risk. Apparently she was maintained in something like a [MEDICATION NAME] compression boot on both legs at the nursing home to control the [MEDICAL CONDITION]. There was rugor, generalized, below the knee. There are large areas of flaking of the skin and there is a desquamated area on the medial malleolus of the left ankle which is very tender. There is some dark to black debris between the toes, which appears to be secondary to poor hygiene of the use of the [MEDICATION NAME] boots without significant hygiene between cleansing's...and appears to be chronic chemical [MEDICAL CONDITION] and [MEDICAL CONDITION]." Review of the hospital Wound Care Consultation report, dated 05-22-13 indicated the following; "Patient had leg dressing apparently removed in the ED (emergency department), they reported they were green in color and stuck to her skin. Skin severely dry and flaking off on foot. Left toes' skin discolored, leg presents like arterial wounds. Right leg dry with bluish discoloration below the knee." During an interview on 06-07-13 at 9:40 a.m., the hospital wound care specialist indicated the dressings were removed in the emergency room and "when I saw her the left calf was fire red - raw." The resident's record lacked complete documentation of the ongoing nursing assessment as outlined in the resident's plan of care of the residents skin condition, change in status as the resident's wounds continued to deteriorate and failure to follow the physician orders. This Federal tag relates to Complaint IN 523. 3.1-35(g)(2)

Based on record review and interview the facility failed to ensure a resident received treatment, nursing assessment and services which resulted in a resident becoming septic with altered mental status and a deterioration in the resident's skin condition (cellulites), in that when a resident had a history of [REDACTED]. with cellulites in a sample of 4. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 06-06-13 at 9:15 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's current plan of care, dated 03-29-13 indicated the resident had "cellulites." Interventions to this "problem" indicated "Monitor [MEDICAL CONDITION], redness, complaints of pain, red streaking at site skin, notify MD (medical doctor) of s/s (signs and symptoms) promptly, provide treatment per MD order, Provide medication per MD order." A subsequent "current" plan of care, originally dated 10-26-13, indicated the resident had the "potential alteration in skin integrity related to immobility, nutritional status and [MEDICAL CONDITION]." Interventions included "assess/record changes in skin status, report pertinent changes in skin status to physician, administer/monitor effectiveness of/response to preventive treatment(s) as ordered." The record indicated the resident began to experience pain related to the cellulites and the nurse obtained a physician order dated 04-03-13 which instructed the nursing staff to provide [MEDICATION NAME] (a narcotic [MEDICATION NAME]) 5/325 one every four hours for pain. Continued review of the physician orders, dated 04-16-13, indicated "cleanse both legs with soap and water - pat dry - apply [MEDICATION NAME] and cover with ABD (abdominal) pads - wrap with kerlix and secure with tape. Change every shift until healed." Subsequent order dated 05-10-13 instructed the nursing staff to discontinue the previous treatment and provide "unna boots (a compression wrap) to bilateral lower extremities - change every 3 days and as needed." On 05-20-13, the previous order was discontinued and the physician ordered the following "May do culture of wound drainage. Do CBC (complete blood count) on 05-21-13, apply optic lock to left lower leg and cover with kerlix, Secure with tape every 3 days and as needed due to soilage, and apply an ABD pad to right lower leg every day and change as needed due to soilage. Cover with kerlix and secure with tape." Review of the Treatment Administration Record, for May 2013 indicated the change in treatment orders which indicated the nursing staff placed the unna boots on the resident on 05-10-13, 05-14-13 (4 days) and again on 05-17-13. The record indicated the nurse followed the physician order to discontinue the unna boots, and provided treatment to the left lower leg on 05-20-13. The treatment record lacked documentation/information the treatment was provided to the right lower leg which indicated the last treatment to the right lower leg occurred on 05-17-13. The facility monthly nursing assessment, dated 05-18-13 indicated the resident had pain to "bilateral lower legs" and indicated the pain was a "6" on a scale of 1 - 10 (with 10 being the worst). and resident indicated the pain was moderate and frequent." The section of the assessment titled "skin" indicated the resident's skin was "warm, dry" with "circled" areas noted to "front and back of lower extremities." As the resident's condition declined, the resident started to refuse meal service. The "meal and fluid detail report" dated 05-15-13 through 05-21-13 indicated the resident began to refuse breakfast on 05-19-13 as well as lunch and dinner. The resident continued to refuse meals through 05-21-13 at which time the resident was transported to the local area hospital due to mental status changes. The nurse's notes lacked documentation the physician was notified of the continued refusal of nutrition, even though the nursing staff notation indicated that on 05-20-13 the resident was "sleepy, lethargic with poor oral intake, dry oral mucosa, very thirsty today - asked for water a lot." Review of the nurse practitioner report dated 05-20-13 as "exam" indicated "wound nurse and facility is recommending to discontinue the Unna boots and to switch treatments as well as cultures for wound drainage." The "plan" indicated "1. New order to obtain culture for wound drainage. CBC (complete blood count) scheduled for 05-21-13. Discontinue Unna boot. New order to apply (blank) to lower leg, cover with kerlix secure with tape every three days and as needed for soilage and to right lower leg apply ABD pads every day and as needed secondary to soilage and cover with kerlix." A review of the "Other Skin Impairment Assessment," indicated the initial identification of the cellulites was on 02-26-13. and was only noted on the right lower leg. Further review of the assessment indicated by 05-01-13 and again on 05-08-13, the nurse was "unable to measure" the effected areas of the resident's lower extremities. The assessment did not indicate if the area addressed was the right or left lower leg. During interview on 06-07-13 at 1:30 p.m., the Director of Health Services indicated there was no nursing skin impairment assessment for the week of 05-15-13. Additional interview on 06-07-13 at 1:30 p.m., the registered nurse corporate consultant indicated the nurses should have separate assessment sheets for each skin area of concern. Interview on 06-06-13 at 10:20 a.m., the nurse practitioner indicated, "I knew her well. The morning I saw her she was very different (emphatic). She was always confused, but this was a real change. Her WBC count was elevated, and our direction is to send the resident out to the hospital right away because the hospital can treat quicker and in her case monitor in the acute setting." When further interviewed, the nurse practitioner indicated he "never" saw the resident's bilateral lower legs. The "nurses notes," dated from 05-05-13 through 05-21-13 lacked documentation or assessment of the resident's wounds to the lower legs, whether the cellulites was improving or deteriorating, the resident's response to treatment or the resident's degree of pain. A review of the culture report dated 05-21-13 as "collected," indicated the resident had "[MEDICAL CONDITION] - left leg "heavy growth - pseudomonas aeruginosa." Review of the hospital record on 06-07-13 at 9:15 a.m. indicated the following: On 05-21-13 the resident arrived at the local area hospital emergency room and was assessed with [REDACTED]. The physician ordered blood work and determined the resident had an elevated WBC (white blood cell count). The blood work indicated the resident's WBC was 19.60 with a reference range of 4.0 - 10.50. The emergency room physician physical exam indicated the resident was lethargic, had pale conjunctiva and dry mucous membranes, generalized weakness and extremities were [DIAGNOSES REDACTED], warmth bilateral lower extremities. The clinical impression indicated "sepsis, cellulites." The "Emergency Documentation" indicated, "Patient seen per ERMD (emergency room medical doctor) who requested dressing to bilateral lower extremities be removed. Dressing noted to be dry and stained. Noted to have what appeared to be yellow drainage on outer dressing. Dressings were dry and foul smelling. Attempted to remove dressing on left lower extremity but dressing was so dry that it had to be soaked loose with sterile normal saline. Noted multiple layers of gauze dressing and large padded dressing to lower extremity. Dressing on right lower extremity was removed in part per (name of physician). Remainder of dressing on right lower extremity was dry and had to be soaked off with normal saline. Spoke with patient regarding the timeliness of her dressing changes at the nursing facility and she states that her dressing were not changed daily but that someone had told her "something" about changing the dressing every 3 days. The dressing were removed after considerable soaking and effort to cause patient as little pain as possible. Tissue to lower extremities was red and dry with considerable amount of devitalized tissue noted. Small area of bleeding noted to left lower extremity where dressing had adhered to the skin. Noted that patient's lower extremities were extremely painful even at rest. Tissue was very red and wrinkled in appearance." A review of the hospital photos of the resident's bilateral lower extremities indicated the resident had skin areas of concern which included the left foot, left calf, left knee, left inner thigh blisters, left lateral calf and the right calf. The hospital consultation physician notation, dated 05-22-13 indicated the resident "presented to the emergency room (from the nursing home) with bilateral lower extremity swelling, changes in color involving toes and very tight wrappings around both legs. She also presented with altered mental leukocytosis and laboratory results consistent with acute [MEDICAL CONDITION]. She is complaining of increased thirst and pain in her lower extremities. She has wounds and excoriations over both her lower, very bit <sic> tender, and painful to touch with trace [MEDICAL CONDITION]. The resident was also found to have multiple areas of skin breakdown or skin at risk. Apparently she was maintained in something like a [MEDICATION NAME] compression boot on both legs at the nursing home to control the [MEDICAL CONDITION]. There was rugor, generalized, below the knee. There are large areas of flaking of the skin and there is a desquamated area on the medial malleolus of the left ankle which is very tender. There is some dark to black debris between the toes, which appears to be secondary to poor hygiene of the use of the [MEDICATION NAME] boots without significant hygiene between cleansing's...and appears to be chronic chemical [MEDICAL CONDITION] and [MEDICAL CONDITION]." Review of the hospital Wound Care Consultation report, dated 05-22-13 indicated the following; "Patient had leg dressing apparently removed in the ED (emergency department), they reported they were green in color and stuck to her skin. Skin severely dry and flaking off on foot." Interview on 06-07-13 at 9:40 a.m., the hospital wound care specialist indicated the dressings were removed in the emergency room and "when I saw her the left calf was fire red - raw." When interviewed that the facility had previously used an unna boot for the resident's cellulites, the wound care specialist indicated "if that type of treatment was used they should have checked the resident's arterial brachial index or at least get an arterial flow study before using that type of compression. The danger is if you don't have that study prior, you could impede the arterial flow." Interview on 06-07-13 at 1:30 p.m. the Director of Health Services indicated she was unaware if the arterial flow studies were completed prior to the application of the unna boots. The resident was transferred from the emergency room and admitted to the hospital. Review of the facility policy on 06-07-13 at 11:00 a.m., and noted as undated, titled "General Wound and Skin Care Guidelines," indicated the following: "Purpose: To provide measures that will promote and maintain good skin integrity. Procedure: The following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity. 9. Dress chronic wounds using clean technique, since all chronic wounds are contaminated. 10. Cleanse wounds using a non-toxic agent prior to making wound assessment and applying a new dressing. 11. Select a dressing that keeps the wound bed moist and the periwound skin dry. 12. Select a dressing that is at least 2 inches larger than the affected area. 14. Perform the wound treatment. Picture frame dressings, as needed with tape as needed. 15. Reevaluate dressing and skin integrity every shift. 16. Reevaluate the wound's response to the prescribed treatment. Make recommendations for changes as needed. Inform MD (Medical Doctor) of changes in wound status. 17. Know the indications and contraindications for the wound products used. 18. Date, time and initial all dressings at time of application. 20. Document type of wound, location, state (if applicable), length, width, depth (in centimeters), base, drainage, periwound tissue, and treatment of [REDACTED]." This Federal tag relates to Complaint IN 523. 3.1-37(a)

Based on observation, interview and record review the facility failed to ensure the safety of 1 resident during a transfer using a lift device. The resident sustained [REDACTED]. The facility failed to ensure the safety of 1 resident with unsafe gaps inside the bed rail and an unsafe gap between the mattress and headboard. This affected 2 of 5 residents reviewed for accidents. (Resident #B, #D) Findings include: 1. The record for Resident #B was reviewed on 2/28/13 at 11:20 a.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #B could not report the correct year and could not recall 2 of 3 words given at the beginning of the Brief Interview for Mental Status (BIMS) assessment. The resident's BIMS assessment was a 7 out of a possible 15. The MDS assessed Resident #B an extensive assist of one person physical assist for transfers and toilet use. The MDS assessed Resident #B to have impairment on both sides regarding the lower extremities. A care plan titled, "ADL (activities of daily living) Self-Care Deficit, dated 9/21/12, indicated, "...Needs assistance or is dependent in...Transfer...Weight bearing...Mechanical lift...." A Rehabilitation Screening dated 9/13/12 for Resident #B indicated, "...Resident was a mechanical lift transfers. Resident had a change...Resident could benefit from skilled PT (physical therapy) to (sign for decrease) assistance needed in long term care...." A physical therapy discharge summary dated 10/18/12 indicated, "...Staff to continue to use a stand up lift to transfer patient for safety...." A Rehabilitation Screening dated 12/17/12 for Resident #B indicated, "...do not show any change in functional mobility (sign for at) this time...." A nurse's note for Resident #B dated 2/13/13 at 1510 (3:10 p.m.) indicated, "Called to Rsd (resident) room per CNA's (Certified Nursing Assistant), noted Rsd kneeling in BR (bathroom)...CNA's reported Rsd did not fall, while attempting to roll Rsd onto her side noted Fx (fracture) to (sign for left) (sign for lower) extremity...911 called." A Fall Circumstance Assessment and Intervention form dated 2/13/13 indicated Resident #B was assisted to the floor with injury to the left lower extremity. The form indicated the resident was transferring from the toilet to a wheel chair with a stand-up lift. The form indicated the root cause was the resident was transferred improperly with a lift device. A physician's orders [REDACTED]." A hospital record with an admission date of [DATE] for Resident #B indicated, "...Diagnosis: [REDACTED]. There is exposed bone...Assessment: This is an open fracture...we will place an [DEVICE]...The risks include loss of extremity....may consider below knee amputation if the family is willing to proceed...." A nurse's note dated 2/22/13 at 1515 "(3:15 p.m.) indicated Resident #B has a left below the knee amputation. During an interview on 2/28/13 at 11:00 a.m., regarding the transfer incident with Resident #B, the Director of Nursing (DoN) indicated 3 CNA's and 2 LPN's were suspended immediately pending an investigation of the incident. A Job Specific Orientation checklist dated 1/3/13 indicated, "...New employee to initial & date each line when completed...." CNA #1's initials were marked on the line for stand-up lifts. A Personnel Action Form dated 2/21/13 for CNA #1 and signed by CNA #1 indicated, "...Termination...Involuntary - Reason: Improper use of equipment (sign for with) serious consequence...." A Job Specific Orientation checklist dated 9/18/12 indicated, "...New employee to initial & date each line when completed...." CNA #2's initials were marked on the line for stand up lifts. An Employee Counseling Record Form dated 2/14/13 for CNA #2 and signed by CNA #2 on 2/25/13 indicated, "...was present during care of a RSD (resident) when all safety measures were not in place and RSD was injured...(name of CNA #2) stated she was present...but engaged in conversation...and unaware sling was not applied correctly...." An Employee Counseling Record Form dated 2/14/13 for CNA #3 and signed by CNA #3 on 2/25/13 indicated, "...was aware coworker did not utilize all safety precautions during a RSD transfer and did not intervene. RSD was seriously injured...." During an interview on 3/1/13 at 1:50 p.m., CNA #2 indicated on 2/13/13 the resident "needed to go to the bathroom." CNA #2 indicated the resident used the Sara 3000 mechanical lift. CNA #2 indicated CNA #1 and CNA #3 were passing ice water and came into the room to assist. CNA #2 indicated CNA #1 applied the sling to Resident #B and attached the sling to the stand-up lift device. CNA #2 indicated the resident was moved to the bathroom by CNA #1. CNA #2 indicated CNA #1 and CNA #3 returned to passing ice water. CNA #2 indicated peri care and incontinence care was provided to Resident #B. CNA #2 indicated Resident #B's "feet slipped off the platform." CNA #2 indicated the device was lowered, and Resident #B's knees were on the ground. CNA #2 indicated, "yelled for help." CNA #2 indicated CNA #1 and CNA #3 returned to help, and LPN #4 and LPN #5 also entered to assess the resident and assist. CNA #2 indicated when Resident #B was repositioned on the ground there was a "snap" and "it was broke." CNA #2 indicated Resident #B went to the hospital. During an interview on 3/1/13 at 2:26 p.m., LPN #5 indicated CNA #2 "came and got me." LPN #5 indicated when she entered Resident #B's room, Resident #B was on the lift "chicken winging." LPN #5 indicated the sling was under Resident #B's armpits and the resident's hands were in the down position. LPN #5 indicated Resident #B's knees were on the ground with the resident's weight down on the resident's ankles. LPN #5 indicated the resident was lowered to the ground and assessed. LPN #5 indicated during the attempt to reposition the resident by a "log roll" someone asked, "Oh did her foot hit the lift?" LPN #5 saw the injury to the left ankle and indicated to "get help." During an interview on 3/1/13 at 2:44 p.m., CNA #3 indicated on 2/13/13, while passing ice water with CNA #1, both CNA's entered Resident #B's room to assist CNA #2 with a transfer of Resident #B to the bathroom. CNA #3 indicated CNA #1 retrieved the stand-up lift from the hall. CNA #3 indicated CNA #1 applied the sling to Resident #B and attached the sling to the lift device. CNA #3 indicated, "it looked like the buckles were dangling." CNA #3 indicated CNA #1 operated the device and wheeled Resident #B into the bathroom. CNA #3 indicated CNA #1 indicated, "...all yours," and they returned to finish passing ice water and left Resident #B in the care of CNA #2. During an interview on 3/1/13 at 3:25 p.m., the DoN indicated she had concerns at the scene of the incident on 2/13/13. The DoN indicated the resident was wearing socks that were not skid-proof. The DoN indicated she would not expect that with any transfer. The DoN indicated the CNA's reported the resident "slid out." The DoN indicated, "cannot slide out if in it properly." During a phone interview on 3/1/13 at 3:45 p.m., CNA #1 indicated she and CNA #3 were passing ice water. CNA #1 indicated they entered Resident #B's room to assist CNA #2. CNA #1 indicated she applied the sling to Resident #B and did not buckle the belts around the resident's waist. CNA #1 indicated she did not buckle the leg straps. CNA #1 indicated she transferred the resident into the bathroom on the stand-up lift and placed the resident on the toilet. CNA #1 indicated she and CNA #3 returned to passing ice water and left Resident #B in CNA #2's care. A facility policy provided by the DoN on 2/28/13 at 11:00 a.m., titled, "Guidelines for Resident Transfers," indicated, "...All devices are safe to be used by one staff member per manufactures guidelines...." The Sara 3000 Operating and Product Care Instructions, Issue 4, September 2010, provided by the DoN on 2/28/13 at 12:10 p.m., indicated, "...Lower Leg Straps: Accessory used to ensure that the lower parts of the resident's legs stay close to the knee support...Ensure that the straps are firm but comfortable for the resident...Warning: The sling chest support strap must always be applied and fastened when using the sling...." 2. The record for Resident #D was reviewed on 3/1/13 at 10:40 a.m. [DIAGNOSES REDACTED]. A care plan titled, "ADL Self-Care Deficit" dated 2/4/13 indicated, "...Prefers to sleep in r/c (recliner)...1/2 side rails as an enabler...." A Restraint/Enabler Circumstance Assessment and Intervention dated 1/9/13 for Resident #D indicated side rails for positioning and to assist with mobility. The form indicated Resident #D had dementia and decreased mobility. An Assessment Review and Considerations dated 1/10/13 indicated Resident #D was a fall risk due to cognitive impairment and mobility impairment. A physician's orders [REDACTED]. During an observation in the presence of the DoN on 2/28/13 at 2:40 p.m., Resident #D had 1/2 siderails bilaterally to the head of the bed. The bed was against the wall. The 3 gaps inside each of the side rails measured respectively 8 inches x 8.5 inches, 8 inches x 17 inches and 8 inches x 8.5 inches. The gap between the headboard and the mattress measured 4.5 inches wide. Resident #D was up in a wheel chair at the time of the observation. During an interview on 2/28/13 at 2:45 p.m., the DoN indicated the maintenance staff would remove the bed from the room. A facility policy provided by the Nurse Consultant on 2/28/13 at 4:05 p.m., titled, "Guidelines for Bed Frame Fitting," indicated, "...Bed frames, mattresses and side rails shall be monitored to ensure proper fit...There should be mo (sic) more than 2.5 inches between the head board and the mattress...There should be no more than 4.5 inches between the side rail bars...." This Federal Tag relates to Complaint IN 813. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review, observation and interview, the facility failed to identify, assess, and implement interventions to prevent weight loss and prevent the possibility of weight loss for 7 of 14 residents reviewed for weight loss in a sample of 17. (Resident # 11, # 65, # 104, # 63, # 83, # 4, and # 20) Resident # 11 experienced a 45.4 pound weight loss which was a 21% loss in 90 days, without intervention. Finding include: 1. An undated policy titled "Nutritional Management Guidelines" was provided by the Nurse Consultant on 2/18/11 at 1:20 p.m., and deemed as current. The policy indicated: "Purpose: To ensure all residents are assessed for nutritional needs with interventions implemented as appropriated to maintain proper nutritional balance...2. Nutritional assessment will be completed quarterly and as needed thereafter...5. Residents identified to be a nutritional risk may include but are not limited to: a. Significant unplanned weight loss 1. 5 % in one month, 7.5 % in three months...b. Identified with chronic weight loss yet not meeting the above criteria. c. Determined to be at risk by nutritional assessment. d. Significant risk factors...f. Compromised lab values 1. Serum [MEDICATION NAME] below 3.5...Approaches to be taken are, but not limited to: d. Implementation of additional caloric products 1. Fortified foods with meals and for snacks 2. High caloric snacks between meals 3. In-house nutritional supplements per physician order [REDACTED]." 2. An undated policy titled "Guidelines for Weight Tracking" was provided by the Administrator on 2/17/11 at 12 p.m. and deemed as current. The policy indicated: "Purpose: To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition...3. The facility dietician will review the resident's nutritional status, ideal body weight and current weight to implement a nutritional program when warranted...8. The...dietician shall be notified of a weight variance of >(greater than) 5 %...." 3. A 11/07 policy titled "Clinically At Risk (CAR) Program Guidelines" was provided by the Administrator on 2/17/11 at 12 p.m., and deemed as current. The policy indicated: "...Criteria for residents who will be followed by the CAR team: Residents who have experienced a significant weight change. Significant weight change is defined as a variance of 2 % in 7 days, 5 % in 30 days, 7.5 % in 90 days...5. The CAR team will review current interventions and potential changes and make recommendations based on individual resident's needs...6. For those interventions that do not require a physician's orders [REDACTED]. dietary/nursing/clinical measures, the responsible clinician will take the appropriate action for implementation...." 4. The record for Resident # 11 was reviewed on 2/15/11 at 1:25 p.m. Current [DIAGNOSES REDACTED]. A 1/28/11 Significant Change Minimum Data Set Assessment (MDS) failed to indicate the resident had had weight loss. The record lack a plan of care for weight loss until 2/17/11. The resident was readmitted to the facility on [DATE]. A "Nutritional Assessment" dated 11/15/10 indicated the resident had an actual weight of 216.4 pounds. The assessment indicated the resident consumed 88.7 % of meals and had an [MEDICATION NAME] of 2.9 (Normal range - 3.3 to 4.5) on 11/1/10. A "Vital Signs and Weight Record" indicated the following weights: 11/17/10: 206.1 12/2/10: 207.4 12/9/10: 208.4 12/16/10: 195.2 Physician and family notified 12/20/10: 190.2 1/3/11: 186 Physician and family notified 1/11/11: 178.6 Physician and family notified 2/9/11: 171.8 Physician and family notified The above form had an identified place for dietary to be notified. This area of the form was blank. physician progress notes [REDACTED]. CAR (Clinically at Risk) meeting notes dated 12/2/10 indicated the resident weighed 207.4 pounds and consumed 63% of meals. On 12/9/10, weight was 208.4 with the resident consuming 66 % of meals. On 12/16/10 the weight was recorded as 195.2 pounds with the resident consuming 70 % of meals. On 12/22/10 the weight was recorded at 190.2 pounds, no consumption was recorded. On 12/29/10 the weight was recorded at 192 with no consumption and on 1/5/11 the weight was recorded at 186 pounds. In the area of the form that indicated "Resident continues with weight instability. See below for updated interventions" did not mention weight loss or any interventions to be implemented. Between 12/2/10 and 1/5/11 the resident lost 21.4 pounds which was a 10.3 % weight loss. The Certified Dietary Manager was not in attendance at the CAR meeting 12/2/10-12/29/10. On 2/18/11 at 10:30 a.m., during interview, the Certified Dietary Manager # 27 indicated she was on sick leave between 12/2-29/10. She did sign the CAR note on 1/5/11 as being in attendance. During the above interview, she indicated she did not know who was to communicate to the dietician during her absence. She further indicated, the resident should have been on the list to see the dietician due to his weight loss. On 12/20/[MEDICATION NAME] (protein supplement) was added for wound healing due to open areas on his bottom. A CAR note dated 1/12/11 indicated the resident weighed 178.6 pounds and consumed 50 % if meals, still no interventions are implemented for the weight loss. A nursing note dated 1/15/11 at 2:30 p.m., indicated the resident was pale and lethargic. A nursing note dated 1/5/11 at 3:40 p.m., indicated the physician was called at the insistence of the daughter due to the resident's change in cognition and a moist cough. A nursing note dated 1/15/11 at 3:50 p.m., indicated the resident could not feed himself and was fed by staff. On 1/15/11 the resident was admitted to the hospital with [REDACTED]. The family declined a gastrostomy tube and speech had suggested a special diet. A 12/7/10 laboratory report indicated the resident's [MEDICATION NAME] was 3.4 which was within normal limit. A 1/16/11 (name of hospital) "Nutritional Assessment Form" indicated the resident had lost 40 pounds in 2 months. The form indicated the resident was placed on sugar free vanilla health shakes with breakfast and dinner, sugar free pudding with breakfast, oatmeal with breakfast and brown sugar portion with breakfast. The form indicated the resident had significant weight loss of 19 % in 2 months which the daughter confirmed, and the resident very likely had protein-calorie [MEDICAL CONDITION]. The resident was readmitted to the facility on [DATE] with a pureed diet with nectar thick liquids. No supplements or other dietary interventions were implemented [MEDICATION NAME]. (protein supplement) A 1/24/11 nursing assessment indicated the resident weighed 178.6 pounds. The resident was admitted to hospice care on 1/27/11. On 2/21/11 at 11:10 a.m. during an interview with (name of hospice) RN, she indicated the resident was started on [MEDICATION NAME] (steroid) on 2/4/11 for appetite stimulation. During an interview with Registered Dietician on 2/17/11 at 2:50 p.m., she indicated she was not aware the resident had significant weight loss until January 27, 2011. She indicated she had not seen the resident until this day. A 2/17/11 "Quarterly -Weekly Nutrition Progress Overview" indicated the resident had a 45.4 pound weight loss which was 21 % in 90 days. At this time, she had recommended sugar free Med Pass 60 milliliters three times daily due to significant weight loss. 5.) Resident #65's record was reviewed on 2/15/11 at 11:51 a.m. Resident #65's current [DIAGNOSES REDACTED]. Resident #65 resided on a secured dementia unit. Resident #65 had a current 2/11 physician's orders [REDACTED]. Resident #65 was admitted to the facility as a residential, assisted living dementia needs resident, on 8/3/09. Her weight at the time of her admission was 276 pounds. She was not on a planned weight loss during her stay in the residential area of the facility. Resident #65 was admitted to the skilled nursing area of the facility on 2/9/11. At this time, Resident#65's weight was 230 pounds (a 46 pound unplanned weight loss while living on the Alzheimer's residential unit). Resident #65 had a current 2/9/11 physician's orders [REDACTED]. Resident #65 had a 2/9/11 "Nursing Admission Assessment & Data Collection" assessment form which indicated the resident was dependent on assistance when dining. The assessment did not address her 46 pound weight loss in a two year period. Resident #65 had a current, 2/9/11, admission nutritional care plan problem due to dementia and diabetes. An approach to this problem was to provide the resident a diet per physician's orders [REDACTED]. Review of the 2/16/11 breakfast menu, which was provided by the Food Services Supervisor on 2/15/11 at 12:12 p.m., indicated residents with regular diets were menued to receive: choice of cereal choice of eggs 4 bacon slices 1 slice of wheat toast 6 ounces of a juice of choice 8 ounces of milk coffee/tea if desired During a 2/16/11, 8:28 a.m. breakfast meal observation, Resident #65 was served 2 glasses of water, 1 piece of toast and 2 strips of bacon. Resident #65 was not served an egg nor an alternative protein as a replacement for the eggs. Resident #65 ate her bacon very quickly, then her toast. It took her 2 minutes to eat all the food served to her. She then took her finger and wiped the crumbs from her plate and licked the crumbs from her finger. During a 2/16/11, 8:38 a.m., interview, cook #35 indicated she did not serve Resident #65 eggs, because the resident did not like eggs. She additionally indicated she never served Resident #65 eggs or a replacement for eggs because, "I can't get much out of her when I ask her what she wants." During a 2/16/11, 8:39 a.m., observation, a protein replacement was requested and blueberry yogurt was served to Resident #65. Resident #65 ate 100% of the blueberry yogurt. During a 2/16/11, 12:45 p.m. interview, Resident #65's family indicated the resident had a good appetite and had always eaten eggs when she lived at home. 6.) A review of the 2/15/11, lunch menu, which was provided by the Food Services Supervisor on 2/15/11 at 12:12 p.m., indicated the following: all diet types, with the exception of pureed, where menued to receive bread in some form, either as a roast beef sandwich (2 slices) for finger food's diets or as a "Roast Beef Manhattan" (1 slice) for regular, no added salt, carbohydrate controlled and mechanical soft diets. 7.) During a 2/15/11, 12:46 p.m., interview, Cook #35 indicated she had prepared the meal trays which were served in the Legacy skilled Alzheimer's, dementia secured unit. She indicated she had ran out of bread. She had not served a bread alternate, such as a bun or crackers. She had not called the main kitchen to request additionally bread and she had not notified her supervisor regarding the bread shortage. She indicated she did not know what to do if she ran out of a food item. 8.) Resident #4's record was reviewed on 2/18/11 at 9:15 a.m. Resident #4's current [DIAGNOSES REDACTED]. Resident #4 resided on a secured dementia unit. Resident #4 had a current, 2/11, physician's orders [REDACTED]. Resident #4 had a current, 8/30/10 care plan problem regarding the potential for an alteration in nutritional status. An approach to this problem was to serve a diet as ordered. Resident #4's weight history was the following: 8/10-140.0 pounds 9/10-142.6 pounds 10/10-138.6 pounds 11/10-137.8 pounds 12/10-136.0 pounds 1/11-136.0 pounds 2/11-135.0 pounds Resident #4 weight record indicated she was having a slow gradual loss of weight, resulting in a weight loss of 3.57% (5 pounds) in six months. Resident #4 had a 4/14/10 clinically at risk note which indicated she would be served finger foods, when a mechanical soft diet would permit, in order to encourage the resident to pick up the food with her hands and eat. The decision was made due to the resident attempting to pick up food items. During a 2/15/11, 12:15 p.m. to 12:40 p.m., observation of meal service Resident #4 was served ground roast beef, mashed potatoes and gravy, greens and cherry pie. Resident #4 was not served bread. 9.) Resident #63's record was reviewed on 2/18/11 at 10:00 a.m. Resident #63's current diagnoses, included, but were not limited to, dementia, depression and anxiety. Resident #63 resided on a secured dementia unit. Resident #63 had a current, 2/11, physician's orders [REDACTED]. Resident #63 had a current, 8/30/10, care plan problem regarding a potential for alteration in nutritional status due to dementia. An approach to this problem was to serve the diet as ordered. During a 2/15/11, 12:15 p.m. to 12:40 p.m., observation of meal service Resident #63 was served ground roast beef, mashed potatoes and gravy, greens and cherry pie. Resident #63 was not served bread. 10.) Resident #20's record was review on 2/18/11 at 9:30 a.m. Resident #20's current [DIAGNOSES REDACTED]. Resident #20 resided on a secured dementia unit. Resident #20 had a current ,2/11, physician's orders [REDACTED]. Resident #20 had a current, 12/27/10, care plan problem regarding the potential for an alteration in nutritional status due to dementia. An approach to this problem was to serve a diet as ordered. Resident #20's weight history was the following: 12/10-151 pounds 1/11-146.5 pounds 2/11-147 pounds Resident #20 has had a 4 pound-2.64% weight loss since admission. During a 2/15/11, 12:15 p.m. to 12:40 p.m., observation of meal service Resident #20 was served roast beef, mashed potatoes and gravy, greens and cherry pie. Resident #20 was not served bread. 11.) Resident #83's record was reviewed on 2/18/11 at 10:15 a.m. Resident #83's current diagnoses, included, but were not limited to, organic mental syndrome, diabetes and depression. Resident #83 resided on a secured dementia unit. Resident #83 had current 2/11, physician's orders [REDACTED]. Resident #83 had a current, 9/1/10, care plan problem regarding the risk for alteration in nutritional status due to dementia. An approach to this problem was to serve a diet as ordered. Resident #83's weight history was as follows: 8/10-178.60 pounds 9/10-176.0 pounds 10/10-176.40 pounds 11/10-168.80 pounds 1/11-164.0 pounds 1/11-161.20 pounds Resident #83 had a 17.4 pound- 9.4% weight loss in 6 months. During a 2/15/11, 12:15 p.m. to 12:40 p.m., observation of meal service Resident #83 was served ground roast beef, mashed potatoes and gravy, greens and cherry pie. Resident #83 was not served bread. 12.) Resident #104's record was reviewed on 2/15/11 at 11:50 a.m. Resident #104's current [DIAGNOSES REDACTED]. Resident #104 resided on a secured dementia unit. Resident #104 had a current, 2/11, physician's orders [REDACTED]. Resident #104 had a , 2/2/11,current care plan problem regarding his potential for weight loss because he had a [DIAGNOSES REDACTED]. Resident #104's weight history was as follows: Admission weight 2/19/10-128 pounds 9/6/10-118 pounds 10/2/10-114.8 pounds 11/2/10-114.8 pounds 12/10-110.4 pounds 1/1/11-110 pounds 2/3/11-107.8 pounds Resident #104 had a 10.2 pound-8.6% weight loss in 6 months and a 20.2 pound-15.7% weight loss in one year. During a 2/21/11, 1:35 p.m. interview, the Director of Nursing indicated Resident #104 had a finger food diet order in hopes he would pick up food and self feed, even while moving about, in order to increase consumption. During a 2/15/11, 12:15 p.m. to 12:40 p.m., observation of meal service Resident #104 was served roast beef, mashed potatoes and gravy, greens and cherry pie. Resident #104 was not served bread. During a 2/15/11, 12:15 p.m. to 12:40 p.m., observation of meal service, Resident #104 showed no interest in his roast beef, mashed potatoes and gravy and greens. Resident #104 got up from the table multiple times and walked around. Staff members tried to redirect him to his roast beef without success. Resident #104 did not have any item on his tray that he could eat with his fingers or carry as he moved about the unit. With every attempt to redirect, he showed no interest in the roast beef . At 12:25 p.m., a staff member began to serve desserts. An unknown staff voice asked Resident #104 if he would like cherry pie. Resident #104 went quickly to the dining table and sat down. He was served cherry pie. Resident #104 smiled and ate 100% of his cherry pie within 2 minutes of it being served. As indicated above resident #104's care plan indicated the family should bring in food the resident enjoys. Resident #104 ate the cherry pie with signs of enjoyment. The facility staff in the area did not offer Resident #104 any additional cherry pie. Resident #104 was not offered any additional cherry pie by the time the meal was concluded. During a 2/17/11, 4:30 p.m. interview, the Director of nursing indicated Resident #104, who was a poor eater and had a [DIAGNOSES REDACTED]. 3.1-46(a)(1)

Based on observations, record review, and interviews, the facility failed to ensure pressure areas were assessed and preventive measures and treatments were utilized to promote the healing of these pressure areas for 4 of 5 residents reviewed in a sample of 17, with 1 resident's pressure area (Resident #51) deteriorating in a short period of time. (Resident #'s 93, 109, and 11) Findings include: 1. The "PRESSURE PREVENTION GUIDELINES" policy was provided by the Director of Nursing on 2/17/11 at 12:00 p.m. This current policy indicated the following: "Purpose: To maintain good skin integrity and avoid development of pressure ulcers. ...Hygiene ...Inspect the skin daily during are for signs of breakdown or changes to the skin. ...Activity/Mobility ...Elevate heels off the bed-avoid use of (heel protectors) ...Nutrition ...Monitor nutrition and hydration status; if inadequate, assess labs and obtain dietary consultation....." The "Selection of Therapeutic Support Surfaces Guidelines" policy was provided by the Administrator on 2/17/11 at 12:00 p.m. This current policy indicated the following: "Purpose: To provide an appropriate therapeutic surface when determined to be medically necessary by the interdisciplinary team and/or the physician for prevention and healing of skin impairment. Procedure and considerations: ...6. Because heels and elbows have relatively little surface area, it is difficult to redistribute pressure on these two surfaces. It is important to pay particular attention to reducing the pressure on these areas....." The "Quick-Reference Operating Instructions Sapphire 1100 Alternating Low-Air-Loss Mattress System" policy was provided by the Assistant Director of Nursing on 2/18/11 at 11:30 a.m. This current policy indicated the following: ...* Avoid use of linen between patients and mattress * Use only necessary linen for incontinence management/patient comfort * Top cover will help minimize friction and shear...." The inservice "PROVIDING [MEDICATION NAME] CARE" was provided by the Assistant Director of Nursing (ADON) on 2/18/11 at 10:35 a.m. In an interview at this same time, the ADON indicated the inservice was conducted on a 1 on 1 basis or by the CNA reading the information confirmed by the CNA's signature. This inservice indicated the following: PROPER PERICARE - KEEP RSD'S (RESIDENTS) CLEAN AND DRY ...-ALL INCONTINENT RSD'S TO BE PROPERLY CLEANSED PRIOR TO APPLYING CLEAN BRIEF ...SPECIALTY MATTRESSES - BED PADS ARE NOT TO BE USED!!!!!!!! - RSD'S WHO WEAR BRIEFS ARE NOT TO USE BEDPADS ...WOUND CARE ...- IF TREATMENTS ARE SOILED OR OFF REPORT TO NURSE SO THEY CAN REAPPLY...." 2. On 2/15/11 from 1:47 p.m. to 2:10 p.m., Resident #51's dressing change to an area on the resident's right buttock was observed. The resident was observed lying on top of a blanket folded in quarters with an incontinent pad on top of the blanket and a brief on. She was complaining of her "bottom" hurting. In preparation, LPN #13 was observed to wet a 2 by 2 gauze pad with normal saline. As the resident was positioned, LPN #13 indicated the resident was incontinent of urine and changed her brief. No peri-care was observed when the brief was changed. The resident's open area was pink around the open area with a yellow/white open area. As LPN #13 indicated she was cleansing the area, she was observed to pat the open area with the 2 by 2 wet gauze, turn it over and pat the open area again with the same gauze pad, then, patted it dry in the same manner with a dry 2 by 2 gauze. After opening a 4 by 4 gauze package, she applied 2 pieces of the silver alginate over the open area followed by the opened 4 by 4 gauze pad, and then applied the op site (a type of tape) to one side of the dressing. After turning the resident to the other side, LPN #13 with the same gloves was observed to use her gloved finger to push the silver alginate back up into the open side of the dressing as it had started to fall out when the resident was turned. She then applied the other piece of op site to the dressing. She then proceeded to remove the soiled incontinent pad under the resident and indicated the resident had been incontinent of urine again. The resident's brief was again changed with no peri-care observed as the resident was repositioned with a folded blanket in half under her. On 2/17/11 at 755 a.m. and at 8:50 a.m., Resident #51 was observed up in her wheelchair. She indicated her "bottom" was hurting. On 2/17/11 from 8:50 a.m. to 9:10 a.m., Resident #51's personal care was observed. After the resident was transferred to her bed by CNA #19 and CNA #42, the resident's pants were removed. As they turned the resident, the resident's treatment dressing on her buttocks was observed with no date on it as the brief was removed. The dressing was observed with slight reddish drainage visible under the op site. CNA #19 and CNA #42 indicated the resident had been incontinent of urine with a small amount of loose bowel movement. CNA #42 indicated the resident was constantly incontinent of urine anytime the resident was moved. With gloved hands CNA #19 cleansed the resident's rectal area. No front peri-care was observed completed. At this same time during an interview, CNA #42 indicated they try to keep the resident dry especially in her abdominal folds and would use wipes to clean her unless it is "too bad" then they would use washcloths. Also, at this same time during an interview, CNA #19 indicated they try to keep her as dry as possible by checking her before and after she eats and before and after therapy. On 2/17/11 at 11:00 a.m. during an interview, the Assistant Director of Nursing (ADON) indicated with the Sapphire Mattress used by Resident #51 the linen preferred was 1 sheet and or 1 paper chux. At this same time with the ADON present, the resident, who was in her wheelchair, indicated she had a "sore bottom." The resident had a folded full sheet on the bed presently. The ADON instructed CNA #19 to remove the sheet from the bed, which was done. At this same time the ADON assisted CNA #19 and the resident was transferred back to her bed. On this same day at 11:20 a.m., LPN #44 entered to do the resident's dressing change. The resident's open area on her right buttock was observed with red drainage around the bottom of her open area. As the resident's dressing change was completed, the corner of the silver alginate was observed to have slipped out from 1 side of the 4 by 4 gauze covering it and was taped in this position by LPN #44 to complete the dressing change. On 2/18/11 at 12:40 p.m. during an interview, RN #45 indicated she had completed Resident #51's initial skin measurement. She indicated the area was a small area as measured on the skin sheet on 1/31/11. At this same time during an interview, the Director of Nursing (DON) indicated when she had measured the area on 2/07/11, the area was "like 3 areas merging." On 12/18/11 at 2:20 p.m. with the Nursing Consultant, the opened area on the right upper buttock was observed with white/yellowish center surrounded by redness around the majority of the open area, but with a purplish color noted on the bottom of the open area. On 2/21/11 at 2:45 p.m. during an interview, the ADON and the DON both indicated when cleansing an open wound, one should cleanse from the inside to the outside in a circular motion. Resident #51's record was reviewed on 2/17/11 at 9:55 a.m. The resident's [DIAGNOSES REDACTED]. The physician order, dated 1/25/11, was for a specialty overlay mattress and [MEDICATION NAME] (skin protectant) to buttocks 2 times a day. The physician order, dated 1/26/11, was for the treatment of [REDACTED]. The physician order, dated 2/07/11, was to cleanse the "coccyx" wound with normal saline, apply silver alginate dressing, and cover with 4 by 4 gauze and op site every 3 days and as needed for soilage and/or dislodgement. Check placement every shift. The physician order, dated 2/07/11, was to discontinue the Roho overlay and to place a sapphire mattress on the resident's bed. No information was indicated in the nurse's notes from 1/25/11 to 2/08/11 concerning the resident's coccyx until a new physician order [REDACTED]. The "ASSESSMENT REVIEW AND CONSIDERATIONS," dated 1/25/11, indicated in the "Skin breakdown risk potential" category this resident had the following risk factors, which included mobility impairment, incontinence/moisture, and past history with an individualized care plan initiated to address the identified risk factors and minimize the risk of skin breakdown. The "Nursing Admission Assessment & Data Collection," dated 1/26/11 at 10:00 a.m., indicated a 0.3 cm (centimeter) by 0.2 cm open area on the right upper buttock. The "Skin Plan of Care" indicated no information concerning preventive measures. The "Resident Care Plan," dated 1/25/11, indicated the problem was bowel and bladder incontinence. The goals included, but were not limited to, be free of skin breakdown related to incontinence and to be clean and dry. The interventions included, but were not limited to, provide incontinence care after each episode of incontinence. The "Resident Care Plan," dated 1/25/11, indicated the problem was potential for alteration skin integrity. The goal was the resident was not to develop alteration in skin integrity. The interventions included, but were not limited to, assess/record changes in skin status and provide/monitor effectiveness of pressure relieving or reduction devices as pressure reducing mattress. The "PRESSURE/STASIS/ARTERIAL/DIABETIC ULCER ASSESSMENT" indicated the following: On 1/26/11 the initial identification of the right buttock pressure area was red in color and measured 0.3 centimeters (cm) by 0.2 cm with no depth. On 1/31/11 the stage II pressure area was red and measured 0.5 cm by 0.6 cm with no depth. On 2/07/11 the area was indicated as a stage IV and measured 7.0 cm by 5.0 cm with a 0.1 depth. The wound bed was indicated with 3 areas of dark purple with 80% yellow and 10% pink. There was a small amount of exudate indicated. On 2/12/11 the stage IV pressure area measured 6.0 cm by 5.0 cm with no depth identified. The wound bed was indicated as pink. On 2/14/11 the stage IV pressure area measured 6.7 cm by 4.5 cm with 0.1 cm depth. The wound bed was indicated as 100% thick yellow slough. 3. The record for Resident # 93 was reviewed on 2/17/11 at 9:30 a.m. The resident was admitted [DATE] with a right tibia fracture. A nursing admission assessment dated [DATE] indicated the resident's skin was clear of red or open areas. The resident's plan of care on this form indicated the resident's heels were to be elevated off surfaces. A 9/16/10 "Skin Impairment Circumstance, Assessment and Intervention" form indicated the resident had an unstageable pressure ulcer on his right heel. The form indicated the area was a blister with a discolored middle. A 9/16/10, "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" form indicated the resident had a 4.3 centimeter (cm) by 4 cm blister with a discolored area in the center that measured 2.4 cm by 1.5 cm on the right heel. A 9/23/10 assessment indicated the right heel area was 3 cm by 3.5 cm and was 60 % yellow and 20 % dark necrotic. There was not documentation in the record indicating the area was observed or assessment prior to 9/16/10. 4. The record for Resident # 109 was reviewed on 2/15/11 at 3:40 p.m. A 2/14/11 pressure ulcer assessment indicated the resident had an unstageable area on the right gluteal that was 5.5 cm by 4.5 cm. The area was 60 % dark brown, 30 % slough and 10% red. During a dressing change observation on 2/15/11 at 1:50 p.m. with LPN # 26, the LPN donned gloves and removed the soiled dressing. She then cleaned the wound. The wound was observed to appear as the measurements and description above. The nurse then removed her gloves and washed her hands for less than 8 seconds. She then donned gloves and applied skin prep to the wound edges. Then, with a gloved hand, she placed the Santyl (medication) onto her gloved finger and wiped it into the wound bed. She then removed her gloves and applied the foam dressing and tape. 5. The record for resident # 11 was reviewed on 2/15/11 at 1:25 p.m. A wound sheet dated 2/14/11 indicated the resident had a stage III ulcer to his left heel. During a dressing change observation on 2/16/11 at 8:10 a.m., LPN # 26 removed the soiled dressing. The area was observed to be approximately 2 cm by 1 cm with a yellow wound bed. LPN # 26 then cleaned the wound, removed her gloves, washed her hands then donned gloves. She then applied skin prep to the wound edges. She then placed a small amount of Santyl onto her gloved finger and wiped it into the wound bed and applied the dressing. On 2/21/11 at 9 a.m., during interview, LPN # 26 indicated she should have used a Q-tip to apply the Santyl. She indicated she did not have a Q-tip available, they had spilled out in her treatment cart. 3.1-40(a)(1) 3.1-40(a)(2)