Every finding on record at Waters of New Castle, The

Based on observation, interview, and record review, the facility failed to transfer a resident with a mechanical lift in a safe manner resulting in the resident sustaining a laceration to the forehead requiring 5 stitches and an acute fracture above the knee for 1 of 3 residents reviewed for accidents (Resident D). Finding include:Review of the record of Resident D on 4/13/26 at 12:00 p.m., indicated the resident's diagnoses included, but were not limited to; dated 2/13/26, acquired absence of left leg below the knee amputation; dated 3/27/26, laceration to the forehead requiring 5 stitches; and dated 4/6/26, an acute comminuted angulated fracture involving the distal femoral metaphysis of the left leg acute fracture above the left knee (above the knee fractured bone caused by trauma) and end stage renal disease requiring dialysis (a procedure to remove waste and excess fluid from the blood). The plan of care for Resident D, dated 1/8/2026, indicated the resident had been determined to require a mechanical lift (a mechanical, hydraulic, or electric patient lifting device used to transfer individuals with limited mobility) for safe transfers. The interventions included, but were not limited to, two staff would transfer the resident using the mechanical lift. The fall assessment for Resident D, dated 2/2426, indicated the resident was at high risk for falls. The quarterly Minimum Data Set (MDS) for Resident D, dated 3/3/26, indicated the resident was cognitively intact for daily decision making. The resident was dependent on staff for transfers and the resident had no history of falls. The Progress Note for Resident D, dated 3/27/26 at 5:35 a.m., indicated the resident was lying on the floor on her back. Resident D reported that she slid forward out of the mechanical lift. The resident was immediately sent to the emergency room. The emergency department note for Resident D, dated 3/27/26 at 5:43 a.m., indicated the resident was dropped headfirst from a mechanical lift at the facility. Resident D complained of head, neck, and back pain. The resident had a 3.0-centimeter (cm) laceration with indentation to the left frontal scalp. Resident D had a Computed Tomography (CT) scan of the head and spine that was negative for acute intracranial abnormality or spine fracture. The resident had a head laceration repair with five stitches and discharged back to the facility. The employee statement for CNA 4, dated 3/27/26 (no time), indicated Resident D was in bed and CNA 4 hooked up with all 4 straps to the mechanical lift and CNA 4 began to transfer the resident. Resident D leaned forward and came out of the mechanical lift sling. CNA 4 indicated she thought everyone was busy and wanted to get Resident D up in the wheelchair to eat breakfast before the resident went to dialysis. The employee statement for LPN 5, dated 3/27/26 at 5:35 p.m., indicated he was passing medication when he heard a loud noise, as if someone had fallen. LPN 5 headed towards the commotion and heard his name being called out for help. LPN 5 entered Resident D's room and discovered her lying on the floor on her left side. Resident D had a large gash to her forehead and was complaining of back pain. LPN 5 applied pressure to the wound but was unable to stop the bleeding. Resident D was transferred to a stretcher and transported to the emergency room. The Progress Note for Resident D, dated 3/27/26 at 7:00 a.m., indicated the resident returned from the emergency room accompanied by her family. The resident had a laceration on the forehead with 5 stitches. The resident and family did not want the resident to go to her scheduled dialysis appointment. The dialysis center was notified. Resident D was resting in bed. The Progress Note for Resident D, dated 4/6/26 at 12:18 p.m., indicated the facility transport driver went to pick up Resident D from dialysis and was notified the resident had been sent to the emergency room due to the resident had requested at least 5 times to be sent to the hospital. The Progress Note for Resident D, dated 4/6/26 at 2:20 p.m., indicated the dialysis staff notified the transport driver at 12:00 p.m., that Resident D was sent from the dialysis center by ambulance to the emergency room due to left leg pain. The emergency room report for Resident D, dated 4/6/26 at 2:26 p.m., indicated Resident D fell in March 2026 and experiencing status post left leg pain. An x-ray was completed of the left knee, and the resident had an acute comminuted angulated fracture involving the distal femoral metaphysis. The resident's weight was 139.9 pounds, and her height was 60.98 inches tall. During an observation on 4/13/26 at 1:13 p.m., Resident D was being assisted by staff with eating lunch. The resident had a laceration on her forehead that was scabbed and the resident's face was bruised black and blue around her right eye and forehead. During an observation on 4/13/26 at 1:45 p.m., CNA 1, QMA 2 and CNA 3 transferred Resident D from her wheelchair to the bed by using a mechanical lift. Resident D was provided incontinent care and had a large pink bruise on her left hip. The resident had a below the knee amputation and had an above the knee immobilizer on the left knee and thigh. The resident attempted to talk but was not understandable. During an interview with Resident D's family, on 4/13/26 at 2:26 p.m., they indicated they were notified on 3/27/26 at 5:45 a.m. that Resident D was being sent to the emergency room because she fell out of the mechanical lift. The family member indicated the Administrator reported to her that on 3/27/26 CNA 4 had transferred Resident D alone with the mechanical lift and she fell out of the mechanical lift. The emergency room did not do any x-rays of the resident's left leg on 3/27/26 because she was complaining of head, neck and back pain. Resident D began complaining of left leg pain on 4/6/26 and was found to have a fracture. The doctor said Resident D could not have surgery on the fracture because she would have to have more of her leg amputated. Resident D did not want to have more of her leg amputated and decided to let it heal on its own. During an interview with CNA 4, on 4/14/26 at 6:23 a.m., the CNA indicated she was the CNA that transferred Resident D alone on 3/27/26 when the resident fell out of the mechanical lift. The CNA was getting Resident D up for dialysis and used the mechanical lift and the resident leaned forward and fell out of the lift on her face. CNA 4 indicated she was trained on the proper technique of having two staff when utilizing a mechanical lift. During an interview with LPN 5 on 4/14/26 at 6:38 a.m., the LPN indicated he was the nurse for Resident D on 3/27/26 when she fell out of the mechanical lift. LPN 5 was not aware that CNA 4 was transferring the resident by herself until after it happened. When the LPN got to Resident D's room, she was lying on her left side and was profusely (large amount) bleeding from her forehead. LPN 5 indicated him and three other staff transferred her to the stretcher and Resident D was sent to the emergency room. At the time of the transfer Resident D was complaining of pain everywhere. The guidelines for usage of a mechanical lift provided by the Administrator, on 4/14/26 at 10:47 a.m., indicated two staff members were required when using a mechanical lift. When utilizing a mechanical lift, one person should always maintain control of the resident while the second person operates the mechanical lift. The current mechanical lift manufacturing guidelines for the Hoyer HPL700 indicated the maximum weight limit for the lift used was 700 pounds, with a minimum height of 57.75 inches and maximum height of 81 inches. Training videos for the mechanical lift indicated two staff were to be present during the use of the lift (one to stabilize the resident and one to operate the controls) with transfers. This deficient practice was corrected on 3/30/26, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education was provided to all licensed nurses, QMAs and CNAs to ensure mechanical lift safety. All Licensed Nurses, CNAs and QMAs had to complete a competency demonstration with the Director of Nursing of the operation of a mechanical lift safely before they could work the floor. A safety audit was completed for all residents who required a mechanical lift to ensure the lift was appropriate for the resident. All mechanical lifts were inspected to ensure they were in safe working order. The facility continues ongoing audits and observations of mechanical lift transfers. This citation relates to Intake 2966686. 410 IAC (Indiana Administrative Code) 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to ensure residents were free from a significant medication error when Resident B and Resident C received each others evening medications for 2 of 4 residents reviewed for medication error (Resident B and Resident D). Finding include: 1.Review of the record of Resident B, on 2/17/26 at 10:45 a.m., indicated the resident's diagnoses included, but were not limited to, diabetes, major depression disorder, chronic kidney disease (Kidneys are damaged and unable to efficiently filter waste and excess fluid from the blood) and peripheral vascular disease (circulation disorder involving narrowing or blockage of blood vessels).The admission Minimum Data Set (MDS) assessment for Resident B, dated 1/20/26, indicated the resident was cognitively intact for daily decision making. The physician's medication orders for Resident B, on 1/25/26, indicated the resident was prescribed the following medications at bedtime: carvedilol (blood pressure medication) 25 mg, fenofibrate (cholesterol medication) 145 mg, gabapentin (treatment for nerve pain) and oxycodone (opioid pain medication) 10 mg. On 1/25/26, the resident had not received the prescribed medications. Resident B was administered the following medications in error, on 1/25/26 at bedtime, Tylenol (over the counter pain medication) 500 milligrams (mg) two tablets, baclofen (muscle relaxer) 10 mg, clonazepam (antianxiety medication) 0.5 mg, ferrous sulfate (iron supplement) 325 mg, florastor (probiotic) 250 mg, guaifenesin (over the counter treatment for chest congestion) 200 mg, remeron (antidepressant) 15 mg, pantoprazole (over the counter medication for reducing stomach acid), tamsulosin (medication to improve urinary flow) and geodon (antipsychotic) 60 mg. The progress note for Resident B, dated 1/26/26 at 8:50 a.m., indicated the Director of Nursing (DON) was notified by the resident and his family member at bedside, that he had received another resident's medication at bedtime last evening. Resident stated he felt very tired and sleepy this am. Resident was alert and oriented at that time, responding appropriately. The Medical Director was notified. New orders were obtained to monitor vital signs and complete Neurological assessments every 4 hours for 12 hours and to notify the Medical Director if the resident experienced any change in his condition. There were no abnormal vital signs or neurological assessments documented for Resident B on 1/26/26. 2.Review of the record of Resident C on 2/17/26 at 11:26 a.m., indicated the resident's diagnoses included, but were not limited to, borderline personality (instability in moods), cerebral palsy (neurological disorder affecting body movements), anxiety, psychotic disorder (loss of contact with reality), dementia (decline in mental ability) and muscle weakness. The resident was allergic to haldol (antipsychotic medication) and prozac (antidepressant). The quarterly MDS assessment for Resident C, dated 2/9/26, indicated the resident was severely impaired for daily decision making.The physician's medication orders for Resident C, on 1/25/26, indicated the resident was prescribed the following medications at bedtime: Tylenol 500 milligrams (mg) two tablets, baclofen 10 mg, clonazepam 0.5 mg, ferrous sulfate 325 mg, florastor 250 mg, guaifenesin 200 mg, remeron 15 mg, pantoprazole, tamsulosin and geodon 60 mg. On 1/25/26, the resident had not received the prescribed medications. Resident C was administered the following medications in error, on 1/25/26 at bedtime, carvedilol 25 mg, fenofibrate 145 mg, gabapentin and oxycodone 10 mg. The progress note for Resident C, dated 1/26/26 at 8:50 a.m., indicated the DON was notified that the resident may have received another resident's medication. The resident was alert and oriented to self and staff per baseline. The Medical Director was notified. New orders were obtained to monitor vital signs and complete Neurological assessments every 4 hours for 12 hours and to notify the Medical Director if the resident experienced any change in his condition. There were no abnormal vital signs or neurological assessments documented for Resident C on 1/26/26. During an interview with the Nurse Practitioner (NP) on 2/17/26 at 11:55 a.m., indicated she was Resident C's primary care provider and was notified of the resident receiving Resident B's medication on 1/25/26. The NP assessed the resident and he looked great, his vital signs were stable. There was no indication that Resident C required lab work or hospitalization. The resident remained at his baselineDuring an interview with the Medical Director on 2/17/26 at 12:05 p.m., He indicated he was notified of Resident B and Resident C receiving each other's medication on the evening of 1/25/26. The Medical Director reviewed the medications and ordered vital signs and neurological assessments for both residents. Resident B and Resident C remained at baseline and had no abnormal vital signs or abnormal neurological assessments. There were no concerns about health or safety for either resident. The facility monitored the residents closely and kept him informed every hour. There were no side effects for either resident, and there was no indication for laboratory test to be drawn or hospitalization. During an interview with the DON on 2/17/26 at 12:10 p.m., RN 1 preset up Resident B and Resident C's medication and put them in a medication cup on the evening of 1/25/26. Resident B questioned RN 1 that he did not normally take that many medications in the evening time but went ahead and took the medications. RN 1 had gotten Resident B and Resident C's medication cups mixed up. Resident B and Resident C's vital signs remained stable and there were no abnormal neurological assessments. During an observation on 2/17/26 at 11:15 a.m., Resident B and Resident C's rooms were next to each other. Resident C was in his room sitting in his wheelchair, the resident was nonverbal. The medication administration policy provided by the Administrator on 2/17/26 at 12:35 p.m., indicated the procedure included, but were not limited to the following, verify that there was a physician's order for the medication, check the label on the medication and confirm the medication name and dose with the Medication Administration Record (MAR), check the medication dose and re-check to confirm the proper dose and confirm the identity of the resident. This deficient practice was corrected on 2/5/26, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education was provided to all licensed nurses and QMA's to ensure medications were provided to residents in a safe and accurate manner and an medication pass observation of all licensed nurses and QMA's was completed by the Director Of Nursing (DON) prior to administering medications to residents without oversight of the DON. The facility continues ongoing reviews with annual competency skill checks of medication administration. This citation relates to Intake 2728799.

Based on observation, interview and record review, the facility failed to ensure residents' call lights were with in reach for 2 of 2 residents reviewed for accommodation of needs (Resident 14 and Resident 69). Findings include:1.During an observation on 1/13/2026 11:01 a.m., Resident 14 was sitting in her room in a geriatric chair, the resident's touch pad call light was hanging on the wall behind her bed, not within reach of the resident. The roommates call light was activated. During an interview with the Staffing Coordinator on 1/13/26 at 11:15 a.m., the Staffing Coordinator indicated whoever brought Resident 14 back to her room was responsible to provide her with her call light. The Staffing Coordinator provided Resident 14 with her touch pad call light. Review of the clinical record of Resident 14 on 1/16/26 at 11:15 a.m., indicated the resident's diagnoses included, but were not limited to, chronic heart failure, lack of coordination, unsteadiness on feet, chronic obstructive pulmonary disease, major depressive disorder and osteoarthritis. The care plan for Resident 14, dated 9/26/2020 (target date 2/11/26), indicated the resident required assistance with activities of daily living. The interventions included, but were not limited to, keep call light in reach. The care plan for Resident 14, dated 11/3/23, indicated the resident was at risk for falls. The interventions included, but were not limited to, keep call light in reach. The annual Minimum Data Set (MDS) assessment for Resident 14, dated 11/8/25, indicated the resident was severely impaired for daily decision making. 2.During an observation and interview on 1/13/2026 at 11:27 a.m., Resident 69 was lying in bed and indicated she could not find her call light and requested help. The resident's call light was on the floor behind her bed. The resident indicated this was not the first time she was unable to find her call light. The roommates call light was activated. CNA 3 came into the resident's room and provided Resident 69 with her call light. Review of the clinical record of Resident 69 on 1/16/26 at 11:45 a.m., indicated the resident's diagnoses included, but were not limited to, respiratory failure, chronic kidney disease, weakness, heart failure, difficulty walking, diabetes, anxiety and unsteadiness on feet. The care plan for Resident 69, dated 3/18/25, indicated the resident was at risk for falls due to weakness. The interventions included, but were not limited to, keep call light in reach. The quarterly MDS assessment for Resident 69, dated 10/19/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The call light policy provided by the Executive Director on 1/16/26 at 9:45 a.m., indicated the facility would ensure that the call light was accessible to residents. 3.1-(v)(1)

Based on observation, interview, and record review, the facility failed to follow a physician's order for humidified oxygen for 1 of 2 residents reviewed for respiratory care. (Resident 13) Findings include:The clinical record for Resident 13 was reviewed on 01/14/2026 at 10:31 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), mild intermittent asthma, and anxiety.The Annual Minimum Data Set (MDS) assessment, dated 1/2/26, indicated Resident 13 was cognitively intact.During an observation and interview with Resident 13 on 1/13/26 at 11:13 a.m., the resident indicated they were on oxygen at home. Oxygen was on the resident at 1 L/min (liter per minute) with no humidified oxygen hooked up to the oxygen tank.Resident 13 had a physician's order, dated 1/7/26, that indicated O2 (oxygen) at 1 to 2 L/min (liters per minute) via nasal cannula as needed for shortness of breath and to change the humidifier bottle once weekly, on Tuesday, during the day shift and as needed.The January 2026 Medication Administration Record (MAR) indicated the resident's humidifier bottle was changed on 1/13/26.During an observation and interview with Resident 13 on 1/14/25 at 12:28 p.m., no humidity bottle was hooked up to the oxygen tank. Resident 13 indicated they usually have it on their oxygen tank at home and wondered why it was not on the tank in the facility.During an observation and interview with Qualified Medication Assistant (QMA) 2 and Resident 13 on 1/14/26 at 1:36 p.m., QMA 2 verified that no humidity was applied to Resident 13's oxygen tank. QMA 2 then applied humidity bottle to the oxygen tank. Resident 13 did not decline or voice any refusal of the oxygen humidity being applied. During an interview with Resident 13 on 1/15/26 at 1:02 p.m., they indicated they did not have a problem with humidity bottle on their oxygen tank, had it on at home, wondered why they did not have it here, but did not question it. Resident 13 indicated yesterday, 1/14/26, one of the nurses came in to their room, noticed they did not have humidity bottle to their oxygen, and put it on right then. Resident 13 indicated that was all they had heard about the humidity bottle needing to be on the oxygen tank. A plan of care, dated 1/13/26, indicated Resident 13 was at risk for respiratory distress related to asthma and copd diagnosis. The interventions included, but were not limited to, administer O2 (Oxygen) per MD (Physician) order. An Oxygen Administration Policy was provided by the Executive Director (ED) on 1/16/26 at 9:45 a.m. It indicated .Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders for oxygen administration.3. Assemble the equipment and supplies as needed.Steps in the procedure: 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar.14. Periodically re-check the water level in humidifying jar. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: .1. Date and time the procedure was performed. 8. If the resident refused the procedure, the reason (s) why and the intervention taken.Reporting: 1. Notify the supervisor if the resident refuses the procedure. 3.1-47(6)

Based on observation, interview and record review, the facility failed to ensure a newly admitted resident had his pain medication available as ordered by the physician for 1 of 1 residents reviewed for pain (Resident 66). Finding include:During an interview with Resident 66 on 1/13/2026 at 11:44 a.m., the resident indicated he had been without his tramadol pain medication since he was admitted to the facility on [DATE]. The nurses told him that it had something to do with the prescription not being signed. The resident indicated his pain level had been a 3 out of a 1 to 10 pain scare (one being no pain and 10 being the worst pain). The resident indicated his left hip was sore because he had broke it and had surgery. During an observation and interview with Resident 66 on 1/14/2026 at 1:01 p.m., the resident indicated he had been requesting his tramadol pain medication every day since admission because he needed to help him walk with his walker. The resident indicated not having his tramadol pain medication available prevented him from walking and it slowed him down for sure. During an observation the resident had a rolling walker beside his bed. During an interview with Resident 66 on 1/15/2026 at 10:43 a.m., the resident indicated he did receive Tylenol for pain, but it did not help at all. The nurses kept telling him the facility did not have tramadol. Review of the clinical record of Resident 66 on 1/14/2026 at 10:54 a.m., indicated the resident's diagnoses included, but were not limited to, orthopedic aftercare, left fracture, diabetes, hypertension, contracture of left hand and osteoarthritis. The resident was admitted to the facility on [DATE]. The hospital note for Resident 66, dated 12/2/25, indicated the resident had a left hip fracture and required a open reduction and internal fixation surgery on 12/4/25. The progress note for Resident 66, dated 1/10/26 at 6:30 p.m., indicated the resident was admitted from another long term care facility. The resident was alert and oriented and was able to make his needs known. The physician's order for Resident 66, dated 1/10/26, indicated the resident was ordered tramadol 50 milligrams (mg) every 6 hours as needed for pain. The care plan for Resident 66, dated 1/10/26, indicated the resident was at increased risk in pain/discomfort or had current pain. The interventions included, but were not limited to, administer pain medication as ordered. During an interview with the Director Of Nursing (DON) on 1/14/26 at 12:45 p.m., the DON indicated the facility had tramadol available in the automated dispensing cabinet. The resident was admitted to the facility with an invalid prescription for tramadol. The nurse attempted to call the after hour company twice to get the correct prescription and they never returned the nurses calls. The Nurse Practitioner (NP) does not have privileges and authority yet to sign prescriptions. The nurse could have called the DON or the Administrator and they would have contacted the Medical Director to sign the prescription, but she did not. The DON found about the situation on 1/13/26 and got the prescription signed. The pain policy provided by the Executive Director (ED) on 1/16/26 at 9:45 a.m., indicated the provider would order appropriate medication interventions to address the individual's pain. The automated medication dispensing machine policy provided by the ED on 1/16/26 at 9:45 a.m., indicated the nursing staff would use the machine for to distribute medications for emergency, first dose and other situations where the medication was not readily available from the pharmacy. No medications would be removed from the machine without a valid prescription or upon a physician order. 3.1-37(a)

Based on interview and record review, the facility failed to monitor valproic acid levels for a resident with a diagnosis of seizures and receiving Divalproex Sodium for 1 of 5 residents reviewed for unnecessary medications. (Resident 5) Findings include: The clinical record for Resident 5 was reviewed on 1/14/2026 at 11:10 a.m. The resident's diagnoses included, but were not limited to, epilepsy (chronic brain disorder causing recurring seizures), muscle weakness, and chronic kidney disease.The Annual Minimum Data Set (MDS) assessment, dated 9/20/25, indicated Resident 5 was moderately cognitively impaired for daily decision making, had seizure disorder, and received anticonvulsants.During a review of Resident 5's current medication orders on 1/15/26 at 10:51 a.m., Resident 5 was ordered Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium), staff were to administer 1 tablet by mouth two times a day for seizure with a start date of 11/10/25.Resident 5's Electronic Health Record (EHR) indicated no valproic acid levels were drawn or monitored since January 2025.A plan of care, dated 1/9/26, indicated Resident 5 was at risk for seizure activity related to seizure disorder. The interventions included, but were not limited to, administer medication as directed and follow pharmaceutical recommendations and medication levels as ordered per physician.During an interview with the Director of Nursing (DON) on 1/15/26 at 2:00 p.m., they indicated they could not find where Resident 5 had valproic acid levels drawn in the last year.During an interview with Nurse Practitioner (NP) on 1/16/26 at 10:14 a.m. they indicated there was no order for a valproic acid level for Resident 5 since taking over her care in May 2025 and now there was an order for maintenance. The NP indicated they normally have an order for valproic acid levels to be drawn routinely, it was standard practice. The NP indicated it was brought to her attention yesterday and orders were put in to monitor valproic acid levels every six months ongoing.During an interview with the DON on 1/16/26 at 10:40 a.m., they indicated they follow what the physician's orders in regards to lab orders and monitoring.The Medication Utilization and Prescribing Policy was provided by the Executive Director (ED) on 1/16/26 at 11:12 a.m. It indicated .Monitoring: 1. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications.The Seizures and Epilepsy Policy was provided by the Executive Director (ED) on 1/16/26 at 11:12 a.m. It indicated .Monitoring: 2. The physician will monitor antiepileptic medication blood levels periodically.According to the Dr. Oracle Medical Advisory Board & Editors, 2025, valproate levels should be checked every 6 months in patients taking divalproex sodium (Depakote) for seizures, as recommended by the most recent and highest quality study. The monitoring of valproate levels is crucial to maintain therapeutic efficacy while minimizing adverse effects. 3.1-48(a)(3)

Based on interview and record review, the facility failed to accurately code two Minimum Data Set (MDS) assessments related to an antipsychotic medication for 1 of 1 residents reviewed for suicidal attempts. (Resident B) Findings include: The clinical record of Resident B was reviewed on 5-1-24 at 9:52 a.m. His diagnoses included, but were not limited to, anxiety, depression, nightmare disorder and suicidal ideation. His most recent MDS assessment, a quarterly assessment dated [DATE], indicated he received antipsychotic medications in Section N0415A, related to medications ordered for the resident. However in Section N0450A, the MDS assessment was coded to reflect he did not receive antipsychotic medications, thus negating the use of a gradual drug reduction information for the use of this type of medication. In the prior MDS, an annual assessment, dated 11-17-23, this information was identified in the same manner. In an interview with the MDS Coordinator on 5-1-24 at 11:34 a.m., she indicated it appeared as if she had coded the information for the use of an anti-psychotic incorrectly. She indicated the clinical record indicated he had received Zyprexa, an antipsychotic medication, during the look-back period period of 7 days for each of the MDS assessments. A review of Resident B's medication administration record (MAR) for November, 2023, indicated he had received Zyprexa 2.5 milligrams (mg) twice daily from 11-15-23 through 11-30-23. A review of the February, 2024 MAR indicated he had received Zyprexa 2.5 mg twice daily for 2-1-24 through 2-29-24. In an interview with the Executive Director on 5-1-24 at 2:30 p.m., she indicated the facility does not have a specific policy or procedure related to the MDS assessment process, but uses the current RAI (Resident Assessment Instrument) Manual for reference to any MDS assessments. The Centers for Medicare and Medicaid Long-Term Care Facilities Resident Assessment Instrument 3.0 User's Manual, version 1.1811, October, 2023, indicates in Section N, Medications, for Section N0415, High Risk Drug Classes: Use and Indication, the appropriate high-risk medications should be checked, such as antipsychotic medications have been administered in the 7-day look back period. Residents taking medications in these medication categories and pharmacological classes are at risk of side effects that can adversely affect health, safety, and quality of life. In Section N, Section N0450A, Antipsychotic Medication Review, this portion requests, Did the resident receive antipsychotic medications since admission/entry or readmission or the prior OBRA assessment, whichever is more recent? The response choices for N0450A provided for selections of yes, or no. This Federal tag relates to Complaint IN00432528. 3.1-37(a) 3.1-37(c)(13)

Based on observation, interview and record review the facility failed to provide fresh ice water for 1 of 2 residents reviewed for hydration (Resident 4). Finding include: During an observation and interview on 9/27/23 at 1:52 p.m., Resident 4 indicated she had to ask if she wanted ice water, she hasn't gotten fresh ice water since last night. The facility staff were observed passing out fresh ice water and went by Resident 4's room without providing fresh water. During an observation on 9/27/23 at 2:40 p.m., Resident 4 continues to have a half cup of warm water. The resident indicated her and her roommate had not received fresh water since last night. During an observation on 9/28/23 at 9:45 a.m., Resident 4 continues with the same half cup of warm water with no fresh ice water available. During an observation on 9/28/23 at 11:00 a.m., Resident 4 continues with a cup of warm water with no fresh ice water available. Resident 4 was laying in bed with her eyes closed. During an interview and observation on 9/28/23 at 1:42 p.m., Resident 4 had two cups of warm water. The resident indicated she frequently did not receive fresh ice water, she often had to request ice water from staff. Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnoses included, but were not limited to, age related physical debility, osteoarthritis, pain in right/left knee atrial fibrillation, hypertension, urinary tract infection, gout, anxiety and major depressive disorder. The plan of care for Resident 4, dated 10/18/22, indicated the resident was at risk for dehydration related to diuretic medication use. The interventions were monitor weight and vital signs, observe for increased signs of edema and report any changes to the physician. The Quarterly Minimum Data (MDS) assessment for Resident 4, dated 7/20/23, indicated the resident was cognitively intact for daily decision. The resident was consistent and reasonable. During an interview with the Director Of Nursing (DON) on 9/28/23 at 2:20 p.m., indicated the facility protocol for providing residents with fresh ice water was it was passed first thing in the morning and in the evening. The facility also had a drink cart that passed out fluids twice a day. The DON indicated it was nursing's responsibility to ensure Resident 4 had fresh ice water. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's privacy curtain was wide enough to provide full visual privacy. This affected 1 of 1 resident reviewed. (Resident 32) Findings include: On 9/27/23, at 11:11 a.m., Resident 32's curtain, between her bed and her roommate's bed, was observed and did not extend from the wall at the head of her bed to the wall past the foot of her bed. The area from the foot of her bed to the wall past the foot of her bed was left exposed for approximately 4 feet. The track on the ceiling, that the curtain was hung from, extended from the wall at the head of her bed to the wall that went past the foot of her bed. There were 10 empty curtain hooks in the curtain track. Resident 32 indicated that anyone could see her in her bed if they walked into her room because the curtain didn't go down far enough. On 9/28/23, at 2:45 p.m., Resident 32 was in bed, with her eyes closed, and the curtain between the beds was not wide enough to extend from wall to wall for privacy. Resident 32's record was reviewed, on 9/28/23, at 11:16 a.m. and indicated diagnoses, that included, but were not limited to, right knee contracture, type 2 diabetes mellitus, generalized muscle weakness, and difficulty in walking. A quarterly Minimum Data Set assessment, dated 8/16/23, indicated Resident 32 was cognitively intact. On 9/29/23, at 11:47 a.m., Resident 32 was in her room, seated in a wheelchair, and the curtain was observed with the Administrator. The Administrator indicated the curtain should be wide enough to go to the wall. A Policy for Dignity was provided by the Administrator, on 9/29/23, at 1:10 p.m., and included, but was not limited to .Privacy .4.) Staff will provide privacy for residents during any personal care and/or treatment. The privacy curtain must be pulled anytime that the resident needs to have privacy. Examples include but are not limited to bathing, showers, and so on 3.1-3(p)

Based on interview and record reviewed, the facility failed to accurate code six-month prognosis and hospice services (Resident 12) and medications (Resident 16) for 2 of residents reviewed for Minimum Data Set (MDS) accuracy. Findings include: 1. The clinical record for Resident 12 was reviewed on 9/29/2023 at 11:05 a.m. The medical diagnosis included respiratory failure with hypoxia. A Quarterly MDS assessment, dated got 6/28/2023, indicated that Resident 12 did not have a six-month or less prognosis and did not receive hospice services. A Quarterly MDS assessment, dated for 9/28/2023, indicated that Resident 12 did not have a six-month or less prognosis. A physician order, dated 5/6/2021, indicated Resident 12 received hospice services. A hospice recertification, dated 3/19/2023, indicated Resident 12 has a six month or less prognosis if disease runs its normal course and was recertified for hospice services. 2. The clinical record for Resident 16 was reviewed on 9/29/2023 at 10:55 a.m. The medical diagnosis included chronic obstructive pulmonary disease. A Quarterly MDS assessment, dated 7/17/2023, indicated that Resident 16 received seven days of anticoagulation medication. The medication administration record for Resident 16 for July 2023, indicated that Resident 16 did not receive anticoagulation medication. An interview with the MDS Coordination on 9/29/2023 at 11:02 a.m. indicated that she could not find where Resident 16 used anticoagulation medications and verified that Resident 12 was on hospice services during the aforementioned quarterly assessments. She indicated she would be modifying the assessments discussed and that they code to the MDS Resident Assessment Instrument.

Based on interview and record review the facility failed to develop a plan of care for a resident with recurrent Urinary Tract Infections (UTI) for 1 of 1 resident reviewed for UTI (Resident 4). Finding include: Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnosis included, but were not limited to, chronic Urinary Tract Infection (UTI). The physician order for Resident 4, dated 7/21/23, indicated the resident was ordered to be seen by the urologist for recurrent UTI's. The physician order for Resident 4, dated 8/16/23, indicated the resident was ordered keflex (antibiotic) 250 milligrams (mg) indefinitely for recurrent UTI's. The urology report for Resident 4, dated 9/18/23, indicated the resident was being seen for recurrent UTI's. During an interview with Resident 4 on 9/28/23 at 1:42 p.m., indicated she had a long history of UTI's. During an interview with the Director Of Nursing (DON) on 9/28/23 at 2:20 p.m., verified Resident 4 did not have a plan of care in place for UTI's. The DON indicated it was the responsibility of the Minimum Data Set (MDS) Coordinator in develop the plan of care. The care plan policy provided by the Administrator on 9/29/23 at 10:50 a.m., indicated the facility Interdisciplinary team in conjunction with the resident, resident's family as appropriate along with a hands on caregiver, such as a certified nursing assistant will discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well being attainable for the resident. 3.1-35(a)

Based on observation, interview and record review the facility failed to assess and monitor bilateral feet edema (swelling) for 1 of 1 resident reviewed for edema (Resident 4). Finding include: During an observation on 9/27/23 at 2:01 p.m., Resident 4 was sitting in a chair, her bilateral feet were swollen. During an observation and interview with Resident 4 on 9/28/23 at 1:42 p.m., the resident was laying in bed, her bilateral feet were swollen. The resident indicated her feet did swell often. The resident indicated nursing had not assessed her feet edema. Review of the record of Resident 4 on 9/28/23 at 10:28 a.m., indicated the resident's diagnoses included, but were not limited to, age related physical debility, osteoarthritis, pain in right/left knee atrial fibrillation, hypertension, urinary tract infection, gout, anxiety and major depressive disorder. The plan of care for Resident 4, dated 10/18/22, indicated the resident was at risk for dehydration related to diuretic medication use. The intervention included, but were not limited to, observe for increased signs of edema and report any changes to the physician. The plan of care for Resident 4, dated 10/18/22, indicated the resident had a diagnosis of atrial fibrillation. The intervention included, but were not limited to, observe for signs and symptoms of edema. The Quarterly Minimum Data (MDS) assessment for Resident 4, dated 7/20/23, indicated the resident was cognitively intact for daily decision. The resident was consistent and reasonable. During an interview with the Director Of Nursing (DON) on 9/28/23 at 2:20 p.m., indicated the expectation of the facility was nursing would be assessing and monitoring Resident 4's bilateral feet edema. The DON indicated she could not find an assessment/monitoring of the resident's edema and would continue looking for it. During an interview the DON on 9/29/23 at 11:15 a.m., indicated she was not able to find an assessment from nursing for Resident 4's bilateral feet swelling. The DON indicated there was a physician order now to monitor the edema every shift now. 3.1-37(a)

The facility failed to obtain a [MEDICATION(S)] level (medication therapeutic level), and complete blood count (CBC) ordered for increased white blood cell (WBC) count for a resident experiencing increased confusion, mild but significant leukocytosis (WBC), and increase coughing resulting in hospitalization for pneumonia for 1 of 4 residents reviewed for compliance with laboratory orders. (Resident G) Findings include: The clinical record for Resident G was reviewed on 8/22/2022 at 1:35 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set Assessment, dated 5/26/2022, indicated that Resident G had a mild cognitive impairment and needed assistance with all activities of daily living. An emergency room (ER) visit document for Resident G dated 8/17/2022, indicated an elevated WBC of 13.6 K/uL. (A normal WBC level is 4.5-11 K/uL) Resident to return to the facility with primary care physician to follow up as needed. A physician telehealth visit note dated 8/18/2022 at 1:16 a.m. for Resident G, indicated .Orders were given to assess [MEDICATION(S)] levels given increased falls from bed w/o [without] a hx [history] of falls. No order was reflected on the medical record to obtain [MEDICATION(S)] level. An intradisciplinary team note dated 8/18/2022 at 9:32 a.m. for Resident G, indicated .A medication review requested and new order obtained for STAT labs. A physician note dated 8/18/2022 at 10:06 a.m. for Resident G, indicated that .Workup [from ER] included CT [computed tomography] of head which had no acute findings. UA [urinalysis] was normal, but CBC showed a mild but significant leukocytosis at 13.6 [K/uL]. He reportedly has had more coughing lately and his appetite has been poor .repeat of CBC with differential . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse practitioner note for Resident G, dated 8/19/2022 at 9:07 a.m., indicated .Waiting on [MEDICATION(S)] level that was ordered on 8/18 .Elevated white blood cell count: To have CBC today. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note for Resident G on 8/20/2022 at 4:01 p.m., indicated that CBC was not completed due to awaiting lab for lab draw. A nursing progress note on 8/20/2022 at 6:08 p.m. for Resident G, indicated This nurse called to res [sic, resident] at room res was found to be coughing with white froth in his mouth. Res having difficult time and stating unable to cough out what was in his mouth and throat. Stating he was having a hard time breathing. This nurse and CNA encouraging res to cough res stating that he could no longer cough This nurse then got the suction and suction oral cavity and was able to clear frothy and thick yellow sputum. Res no time losing consionous [sic, consciousness]. O2 [sic, oxygen] obtained and 48% on room air O2 applied at 4L [liters] and O2 Saturations at 78% Res taken to ER report called and Son [redacted] notified of actions taken. An inpatient history and physical from 8/20/2022 indicated that labs obtained in the ER reflected Resident G had a WBC result at 6:38 p.m. at 8/20/2022 was 25.8 K/uL. A nursing progress note dated 8/20/2022 at 9:45 p.m, indicated that Resident G was being admitted to the Intensive Care Unit from the ER for pneumonia and [CONDITION(S)] (low oxygen saturation). An interview with the Assistant Director of Nursing on 8/22/2022 at 1:31 p.m., indicated that the CBC and [MEDICATION(S)] level for Resident G were not complete because they were ordered incorrectly. The order was resubmitted to the lab but had not been completed by the time the resident was sent back to theER on [DATE]. An interview with Director of Nursing on 8/22/2022 at 3:35 p.m., indicated the STAT lab indicated in the IDT note for Resident G from 8/18/2022 was the [MEDICATION(S)] level per her belief. It has not been completed at the time of his transfer to the ER. A policy entitled, Lab Scheduling/Tracking, was provided by the Administrator on 8/22/2022 at 2:28 p.m. The policy indicated, It is the policy of the facility to ensure that laboratory tests ordered by the physician are systematically schedule and tracked so that ordered lab work is obtained .As lab orders are received, the charge nurse will complete the appropriate requisition and enter it into the system .Any omitted labs will be researched, and the lab will be contacted for an explanation as to the delay. If necessary, the physician will be notified, and another order will be requested. 3.1-49(a)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 residents reviewed for respiratory and other health-related conditions had timely and accurate assessments conducted in order to develop care plans that accurately reflect the resident's care and service needs. (Resident 41) Findings include: The clinical record of Resident 41 was reviewed on 8-19-22 at 2:35 p.m. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission Minimum Data Set (MDS) assessment, dated 7-17-22, indicated he was cognitively intact and indicated he received supplemental oxygen therapy, but did not indicate he utilized [CONDITION(S)] therapy. In an observation and interview of Resident 41 on 8-22-22 at 11:25 a.m., he was observed wearing supplemental oxygen via a nasal cannula with the rate at two liters per minute, with his respirations nonlabored. A [CONDITION(S)] machine was observed located on his bedside table. In an interview at this time, Resident 41 indicated he used the oxygen during the day and at night time, he uses the oxygen plus his [CONDITION(S)]. He indicated he has not had oxygen saturation levels checked daily by facility staff, as it had been occurring once daily or once every other day or sometimes less often. I figured they would check on [my] oxygen level at least once or twice a day. I would really like them to check it at least once a day. He indicated he brought the [CONDITION(S)] machine from home upon admission and had obtained it from his insurance and medical provider. In review of Resident 41 documents that reflected the facility's documentation of his oxygen saturation levels, it indicated on his admission on 7-13-22, it was documented as 98% (percent). The next documentation of his oxygen saturation was not dated until 7-28-22, 15 days later. A review of Resident 41's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders were in place for checking of the oxygen saturation until 7-27-22. His orders did reflect he was ordered to receive medications and treatments that are used in persons for diabetes, cardiovascular health and respiratory medications. The initial admission nursing assessment, dated 7-13-22, indicated Resident 41 utilized oxygen therapy, with an oxygen saturation rate of 98% and had brought in a [CONDITION(S)] machine from home. The documentation failed to identify the settings for the [CONDITION(S)] machine. In an interview with the MDS Coordinator and the Social Services Designee (SSD) on 8-22-22 at 2:45 p.m., the SSD provided copy of Resident 41's initial care plan meeting with his family, dated 7-14-22. The initial care plan meeting indicated he utilized oxygen, but did not address the use of a [CONDITION(S)] machine. The MDS Coordinator indicated the current care plans did not address the concerns of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator indicated the current care plans did not reflect concerns with [CONDITION(S)], oxygen usage, [CONDITION(S)] usage, diabetes or heart health issues. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Oxygen Administration. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician .Residents with oxygen orders, routine and PRN, will have oxygen saturation levels measured by oximetry per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxygen saturation will be checked and documented every shift to meet order specifications .Pulse Oximetry: Residents who have oxygen orders, whether scheduled or PRN will have oxygen saturation levels measured no less than daily. If MD orders states 'to maintain Sat' then oxygen saturation will be checked and documented every shift. MD will be notified whenever titration is required to maintain a saturation, which indicate a change in condition. Lung sounds and assessment will be reported to the MD at that time. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Continuous Positive Airway Pressure ([CONDITION(S)]). This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, Purpose: To improve ventilation on patients with obstructive sleep apnea (OSA), airway obstruction and upper airway resistance .Guideline: [CONDITION(S)] therapy must have a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient should be assessed before and after therapy has been initiated for any hazards or adverse effects such as pneumothorax and gastric distension .Procedure: Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g. 5 cm H2O .Set [CONDITION(S)] level according to the physician ordered level . On 8-22-22 at 3:12 p.m., the Administrator provided a copy of a policy and procedure, entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 9-18-18. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of the facility to ensure every resident has a Baseline Care Plan completed and implemented within 48 hours of Admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed. The Baseline Care Plan will be discontinued upon the completion of the Comprehensive Care Plan .Procedure: Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan will be completed within 48 hours of admission and will address areas of imminent concerns. At a minimum, it will address initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations, interview(s) with the resident and/or representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment .Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed by the IDT team . The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAA's . 3.1-31(a) 3.1-31(c)(1) 3.1-31(c)(2) 3.1-31(c)(3) 3.1-31(c)(4) 3.1-31(c)(6) 3.1-31(d)(1) 3.1-31(e)

Based on interview and record review, the facility failed to ensure a level 1 PASARR (preadmission screening and resident review) was conducted after admission to the facility and follow-up with the need for a level 2 PASARR for a resident with a mental disorder. (Resident 37) Findings include: Resident 37's record was reviewed on 8/19/22 at 2:44 p.m. and indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set assessment, dated 7/12/22, indicated Resident 37 was moderately cognitively impaired, had moods but no behaviors, was totally dependent on staff for activities of daily living, had impairment on one side of both upper and lower extremities in functional limitation in range of motion, did not walk, used a wheelchair, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 4/5/22, indicated: At risk for behavioral disturbances r/t (related to) dx (diagnosis): [CONDITION(S)]. On Antipsychotic med. Goal: Will have no adverse reaction to antipsychotic meds daily tnr (through next review). Will have no episodes of behavior r/t dx: daily TNR. Interventions: Antipsychotic meds per order. Approach resident calmly & quietly. GDR (gradual dose reduction) per guidelines. Monitor for effectiveness of meds, and interventions. Notify MD, Family and IDT (Interdisciplinary Team) of change in behaviors. Observe for adverse reactions to antipsychotic med such as but not limited to: Observe for behaviors. Psych per order. A care plan dated 4/29/22, indicated a focus of: 'Resident has dx. (diagnosis) of [CONDITION(S)] and paranoia. Goals: The resident will be monitored for EPS (extrapyramidal side effects i.e. inability to sit still, involuntary muscle contractions and involuntary facial movements) through next review date. The resident will be monitored for s/sx (signs/symptoms) of [CONDITION(S)] through the next review date. Interventions: AIMS (Abnormal Involuntary Movement Scale) upon admission and quarterly thereafter. GDR per schedule. MD notified of any delusions, hallucinations, increased paranoia, and changes in behavior. Meds as ordered. Psych evals as ordered. A document completed by Maximus, and Notice of PASRR Level I Screen Outcome, dated 9/21/20, indicated no PASARR level II was required. The document was completed at the facility Resident 37 had been admitted from. There was no current PASARR that was completed by the current facility. A policy for Ascend - PAS (Pre-Admission Screening) and LOC (Level of Care) was provided by the Administrator on 8/24/22 at 1:30 p.m. The policy included, but was not limited to, Purpose: Based on the PAS and Level of Care (LOC) changes effective 7.1.16; the Division of Aging is using Assessment Pro to tract patients from hospitals/home to facility. This new procedure requires a detailed clinical assessment of the patients demanding nursing administration and the business office to work together to ensure timely payment from Medicaid. Procedure: 1. Level 1 - either by hospital or nursing facility PRIOR to admission .All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level 1 PASRR completed to screen for possible mental illness (MI), intellectual disability (id), developmental disability (DD), or related conditions .Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview, and record review, the facility failed to develop a care plan for a resident who received a cholesterol lowering medication (Resident 23), and failed to develop a care plan for a resident who used oxygen, a continuous positive airway pressure machine ([CONDITION(S)]), and had [CONDITION(S)] and diabetes (Resident H). This affected 2 of 20 residents reviewed for care plans. 1. Resident 23's record was reviewed on 8/19/22 at 1:12 p.m. and indicated he had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no care plan in the resident's record to address the use of [MEDICATION(S)]. On 8/24/22 at 1:30 p.m., the Administrator provided a care plan for increased lipid levels associated with [CONDITION(S)], dated 8/22/22. The Administrator indicated the care plan had just been added. 2. The clinical record of Resident 41 was reviewed on 8-19-22 at 2:35 p.m. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission Minimum Data Set (MDS) assessment, dated 7-17-22, indicated he was cognitively intact and indicated he received supplemental oxygen therapy, but did not indicate he utilized [CONDITION(S)] therapy. In an observation and interview of Resident 41 on 8-22-22 at 11:25 a.m., he was observed wearing supplemental oxygen via a nasal cannula with the rate at two liters per minute, with his respirations nonlabored. A [CONDITION(S)] machine was observed located on his bedside table. In an interview at this time, Resident 41 indicated he used the oxygen during the day and at night time, he uses the oxygen plus his [CONDITION(S)]. He indicated he has not had oxygen saturation levels checked daily by facility staff, as it had been occurring once daily or once every other day or sometimes less often. I figured they would check on [my] oxygen level at least once or twice a day. I would really like them to check it at least once a day. He indicated he brought the [CONDITION(S)] machine from home upon admission and had obtained it from his insurance and medical provider. A review of Resident 41's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders were in place for checking of the oxygen saturation until 7-27-22. His medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial admission nursing assessment, dated 7-13-22, indicated Resident 41 utilized oxygen therapy and had brought in a [CONDITION(S)] machine from home. The documentation failed to identify the settings for the [CONDITION(S)] machine. In an interview with the MDS Coordinator and the Social Services Designee (SSD) on 8-22-22 at 2:45 p.m., the SSD provided copy of Resident 41's initial care plan meeting with his family, dated 7-14-22. The initial care plan meeting indicated he utilized oxygen, but did not address the use of a [CONDITION(S)] machine. The MDS Coordinator indicated the current care plans did not address the concerns of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator indicated the current care plans did not reflect concerns with [CONDITION(S)], oxygen usage, [CONDITION(S)] usage, diabetes or heart health issues. On 8-22-22 at 3:12 p.m., the Administrator provided a copy of a policy and procedure, entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 9-18-18. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of the facility to ensure every resident has a Baseline Care Plan completed and implemented within 48 hours of Admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed. The Baseline Care Plan will be discontinued upon the completion of the Comprehensive Care Plan .Procedure: Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan will be completed within 48 hours of admission and will address areas of imminent concerns. At a minimum, it will address initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations, interview(s) with the resident and/or representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment .Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed by the IDT team . The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAA's . 3.1-35(a) 3.1-35(b) 3.1-35(c)(1) 3.1-35(d)(1) 3.1-35(d)(2) 3.1-35(d)(2)(A) 3.1-35(d)(2)(B)

Based on observation, interview and record review the facility failed to assist residents with Activities of Daily Living (ADLs) assistance with grooming, showers and nail care for 3 of 4 residents reviewed for ADL assistance. (Residents D, H, and B) Findings include: 1. On 8/17/22 at 10:51 a.m., Resident D was observed with her hair disheveled and uncombed. She indicated she has been here since Thursday (6 days) and has had no shower since admission. Resident D's record was reviewed on 8/19/22 at 10:24 a.m. and indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A five day Medicare Minimum Data Set assessment, still in progress, indicated completed sections for the following: resident was cognitively intact, required extensive assistance of one for bed mobility, limited assistance of one for transfers, eating, bathing, and walking, and extensive assistance of one for dressing, toileting, and personal hygiene including combing hair. An Admission Activity Resident Interview, dated 8/11/22 indicated it is somewhat important for her to choose between a tub bath, shower, bed bath or sponge bath. An Activity Admission Assessment, dated 8/12/22, indicated she was cognitively intact, hearing was normal, had no problem with verbal communication, speech was clear, and she preferred showers. A care plan dated 8/11/22 indicated: Resident requires assistance with ADL'S. Goal: Resident will have all ADLS met by staff TNR (through next review). Interventions: Assist as needed so resident is clean and dry. Bathe per resident preference 2x [weekly]. Follow patient preferences as detailed on CNA pocket worksheet. Keep call light in reach. Notify and update MD and family as needed. staff assist as needed with bed mobility. staff assist as needed with eating. staff assist as needed with transfers. staff assist with toileting as needed. therapy screen as needed and quarterly. On 8/19/22 at 10:50 a.m., Resident D was lying in bed with her TV on. Her hair was uncombed and she said no one has helped her with her hair today but they will brush her hair if she asks them. She said she lets them brush it but she likes to pull it up herself because she can't get it down after they put it up for her. On 8/22/22 at 4:25 p.m., two family members were visiting Resident D and both indicated she has not had a shower since she has been here. Resident D said she combed her hair herself with her fingers today. Said she has not had her hair shampooed since admission either. Resident said she prefers showers to bed baths. On 8/23/22 at 1:55 p.m., Resident D indicated she has not yet had a shower, nor a shampoo, and her hair was observed to be very fly away and uncombed. Review of shower sheets and shower documentation under the task section for CNA notes indicated no documented shower since admission. On 8/23/22 at 12:03 p.m., p.m., CNA 5 indicated there is a sheet at the nurse's station that has the shower days on it. She said if a resident refuses a shower, it is written on the shower sheet and the nurse would document it too. LPN 6 indicated if a resident refused, the nurse would talk to the resident and see if a different time or day would be better, and it would also be documented in the progress notes. The shower schedule indicated Resident D's showers would be on Wednesday and Saturday, which indicated she should have had three showers since admission. Review of progress notes dated 8/11/22 through 8/23/22 did not indicate any notes related to Resident showers or refusal of showers. 2,) Review of the record of Resident B on 8/18/22 at 11:40 a.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physical therapy evaluation and plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment, dated 2/7/22, indicated the resident was severely impaired for daily decision making. The resident was not transferred during the assessment period. The ADL documentation for Resident B, dated February 2022, indicated the resident was transferred 11 times in 28 days. During an interview with Resident B's family member on 8/23/22 at 1:59 p.m.,, indicated the resident was suppose to be gotten out of bed daily. The Family member indicated she had talked to the facility about the concern of the resident not being transferred out of bed on a daily basis. The family member indicated they visited the facility almost daily and the resident had only been gotten up a few times during her stay at the facility. During an interview with the Director Of Nursing on 8/23/22 at 10:28 a.m., indicated the management team would be responsible to ensure dependent residents were assisted out of bed per their preference. The CNA's would be responsible to transfer dependent residents out of bed. 3. The clinical record of Resident H was reviewed on 8-19-22 at 11:22 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent Minimum Data Set assessment, dated 6-24-22, indicated she was cognitively impaired, required extensive assistance of one person for personal hygiene activities, such as nail care, and was dependent for assistance with bathing of one person. A review of CNA Shower Checklist forms, dated 7-13-22 through 8-17-22, indicated Resident H had received her preferred bed bathes. The document indicated she had received nail care of nails clipped and cleaned on 7-16-22, 7-22-22, 7-23-22, 7-30-22 and 8-6-22. The document indicated Resident H had her nails clipped, but not cleaned on 7-13-22, 8-13-22. The document indicated on 7-27-22, her nails were cleaned, but did not need clipping. The document indicated Resident H did not have her nails clipped or cleaned on 8-17-22. In observations of Resident H on 8-18-22 at 2:12 p.m., 8-19-22 at 11:00 a.m., and 8-19-22 at 3:15 p.m., all of her fingernails appeared long and discolored with a yellow cast to them with a large amount of dark to medium brown-colored debris under each nail. In an interview with Resident H on 8-18-22 at 2:12 p.m., she indicated she would prefer her fingernails to be trimmed and cleaned. After a dressing change observation on 8-19-22 at 3:15 p.m., with LPN 3 and CNA 4, both staff members were queried as to Resident H's fingernail status. Both staff members replied they had not noticed anything unusual until it was brought to their attention at the time of query. On 8-19-22 at 4:30 p.m., the Administrator provided a copy of an undated policy entitled, Activities of Daily Living (Routine Care). This policy was indicated to be the current policy utilized by the facility. This policy indicated, Residents are given routine daily care and HS [bedtime] care by a C.N.A. or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed. ADL care is coordinated between the resident and the care givers with emphasis on resident preference as much as possible .ADL care of the resident includes: assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care .assisting with movement and ambulation and ROM [range of motion] as indicated and care planned .do all required ADL documentation as required per policy and regulations. This Federal tag relates to Complaint IN 621. 3.1-38(a)(2)(A) 3.1-38(a)(2)(B) 3.1-38(a)(3)(B) 3.1-38(a)(3)(E) 3.1-38(B)(2) 3.1-38(B)(3)

Based on observation, interview and record review the facility failed to implement fall interventions for residents who were at high risk of falls for 2 of 6 reviewed for accidents (Resident 12 and Resident 22). Findings include: 1.) During an observation on 8/18/22 at 1:40 p.m., Resident 22 was sitting in her wheelchair in her room brushing her hair, the resident had a rolling bedside table sitting beside her. During an observation on 8/19/22 at 10:55 a.m., Resident 22 was sitting in a wheelchair in her room with a rolling bedside table beside her. During an observation on 8/23/22 at 11:03 a.m., Resident 22 was laying on couch with a rolling bedside table next to her with a drink on it. During an interview with LPN 7 ON 8/23/22 at 11:06 a.m., indicated she was the nurse caring for Resident 22. LPN 7 indicated she was unsure who was responsible to ensure the fall intervention of not having a bedside table in her room was implemented. LPN 7 indicated it would be all the staff's responsibility to ensure fall interventions were in place. During an interview with the Director Of Nursing (DON) on 8/23/22 at 11:23 a.m., indicated it was all staff's responsibility to ensure fall interventions were in place. The CNA's were verbally told what fall interventions were to be implemented for each resident and also the interventions were on the residents kardex. The DON indicated LPN 7 had reported to her that Resident 22 had a rolling bedside table in her room and the CNA removed it from the room. The DON indicated the resident was not suppose to have a rolling bedside table in her room because had attempted to use it as a walker and fell . Review of the record of Resident 22 on 8/23/22 at 1:15 p.m., indicated the resident's diagnoses included, but were not limited to, dementia, [CONDITION(S)] disorder and repeated falls. The Quarterly Minimum Data Set (MDS) assessment for 22, dated 6/27/22, indicated the resident was severely impaired for daily decision. The resident required extensive assistance of two people for transfers, the resident required limited assistance of one person to walk in her room. The resident's mobility devices were walker and wheelchair. The resident has had two or more falls since previous MDS and one with an injury. The Interdisciplinary team (IDT) progress note for Resident 22, dated 7/6/22 at 5:30 p.m., indicated the resident had been ambulating in her room using a rolling bedside table to walk with instead of a walker and fell . The new intervention would be to have the bedside table removed from the residents room and provide resident with meals outside of her room so staff could monitor for safety. The fall risk assessment for Resident 22, dated 7/18/22, indicated the resident was at high risk for falls. The plan of care for Resident 22, revision date 7/21/22, indicated the resident was at risk for falls due to history or recent fall, impaired balance, [CONDITION(S)], dementia, incontinence, arthritis, wandering, depression with antidepressant use and visual depth perception deficit. The interventions included, but were not limited to, remove rolling bedside table from her room (7/6/22). The incident report for Resident 22 provided by the DON on 8/23/22 at 2:50 p.m., indicated the resident had fell 11 times in the past 3 months. 2.) During an observation on 8/19/22 at 2:12 p.m., Resident 12 was sitting in her room in a walker drinking coffee. The resident did not have a bedside commode in her room. Review of the record of Resident 12 on 8/24/22 at 11:07 a.m., indicated the resident's diagnoses included, but were not limited to, mild cognitive impairment, history of falling, unsteadiness on feet, [CONDITION(S)] and [CONDITION(S)]. The plan of care for Resident 12, dated 1/4/22, indicated the resident was at risk for falls due to a history of falls. The interventions included, but were not limited to, bedside commode to be provided to resident (5/11/22). The IDT progress note for Resident 12, dated 5/11/22 at 12:36 a.m., met to review fall. At time of fall resident was attempting to transfer into bathroom. At time of fall resident was in her wheelchair which has extended break handles, proper footwear, and light to the bathroom was on. Immediate Intervention for a bedside commode to be provided for resident to allow more room for resident to transfer onto toilet. care plan reviewed and updated. The fall risk assessment for Resident 12, dated 5/11/22, indicated the resident was at high risk for falls. During an interview with Resident 12 on 8/24/22 at 11:00 a.m., resident indicated she had never had a bedside commode none observed in room she indicated she would like to have one because when she needs to go to the bathroom she needs to go right away. During an interview with QMA 8 on 8/24/22 at 11:05 a.m., indicated she did care for Resident 12 and was unsure if she had ever seen a bedside commode in her room. During an interview with LPN 7 on 8/24/22 at 11:10 a.m., indicated it had been awhile since she seen a bedside commode in Resident 12's room but was unable to say how long it had been. The LPN indicated she thought the facility may have taken it out for some reason unknown to her. The fall policy provided by the DON on 8/24/22 at 9:15 a.m., indicated based on the results of the fall investigation the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. 3.1-(a)(1)

Based on observation, interview, and record review, the facility failed to ensure resident's catheter drainage bags did not touch the floor, failed to have complete documentation of urine output and complete physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected 4 of 5 residents reviewed for urinary catheters. (Residents 7, H, 29 and 159) Findings include: 1. Resident 7's record was reviewed on 8/18/22 at 2:40 p.m. and indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 7 was mildly cognitively impaired, and had an indwelling Foley catheter. A care plan, dated 4/21/22, indicated Resident has an indwelling catheter related to [CONDITION(S)] ([CONDITION(S)]) with obstruction. Goal: Resident will be free of S/Sx of infection related to indwelling catheter, and catheter will remain patent daily through next review. Interventions .Maintain drainage bag and tubing to prevent discomfort or infection On 8/22/22 at 4:10 p.m., Resident 7's catheter drainage bag was observed lying on the floor, the dignity cover was on it but the top and bottom part of the catheter drainage bag was in contact with the floor. On 8/22/22 at 4:15 p.m., CNA 5 indicated she put the bag on the bed frame and it must have slid off when the resident moved. 2. The clinical record of Resident 29 was reviewed on 8-18-22 at 10:30 a.m. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission Minimal Data Set assessment, dated 7-3-22, indicated he was cognitively intact, required limited assistance of 2 or more persons for toileting and was continent of bowel and bladder. It did not indicate any use of a urinary catheter device. In observations on 8-15-22 at 1:54 p.m. and 8-18-22 at 11:20 a.m., Resident 29's urinary catheter bag was lying on the floor. In an interview with Resident 29 on 8-18-22 at 11:20 a.m., he indicated the nursing staff usually hangs his catheter bag off of the bedframe. He denied any pain or discomfort with the indwelling catheter. Resident indicated he did not have a catheter prior to fracture of his leg and has been at facility since June, 2022. Resident 29 indicated he was informed the reason for his urinary catheter was that since he was unable to walk, it would be easier for him to deal with urination. In an interview with CNA 2 on 8-18-22 at 1:16 p.m., she indicated Resident 29 was able to urinate without problems when he first admitted to the facility. She indicated, He started having problems with being able to urinate; he would try and strain and he had a terrible time. At first, the nurses would in and out cath him and sometimes would get 1000 cc's. I can't remember exactly when he got a foley catheter put in, but he seems a lot more comfortable. In review of Resident 29's clinical record, there was a lack of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the nursing progress notes, after placement of the indwelling catheter on 7-18-22 or 7-19-22, there was intermittent documentation of the resident's urinary status not reflective of the indwelling catheter, as follows: -7-21-22 at 12:01 a.m.: continent. -7-21-22 at 6:21 p.m.: incontinent of bowel and bladder. -7-23-22 at 11:40 a.m.: incontinent of bowel and bladder. -7-26-22 at 11:25 p.m.: continent. -8-14-22 at 12:06 a.m.: continent. -8-16-22 at 1:03 a.m.: continent. In an interview with the Director of Nursing (DON) on 8-18-22 at 2:10 p.m., she indicated a nursing progress note, dated 7-18-22, demonstrated the nurse had called and obtained a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON provided a copy of the order which reflected on 7-18-22, but noted to be dated 8-19-22, as the date of confirmation, the MDS Coordinator obtained an order from the resident's attending physician, which indicated the facility was to place an indwelling catheter for urinary retention with the catheter, which included the size of catheter and the balloon size and to change it every 30 days and as needed. On 8-23-22 at 8:55 a.m., in an interview with the DON, she indicated, I haven't really looked at [name of Resident 29]'s documentation about his catheter. I know he had a catheter before he admitted here. I don't think he had one when he first came to us. He also had several in and out caths before he had one anchored. Maybe the documentation of him being continent or incontinent had to do with his bowels. Plus, he would take himself to the bathroom at times without asking for help and not put the cath bag back where it was off the floor. Last week, once we knew you were looking at concerns with catheters [during the annual survey process], we did an audit of all the residents with catheters. So, that is when we starting looking at the cath orders .I think part of the problem with some of our documentation has to do with having so many agency staff during Covid. I could never figure out how to motivate them to get the documentation that was required done. At one point, we had up to 95% of the staff that was agency staff. Starting this spring, we have been able to begin to get new staff and we are now completely without any agency staff and we can begin to get more training completed. 3. The clinical record of Resident H was reviewed on 8-19-22 at 11:22 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent Minimum Data Set assessment, dated 6-24-22, indicated she was cognitively impaired, required extensive assistance of one person for personal hygiene activities, such as nail care, and was dependent for assistance with bathing of one person. Observations were conducted on 8-17-22 at 1:48 p.m. and 8-18-22 at 2:12 p.m. in which Resident H's catheter bag was observed to be in contact with the floor. In an observation and interview with Resident H on 8-18-22 at 2:12 p.m., she indicated she has had a urinary catheter for an unknown amount of time and for an unknown reason. The catheter bag bottom was observed in contact with the floor and not attached to bed frame. The urine in the catheter tubing was observed to be a clear yellow color without any sediment. Resident H indicated she has a history of urinary tract infections ([CONDITION(S)]'s) and currently has some low abdominal discomfort and some pelvic area pain and burning; she is uncertain if she is currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The catheter order did not specify the size of the tube or balloon of the catheter. Another catheter order, dated 6-17-22, did not specify the size of the tube or balloon of the catheter. A catheter order, dated 8-18-22 at 7:00 p.m., indicated, Catheter: Change fig bag/drainage bag with privacy bag twice a month every night shift every 14 days for catheter care. A catheter order, initiated on 8-18-22 at 7:00 p.m., indicated to place an indwelling catheter for wound healing, specifying the catheter size and to be replaced every 30 days. This order was discontinued on 8-19-22 at 7:00 p.m., and replaced with a different-sized catheter for wound healing and to be replaced every 30 days. None of the catheter-related orders alluded to conducting routine catheter-cleaning care. A review of the clinical record indicated Resident H had been recently treated for [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 100 milligrams (mg) twice daily for 7 days from 7-14-22 until 7-21-22. -[MEDICATION(S)] 500 mg twice daily for 10 days from 8-2-22 until 8-11-22. On 8-23-22 at 8:55 a.m., in an interview with the DON, she indicated, in the previous week, it had come to the attention of the facility during the facility's annual survey, the survey team was looking at catheter-related issues. We did an audit of all the residents with catheters. So, that is when we starting looking at the cath orders. 4.) During an observation on 8/16/22 at 2:32 p.m., Resident 159 was laying in bed with a catheter in place in a privacy bag hanging on the frame of the bed. Review of the record of Resident 159 on 8/24/22 at 10:00 a.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note for Resident 159, dated 7/21/2022 at 5:00 p.m., indicated the resident was admitted to the facility with a Foley catheter in place. The plan of care for Resident 159, dated 8/10/22, indicated the resident had a Foley catheter. The interventions were, change indwelling Foley catheter as ordered, complete catheter care every shift, update the physician and family of any changes as needed and urology follow up as needed/ordered. This indicated the resident did not have a plan of care for Foley catheter for 21 days after his admission to the facility. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This indicated the resident had not had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The indwelling urinary catheter care policy provided by the Administrator on 8/19/22 at 4:30 p.m., indicated the purpose was to cleanse and maintain hygiene to perineal area and indwelling catheter. To remove mucous from around indwelling catheter to prevent excoriation, inflammation and discomfort. The procedure included, but were not limited to, enter the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-47(a)(3)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 residents reviewed for oxygen therapy and associated respiratory issues had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 41) Findings include: The clinical record of Resident 41 was reviewed on 8-19-22 at 2:35 p.m. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission Minimum Data Set (MDS) assessment, dated 7-17-22, indicated he was cognitively intact and indicated he received supplemental oxygen therapy, but did not indicate he utilized [CONDITION(S)] therapy. In an observation and interview of Resident 41 on 8-22-22 at 11:25 a.m., he was observed wearing supplemental oxygen via a nasal cannula with the rate at two liters per minute, with his respirations nonlabored. A [CONDITION(S)] machine was observed located on his bedside table. In an interview at this time, Resident 41 indicated he used the oxygen during the day and at night time, he uses the oxygen plus his [CONDITION(S)]. He indicated he has not had oxygen saturation levels checked daily by facility staff, as it had been occurring once daily or once every other day or sometimes less often. I figured they would check on [my] oxygen level at least once or twice a day. I would really like them to check it at least once a day. He indicated he brought the [CONDITION(S)] machine from home upon admission and had obtained it from his insurance and medical provider. In review of Resident 41 documents that reflected the facility's documentation of his oxygen saturation levels, it indicated on his admission on 7-13-22, it was documented as 98% (percent). The next documentation of his oxygen saturation was not dated until 7-28-22, 15 days later. A review of Resident 41's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No orders were in place for checking of the oxygen saturation until 7-27-22. The initial admission nursing assessment, dated 7-13-22, indicated Resident 41 utilized oxygen therapy, with an oxygen saturation rate of 98% and had brought in a [CONDITION(S)] machine from home. The documentation failed to identify the settings for the [CONDITION(S)] machine. In an interview with the MDS Coordinator and the Social Services Designee (SSD) on 8-22-22 at 2:45 p.m., the SSD provided copy of Resident 41's initial care plan meeting with his family, dated 7-14-22. The initial care plan meeting indicated he utilized oxygen, but did not address the use of a [CONDITION(S)] machine. The MDS Coordinator indicated the current care plans did not address the concerns of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator indicated the current care plans did not reflect concerns with [CONDITION(S)], oxygen usage, [CONDITION(S)] usage or heart health issues. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Oxygen Administration. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician .Residents with oxygen orders, routine and PRN, will have oxygen saturation levels measured by oximetry per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxygen saturation will be checked and documented every shift to meet order specifications .Pulse Oximetry: Residents who have oxygen orders, whether scheduled or PRN will have oxygen saturation levels measured no less than daily. If MD orders states 'to maintain Sat' then oxygen saturation will be checked and documented every shift. MD will be notified whenever titration is required to maintain a saturation, which indicate a change in condition. Lung sounds and assessment will be reported to the MD at that time. On 8-22-22 at 1:40 p.m., the Assistant Director of Nursing provided a copy of an undated policy and procedure, entitled, Continuous Positive Airway Pressure ([CONDITION(S)]). This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, Purpose: To improve ventilation on patients with obstructive sleep apnea (OSA), airway obstruction and upper airway resistance .Guideline: [CONDITION(S)] therapy must have a written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient should be assessed before and after therapy has been initiated for any hazards or adverse effects such as pneumothorax and gastric distension .Procedure: Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g. 5 cm H2O .Set [CONDITION(S)] level according to the physician ordered level . On 8-22-22 at 3:12 p.m., the Administrator provided a copy of a policy and procedure, entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 9-18-18. This policy and procedure was indicated to be the current policy utilized by the facility. This policy indicated, It is the policy of the facility to ensure every resident has a Baseline Care Plan completed and implemented within 48 hours of Admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed. The Baseline Care Plan will be discontinued upon the completion of the Comprehensive Care Plan .Procedure: Upon admission to the facility, the admitting nurse will initiate the Baseline Care Plan Assessment to establish an initial plan of care to identify potential problems and to initiate appropriate goals and interventions. The Baseline Care Plan will be completed within 48 hours of admission and will address areas of imminent concerns. At a minimum, it will address initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations, interview(s) with the resident and/or representative, information obtained from the physician as well as review of the available medical records on admission will be reference points for development of the Baseline Care Plan Assessment .Within 72 hours following the admission of the resident, the Baseline Care Plan Assessment will be reviewed/discussed and revised as needed by the IDT team . The Baseline Care Plan will continue to be revised until the final completion of the Comprehensive Care Plan .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAA's . 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to identify an alteration in skin integrity that was later identified as an unstageable pressure ulcer, initiate treatments for an identified alteration in skin integrity, sign-off treatments for pressure ulcers, and conduct weekly wound assessments for 3 of 4 residents reviewed for pressure ulcers (Resident B, C and D). Findings include: 1. The clinical record for Resident B was reviewed on 1/12/2022 at 1:24 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated 9/30/2021, indicated Resident B was cognitively impaired and needed extensive assistance of two staff members for bed mobility and extensive assistance of one staff member for hygiene tasks. A preventative skin care plan, dated 1/15/2019, listed the interventions of turning and repositioning every 2 hours and as needed as well as skin assessment per facility policy. A pressure ulcer skin care plan, dated 7/12/2021, listed a pressure ulcer to the right ischium with interventions of treatment as ordered and wound care appointments as ordered. A Mini Nutritional Assessment was completed on 1/4/2022 and scored Resident B as malnourished. A Braden Scale (scale used to predict the risk of pressure areas) was completed on 1/7/2022 and scored Resident B at very high risk. Resident B had an extensive history of pressure areas, including the most severe current pressure area on the right ischium with identification date of 2/14/2021. Resident B had a pressure area listed as a deep tissue injury to the left heel in 2019 that healed and a reoccurrence of pressure area to left heel, stage 2, in April of 2021. A discontinued physician ordered from 6/25/2021, indicated for Resident B to wear bilateral heel protectors. A discontinued physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was admitted to the hospital on 12/20/2021. A wound care note during her hospital stay, dated 12/27/2021, indicated a deep tissue pressure injury to Resident B's left heel with a red/purple color and surrounding [CONDITION(S)] (redness). Resident B was readmitted to the facility on [DATE] and had no weight documented until 1/13/2022. An admission/re-admission assessment, dated 12/31/2021, indicated a stage three pressure area to the buttocks with no other skin impairments documented. A wound center note from 1/3/2022, indicated left heel ecchymosis (a discoloration of the skin resulted from bleeding underneath) as well as a stage four wound to the gluteus (buttock). A weekly skin check was signed off the medication and treatment administration record on 1/7/2022 with NA listed on both the Yes and also on the No boxes. An observation on 1/12/2022 at 11:35 a.m., Resident B was lying on her back with her feet towards the right side of the bed. No offloading measures to heels observed. A low air loss mattress was in place and functioning. An observation on 1/12/2022 at 3:17 p.m., Resident B was lying on her back with her feet towards the right side of the bed. She did not appear to have been repositioned or turned. No offloading measures to heels observed. Resident B was noted to have a wound vacuum dressing to her right ischium area and a reddened left heel with a central dark scab. Resident B indicated yes when asked if her heel hurt. An interview with LPN (Licensed Practical Nurse) 3 on 1/12/2022 at 3:20 p.m., indicated the nursing aides should reposition Resident B but she didn't know the last time it was done. She repositioned Resident B at that time. LPN 3 indicated this was the first time she worked with Resident B and was not aware of her wounds. A wound assessment on 1/12/2022 at 7:46 p.m., indicated a stage 2 pressure area to Resident B's left Achilles- 0.6 x 0.7 x 0.1 cm with surrounding redness with identification on 1/12/2022. Sure prep with padding and kerlix (gauze) wrap were ordered at that time. A wound assessment on 1/12/2022 at 7:53 p.m., indicated a suspected deep pressure injury to Resident B's left buttock-2.0 x 4.0 x 0 cm was identified on 1/12/2022. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Assistant Director of Nursing on 1/12/2022 at 4:29 p.m., indicated she had assessed two new skin issues with Resident B. That LPN 5 had notified her of new areas. A pressure area to the left heel and a suspected deep tissue area to the buttock were discovered. She attributed the heel to Resident B's contractures and believed the buttock area was related to her urinary catheter tubing. Asked if they had any preventative measures in place for Resident B's heels and she indicated no that the facility had tried heel protectors and boots in the past, but Resident B would displace them and cause other skin issues. An interview with RN 9 on 1/13/2022 at 12:23 p.m., indicated RN (Registered Nurse) 9 was a provider for Resident B during her hospital stay in the end of December 2021. RN 9 review the hospital wound care documentation and indicated Resident B had a deep tissue pressure area to the left heel with redness that bridged over the back of the foot. 2a. The clinical record for Resident C was reviewed on 1/12/22 at 1:15 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS assessment, dated 9/26/21, noted Resident C with mild cognitive impairment and needing extensive assistance of one staff person for personal hygiene, dressing and eating. As well as extensive assistance of 2 staff person with bed mobility, transfers and toilet use. No alterations in skin integrity were marked. An interview conducted with Resident C, on 1/12/22 at 2:45 p.m., indicated the dressing on her left heel gets changed about every 2-3 days. A progress note, dated 10/29/21, indicated a red open area with black color center to left outer heel was present measuring 2 x 1.8 centimeters. A dressing was applied, and no further assessment was documented in the clinical record. No treatment orders were noted for Resident C's left heel on 10/29/21. A weekly wound evaluation, dated 11/3/21, indicated an unstageable pressure ulcer to Resident C's left heel measuring 2.5 x 2 centimeters. The area was described as a black/purple scab with small dry slit open around and identified on 11/3/21. The tissue type was documented as 100% skin. A physician order, dated 11/3/21, indicated the following, .Cleanse are [sic] to left heel with NS [normal saline], pat dry and apply abd [abdominal pad] with [MEDICATION(S)] [sic]. one time a day related to TYPE 2 DIABETES MELLITUS 2b. The electronic treatment administration record (ETAR) for November of 2021 was reviewed and noted 9 of 28 administrations of the left heel wound treatment were left blank. The ETAR for December of 2021 was reviewed and noted 14 of 31 administrations of the left heel wound treatment were left blank. The ETAR for January of 2022 was reviewed and noted 4 of 12 administrations of the left heel wound treatment were left blank. 2c. The following weekly wound assessments were noted in Resident C's clinical record pertaining to the left heel: 11/7/21, 11/14/21, 11/28/21, 11/30/21, 12/7/21, 12/14/21, 12/21/21, & 1/9/22. There were no other weekly wound assessments located in Resident C's clinical record. A care plan for a left heel wound, revised 11/4/21, indicated the following, .wound is present to left heel .Interventions .skin checks weekly and prn [as needed] .treatment as ordered 3. The clinical record for Resident D was reviewed on 1/13/22 at 1:16 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medicare 5-day MDS assessment, dated 11/17/21, indicated Resident D was cognitively intact and required extensive assistance with 2 staff persons for bed mobility and extensive assistance with 1 staff person for personal hygiene. A stage 3 pressure ulcer was marked as present on the assessment. A readmission assessment, dated 11/12/21, noted a stage 3 pressure ulcer to the coccyx measuring 6.1 x 1.9 centimeters. A physician order, dated 11/12/21, noted for Santyl ointment to the coccyx daily for a stage three pressure ulcer. Weekly wound evaluations, dated 11/19/21, indicated there were 2 coccyx wounds that were identified as stage 2 pressure ulcers with measurements and description noted. The next weekly would evaluation wasn't completed until 11/30/21. One coccyx wound was still described as a stage 2 while the other was labeled as an unstageable pressure ulcer. The treatment remained the same. There were no weekly wound evaluations completed for the month of December of 2021. The weekly wound evaluations, dated 1/6/22, indicated a stage 2 to the coccyx that appeared smaller in size and an unstageable to the coccyx that was larger in size since 11/30/21. A care plan for wounds, revised 1/12/22, indicated the following, .wounds are present Coccyx [sic] .Interventions .skin checks weekly and prn [as needed] .treatment as ordered An interview conducted with the Assistant Director of Nursing (ADON), on 1/13/22 at 3:30 p.m., indicated the MDS Staff Person would do the wounds and they no longer work here. Now the facility was trying to get back on track. We used to always conduct SWAT (Skin and Weight Assessment Team) meetings on Thursdays with wound rounds. We have corporate setting us up with an outside company to conduct wound rounds with us. She indicated she hasn't checked the ETAR for completion. If a resident had a wound, they should be on weekly weights with the SWAT review. A policy titled S.W.A.T. Program, undated, was provided by the Director of Nursing on 1/13/22 at 9:45 a.m. The policy indicated the following, .SYSTEM FOR ASSESSMENT OF WOUNDS ONCE IDENTIFIED .Immediate completion of wound assessment with wound measurements and description to be completed upon discovery of wound .Notify MD/NP [Medical Doctor/Nurse Practitioner] for orders for treatment and enter order into medical record and onto the Treatment/Medication Record as orders received .Notify DON/ADON and Wound or Treatment Nurse .Materials needed for S.W.A.T. meeting .Skin Assessments .Treatment Records .Procedure .S.W.A.T. meets weekly This Federal tag relates to Complaint IN 011. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a treatment was initiated after identification of stage 2 pressure ulcers [partial thickness ulcer] that worsened and resulted in hospitalization related to [CONDITION(S)] [condition that occurs when the body's response to an infection damages its own tissues], failed to assess skin impairments that were documented as present upon admission to the coccyx and buttocks/gluteus, complete treatments for pressure ulcers as ordered by the physician, and follow recommendations from the wound clinic for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: 1a. The clinical record for Resident B was reviewed on 7/9/21 at 11:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was admitted to the facility on [DATE]. An Admission Assessment, dated 4/30/21, documented a bacterial wound to Resident B's groin, right buttock, and right inner thigh. The assessment indicated the following, .Resident has wound from groin, right inner thigh and then goes to the back of leg into right buttock due to Necrotizing fascitis [fasciitis], wound vac in place There was no mentioning of pressure ulcers. A progress note, dated 5/1/21, indicated the following, .Wound showing muscle to right inner thigh/peri [perineal] area, wound Vac put in place, resident tolerated fair There was no indication of other wounds present on Resident B. A physician order, dated 4/30/21, indicated the use of a wound vac to right thigh and change every Monday, Wednesday, and Friday. There were no other skin treatments initiated upon admission for Resident B. A wound care plan, initiated 5/3/21, indicated the following, .Has DX [diagnosis]: wounds with wound vac in place, severe pain with repositioning with need for Foley catheter An Admission Minimum Data Set (MDS) assessment, dated 5/7/21, noted the need for extensive assistance with 2 staff person for bed mobility and transfers along with extensive assistance with 1 staff person for dressing, toileting, and personal hygiene. Open [CONDITION(S)] were marked as present but no pressure ulcers, venous wounds, arterial wounds, and/or surgical wounds present. 1b. A wound care plan, initiated 4/30/21 and revised 6/11/21, indicated the following, .wound is present .[CONDITION(S)] .stage 3 coccyx [sic] .Stage 2 left and right gluteal [sic] .Interventions .LAL [low air loss] mattress .skin checks weekly and PRN [as needed] .treatment as ordered A care plan, initiated on 5/1/21, indicated the following, .potential for weight loss R/T [related to]: decline in overall health, poor intakes A nutrition care plan, initiated on 5/5/21, indicated the following, .1. Res. [resident] has Dx. [diagnosis] of Dysphagia [difficulty swallowing]; (tube feeding d/c on 5/17/21) .4. Res. receives a Regular diet with <25% meal intakes; at risk for weight loss Resident B's feeding tube was discontinued, and she was started on a diet to consume food by mouth. A supplement was initiated on 6/8/21 along with an appetite stimulant medication on 6/10/21 due to having poor intake. A weekly wound evaluation, dated 5/7/21, indicated a stage 2 pressure ulcer was located on Resident B's left gluteus and marked as present upon admission. The wound measured 0.4 cm in length x 0.6 cm in width x 0.2 cm in depth and consisted of 100% granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process). The current treatment was listed as [MEDICATION(S)] gentle (bordered foam). A document from Advanced Wound Center, dated 5/7/21, indicated a stage 2 pressure ulcer was noted to Resident B's left gluteus. The plan was to treat with [MEDICATION(S)] gentle (bordered foam) dressing daily. A weekly wound evaluation, dated 5/14/21, indicated the stage 2 pressure ulcer was larger with measurements of 1.2 cm in length x 1 cm in width x 0.2 cm in depth. The current treatment was listed as [MEDICATION(S)] gentle. A weekly wound evaluation, dated 5/21/21, indicated the stage 2 pressure ulcer was larger with measurements of 2.8 cm in length x 3.8 cm in width x 0.2 cm in depth. The wound consisted of 50% slough tissue (devitalized/dead tissue) and 50% granulation tissue. Current treatment was [MEDICATION(S)] gentle. There were no physician orders for [MEDICATION(S)] gentle noted in Resident B's clinical record during her stay at the facility. A weekly wound evaluation, dated 5/28/21, indicated the stage 2 pressure ulcer was larger with measurements of 4.9 cm in length x 4.5 cm in width x 1 cm in depth. The wound consisted of 100% granulation tissue. Current treatment was with Santyl. A document from Advanced Wound Center, dated 5/28/21, indicated a stage 3 pressure ulcer was noted to Resident B's left gluteus. The plan was to treat with Santyl, cover with bordered foam, and change daily. There were no physician orders for Santyl for May of 2021. A weekly wound evaluation, dated 6/4/21, indicated the left gluteus was now an unstageable pressure ulcer and measured 5 cm in length x 3 cm in width x 0.1 cm in depth. The wound consisted of 100% slough and current treatment with Santyl. There were no physician orders for Santyl dated 6/4/21. A weekly wound evaluation, dated 6/11/21, indicated the unstageable pressure ulcer was larger with measurements of 7.1 cm in length x 7.9 cm in width x 0.1 cm in depth. The wound consisted of 25% granulation tissue and 75% slough tissue with current treatment noted as Santyl. A document from Advanced Wound Center, dated 6/11/21, indicated the ulcer noted to Resident B's left gluteus was then unstageable. The plan was to treat with Santyl, cover with bordered foam, and change daily. A physician order, dated 6/12/21, indicated the following, .Cleanse bilateral buttocks and coccyx with soap and water every day. Apply Santyl ointment directly to wound bed and cover with bordered gauze (6x6) .every day shift for skin health There were no previous orders for Santyl noted in Resident B's clinical record. A weekly wound evaluation, dated 6/18/21, indicated the unstageable pressure ulcer appeared smaller with 25% granulation tissue and 75% slough tissue and current treatment with Santyl. A document from Advanced Wound Center, dated 6/18/21, indicated the unstageable pressure ulcer appeared smaller and the plan was to continue to treat with Santyl, cover with bordered foam, and change daily. 1c. A weekly wound evaluation, dated 5/7/21, indicated a stage 2 pressure ulcer was located to Resident B's right gluteus and marked as present upon admission. The wound measured 0.9 cm in length x 0.8 cm in width x 0.1 cm in depth and consisted of 100% granulation tissue. The current treatment was listed as duoderm (hydrocolloid dressing is biodegradable, breathable, and adheres to the skin). There were no physician orders for the duoderm treatment dated 5/7/21. There was no mention of a pressure ulcer to Resident B's buttocks upon admission in the clinical record. A document from Advanced Wound Center, dated 5/7/21, indicated a stage 2 pressure ulcer was noted to Resident B's right gluteus. The plan was to treat with duoderm and change every third day. A weekly wound evaluation, dated 5/14/21, indicated the stage 2 pressure ulcer was larger with 100% granulation tissue present. The current treatment was with duoderm. A weekly wound evaluation, dated 5/21/21, indicated the stage 2 pressure ulcer was larger and measured 3.5 cm in length x 4.1 cm in width x 0.1 cm in depth. The wound consisted of 100% granulation tissue and the current treatment was with duoderm. There were no physician orders for a duoderm treatment to Resident B's right gluteal noted in the clinical record. A weekly wound evaluation, dated 5/28/21, indicated the stage 2 pressure ulcer was larger and measured 5.5 cm in length x 5.6 cm in width x 0.1 cm in depth. There was 100% granulation tissue and current treatment with Santyl. There were no physician orders for Santyl dated 5/28/21. A document from Advanced Wound Center, dated 5/28/21, indicated a stage 3 pressure ulcer was noted to Resident B's right gluteus. The plan was to treat with Santyl, bordered foam, and change daily. A weekly wound evaluation, dated 6/4/21, indicated the pressure ulcer to Resident B's right gluteus was then unstageable and measuring 5.6 cm in length x 3.1 cm in width x 0.1 cm in depth. There was 100% slough tissue present and current treatment with Santyl. There were no orders for Santyl dated 6/4/21. A weekly wound evaluation, dated 6/11/21, indicated the unstageable pressure ulcer to the right gluteus was larger and measuring 7 cm in length x 5.5 cm in width x 0.1 cm in depth. The wound consisted of 90% slough tissue and 10% granulation tissue with current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A document from Advanced Wound Center, dated 6/11/21, indicated an unstageable pressure ulcer was noted to Resident B's right gluteus. The plan was to treat with Santyl, bordered foam, and change daily. A care plan for wounds, revised 6/11/21, indicated the following, .stage 3 coccyx .stage 2 left and right gluteal .Interventions .skin checks weekly and PRN [as needed] .treatment as ordered A physician order, dated 6/12/21, indicated the following, .Cleanse bilateral buttocks and coccyx with soap and water every day. Apply Santyl ointment directly to wound bed and cover with bordered gauze (6x6) .every day shift for skin health There were no previous orders for Santyl noted in Resident B's clinical record. A weekly wound evaluation, dated 6/18/21, indicated the unstageable pressure ulcer appeared smaller with 90% slough tissue and 10% granulation tissue present. Current treatment was with Santyl. A document from Advanced Wound Center, dated 6/18/21, indicated the unstageable pressure ulcer appeared smaller and the plan was to continue to treat with Santyl, cover with bordered foam, and change daily. A progress note, dated 6/21/21 at 9:10 p.m., indicated Resident B was admitted to the hospital due to a vaginal/rectal fistula, wounds, and a urinary tract infection. Hospital records, dated 6/22/21, indicated the following, .She presented to OSH [outside hospital] from ECF [extended care facility] with c/o [complaints of] worsening AMS [altered mental status] .worsened labial, right leg, et [sic] decubitus ulcer .Ct [Computed tomography] scan showing sacral decubitus ulcer and concerns for rectovaginal fistula .General surgery was consulted for evaluation surgical intervention of the rectovaginal fistula and surgical debridement of sacral decubitus ulcer .plan .decub [decubitus] ulcer will need surgical debridement, tentatively scheduled for OR [operating room] tomorrow Hospital records, dated 7/3/21, indicated the following, .Patient was evaluated by surgery and had MRI [magnetic resonance imaging] of pelvis with contrast which revealed large sacrococcygeal decubitus ulcer with [CONDITION(S)] extending to the coccyx, mild changes and bony signal underlying the defect, 2 additional decubitus ulcers within subcutaneous tissue abutting the medial aspect of the gluteus maximus muscles with associated reactive myositis, diffuse intramuscular [CONDITION(S)]. She was taken to the OR on /23 [6/23/21] and had I&D [incision and drainage of a wound] in the OR cultures were sent which revealed gram-positive cocci and gram-negative rods on the stain and E. coli on preliminary culture results .Assessment/Plan .SEPTIC SHOCK .likely due to sacral [CONDITION(S)] .[CONDITION(S)] .2/2 [secondary to] septic shock vs cardiogenic shock 1d. A weekly wound evaluation, dated 5/7/21, indicated a stage 3 pressure ulcer was located to Resident B's coccyx and was marked as present upon admission. The wound measured 1.5 cm in length x 1.1 cm in width x 0.3 cm in depth and consisted of 100% slough (a mass of dead tissue separating from an ulcer). The current treatment was Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal). There was no mentioning of a pressure ulcer to Resident B's coccyx upon admission located in the clinical record. A physician order, dated 4/30/21, indicated the use of Santyl ointment to Resident B's coccyx and to be changed daily. A document from Advanced Wound Center, dated 5/7/21, indicated a stage 3 pressure ulcer to Resident B's coccyx. The plan was to treat with Santyl daily and follow-up in 2 weeks. A weekly wound evaluation, dated 5/14/21, indicated no changes to Resident B's coccyx wound. A weekly wound evaluation, dated 5/21/21, indicated Resident B's coccyx wound was larger with measurements of 4 cm in length x 3.1 cm in width x 0.3 cm in depth. A weekly wound evaluation, dated 5/28/21, indicated the coccyx wound was larger and measuring 4.6 cm in length x 3.9 cm in width x 0.1 cm in depth. A document from Advanced Wound Center, dated 5/28/21, indicated a stage 3 pressure ulcer to Resident B's coccyx with the same measurements noted on the weekly wound evaluation, dated 5/28/21. The plan was to treat with Santyl daily. The electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 5/11/21, 5/13/21, 5/14/21, 5/17/21, 5/18/21, 5/22/21, 5/23/21, 5/26/21, & 5/28/21. A weekly wound evaluation, dated 6/4/21, indicated the coccyx wound was now unstageable (ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) and larger measuring 6.9 cm in length x 3.4 cm in width x 0.1 cm in depth. The wound was covered with 100% slough tissue. A weekly wound evaluation, dated 6/11/21, indicated the coccyx wound measured 5.6 cm in length x 4.7 cm in width x 0.3 cm in depth with 90% slough tissue. A document from Advanced Wound Center, dated 6/11/21, indicated an unstageable pressure ulcer to Resident B's coccyx with the same measurements noted on the weekly wound evaluation, dated 6/11/21. The plan was to continue with treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A weekly wound evaluation, dated 6/18/21, indicated the coccyx wound was larger and measured 5.9 cm in length x 6.2 cm in width x 0.5 cm in depth. There was 90% slough tissue present. The EMAR, dated June of 2021, indicated the order for Santyl to Resident B's coccyx wound was not signed off as administered on 6/2/21, 6/19/21, and 6/20/21. An interview conducted with the Interim Executive Director (ED), on 7/12/21 at 4:45 p.m., indicated the situation involving Resident B and her skin impairments was before she was acting as the Interim ED. She had very limited knowledge about Resident B. Interim ED took over on 6/29/21 and the Interim Director of Nursing (DON) started a couple days before she did. A policy titled PHYSICIAN ORDERS, undated, was provided by the Interim ED on 7/12/21 at 3:42 p.m. The policy indicated the following, .It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission A policy titled SKIN AND WEIGHT ASSESSMENT TEAM (SWAT), undated, was provided by the Interim ED on 7/12/21 at 3:12 p.m. The policy indicated the following, .SYSTEM FOR ASSESSMENT OF WOUNDS ONCE IDENTIFIED .Immediate completion of wound assessment with wound measurements and description to be completed upon discovery of wound .Notify MD/NP [Medical Director/Nurse Practitioner] for orders for treatment and enter orders into medical record and onto the Treatment/Medication Record as orders received .Update Care Plan - and follow interventions .Procedure: PRESSURE ULCER ASSESSMENT .Pressure Ulcer Assessments will be performed on all pressure ulcers at least weekly .Any area not making positive progress in a 2 week period should be reported to the physician for a possible alternate treatment plan .NOTE: Any skin changes should be documented immediately and reported to appropriate parties with treatment put into place by physician order This Federal tag relates to Complaint IN 452. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review the facility failed to provide [MEDICATION NAME] (pain medication) for a resident who had a knee replacement resulting in extreme pain, tearfulness, inability to sleep and inability to get out of bed for 1 of 2 residents reviewed for pain management (Resident 203). Finding include: During an interview with Resident 203, on 8/04/19 at 11:51 a.m., she indicated the facility did not manage her pain well when she was first admitted to the facility. The resident indicated she had to go from 7/27/19 until 7/29/19 without her pain medication. The resident indicated it was awful and she was in terrible pain. She had a right knee replacement on 7/22/19. She felt the facility should have addressed she did not have enough medication on her prescription to last. The facility should have made it a priority when she was admitted on [DATE] to ensure she would have enough pain medication for the weekend. The resident showed me her right knee, it was swollen, intact with glue and had an approximately 5 inch incision. Review of the record of Resident 203 on 8/6/19 at 9:55 a.m., indicated the resident's [DIAGNOSES REDACTED]. The hospital discharge documentation for Resident 203, dated 7/25/19, indicated the discharge [DIAGNOSES REDACTED]. The physician recapitulation for Resident 203, dated 7/25/19, indicated the resident was ordered [MEDICATION NAME] tablet 7.5 milligrams (mg) -325 mg ([MEDICATION NAME]- [MEDICATION NAME]) one tablet every fours hours for pain and [MEDICATION NAME] 7.5 mg - 325 mg two tablets every four hours for severe pain. The resident was also ordered Tylenol 325 mg. The pain review for Resident 203, dated 7/28/19 at 2:29 p.m., indicated the resident had pain or hurting in the past five days frequently. The pain had made it hard to sleep at night and limited her day to day activities. The resident rated her pain as a 7 on the 1-10 pain scale. The resident's leg pain was located on her right leg surgical incision. The resident indicated her pain lasted until her pain medication kicks in, and has had since surgery. The pain medication was what alleviated her pain and movement made it worse. The pain affected the resident's sleep, mood, socialization, activities of daily living and physical activity. The Admission Minimum Data Set (MDS) for Resident 203, dated 8/1/19, indicated the resident was cognitively intact for daily decision making, consistent and reasonable and had experienced pain in the last five days frequently. Review of the Medication Administration Record [REDACTED]. The resident received Tylenol 325 mg two tablets on 7/29/19 at 10:38 a.m., for a pain level of 10 and it was ineffective. During an interview, with RN 2 on 7/29/19 8/7/19 (clarify dates) at 10:10 a.m., indicated when she came to work on 7/29/19, Resident 203 reported to her that she had been out of her pain medication over the weekend. RN 2 reported this to the Assistant Director Of Nursing (ADON) and the ADON went to the Medical Director's office and got a prescription signed for the pain medication. RN 2 indicated it took pharmacy awhile to process the order and the resident did not receive her pain medication until 1:25 p.m. on 7/29/19. During an interview with the Director Of Nursing (DON) and the ADON on 8/7/19 at 10:28 a.m., indicated when Resident 203 was admitted to the facility the hospital sent a prescription for [MEDICATION NAME] for 15 tablets. The DON indicated the nurse should have been monitoring the narcotic sheet to ensure the resident did not run out of her pain medication. The DON indicated the resident ran out of her pain medication on 7/27/19 and on 7/29/19 the ADON went to the Medical Director and got a prescription for the pain medicine. The DON indicated Resident 203 had an appointment at her orthopedic office on 8/6/19 and had reported the resident had run out of her pain medication. The orthopedic doctor's office called her about the situation and that is how she found out. The nurse should have called the Medical Director or the physician on call for a prescription for the pain medicine when Resident 203 ran out of her [MEDICATION NAME] pain medicine. The facility did have [MEDICATION NAME] in their Emergency Drug Kit (EDK) and when a prescription was sent to the pharmacy the facility would get a code from the pharmacy to pull the medication from the EDK. During an interview with Resident 203 on 8/8/19 at 9:50 a.m., she indicated during the time she went with out her [MEDICATION NAME] pain medication from 7/27/19 to 7/29/19 she experienced extreme pain in her right knee. She laid in her bed during that time and cried the entire time. She could not sleep and laid in bed rubbing her right leg. Her orthopedic doctor had told her to stay ahead of the pain and not wait to take it until the pain was really bad and now she understood why. The management of pain policy, provided by the Administrator on 8/7/19 at 12:30 p.m., indicated the mission of the facility was to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy was to accomplish that mission through an effective pain management program, providing the residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. Residents and families are encouraged to report pain early so pain management can be more effective. 3.1-37(a)