Every finding on record at Wedgewood Healthcare Center

Based on interview and record review, the facility failed to ensure a resident (Resident B), with impaired cognition, had a staff member present at an outside appointment for 1 of 3 residents reviewed for supervision. Findings include:The clinical record for Resident B was reviewed on 7/23/26 at 9:08 a.m. The resident's diagnoses included, but were not limited to, dementia (loss of memory, thinking skills, and the ability to do daily tasks) with psychotic disturbance (hallucinations, paranoia, delusions) and aphasia (a brain disorder that affects how you speak, read, write and understand others). The Brief Interview of Mental Status (BIMS) assessment, dated 6/15/26 at 7:48 a.m., indicated Resident B had moderately impaired cognition. The wound care center note, dated 6/15/26 at 9:30 a.m., indicated the resident was seen at the facility and the resident's aphasia limited the ability to obtain any history from him. The recommendation was for the resident to have a caregiver or family member present for the next visit. The current intake concern indicated Resident B was sent to an outside appointment without an escort. The resident exited the appointment and was found by the van driver of an outsourced transport company. During a telephone interview, on 7/23/26 at 12:21 p.m., the van driver indicated on 6/15/26, he came to the facility to pick-up Resident B for his appointment. He asked the staff if the resident was going to have an escort go with him and was told no. He transported the resident to his appointment at the wound care center. When he went back to pick the resident up to transport back to the facility, he saw the resident walking through the parking lot towards the street. He stopped the resident and assisted him back into the transport van. On the way back to the facility, the resident kept pointing like he wanted to stop. He could not understand the resident or what he was trying to say. He told the resident he could not stop and that maybe, when they returned back to the facility, someone from the facility could take him where he needed to go. During an interview, on 7/23/26 at 12:51 p.m., the Executive Director indicated a staff member should have went with Resident B to his appointment. On 7/23/26 at 11:49 a.m., the Executive Director provided a current, undated copy of the document titled Resident Transportation. It included, but was not limited to, It is the policy of this facility to provide resident centered care .Procedure .Provide an escort with a cell phone, as needed to contact the facility in the event of an emergency This Citation relates to Intake 3064314,410 IAC (Indiana Authorization Code) 16.2-3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a self-administration assessment was in place for a resident (Resident F) for 1 of 3 residents reviewed for resident rights. Findings include:During an observation on 11/17/25 at 9:35 a.m., the following was observed in Resident F's room:-a medication cup with a oval white pill -an Albuterol hand-held inhaler-an Anora hand-held inhaler During an interview, on 11/17/25 at 9:37 a.m., Resident F indicated the medication in the cup was his Lasix (diuretic) from yesterday that he had forgotten to take. The doctor said it was okay for him to have the rescue inhalers at bedside. The clinical record for Resident F was reviewed on 11/17/25 at 10:05 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), hypertension and anxiety. The admission Minimum Data Set (MDS) assessment, dated 9/25/25, indicated the resident's cognition was intact. The resident's November medication administration record indicated Resident F received the following medications:-Anoro Ellipta 62.5 - 25 mcg/act (microgram/actuation), inhale one puff daily in the morning for COPD-Lasix 40 mg (milligram) daily in the morning for hypertension-Albuterol Sulfate HFA 108 (90 base) mcg/act, inhale 2 puffs orally every 6 hours as needed for shortness of air/wheezingThe clinical record lacked documentation of a self-administration medication assessment and physician's order for the resident to self-administer medications.During an interview, on 11/18/25 at 2:05 p.m., Registered Nurse (RN) 5 indicated before a resident can self-administer medications, the resident should be assessed for self-administration and a physician's order should be in place.On 11/18/25 at 2:55 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Resident Self-Administration of Medications. It included, but was not limited to, Policy.It is the policy of this facility to provide resident centered care.Procedure.Residents may not self-administer medication until the assessment is completed.Physician/Provider order is required for residents to self-administer medication. 3.1-11(a)

Based on observation, record review, and interview, the facility failed to ensure (ADL) Activities of Daily Living care, related to laundry and bowel and bladder was provided for 1 of 5 residents reviewed for ADL care. (Residents 41) Findings include:During an observation, on 9/22/25 at 2:00 p.m., Resident 41 had a urinal sitting on his bedside dresser three fourths full of straw-colored urine. The resident indicated that the urinal was there from night shift and no one had emptied it. The resident's bed had food debris and brown spots on his sheets. The resident's chair had a pile of clothing laying in it, and he indicated staff were supposed to take his clothes to the laundry, but the clothes had been in the chair for several days. During an observation, on 9/25/25 at 10:30 a.m., the resident's urinal was sitting on his bedside dresser half full of urine. He indicated that it was his urinal he used during the night. His dirty clothes were still in his chair. During an observation, on 9/25/25 at 2:00 p.m., the resident's urinal was still sitting on his bedside dresser half full of urine from the night shift. His dirty clothes had not been taken to laundry by the staff. The resident indicated he was going to gather up his clothes and take them to the laundry himself. His bed had not been changed, and the resident indicated the only time staff changed his bed was when he asked them to. The bed had food debris and stains on the sheets.The record review, on 9/22/25 at 2:29 p.m., indicated Resident 41's diagnoses included, but were not limited to, spinal stenosis, weakness, major depression disorder, and anxiety. The care plan, dated 3/21/25, indicated the resident had ADL deficit related to weakness. The interventions include, but were not limited to, the resident would improve his current level of function. The Quarterly Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. The resident was dependent on staff to maintain personal and toileting hygiene. During an interview, on 9/26/25 at 9:00 a.m., RN 6 indicated the Certified Nursing Aide (CNAs) or nurses should empty the urinals and take the resident's clothes to the laundry. The urinal should not be sitting on the bedside dresser with urine in it.During an interview, on 9/26/25 at 9:30 a.m., CNA 7 indicated the CNAs should empty the residents' urinals and take their clothes to the laundry.The position description of the Certified Nursing Aide, dated 6/2019, indicated the job duties and responsibilities included but were not limited to, . provide personal care functions to residents, Monitor and respond to resident request and needs in a dignified and respectful manner. Maintain a clean and pleasant environment for residents. Maintain physical environment in a clean, safe, and pleasant manner.3.1-38(a)(3)

Based on record review and interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for 1 of 6 residents reviewed for accuracy of assessments. (Resident 40)Findings include:During an interview with Resident 40, on 9/22/25 at 11:08 a.m., she indicated she wanted to return home to her apartment and was just waiting on a call that one had opened. She had been planning to return home since she came into the facility, but had a few setbacks that initially caused her uncertainty.The clinical record for Resident 40 was reviewed on 9/24/25 at 9:10 a.m. The resident's diagnoses included, but were not limited to, generalized anxiety disorder, emphysema, and chronic obstructive pulmonary disease.A care plan, dated 9/26/22, indicated the resident wished to be discharged to her prior assisted living facility. The interventions included, but were not limited to, establish a pre-discharge plan. Evaluate her progress and revise plan as needed.The Quarterly MDS assessment, dated 4/9/25, indicated the resident was alert and oriented, she had no mood or behavior issues; and was set up or supervision for all Activities of Daily Living (ADLs), bed mobility and transfers.Under the section Discharge, the questions for return to the community and was there an active discharge plan in place were both answered No.The Annual MDS assessment, dated 7/11/25, indicated the resident was alert and oriented, had no mood or behavior issues, and was independent for ADLs, bed mobility and transUnder the section Discharge, the question that asked if there was an active discharge planning already occurring for the resident to return to the community, the answer was NO.The section also asked the resident if she wanted to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community, the answer was unknown or uncertain.During an interview, on 9/26/25 at 10:00 a.m., the Social Services Director indicated when the resident went to the meeting at (Name of Apartments), she decided it was too small to suit her. She also found out she could return to the apartments where she used to live. The resident's anxiety got high whenever she got a call from the person at her former apartments. Each time she spoke to the resident about her plans, the resident indicated she was still thinking about it and was uncertain what she was going to do. The Social Service Assistant, indicated at that time, he only came into this position in March and was playing catch up with the notes and MDS assessments. He assumed that because the resident was on the Rehabilitation Hall but was not getting therapy anymore, she was going to be long term and was why he coded the MDS assessments as No.In an interview, on 9/26/25 at 11:00 a.m., the Director of Nursing (DON) indicated there was no policy which addressed coding the MDS assessment. The Resident Assessment Instrument (RAI) manual was followed.3.1-31(d)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident was provided proper management of the urinary catheter drainage system related to lack of catheter care orders, tubing and bag on floor, and lack of securement device for 1 of 7 residents reviewed for bowel and bladder. (Resident 4)Findings include:During an observation, on 9/22/25 at 1:00 p.m., the resident was sitting in his recliner. The urinary catheter drainage system had a dignity bag covering the drainage bag, but the tubing was lying on the floor.During an observation, on 9/23/25 at 9:02 a.m., Resident 4 was in his room asleep in his recliner. The urinary tubing of the drainage system was compressed between the resident's legs. The tubing had backed up with dark yellow urine and sediment. A securement device was not secured to either of the resident's legsDuring an observation of catheter care, on 9/25/25 at 10:15 a.m., the resident's catheter care was completed and a securement device was not secured to either of the residents' legs.The record for Resident 4 was reviewed on 9/22/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, obstructive and reflux uropathy, muscle weakness, type 2 diabetes mellitus without complications, the need for assistance with personal care, primary osteoarthritis, and benign prostatic hyperplasia without lower urinary tract symptoms.The care plan, dated 8/6/24 and revised on 6/4/25, indicated the resident required an indwelling urinary catheter due to obstructive uropathy. The interventions included, but were not limited to, dated 3/29/25, provide catheter care every shift and PRN (as needed); change the catheter per medical provider order, and PRN; staff to use enhanced barrier precautions when providing personal hygiene, toileting and perineum care, and providing care to a urinary catheter; ensuring a securement device is in place; observe for signs of pain due to the catheter, and for signs and symptoms of a urinary tract infection (UTI).The laboratory recusation, collected on 7/3/25 and results dated 7/5/2025, indicated the resident had a high level of Candida Glabrata.The Annual Minimum Data Set assessment (MDS), dated [DATE], indicated the resident's cognition was moderately impaired.The nurse's note, dated 7/16/25 at 1:52 p.m., indicated the resident's catheter was leaking. The urinary catheter was replaced using sterile technique.The laboratory results, collected on 7/17/25 and results dated 7/19/2025, indicated the resident had Klebsiella pneumoniae with Gram Negative Growth, > (grater) 100,000 colony-forming units per milliliter (cfu/ml). The resident had a history of the multidrug-resistant organism (MDRO) called Extended-spectrum beta-lactamases (ESBL).The clinical record lacked documentation of orders for the resident's catheter care. During an interview, on 9/23/25 at 1:00 p.m., Resident 4 indicated that he had not been on antibiotics for urinary infections recently but had chronic infections with antibiotics needed twice in July. The resident reported that catheter care wasn't done daily but was unable to verbalize how many times a day or a week that the catheter care was completed. The resident indicated that he would always have the catheter because of obstructions in his urinary system.During an interview, on 9/25/25 at 10:12 a.m., the DON indicated that she had identified the lack of physician's orders for catheter care on Resident 4. A new physician's order, dated 9/25/25, was entered into the resident's clinical record by the Director of Nursing (DON).During an interview, on 9/25/25 at 10:30 a.m., CNA 8 indicated that she would report any changes in the resident to the nurse working that day and CNA 9 indicated that changes to watch in the resident was abdominal or back pain, any discharge from the penis, or blockage. CNA 8 indicated that there was no way to document the resident's output, so they would inform the nurse after emptying the resident's catheter and CNA 9 indicated that catheter care was performed every two hours. A current facility policy, titled Catheter Care, undated and provided by the Director of Nursing on 9/25/25 at 11:00 a.m., included but was not limited to, It is the policy of this facility to provide resident care that meets the physiological, physical and emotional needs and concerns of the residents.Catheter care is performed at least twice daily on residents that have indwelling catheters.The risk of bacteremia in residents with indwelling catheters is 3-36 times more likely.Catheter care: check physician orders.secure catheter to leg with a device or tape.Check that collection bag is not on the floor and is draining properly and securing allowing for no reflux of urine back to the bladder.Document and report any adverse findings to the nurse. 3.1-41(a)

Based on observation, record review and interview, the facility failed to ensure narcotics were administered and documented within the appropriate timeframe for the review of 1 of 32 residents reviewed for pharmacy procedures. (Resident 6) Findings include: During an observation on 9/24/25 at 10:17 a.m., of the 500 Hall Medication Cart, the following concerns were identified: Resident 6's Controlled Drug Administration Record sheet indicated the 0.5 milligram (mg) lorazepam tablet had 13 tablets left on sheet. The medication card had 12 tablets left. The lorazepam was last signed out on 9/24/25 at 4:00 a.m., by Licensed Practical Nurse (LPN) 10. The record for Resident 6 was reviewed on 9/25/25 at 1:25 p.m. The diagnoses included, but were not limited to, atrial fibrillation, upper abdominal pain, heart failure, alcohol use, depression, and anxiety. The care plan, dated 9/10/25, indicated Resident 6 used anti-anxiety medication for anxiety disorder. The interventions included, but were not limited to, consult with the pharmacy or medical provider to consider a dosage reduction when clinically appropriate, observe for side effects of anti-anxiety medications, and provide anti-anxiety medication per the medical provider's orders. The physician's order, dated 9/11/25 at 2:30 p.m., indicated the nurse was to administer 0.5 mg Ativan (lorazepam) to the resident every 8 hours as needed (prn) for anxiety for 14 days. The 5-Day Minimum Data Set (MDS) assessment, dated 9/12/25, indicated the resident was cognitively intact. During an interview on 9/26/25 at 9:54 a.m., RN 6 indicated 9/24/25 was crazy and she checked on the last administration time of the Lorazepam, and it was too early. The RN administered the lorazepam to Resident 6 anyway and thought she would go back later to document it on the Medication Administration Record (MAR), when it was time for the medication, but did not do that and didn't click on the administration in the MAR. The September 2025 MAR indicated the resident received the 0.5 mg Lorazepam tablet prn on 9/24/25 at 4:00 a.m., by LPN 10. The physician's order indicated the next dose of lorazepam could be administered 8 hours later at 12:00 p.m. The September 2025 MAR lacked documentation of the administration of the lorazepam on 9/24/25 by RN 6. During an interview on 9/26/25 at 11:12 a.m., the Director of Nursing (DON) indicated the nurse should follow the five rights when administering medications. The nurse should pull the narcotic at the appropriate time and sign the narcotic out on the Controlled Drug Administration Record sheet and the MAR. She should check the MAR to make sure it was at the appropriate time. If the resident needed the medication early, the nurse should contact the Nurse Practitioner. The current Medication Controlled Drugs and Security policy, included, but was not limited to, . Narcotics, scheduled or controlled drugs are medications that pose a high risk for addiction when improperly taken, and are known to depress the respiratory system which, if taken inappropriately could lead to overdose up to and including death. V. a. In the event a discrepancy is found, check the resident's medication sheets and chart to see if a narcotic has been administered and not recorded. 3.1-25(b)(3)3.1-25(b)(9)

Based on observation, record review, and interview, the facility failed to ensure narcotics were disposed of in a timely manner and document the administration of the narcotic in the Controlled Drug Administration Record sheet for 2 of 32 residents reviewed for narcotic medication storage. (Residents 52 and 6) Findings include:1.During an observation, on [DATE] at 10:17 a.m., of the 500 Hall Medication Cart the following concerns were identified: Resident 52's lorazepam tablet was last administered on [DATE]. The medication was still in the narcotic drawer of the medication cart. Resident 52's lorazepam liquid was last administered on [DATE]. The medication was still in the narcotic drawer of the medication cart. Resident 52's morphine tablet was last administered on [DATE]. The medication was still in the narcotic drawer of the medication cart. The record for Resident 52 was reviewed on [DATE] at 2:00 p.m. The resident's diagnoses included, but were not limited to, bronchus or lung cancer, chronic obstructive pulmonary disease, altered mental status, and bone disorders. The Significant Change in Condition Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was severely cognitively impaired. The care plan, dated [DATE] and revised [DATE], indicated the resident received hospice services. The interventions, dated [DATE] and revised [DATE], included, but were not limited to, administering medications per the medical provider's orders, observe for side effects and effectiveness, report abnormal findings to the medical provider, resident, resident representative, or hospice company. Complete a pain evaluation as needed, and report breakthrough pain to the medical provider.The resident was found without respirations or pulse on [DATE] at 9:20 p.m. The [DATE] Medication Administration Record (MAR) indicated the following: -On [DATE] at 9:00 a.m., the resident's 0.5 mg lorazepam tablet was last administered. -On [DATE] at 2:00 p.m., the resident's 0.5 milliliters (mL) lorazepam liquid was last administered.-On [DATE] at 2:00 p.m., the resident's 0.25 mL morphine was last administered. During an interview, on [DATE] 10:31 a.m., the Director of Nursing (DON) indicated she conducted a weekly removal of narcotics for residents who had expired or discharged . She indicated she must have missed the resident's unused narcotics when she last removed the discontinued medications. 2. Resident 6's 0.5 mg lorazepam tablet had 13 tablets left on the Controlled Drug Administration Record sheet. The medication card had 12 tablets left. The lorazepam was last administered on [DATE] at 4:00 a.m., by Licensed Practical (LPN) 10. The record for Resident 6 was reviewed on [DATE] at 1:25 p.m. The resident's diagnoses included, but were not limited to, atrial fibrillation, upper abdominal pain, heart failure, alcohol use, depression, and anxiety. The care plan, dated [DATE], indicated Resident 6 used anti-anxiety medication for anxiety disorder. The interventions included, but were not limited to, consult with the pharmacy or medical provider to consider a dosage reduction when clinically appropriate, observe for side effects of anti-anxiety medications, and provide anti-anxiety medication per the medical provider's orders. The physician's order, dated [DATE] at 2:30 p.m., indicated staff were to administer the resident's 0.5 mg Ativan (lorazepam) every 8 hours as needed (PRN) for anxiety for 14 days. The 5-Day MDS assessment, dated [DATE], indicated the resident was cognitively intact. The [DATE] MAR indicated the resident received 0.5 mg Lorazepam prn on [DATE] at 4:00 a.m., by LPN 10. During an interview, on [DATE] at 10:28 a.m., RN 6 indicated she should have signed out the narcotic at the time she pulled it. She was rushing and didn't sign the lorazepam out on the Controlled Drug Administration sheet. She had given the lorazepam to Resident 6 prior to administering the breathing treatment to an unknown resident. During an interview, on [DATE] at 11:12 a.m., the DON indicated the nurse should pull the narcotic and sign the narcotic out at that time. The current Medication Controlled Drugs and Security policy, included, but was not limited to, . Narcotics, scheduled or controlled drugs are medications that pose a high risk for addiction when improperly taken, and are known to depress the respiratory system which, if taken inappropriately could lead to overdose up to and including death. 1. b. A record is retained for all drugs destroyed by licensed personnel and by individual state guidelines. V. a. In the event a discrepancy is found, check the resident's medication sheets and chart to see if a narcotic has been administered and not recorded. VII. a. When the prescribed drug is discontinued, or the resident discharged , the container and control sheet must be removed for drug destruction. 3.1-25(b)(3)3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure indwelling urethral catheter orders were in place for a resident with an indwelling urethral catheter for 1 of 3 residents reviewed for bowel and bladder. (Resident D) Findings include: The clinical record for Resident D was reviewed on 11/13/24 at 2:20 p.m. The resident's diagnoses included, but were not limited to, indwelling urethral catheter; and obstructive and reflux uropathy. The quarterly Minimum Data Set (MDS) assessment, dated 10/10/24, indicated the resident had an indwelling catheter. Review of the census record for Resident D indicated he was readmitted to the facility on [DATE] with an indwelling urethral catheter. On 11/13/24 at 2:05 p.m., Resident D was observed in his room with an indwelling urethral catheter in place. The care plan, dated 8/6/24, indicated the resident had an indwelling catheter related to obstructive uropathy. The interventions included, but were not limited to, change the catheter per the medical provider orders, provide catheter care every shift and as needed, enhanced barrier precautions, observe and document for pain and discomfort related to the catheter. Review of Resident D's physician's orders indicated the following: A physician's order, dated 11/13/24, indicated staff were to provide catheter care for Resident D every shift and as needed with soap and water, secure straps if applicable, and document output every shift. A physician's order, dated 11/13/24, for Resident D's indwelling urinary catheter care: cleanse with soap and water every shift. A physician's order, dated 11/13/24, indicated staff were to change the resident's indwelling catheter and drainage bag as needed unless specified by physician order for specified medical reasons. A physician's order, dated 11/13/24, indicated staff were to change the resident's indwelling catheter leg bag and accessories every two weeks and as needed. A physician's order, dated 11/13/24, indicated staff were to change catheter as needed as per MD (medical doctor) order. A physician's order, dated 11/13/24, indicated staff were to ensure Resident D's indwelling urinary catheter was in a privacy bag and catheter leg strap on at all times. A physician's order, dated 11/13/24, indicated staff were to secure the resident's indwelling catheter tubing using anchoring device to prevent movement and urethral traction. A physician's order, dated 11/13/24, indicated staff were to measure and record output every shift of the resident's indwelling urinary catheter. A physician's order, dated 11/14/24, indicated staff were to change the resident's catheter as needed as per MD order The clinical record lacked documentation of any indwelling catheter orders for Resident D from 7/26/24 until 11/13/24. During an interview on 11/15/24 at 3:02 p.m., the Director of Nursing indicated due to the transition of staff, the orders were missed when the resident was readmitted . On 11/15/24 at 1:30 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Catheter Care. It included, but was not limited to, It is the policy of this facility to provide resident centered care that meets the .physical .needs .of the residents 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident's medication administration record accurately reflected the administration on pain medication for 1 of 3 residents reviewed for medical records. (Resident C) Findings include: The clinical record for Resident C was reviewed on 11/13/24 at 10:47 a.m. The resident's diagnoses included, but were not limited to, osteomyelitis and stage 4 (wound that extends to muscle, tendon or bone) pressure ulcer to the sacrum. The physician's order, dated 8/21/24, indicated the resident was to receive Oxycodone (narcotic pain medication) HCl (hydrochloride) 10 mg (milligrams) every 4 hour as needed for pain. Review of the September 2024 controlled drug administration record indicated the pain medication was signed as given 90 times during the month. Review of the September 2024 medication administration record indicated the pain medication was documented as administered 13 times during the month. Review of the October 2024 controlled drug administration record indicated the pain medication was signed as given 38 times to the resident. Review of the October 2024 medication administration record indicated the pain medication was documented as administered 19 times. During an interview on 11/15/24 at 2:51 p.m., Licensed Practical Nurse (LPN) 5 indicated when an as needed narcotic pain medication was administered, the narcotic should be signed out on the controlled drug administration record. Once administered, the medication should be signed off on the medication administration record as administered. On 11/15/24 at 1:30 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Medication Administration Record - the legal documentation for medication administration .Policy .It is the policy of this facility to provide resident centered care .Procedure .Medications will be charted when given This Citation relates to Complaint IN00446311 3.1-50(a)(2)

Based on record review and interview, the facility failed to promptly resolve the grievances and recommendations made by the Resident Council during 12 of 12 meetings and 5 of 7 Food Committee meetings reviewed in that the same issues were being reported as continuing problems. Findings include: 1. The Resident Council meeting, held on 7/25/23, indicated the following concerns were not addressed by the responsible department or resolved: - Clean rooms more. - Better and more snacks for all the halls as residents didn't know where they went - Be informed about medication changes. - Problem with medications on the 500 Hall. - Asked for help twice and did not get it. On 7/25/23, the Director of Nursing (DON) addressed the issue residents were having in getting their showers. No other concerns were addressed. 2. The Resident Council meeting, held on 8/22/23, indicated the following concerns were not addressed by the responsible department or resolved: - Safety concerns - Bed changes not always occurring. - Need to order medications before they ran out. - Wheelchairs and walkers - who repairs them? - Laundry and clothes were a problem. - Rooms and bathrooms were not cleaned. - Not getting treatments done. - New nurses were messing up their medications and not checking blood pressure or blood sugars. - Not being treated nice by some of the nurse aides. - Staff not knocking on doors before coming in. - Aides not answering call lights timely; staff ignoring or turning the light off; night shift aides a problem. - Water not being passed. No response to these concerns could be located or provided. 3. The Resident Council meeting, held on 10/24/23, indicated the following concerns were not addressed by the responsible department or resolved: - New trash bags were not being put in empty cans after trash was collected by housekeeping. - Night time snacks. - Dessert serving size. No response to these concerns could be located or provided. 4. The Resident Council meeting, held on 11/21/23, indicated the following concerns were not addressed by the responsible department or resolved: - Bed linens were not being changed on shower days. - Dressing changes not being done. - Medications still not accurate and running out. - Nursing staff attitude. No response to these concerns could be located or provided. 5. The Resident Council meeting, held on 2/19/23, indicated the following concerns were not addressed by the responsible department or resolved: - Showers were not always hot because the valves were turned the wrong way. - Don't just take clothes and make sure they were labeled. - Would like bacon for the hamburgers. - The food carts still showing up late and when they did show up, they would just sit on the hall. - Pill accuracy still remained a problem. - Dressing changes still not being done. - Smokers blocking the hall at smoking times and smoking where and when they wanted to. No response to these concerns could be found or provided. 6. The Resident Council meeting, held on 2/20/24, indicated the following concerns were not addressed by the responsible department or resolved: - Want to flip their mattresses - Fix broken drawers in several rooms. - Housekeeping needed to take out the trash and clean rooms better. - More snacks need to be available. - Staff need to turn their phones off while at work. - Check and change needed to be every 2 hours and as needed. On 2/20/24, RN 1 addressed the concern regarding the Check and Change and indicated the CNAs (Certified Nurse Aide) would be in-serviced. On 2/20/24, the Director of Housekeeping addressed the concerns and indicated the manager would in-service the housekeepers on the 5+7 steps of cleaning (the cleaning cheek list step by step) and would ensure the trash was taken out and a final walk through the halls to ensure the rooms were being completed. No other concerns were addressed. 7. The Resident Council meeting, held on 3/19/24, indicated the following concerns were not addressed by the responsible department or resolved: - Ice water at night not being passed. - Would like a newspaper even if it was a day old. - Want old cable company back. - Were there any open times in therapy for non-scheduled work outs? - Is there going to be a new schedule for serving in the dining room? - Dresser drawers were still falling apart. - Laundry not able to keep up with their personal clothes - need another aide in there. - Housekeeping still was not cleaning all the rooms. - Dressing changes were still not being completed routinely. - Shift changes were too loud and there was no need to shout. - Want to be spoken to like an adult - not everyone had issues. - Medications were not always accurate, especially when it was a different nurse. On 3/18/24, the DON indicated the issues of dressing changes and medication accuracy were being addressed. On 3/18/24. the Director of Housekeeping addressed the laundry and housekeeping issues and indicated she would continue to hire a part-time person for laundry. The staff would be in-serviced on proper cleaning techniques, and she will be holding the staff more accountable. No other concerns were addressed. 8. The Resident Council meeting, held on 4/16/24, indicated the following concerns were not addressed by the responsible department or resolved: - Please post a real serving schedule that will be adhered to. - Still having hot water issues resulting in having to take a cold shower. - Would like a new serving time for meals, such as 15 minutes earlier. - Please spread out the snacks. - More diabetic friendly meals. - Parties at the nurses station too loud for no reason. - Blood pressure checks were not always being done. - The aides were not doing the check and changing like they should. - Want belongings left in place after cleaning the room. - Felt the facility was making up rules. - Cable was an issue and were not having previous channels. On 4/16/24, the Director of Housekeeping responded to the concerns which involved her department in which she indicated mandatory in-servicing of all front line employees and housekeepers on the 5+7 steps of proper cleaning and will be held accountable. On 4/17/24, the DON addressed the nursing concerns and indicated staff will be educated on the process of passing ice water at the beginning of day shift and night shift and the DON or designee will monitor. Quiet time hours would be put into effect immediately between 5 to 7 AM. The DON or designee would monitor Q (every) 2 hour rounding sheets were being completed. On 4/16/24, the Maintenance Director responded and indicated the dropping off of channels had always been a problem with (name of cable company). No other concerns were addressed. 9. The Resident Council meeting held on 5/21/24, indicated the following concerns were not addressed by the responsible department or resolved: - Windows were being bolted shut. - No night time supervision. - Nursing station too loud during shift change. - No consistent staffing with the CNAs. On /21/24, the Executive Director (ED) indicated the bolting of the windows was only a temporary solution and there would be a permanent solution in the future. There was an evening supervisor on Monday and Tuesday night and there was a weekend supervisor on Friday, Saturday and Sunday. Staff were scheduled on the same hall but were re-assigned when staff were off, and she would continue to work on noise level at the nurse station. No other concerns were addressed. 10. The Resident Council meeting, held on 6/18/24, indicated the following concerns were not addressed by the responsible department or resolved: - Serving in the dining room was not consistent. - No ice water at night. - Wound care not happening consistently. - Call lights being turned off even though help was not given. On 6/18/24, the ED addressed the call lights issue and indicated an in-service and re-education to nursing. No other issues were addressed. 11. The Resident Council meeting, held on 7/25/24, indicated the following concerns were not addressed by the responsible department or resolved: - Staff not serving in the dining room on the weekends. - No one is picking up the phone when there was a call. - Housekeeping not mopping floors. - More thorough cleaning in the bathrooms. - Water still not being passed. - CNAs yelling into and down the hall. - Trash needs to be taken out twice a day. - Wanted cable in the activity room. On 7/18/24, the ED responded to the issue of ice water not being passed and indicated one-on-one education would be done. There would continue to be staff serving in the dining room and the dining room schedule was posted in the dining room and at each nursing station. She would put in a request for IT (computer personnel) to look at getting cable in the activity room. No other issues were addressed. 12. The Resident Council meeting, held on 8/7/24 at 1:30 p.m., indicated the following concerns: - Would not allow any resident who had already served as President to serve again - Residents were not allowed to take the notes during the Resident Council meetings, a staff member was to be there to take the notes. - The remotes to the TVs in the resident rooms did not work separately. One remote worked for both residents in the room and had a tendency to cancel out the other person's TV show if it was pressed. - Waiting a long time for staff to answer the call lights. The aides were turning the lights off without coming in to check on the resident. Lots of call ins on night shift. - Not enough snacks. If one went to an activity or were out of their room, the aides gave out all the snacks and there were none left when they returned to their room. Snacks tend to run out. - The aides were still not passing ice water - Wanted to see their physician and not the Nurse Practitioner all the time. - Not ordering medications in a timely manner. The nurses did not explain to the resident when a new order came in, especially if it was a medication. - Wound treatments were not consistently being done. - Housekeeping still were not cleaning properly. They were not mopping the floors or emptying the trash. One housekeeper was observed to clean a resident's commode and then used the same rag to clean the sink. Dirty shower rooms in which some residents refused to go in for their showers. - Staff who had to serve the dining room were frequently complaining about having to do it. They seem to have an attitude problem. The assigned dining room personnel were not always showing up to serve. - Meal tickets did not match what was served, especially if the resident ate in their room. - The residents were not aware of their rights and rules of the facility. Resident 34 indicated that so much paperwork was thrown at them to sign when they were first admitted to the facility, he didn't know what it all was. - If suggestions were made by the residents or Resident Council, they were not followed up on and residents did not know the outcome of the concerns they voiced at the meetings. - Did not know the 1-800 hotline number to the State Department of Health when they wanted to make a complaint. The facility's current policy on Resident Council dated effective 4/22/21 as presented by the ED included, but was not limited to, Policy: .While it is the residents' choice to have in attendance, Administration should ask permission to attend (even for a short appearance) to assure residents that all grievances and concerns are as important to management as they are to the resident .4. Document the Resident Council on the Resident Council Minutes Form. Any concerns voiced at the meeting should be documented on the Concern Form and distributed to the appropriate Department Head . 3.1-3(k) 3.1-3(l) 3.1-7(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner for 4 of 4 kitchen observations. This deficient practice had the potential to affect all 97 residents currently residing at the facility. Findings include: 1. During the initial tour of the kitchen, on 8/5/24 at 9:30 a.m., while accompanied by the Dietary Manager and the Regional Dietary Manager, the following concerns were observed: In the Dry Storage Room the following was observed: - Three (3) of three (3) food shelves had crumbs under them - raisin bran. pieces of paper and spaghetti noodles. - A small blue cup was in the large sugar bin - (the Regional Dietary Manager indicated this was not supposed to be left in there and removed it). - The top of the large seasoning storage bin was heavily soiled with brown drips and food particles on it and down the sides. In the Walk in freezer the following was observed: - There was a 2 foot by 2 foot area of ice under the milk crates below the condenser unit, which was approximately 3/4 inch thick. Two cup sized thick ice spots were observed under the right shelving on the floor. The Dietary Manager indicated there was a repair last week on the unit and they had to clean it up every day and she didn't have time yet to clean it up this morning. The Maintenance Director also indicated that the unit was functioning fine, but the ice would appear every time after the unit went on the defrost cycle. The freezer was currently on the defrost cycle and the food remained frozen. In the Walk in refrigerator the following was observed: - There were large containers of peas, rice and gravy were on the shelf with a use-by date of 8/1/24. The Dietary Manager indicated the facility's policy was after 3 days, the items got thrown away. In the Kitchen the following was observed: - Plastic cup lids, a wadded piece of paper, and food crumbs were under the steam table, the table holding the coffee pot, the prep table and toaster. - One sink and the eye wash station had heavy soil of whitish/black dirt with a sand-like texture. - The left side of the reach-in refrigerator had red spills under the rack containing juices. - The shelf below the steamer and the shelf holding the steamer had multiple white dried water spots. - The top of the steamer had a heavy build up of grease with food crumbs in it. - The stove top burners had a heavy build up of orange food particles and black crust. 2. During a second kitchen observation on 8/5/24 at 11:40 a.m., while [NAME] 3 was getting the meal ready, the following concerns were observed: - The same issues identified at 9:30 a.m. remained. 3. During a kitchen observation on 8/8/24 at 10:15 a.m., while accompanied by the Dietary Manager, the following concerns were observed: - In the walk-in freezer, the floor under the condenser unit and milk crates had a half inch area of thick ice covering half the area under the crates. - In the walk-in refrigerator, there was a large container of BBQ chicken on the shelf with a storage date of 8/5/24 and a use-by date of 8/7/24. - The stove had the same dried food particles and black crust. - Plastic cup lids, a wadded piece of paper, and food crumbs were under the steam table, the table holding the coffee pot, the preparation table and toaster. - The shelf below the steamer and the shelf holding the steamer had multiple white dried water spots. The top of the steamer had a heavy build up of grease with food crumbs in it. - The left side of the reach-in refrigerator had red spills under the rack containing juices. - At 10:30 a.m., in the serving area of the dining room, a large container of bleach wipes were next to the china cups in the cabinet for the residents' use. The Dietary Manager indicated they were used by nursing and never should have been in that cabinet next to the coffee cups. 4. During a kitchen observation on 8/12/24 at 10:30 a.m., the ice remained on the floor inside the walk-in freezer under the milk crates and condenser unit as previously seen on 8/8/24 at 10:15 a.m. The Dietary Manager indicated that the ice had been removed and was no longer an issue. When shown the ice on the floor, she indicated she thought the ice was on the condenser pipes and was not aware of it being on the floor. The current Cleaning Log for the Prep [NAME] indicated her responsibilities for Monday through Friday included, but were not limited to the following: - Sweep and mop dry storage room - Make sure all bins were closed in dry stock room. - Sweep and organize the walk in (remove all out dated items). The current Cleaning Log for the Main [NAME] indicated her responsibilities for Monday through Sunday daily included, but were not limited to the following: - Sweep floor from the plate holder to the sink. - Remove all food and liquids that were visible. The current Monday through Friday, tasks which were to be completed on any of those days: - Deep clean the steam table and fryer The Cleaning Log for Aide One/Dishwasher indicated her responsibilities for Monday through Sunday daily included, but were not limited to, - Sweep and mop from double doors, to the back door and around the dish room area. The Cleaning Log for the 2nd Aide indicated her responsibilities for Monday through Sunday daily included, but were not limited to, - Clean both sinks (eye wash station) - Sweep and mop from toaster around to the sink. The Monday through Friday tasks were to be completed on any day of those days: - Deep clean inside and out of the reach in - remove any outdated items Review the Cleaning logs, dated 8/4/24 through 8/11/24, indicated all tasks had been completed as assigned for Aide One's and 2nd Aide's Monday through Sunday cleaning logs. During an interview with the Dietary Manager on 8/8/24 at 1:30 p.m., she indicated she did not have policies which addressed Leftovers and the Cleaning of the kitchen. 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to ensure smoking materials were secured in a locked area when not in use for 5 of 25 smokers reviewed for accidents hazards. (Residents 6, 46, 54, 72, and 86) Findings include: 1. During an observation on 8/9/24 at 10:00 a.m., Resident 6 had her cigarettes and lighter laying on the bedside table. The resident was sound asleep sitting up in her wheelchair. During am observation on 8/9/24 at 1:00 p.m., Resident 6 had her cigarettes and lighter laying on her bedside table. She had just finished eating her lunch. During an interview on 8/11/24 at 12:55 p.m., Resident 6 indicated she did not lock up her lighter. She indicated the staff trust me with my lighter When she left her room, she would hide her lighter and cigarettes underneath her left leg where no one could see them. During an observation on 8/12/24 at 8:30 a.m., Resident 6 had her cigarette lighter laying on her bedside table. 2. During an interview on 8/9/24 at 1:00 p.m., Resident 54 indicated she had her cigarettes and lighter in her purse. She would keep her purse in bed with her so no one would steal it. 3. During an interview on 8/9/24 at 2:30 p.m., Resident 46 indicated he did go outside to smoke. He would keep his cigarettes and lighter in his beside dresser or in his pocket. He did not lock up his lighter and there wasn't a lock on the dresser drawers. 4. During an interview on 8/9/24 at 2:50 p.m., Resident 86 indicated she kept her cigarettes and lighter in her room. She indicated they were not locked up. The resident had her lighter laying on the picnic table while outside smoking. 5. During an interview on 8/9/24 at 3:00 p.m., Resident 72 indicated she was a smoker, and she kept her cigarettes and lighter in her purse. She had no way to lock up her lighter, so she slept with her purse which contained her cigarettes and lighter. During an interview on 8/9/24 at 1:30 p.m., Social Services Director indicated the social service staff would do the smoking evaluation on the residents that smoke. The residents were allowed to keep their cigarettes and lighter in their rooms. The lighters were not locked up. The residents kept their lighters with them. The residents would turn in their lighters at bedtime. She indicated there were residents that resided on all the floors that were independent smokers. The review of the residents on Halls 100, 300, 400, and 500, there were 25 residents that smoked. Each resident had their own cigarettes and lighter. There were 8 residents that resided on the units that were confused and had a diagnosis of dementia. The Resident/Patient Smoking policy, dated 3/25/18, included, but was not limited to, .a. Secure smoking materials in a locked area when not in use by the resident/patient for both independent and supervised smokers . 3.1-45(a)

Based on record review and interview, the facility failed to ensure a dialysis access site was monitored and the physician was notified for 1 of 2 resident reviewed for dialysis. (Resident 51) Findings Include: The record for Resident 51 was reviewed on 8/8/24 at 10:56 a.m. The diagnoses included, but were not limited to, peripheral vascular angioplasty with implants and grafts, anemia in chronic kidney disease, hypo-osmolality and hyponatremia, chronic kidney disease, diabetes, and acute kidney failure.c The physician orders, dated 4/15/24,indicated staff were to monitor the dialysis site for signs and symptoms of infection, monitor the graft site for signs and symptoms of infection, and monitor for thrill and bruit every shift. The physician's order, dated 4/25/24, indicated the resident was to receive hemodialysis every Tuesday, Thursday, and Saturday. The Annual MDS (Minimum Data Set) assessment, dated 5/10/24, indicated the resident was cognitively intact. , The care plan, initiated on 4/16/24 and revised on 8/7/24 indicated, Resident 51 was currently on dialysis therapy. He had a newly placed AV (Arteriovenous) fistula in his left arm; however, dialysis was currently still being performed per port in his upper right chest. The dialysis port was resolved on 8/7/24. The interventions included, but were not limited to, administer medications per physician orders, and report abnormal findings, evaluate the AV fistula and chest port for bleeding, monitor the access site for signs and symptoms of infection, and report the abnormal findings to the physician. The nurse's note, dated 6/16/24 at 10:00 p.m., indicated Resident 51 was informed of swelling at his AV fistula and his upper left arm when he got back from his dialysis on Saturday. The AV fistula appeared to be swollen. The resident preferred to wait and inform the NP (Nurse Practitioner) in the a.m. The clinical record lacked documentation indicating the NP was notified and the dialysis site was monitored every shift per physician orders. The review of MAR (Medication Administration Record) indicated the following related to the nursing assessment of the resident's bruit and thrill (Assessing a bruit and thrill in a dialysis fistula helps determine if the fistula is working and to identify potential issues): - On 6/5/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/7/24, 6:00 p.m. to 6:00 a.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/11/24,6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/13/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/20/24,6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/23/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/24/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/25/24, 6:00 p.m. to 6:00 a.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/29/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. - On 6/39/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of bruit and thrill. The review of the MAR indicated the following related to the nursing assessment of the resident's dialysis site for signs of infection: - On 6/5/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/7/24, 6:00 p.m. to 6:00 a.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/11/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/13/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/20/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/23/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/24/24, 6:00 a.m. to 6:00 p.m., and 6:00 p.m. to 6:00 a.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/25/24, 6:00 p.m. to 6:00 a.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/29/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. - On 6/39/24, 6:00 a.m. to 6:00 p.m., the MAR lacked documentation related to the monitoring of the resident's dialysis site. During an interview on 8/12/14 at 8:30 a.m., LPN (Licensed Practical Nurse) 5 indicated the dialysis fistula or catheter should be assessed every shift. If there were any signs and symptoms of edema, she would immediately call the physician. She would never let the resident decide when to call the physician. During an interview on 8/12/24 at 9:18 a.m., Regional Director of Clinical Operations (RDCO) indicated she did not see a follow up note where the nurse called the physician about the fistula edema. She should not have let the resident make the decision when to call the physician. The current Hemodialysis Care and Monitoring policy indicated . Residents may have specific signs/symptoms on non-dialysis days or on dialysis days that may include but are not limited to: i. Nausea above baseline ii. Fatigue greater than baseline iii. Pain iv. Pruritus [itchy] skin: 1. Lotion or emollient may relieve v. Reduced cognition or mental clarity from baseline vi. Thrombosis at or near site 1. Felt as a hard knot, may include pain, redness or swelling: a. Do not massage b. Contact physician . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed for proper procedures during 2 of 2 observations of incontinence care related to infection control. (Resident 196) Findings include: 1. The record for Resident 196 was reviewed on 8/7/24 at 11:00 a.m. The resident's diagnoses included, but were not limited to, encephalopathy, acute kidney failure, dementia, anxiety disorder, intellectual disabilities, muscle weakness, abnormalities of gait and mobility, lack of coordination, and cognitive communication deficit. The Admission MDS (Minimum Data Set) assessment, dated 7/26/24, indicated the resident was severely cognitively impaired. He was frequently incontinent of bowel and bladder. The care plan, dated 8/1/24, indicated the resident was incontinent of bowel and bladder due to impaired cognition and impaired mobility. The interventions, dated 8/1/24, indicated for staff to apply barrier creams as needed, check the resident for incontinence., wash, rinse, and dry the perineum. During an observation of wound care for Resident 196 on 8/9/24 at 10:21 a.m., Wound Nurse and LPN (Licensed Practical Nurse) 7, both performed hand hygiene. LPN 7 turned off the faucet with her bare hand. They both applied gloves. LPN 7, cleaned the shaft of the resident's penis with 7 swipes of the same area of the wipe in a downward motion. She obtained another wipe and with 7 swipes with the same area of the wipe, cleaned down on the resident's penis shaft. She obtained another wipe and with 12 swipes with the same area of the wipe, cleaned the penis tip and continued with 4 swipes on the creases and scrotum, with the same area of the wipe. The resident was rolled and with the wipe, she cleaned the rectal area, using a back to front motion, pulling around the wound dressing, toward the scrotum on the resident's left buttock. One side of the dressing was loose. The right buttock was not cleaned. The resident wasn't dried, and no barrier cream was applied. 2. During an observation of incontinence care for Resident 196 on 8/9/24 at 1:46 p.m., CNA (Certified Nurse Aide) 9 and CNA 8 performed hand hygiene. The staff both applied gloves. CNA 9 obtained wipes and with 5 swipes on the same area of the wipe, she cleaned the resident's penis, she folded the wipe and with 1 swipe, cleaned the penis and folded the wipe again and cleaned the penis. She performed hand hygiene and applied gloves. She indicated the resident's brief was dry. The wound dressing to the sacral wound was observed to be folded on one side and was hanging loose. No barrier cream was applied, and the resident wasn't dried. CNA 9 indicated the barrier cream was out of stock, but was ordered. She felt she performed good incontinence care for the resident. During an interview on 8/9/24 at 2:05 p.m., CNA 9 indicated the resident was not a heavy wetter. She indicated she would fold the wipe with each swipe to clean the resident during care. During an interview on 8/9/24 at 2:08 p.m., CNA 8 indicated the amount the resident urinated varied on how much the resident drank. The CNA did not want to answer if while they were performing incontinence care staff had used the same area of the wipes multiple times. The current Perineal Care-Male and Female policy, included, but was not limited to, . 9. Gently dry the perineum following the same sequence [penis, scrotum and inner thighs] . 13. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. 14. Dry area thoroughly . 3.1-18(a)

Based on interview and record review, the facility failed to follow medication administration parameters (Residents B, D and H); obtain blood pressure as ordered for 7 days (Resident F); and complete non-pressure wound treatments as ordered (Residents B and D) for 4 of 6 residents reviewed for quality of care. Findings include: 1.a. The clinical record for Resident B was reviewed on 7/24/24 at 1:35 p.m. The resident's diagnoses included, but were not limited to, diabetes, hypertension, and morbid obesity. The care plan, dated 10/27/23, indicated the resident had hypertension (high blood pressure) and staff were to administer the resident's medications as ordered by the medical provider. The physician's order, dated 11/21/23, indicated the resident was to receive Carvedilol 12.5 mg (milligrams) twice daily at 8:00 a.m. and 8:00 p.m. for hypertension. Staff were to hold the resident's medication for a SBP (systolic blood pressure) less than 110 or a pulse less than 60. The resident's May and June 2024 MAR (medication administration record) indicated the following: - On 5/06/24 at 8:00 p.m., the resident's Carvedilol was administered with no blood pressure or pulse obtained. - On 6/17/24 at 8:00 p.m., the resident's Carvedilol was administered with no blood pressure or pulse obtained. - On 6/23/24 at 8:00 p.m., the resident's Carvedilol was administered with no blood pressure or pulse obtained. The physicians' order, dated 11/20/23, indicated the resident was to receive Hydralazine HCl (hydrochloride) 50 mg every 8 hours at 7:00 a.m., 3:00 p.m., and 11:00 p.m. Staff were to hold the resident's medication if the resident's SBP was less than 115. The resident's May and June 2024 MAR indicated the following: - On 5/06/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 5/25/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 5/26/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 6/01/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 6/05/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 6/10/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 6/17/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 6/23/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. - On 6/24/24 at 11:00 p.m., the resident's Hydralazine was administered with no documented blood pressure. 1.b. The care plan, dated 11/20/23, indicated the resident was at risk for impaired skin integrity and staff were to administer treatments as ordered by the medical provider. The physician's order, dated 1/10/24, indicated Nystatin External cream was to be applied to the resident's abdominal folds and groin area every day and night shift due to moisture associated skin damage and fungal infection. Review of the June 2024 treatment administration indicated the resident's treatment was not completed on the following days: - 6/02/24 on night shift - 6/05/24 on day shift - 6/09/24 on night shift - 6/11/24 on day shift - 6/20/24 on day shift - 6/23/24 on day shift - 6/24/24 on day shift - 6/29/24 on day shift - 6/30/24 on day shift During an interview on 7/26/24 at 1:25 p.m., LPN (Licensed Practical Nurse) 6 indicated the physician orders should be followed. If parameters were set by the physician for a resident's blood pressure medication, the resident's blood pressure should have been obtained prior to the medication administration. If the blood pressure was out of the parameters, the medication should have been held. When medications or treatments are administered/completed, the medication record and treatment record should have been initialed. On 7/25/24 at 1:48 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, MAR: Medication Administration Record - the legal documentation for medication administration .Policy .It is the policy of this facility to provide resident centered care .Administer medication only as prescribed by the provider .Medications will be charted when given .Record pertinent information prior to giving medication .Blood pressure .Apical pulse .Blood sugar .Documentation of medication will be current for medication administration 2.a. The clinical record for Resident D was reviewed on 7/24/24 at 1:59 p.m. The resident's diagnoses included, but were not limited to, hypertension and surgical incision. The care plan, dated 5/31/24, indicated the resident had hypertension and staff were to administer the resident's medications per the medical provider's order. The June 2024 MAR indicated the resident was to receive Metoprolol Tartrate (antihypertensive medication) 50 mg two times a day at 8:00 a.m. and 8:00 p.m. The resident's medication was to be held by staff for a SBP less than 110 or a pulse of less than 60. Review of the resident's June 2024 MAR indicated the following: - On 6/05/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 6/10/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 6/17/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 6/23/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 6/24/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. Review of the resident's July 2024 MAR indicated the following: - On 7/02/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 7/08/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 7/15/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 7/22/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. - On 7/23/24 at 8:00 p.m., the resident's Metoprolol Tartrate was administered with no blood pressure or pulse obtained. 2.b. The care plan, dated 6/7/24, indicated the resident had a surgical incision to the abdomen and staff were to administer treatments as ordered by the medical provider Review of the June 2024 TAR indicated staff were to cleanse the resident's abdominal incision with normal saline and apply a dry dressing daily. The June 2024 TAR lacked documentation that the treatment was completed on the following days: 6/5/24, 6/7/24, 6/11/24, 6/13/24, 6/20/24, 6/23/24, 6/24/24, 6/29/24 and 6/30/24. 3. The clinical record for Resident F was reviewed on 7/24/24 at 2:40 p.m. The resident's diagnosis included, but was not limited to, hypertension. The care plan, dated 11/15/22, indicated the resident had hypertension and staff were to observe the resident for signs/symptoms of elevated blood pressure. The June 2024 medication administration record indicated the resident's blood pressure was to be checked daily in the morning, from 6/20/24 through 6/26/24, due to an elevated blood pressure. The resident's clinical record lacked documentation of the resident's blood pressure from 6/23/24 through 6/26/24. 4. The clinical record for Resident H was review on 7/24/24 at 1:00 p.m. The resident's diagnosis included, but was not limited to, hypertension. The care plan, dated 1/30/23, indicated the resident had hypertension and staff were to administer the resident's medications per the medical providers orders. The physician's order, dated 5/28/23, indicated the resident was to receive Coreg (medication for high blood pressure) 6.25 mg twice daily at 8:00 a.m. and 8:00 p.m Staff were to hold the resident's medication for a SBP less than 110 or a pulse less than 60. Review of the resident's May 2024 MAR indicated the following: - On 5/02/24 at 8:00 a.m., the resident's Coreg was administered when the resident's SBP was 109. - On 5/04/24 at 8:00 a.m., the resident's Coreg was administered when the resident's SBP was 100 and a pulse of 59. - On 5/05/24 at 8:00 a.m., the resident's Coreg was administered when the resident's SBP was 102. - On 5/08/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. - On 5/10/24 at 8:00 a.m., the resident's Coreg was administered when the resident's SBP was 107. - On 5/15/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. - On 5/20/24 at 8:00 a.m., the resident's Coreg was administered when the resident's pulse was 59. - On 5/23/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. Review of the resident's June 2024 MAR indicated the following: - On 6/06/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. - On 6/19/24 at 8:00 a.m., the resident's Coreg was administered when the resident's SBP was 107. - On 6/19/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. - On 6/28/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. - On 6/30/24 at 8:00 a.m., the resident's Coreg was administered when the resident's SBP was 108 and a pulse of 58. Review of the resident's July 2024 MAR indicated the follwing: - On 7/03/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. - On 7/04/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. - On 7/17/24 at 8:00 p.m., the resident's Coreg was administered with no blood pressure or pulse obtained. This Citation relates to Complaints IN00437398 and IN00439287 3/1-37

Based on interview and record review, the facility failed to ensure Indwelling catheter care was completed for 1 of 1 residents reviewed for Indwelling catheters. (Resident E) Findings include: The clinical record for Resident E was reviewed on 7/24/24 at 3:03 p.m. The resident's diagnosis included, but was not limited to, sacral region pressure ulcer, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). The care plan, dated 2/15/23, indicated the resident required a condom catheter due to impaired skin integrity and staff were to provide catheter care every shift. The March 2024 treatment administration record (TAR) indicated staff were to cleanse the resident's condom catheter with soap and water every shift and to change the drainage bag weekly on Mondays. The resident's March 2024 TAR indicated the resident's condom catheter care was not completed on the following dates and shifts: - 3/01/24 - 3/02/24 on day shift - 3/04/24 on night shift - 3/05/24 on day shift - 3/07/24 on day shift - 3/10/24 on day shift - 3/11/24 on day and night shift - 3/13/24 on night shift - 3/15/24 on night shift - 3/17/24 and 3/18/24 on night shift - 3/21/24 on day shift - 3/28/24 on night shift - 3/30/24 on night shift - 3/31/24 on day shift The resident's March 2024 TAR indicated the resident's drainage bag was not changed on 3/11/24 at 9:00 a.m. The resident's April 2024 TAR indicated staff were to cleanse the resident's condom catheter with soap and water every shift and to change the drainage bag weekly on Mondays. The resident's April 2024 TAR indicated the resident's condom catheter care was not completed on the following dates and shifts: - 4/02/24 on night shift - 4/08/24 on day shift - 4/09/24 on night shift - 4/10/24 on day shift - 4/15/24 on day shift - 4/16/24 on night shift - 4/23/24 on night shift - 4/28/24 on night shift - 4/30/24 on day shift The resident's April 2024 TAR indicated the resident's drainage bag was not changed as ordered on 4/8/24, 4/15/24 and 4/22/24. During an interview on 7/26/24 at 1:25 p.m., LPN (Licensed Practical Nurse) 6 indicated when a nurse completes any treatment, it should have been signed off on the treatment administration record. On 7/25/24 at 1:48 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Catheter Care. It included, but was not limited to, Policy .It is the policy of this facility to provide resident care .Catheter care is performed at least twice daily on residents .for as long as the catheter is in place This Citation relates to Complaint IN00439287 3.1-41

Based on observation, interview and record review, the facility failed to ensure a staff member followed infection control practices for 1 of 5 observations related to infection control. ( CNA 4) Findings include: During an observation on 7/23/24 at 8:13 p.m., CNA (Certified Nursing Aide) 4 was observed to exit a resident's room wearing gloves and carrying a soiled brief in one gloved had and a soiled pair of pants in the other. During an interview on 7/26/24 at 12:34 p.m., CNA 5 indicated after resident care was provided, soiled briefs should be placed in a bag and soiled clothing in a separate bag. Soiled gloves should have been removed prior to exiting the resident's room and all soiled clothing should be in a bag. The bagged items should then be placed in the soiled utility room. On 7/25/24 at 1:48 p.m., the Regional Director of Clinical Operations provided a current copy of the document titled Infection Prevention Program effective 3/9/2000. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Residents have the right to reside in a safe environment that .reduces the risk of acquiring infections .The facility infection prevention program .addresses .prevention and control of infections among residents and employees 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure a resident that self-administered medications was appropriately assessed for self-administration for 1 of 3 residents reviewed for medications. (Resident E) Findings include: The clinical record for Resident E was reviewed on 3/20/24 at 1:30 p.m. The resident's diagnoses included, but were not limited to, osteoarthritis, morbid obesity, congestive heart failure, chronic respiratory failure with hypoxia, depression, and hypertension. Review of the March 2024 physician's orders indicated the resident was to receive the following medications every morning: -Aspirin 81 mg (milligrams) chewable for heart health -Carvedilol 3.125 mg twice daily for hypertension -Clopidogrel Bisulfate 75 mg daily for heart health -Ergocalciferol 1.25 mg daily for supplement -Gabapentin 100 mg twice daily for health maintenance -Lexapro 10 mg daily for depression On 3/20/24 at 11:40 a.m., Resident E was observed resting in bed in her room. On the resident's bedside table was a medication cup with 6 unidentified medications. The medication cup had 9:00 a.m. written on the side in red marker. On 3/20/24 at 11:42 a.m., LPN (Licensed Practical Nurse) 10 entered Resident B's room. She indicated she handed the resident her medications to take this morning, but she did not watch the resident take the medication because she had a lot going on. She made a mistake. During an interview on 3/20/24 at 2:22 p.m., the Regional Director of Clinical Operations indicated there were no residents in the facility that self-administered medications. The clinical record lacked an assessment for the resident to self administer medications. On 3/20/24 at 2:22 p.m., the Regional Director of Clinical Operations provided the current, undated copy of the document titled Medication Administration. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Safety of residents .is a top priority of care .Procedure .Remain with resident until the medication is swallowed .Do not leave medications at bedside 3.1-11(a)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) representative was provided a bed hold notification information, in a timely manner, for 1 of 3 residents reviewed for transfer/discharge. Findings include: The clinical record for Resident B was reviewed on 9/15/23 at 10:25 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, adjustment disorder, post traumatic stress disorder, schizoaffective disorder and bipolar disorder. The progress note, dated 8/16/23 at 9:16 a.m., indicated the resident was sent to a psychiatric hospital related to behaviors towards staff. Review of the bed hold authorization form indicated Resident B's representative was not informed related to the bed hold policy until 9/6/23 which was three weeks after his discharge to the hospital. During an interview on 9/15/23 at 10:51 a.m., the complainant indicated she was notified of the bed hold authorization on 9/6/23. During an interview on 9/15/23 at 12:41 p.m., the Admissions Coordinator indicated the bed hold authorization got missed. On 9/15/23 at 1:09 p.m., the Regional Director of Clinical Operations provided a current copy of the document titled Bed Hold Policy dated 2/17/17. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .It is the intent of this facility to obtain the proper authorization .The bed hold authorization form may be signed prior to the patient leaving the building, or within 24 hours of the resident leaving the facility or the following business day if the resident leaves on the weekend or a holiday This Federal tag relates to Complaint IN00416995. 3.1-12(a)(25)(A)

Based on record review and interview, the facility failed to ensure the physician's orders were followed to schedule a paracentesis for a resident with ascites and jaundice which resulted in the unstable hospitalization which was followed by the death of Resident C for 1 of 32 residents reviewed for Quality of Care. (Resident B) The Immediate Jeopardy began on 9/30/22 when facility staff failed to schedule an appointment as ordered for Resident C to have a paracentesis (procedure to remove excess fluid buildup from the abdomen) procedure performed to relieve the resident's ascites (collection of fluid in the abdomen). The Executive Director (ED), Director of Nurses (DON) and Regional Director of Clinical Operations (RDCO) were notified of the immediate jeopardy at 12:51 p.m. on 6/20/23. The immediate jeopardy was removed on 6/21/23, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The record for Resident B was reviewed on 6/19/23 at 11:00 a.m. The diagnoses included, but were not limited to, cognitive communication deficit, acute kidney failure, and alcoholic cirrhosis of liver with ascites. The hospital report, dated 9/8/22, indicated the resident was treated in the hospital for weakness that had started several months prior and gotten progressively worse. He had a history of multiple falls within the past few months and had a decreased appetite. He had a large amount of ascites in the abdomen pelvis. The ascites could be due to severe hypothyroidism but additional work-up would need to be done. Gastroenterology was following him, and he was receiving paracentesis. He desired skilled rehabilitation placement at discharge. The nurse's note, dated 9/19/23 at 7:06 p.m., indicated the resident arrived at the facility via his personal vehicle escorted by a family member. His blood pressure was hypotensive at 92/61, but he was asymptomatic. He was in no distress. His orders were verified by the Nurse Practitioner (NP). The nurse's note, dated 9/21/22 at 10:35 a.m., indicated the resident had been assisted up from the floor by therapy where he had gone down on his knees while using his walker. The SBAR (Situation Background Assessment Recommendation) note, dated 9/21/22 at 10:47 a.m., indicated the resident's vitals were within normal limits. He had been walking back from the bathroom with 2 therapists when his knees buckled and hit the floor slightly. The only new intervention was for staff to remind the resident to use the call light for assistance and to alert staff to have hands on assistance was implemented. The nurse's note, dated 9/23/22 at 4:01 a.m., indicated the resident was on an antibiotic therapy for an upper respiratory infection. He had a round, distended abdomen which was nontender with active bowel sounds. He refused his bolus feeding because it made him feel nauseated. The Wound NP's note, dated 9/27/22 at 6:33 p.m., indicated the resident's abdomen was taut and he had observed ascites. The nurse's note, dated 9/29/22 at 7:15 p.m., indicated the resident refused to eat due to an upset stomach. He asked for assistance to toilet but was unable to urinate. The NP's order, dated 9/30/22 at 1:30 p.m., indicated to set up an appointment for paracentesis for ascites one time only. The NP's note, dated 9/30/22 at 8:30 p.m., indicated the resident was developing ascites. He had diffusely located jaundice which was gradual in onset. The plan indicated to set up paracentesis for ascites and for her to conduct a return NP visit in 1 week. The clinical record lacked documentation of any appointments being scheduled for the resident's paracentesis as ordered by the NP. The nurse's note, dated 10/4/22 at 11:35 a.m., indicated the resident was sitting on the floor with his walker. The nurse had assisted him to the restroom and when he was walking back to his bed he stumbled over his feet and sat down on the floor. He indicated he felt weak and had to go to the floor. The NP was notified and indicated staff were to continue to monitor the resident and report any changes. The physician's note, dated 10/11/22 at 8:20 a.m., indicated the resident had a change in condition. He had altered mental status and labored breathing. His vitals were unstable, and he had blue fingertips and pale skin. His blood pressure was 84/40, his heart rate was 47, his respiratory rate was 24, and his temperature was 96.9 Fahrenheit. He was sent to the emergency department for evaluation and management of acute respiratory failure and altered mental status. The nurse's note, dated 10/11/22 at 2:30 p.m., indicated the resident was found on the floor during morning round by the CNA (Certified Nurse Aide). He had an unwitnessed fall. The nurse saw him lying on the floor on his right side. He could not state his name or where he was. The nurse assessed the resident and notified the on-call provider. The resident was sent to the emergency room . The nurse's note, dated 10/11/22 at 7:16 p.m., indicated the resident was admitted to the intensive care unit for a diagnosis of resident found down. The hospital final report, dated 10/14/22, indicated on 10/11/22 the resident had cirrhosis of the liver and hypotension. His GCS (Glasgow Coma Scale) was an 8 (a score of 8 or less being indicative of severe brain injury) on arrival to the emergency department and he was intubated. His initial pressures were in the 60's and he was started on Levophed. He likely had septic shock. His core body temperature was 87.62 degrees Fahrenheit and he was placed on a bearhugger (a forced air warming system to warm the resident's body). His creatinine was 5.9 (indicative of severe kidney damage), his BUN (Blood Urea Nitrogen)was 39 mg/dL (normal value 7 to 20 mg/dl). A catheter for CRRT (a non-stop, 24-hour dialysis therapy) was going to be placed. His upper and lower extremities were cold and mottled. On 10/12/22 the resident remained hemodynamically unstable and he was receiving CCRT. The resident's CT (Computed Tomography) scan showed he had a large collection of ascites. Paracentesis was performed on 10/14/22 with 5.7 liters of output obtained. A culture of his ascites fluid was obtained from the resident's abdomen. His diagnoses included altered mental status, renal failure, and sepsis. He had end stage hepatorenal syndrome. On 10/14/22 the family indicated they were ready to move towards comfort measures only. He was not likely to improve clinically. Orders for comfort measure were processed. During an interview on 6/19/23 at 1:37 p.m., the Nurse Practitioner indicated she did vaguely recall the patient, but she would have to review her notes for some information because the patient was there back in September. Usually when they came in on admission, she would see them. Then two weeks after admission and anytime something came up, as well as monthly regulatory visits if they didn't have an acute need. She could not recall the visit on 9/30/22. She did assess him for ascites. Her expectation was for the nurse to set up outpatient paracentesis with a GI (gastrointestinal) doctor. She would have given orders to the nurse to set up the appointment. She did give the orders to the nurse. It would have been done verbally and she would have put the order in the resident's record. She would have wanted it done within 7 days at the minimum if she felt he needed paracentesis. The ideal was to see him in a week. She indicated he should have had the appointment set up. During an interview on 6/19 at 2:24 p.m., the RDCO (Regional Director of Clinical Operations) indicated the order to schedule an appointment for paracentesis was in the resident's record. During an interview on 6/19/23 at 2:30 p.m., the NP indicated the resident had an order for an appointment, but they did not have any documentation of whether or not he went out to the appointment. They did not find any documentation that the appointment was scheduled. She did not know if he had any paracentesis until he went out on 10/11/22 when he went out to the hospital. Up until that time he was not symptomatic. He had no shortness of breath or trouble breathing, so she would have been ok with an extended wait period. She did not give any orders for an extended wait period, but she didn't give any orders for seven days either. During an interview on 6/20/23 at 9:44 a.m., LPN 7 indicated she did not recall the resident. She did not recall sending any residents out for paracentesis. They would chart that they went LOA to doctors' appointments. Sometimes they put an order in the system but sometimes they did not. Usually, the nurses were responsible for setting up transportation and appointments. During an interview on 6/20/23 at 10:12 a.m., the RDCO indicated she was still not sure if the resident had ever gone to any appointment for paracentesis. They were still trying to get the information. During an interview on 6/20/23 at 10:16 a.m., the resident's family member indicated prior to coming to the facility the resident had been told he would need to have fluid taken off weekly, however she was not sure if that had been put in his orders. When he went to the facility, he was there for three weeks and they never had any fluid taken off When his stomach filled up with fluid he had no energy, he couldn't move, and he couldn't eat. She kept asking about his paracentesis while he was at the facility, they kept saying they were waiting on an appointment. One night he finally got up and fell , and they sent him to the hospital. They took him out on 10/11/23 and he passed away at the hospital on 10/14/22. They took off over five liters of fluid at the hospital. He never did regain consciousness at the hospital. She came in and saw him three times weekly while he was there. They never scheduled an appointment for him to have his fluid taken off. In fact, she ran into the NP on 10/10/23 before he went to the hospital and asked her why she still hadn't made the appointment. The NP asked her who his GI doctor was, and she told them. The NP told her she had tried to reach them, but the GI doctor wouldn't return her calls. His feet and legs were swelling, his stomach was swollen, and he got weaker and weaker. To her knowledge they did not do anything to help with his ascites. She had a copy of his death certificate, and it said his cause of death was multiple organ failures. If he had an appointment he would have had to have gone by ambulance because he was so weak they couldn't have transported him. He was so weak she couldn't even get him in the car. During an interview on 6/20/23 at 12:29 p.m., the RDCO indicated she had contacted three local hospitals and she could locate no documentation or record of Resident C being at any of their facilities for a paracentesis between the dates of 9/30/22 and 10/10/22. She had looked at all their documentation and the only thing they had was the order to schedule the paracentesis. She did not have any documentation of an appointment date or time, or anything to show that he went out between those dates. The most current, but undated, Physician Orders policy, provided on 6/20/23 at 12:44 p.m. by the RDCO, included but was not limited to, . It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents . III. Execution of Order and Notifications a. The nurse that takes the physician order will be responsible for executing the order or provide safe hand-off to the next nurse . i. Contact laboratory services, radiology services, pharmacy services, therapy or other outside vendors as required to execute the medical order . The immediate jeopardy, that began on 9/30/22, was removed on 6/21/23, when the facility conducted the following: The DON/Designee reviewed all orders given by physicians for the last 30 days to ensure they were initiated and completed per physician's order. An audit was conducted for all orders from 9/30/22 to 6/21/23 to ensure that no specialized appointments were missed. The DON/Designee educated all licensed nurses on the facility's policy identified as, Physician Orders with emphasis on ensuring all orders for appointments were completed. All nurses were educated in person or on phone as well as via app, on scheduling appointments and physician's orders. This Federal Tag relates to Complaint IN00409941. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure narcotic pain medication was reordered in a timely manner for a resident, which resulted in the resident experiencing severe pain, 4 days without her routine pain medication, difficulty sleeping, multiple stools, and irritability, and episodes of extended crying for 1 of 6 residents reviewed for pain. (Resident 8) Findings include: During an observation and interview on 7/18/22 at 9:26 a.m., Resident 8 was resting in bed. She indicated she had a lot of pain. She took [MEDICATION(S)] in the morning and the evening. She didn't known until the night before she had as needed medication she could take. The facility was out of her [MEDICATION(S)] currently. She indicated she got mad when they ran out of it and didn't know why they ran out. She hadn't received any of her [MEDICATION(S)] in 2 days. The night prior she was having what she described as withdrawals. She indicated she couldn't lay still and got funny feelings. She felt she was short tempered and irritated. She didn't feel well. The nurse finally give her the as needed medication because she had been crying. It did calm her down and help her, but she still hadn't been able to sleep. She believed that was one of the side effects of coming off the [MEDICATION(S)]. She had been awake for two straight days and nights. The staff told her they ran out of her medication. The nurse had told her said yesterday when she was asking about the [MEDICATION(S)] she may need to call the doctor for a prescription. She rated her current pain at an 8 out of 10 on the numerical pain scale, with 10 being the worst pain. During an observation and interview on 7/19/22 at 5:09 a.m., Resident 8 was resident in bed. She was in tears, her eyes were swollen and reddened from visibly crying and she appeared upset. She indicated she was not doing well. Her pain medication had still not arrived. She rated her pain a 9 on a numerical pain scale, with 10 being the worst. She'd had bowel movements all night long. The aide had to come in and cleaned her up every 2 hours. The clinical record for Resident 8 was reviewed on 7/18/22 at 10:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) Assessment, dated 4/26/22, indicated the resident was cognitively intact. She received a scheduled pain medication. The resident had not received any as needed pain medications or non-medication interventions for pain in the last five days. The pain assessment was not completed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR (Electronic Medical Administration Record) note, dated 7/16/22 at 12:07 a.m., indicated the resident's [MEDICATION(S)] HCl 5 mg was unavailable and the facility was awaiting the medication from pharmacy. The review of the EMAR (Electronic Medication Administration Record) for July 2022 indicated the resident's order for [MEDICATION(S)] HCl 5 mg tablet twice daily at 9:00 a.m. and 10:00 p.m., was not documented as administered on the following dates and times: - 7/15/22 at 10:00 p.m. - 7/16/22 at 10:00 p.m. - 7/17/22 at 9:00 a.m., and - 7/18/22 at 9:00 a.m. - 7/18/22 at 9:00 p.m. The resident received no [MEDICATION(S)] on 7/15/22 or 7/16/22. She received one dose of the medication on 7/17/22 at 2:33 a.m., one dose on 7/18/22 at 9:45 a.m., and one dose on 7/19/22 at 5:49 a.m. The EMAR medication administration note, dated 7/16/22 at 9:54 p.m., indicated the resident's [MEDICATION(S)] HCl 5 mg was not administered due to being ordered from pharmacy. The EMAR medication administration note, dated 7/17/22 at 2:33 a.m., indicated the resident was given [MEDICATION(S)] 50 mg 1 tablet by mouth for pain. The EMAR medication administration note, dated 7/17/22 at 3:41 a.m., indicated the PRN [MEDICATION(S)] pain follow-up scale was a zero and the administration was effective. The EMAR medication administration note, dated 7/17/22 at 10:45 a.m., indicated the facility was still awaiting the medication from the pharmacy. The EMAR medication administration note, dated 7/18/22 at 9:45 a.m., indicated the resident was given [MEDICATION(S)] 50 milligrams as needed for pain. The EMAR medication administration note, dated 7/18/22 at 9:46 a.m., indicated the resident's [MEDICATION(S)] HCL 5 milligram tablet by mouth every morning and at bedtime for pain needed a new prescription from the Nurse Practitioner (NP). The EMAR medication administration note, dated 7/18/22 at 10:32 a.m., indicated the PRN [MEDICATION(S)] pain assessment follow-up was effective, with a pain scale rating of zero. The Nurse Practitioner's note, dated 7/18/22 at 10:32 a.m., indicated the resident was seen by the Nurse Practitioner for a routine follow-up for chronic disease management. There were no prescriptions for the visit. A return visit would be conducted in 1 month. The nurse's note, dated 7/19/22 at 1:48 a.m., indicated the resident's family called and inquired about her pain medication. The nurse placed a call to the pharmacy and was informed the medication would be delivered on the night run. The information was communicated to the resident, the resident stated she understood. She rated her pain at a 7 on the pain scale. The clinical record lacked documentation of the administration of any pain relief to the resident at that time. During an interview on 7/19/2 at 5:12 a.m., CNA (Certified Nurse Aide) 10 indicated the resident was upset because she didn't have her medicine. She had been crying all night about it. She thought it was her [MEDICATION(S)]. The resident had been crying tears all night. They tried to get her to understand. She had been in a lot of pain and had not slept at all. She'd been in there caring for the resident all night and every time she went in, she asked about her pain medication. During an interview on 7/19/22 at 5:16 a.m., LPN (Licensed Practical Nurse) 11 indicated she called pharmacy for her and spoke to her family. When she was on the hall, she saw her call light come on and went in. The resident told her she hadn't received her medication. Her family made a phone call to the facility, and she asked him to let her call the pharmacy. She called them and they said it was being put on the night run and it went out at 8:00 p.m. In the meantime, they found out her medication was routine and not as needed, so when it came in it couldn't just be given. Maybe she was out of it for a day or so. The resident was still upset they couldn't give her medication to her. It was in the facility at this moment, but it was a routine pain medication given twice daily and had scheduled times. She had not spoken to the doctor. She spoke with LPN 12 and the resident didn't appear to be in any tremendous amount of pain. They only had three nurses and it made it hard for them to do their jobs. LPN 11 was not aware of the symptoms of opioid withdrawal, but she felt it could be related to her having frequent bowel movements. During an interview on 7/19/22 at 5:16 a.m., LPN 12 indicated the resident never said anything to her about her pain. She'd been in the room earlier and the resident was talking, laughing, cutting up. She had no idea the resident didn't have her medication in three days. They had to split the hall. A nurse had left at 10:00 p.m. and they didn't get report from her. She had not been informed of the resident crying all night. She hadn't given the resident any of her as needed [MEDICATION(S)]. The CNA had just told her the resident wanted Lomotil, but she didn't know the resident had several bowel movements that night. Had she known of the resident's medication being out, she would have gotten her an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She would have called the pharmacy, talked to the family, and obtained the medication. She never knew the resident was in pain. During an interview, on 7/19/22 at 5:25 a.m., CNA 10 indicated the resident had a lot of bowel movements that night. She asked for [MEDICATION(S)], and said she was using the restroom so much because she didn't have her other medication. LPN 12 questioned the CNA about the resident crying, and the CNA again indicated yes, the resident had been crying all night and it had been going on since before the nurse got there. She indicated LPN 11 had been aware of the resident being in pain. During an interview, on 7/19/22 at 10:23 a.m., the Interim DON indicated she had investigated the incident and found the resident ran out of her [MEDICATION(S)]. The last dose she'd received had been on 7/14/22 at 9:00 p.m. At that point they should have notified the NP, they should have notified her before that. She did not see where a new script was asked for. She read the daily notes every day, so she would not have picked up on it until yesterday unless they had called her, because at 9:00 a.m. on 7/15/22 they signed the medication out as being given. It wasn't in the building. According to the narcotic sheets she ran out on 7/14/22. Therein lied an issue. She doubted it was given because it was an Agency nurse, and she did not know that they would have had access to log in to the Emergency Drug Kit (EDK). She wasn't notified she would have needed access. The reordered the medication yesterday. When the dose came in this morning staff could have called and gotten a one-time order to give the medication. It was not acceptable. The pharmacy had the ability to send an emergency supply, at least a 3-day supply. She could have had her doses on the 15th, 16th, and 17th, and they could have statted (immediately) the medication and taken care of it. She wished staff would have called her. Pain was easily controlled, that was an easy fix that shouldn't have escalated to that point. During an interview, on 7/20/22 at 2:08 p.m., the NP indicated she was aware of the incident with the pain medication, she wrote the script immediately when they notified her the resident was out. She was not contacted prior to let her know the medication was running low. She did expect and rely on staff to notify her of a resident being low on a narcotic, she managed all the residents and relied on them to tell her because it would be difficult for her to keep up with. She was not notified of the resident having any side effects related to being out of the medication. She would expect to be notified of withdrawal symptoms, sweating, pain, nausea, sometimes they can have diarrhea. It depended on the person as far as the withdrawal symptoms. It definitely could cause [CONDITION(S)], and she would think for behaviors it could cause increased anxiety. Going Through [MEDICATION(S)] Withdrawal at www.healthline.com. [NAME] K, et al. (2015). American Society of Addiction Medicine ([NAME]) national practice guideline for the use of medications in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .nlm.nih.gov/pmc/articles/PMC 75/ [MEDICATION(S)]. (2015). samhsa.gov/medication-assisted-treatment/treatment/[MEDICATION(S)].[MEDICATION(S)] is a prescription drug used to treat severe pain [MEDICATION(S)] is itself an opioid and can be addictive When you stop taking [MEDICATION(S)] after you've been taking it for a while, you may experience withdrawal symptoms. Getting through [MEDICATION(S)] withdrawal can be a painful experience . and .Symptoms of [MEDICATION(S)] withdrawal .typically start to appear approximately 24 to 36 hours after you last took the drug .You may be having withdrawal if within the first 30 hours that you stop taking [MEDICATION(S)], you experience: .tiredness .anxiety .restlessness .trouble sleeping .At first, symptoms of withdrawal may feel like the flue .Certain symptoms may peak after about three days .muscle aches and pains .severe nausea .vomiting .cramps .diarrhea. The Pain Management and Assessment policy, last reviewed 1/18/22, provided on 7/20/22 at 9:15 a.m. by the Corporate Nurse, included, but was not limited to, . the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management . Procedure . Pain management considerations . a. To the extent possible and in consideration of cognitive abilities, the nurse will provide a thorough assessment by observation of activities and treatment/relief for detection of pain and to attempt to identify location and any limitations imposed by the pain . f. Impact of pain on quality of life including but not limited to . Sleep loss . Function abilities . appetite . mood . h. Additional symptoms associated with pain . Examples may include nausea, anxiety . physical examination of the site of the pain . movement . activity that causes the pain . as well as any discussion with the resident about any psychological or psychosocial concerns that may be causing or exacerbating the pain . the resident's satisfaction with the current level of pain control . The 1-10 Pain Scale . For residents with intact cognition abilities who can/and are willing to determine their 'worst pain ever' (10) and 'no pain' (1) range using numbers . Breath-through Pain Management . Pain that is above the routine pain and requires interventions along with the current pain management regime . May require, on occasion, adjuvant therapies including pharmacological and nonpharmacological interventions for enhancing pain relief . Pharmacological interventions added to scheduled pain plan may include but are not limited to . non-steroidal anti-[CONDITION(S)] drugs . Side Effect Management . The nurse will observe for and manage side effects including those associated with opioid use . Documentation . Medication pain relief and response . The Controlled Substances Prescriptions policy, last revised 8/20, provided on 7/20/22 at 9::15 a.m., included, but was not limited to, . Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe controlled substances . The prescriber issuing the chart order must also provide the pharmacy with a valid prescription to ensure the delivery of medication .Communicating with the Prescriber . The prescriber is contacted for direction when the medication is not or will not be available for administration . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure appropriate and current interventions were implemented to prevent pressure ulcers which resulted in a resident (Resident G) acquiring a stage 3 (full thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer to the left buttock and a resident (Resident F) acquiring a stage 2 (partial thickness skin loss involving the epidermis, dermis, or both) pressure ulcer to the left buttock and an unstageable (full thickness loss in which the base of the ulcer is covered) pressure ulcer to the left heel and ball of the left foot, for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident G was reviewed on 5/3/21 at 12:12 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimmun Data Set) assessment, dated 1/28/21, indicated the resident's cognition was intact. The resident had no rejection of care, and required two staff members for physical assistance with bed mobility. The quarterly MDS assessment, dated 4/22/21, indicated the resident had no refusal of care. On 5/3/21 at 4:07 p.m., during an observation with the Director of Nursing, the resident's wound to the left buttock was pink in color, visualized as a stage 2, and measured 3 cm (centimeters) in length and 1.5 cm in width with a depth of less than 0.1 cm. The Braden Observation Tool, dated 4/3/21, indicated the resident was a low risk for pressure ulcers due to slightly limited sensory perception, occasionally moist, bedfast, slightly limited mobility, and a potential problem with friction/shearing. Potential interventions for a low risk included frequent turning. The care plan, dated 10/6/20, indicated the resident had a potential for impaired skin integrity and to offer to turn and reposition every 2 hours. The skin grid pressure report, dated 4/20/21, indicated the resident had a stage 2 pressure ulcer to the left buttock which measured 4 cm in length and 2 cm in width with a depth of 0.1 cm. The IDT (interdisciplinary team) note, dated 4/21/21 at 9:28 a.m., indicated the resident had an area to her left buttock. The root cause was due to a standard mattress, limited mobility, and refusal to turn and reposition. The skin grid report, dated 4/22/21, indicated the resident had a stage 3 pressure ulcer to the left buttock which measured 4.5 cm in length and 2.5 cm in width with a depth of 0.1 cm. On 5/4/21 at 11:27 a.m., the Director of Nursing indicated she felt the resident's pressure ulcer was a result of non-compliance with turning and repositioning, personal preference to lay on her back, and personal preference to be in bed. The clinical record lacked documentation of the resident's refusal to turn and reposition. During an interview on 5/3/21 at 12:30 p.m., Resident G indicated she was continent of bowel and bladder and gets up, usually once a shift to use the bedside commode. She can reposition herself in bed somewhat, however, staff do not come in and offer to turn or reposition her in bed. 2. The clinical record for Resident F was reviewed on 5/3/21 at 11:52 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimum Data Set) assessment, dated 2/3/21, indicated the resident's cognition was severely impair. The resident required extensive of two staff members for assistance with bed mobility. During an observation of the left foot on 5/3/21 at 4:00 p.m., with the Director of Nursing, the area to the left inner heel and left ball of foot was dark brown in color. The area to the heel measured 3 cm in length and 2.8 cm in width with no depth. The left ball of the foot measured 3 cm in length and 3 cm in width with no depth. On 5/3/21 at 5:20 p.m., area to the left buttock was pink in color and measured 1 cm in length and 1 cm in width with a depth of <0.1 cm. The Braden Observation Tool, dated 2/4/21, indicated the resident was a moderate risk for pressure ulcers due to a slightly limited sensory perception, very moist, chairfast, slightly limited mobility, and a problem with friction/shearing. Potential interventions for a moderate risk included wedge support for 30 degree side positioning, protect heels, and manage moisture. The care plan, dated 10/12/20, indicated the resident had a potential for skin/tissue integrity related to decreased mobility and to assess skin weekly, turn every 2 hours, and elevate heels off of the bed. The skin grid pressure sheet, dated 4/23/21, indicated the resident had a suspected deep tissue injury to the left heel which measured 3 cm (centimeters) in length, 3 cm in width, 0.1 cm in depth, skin prep to the area every shift, and a heel protector to the left foot at all times. The skin grid pressure sheet, dated 4/27/21, indicated the area to the left heel measured 3 cm in length, 3 cm in width, no depth, and classified as an unstageable area. The skin grid pressure sheet, dated 4/23/21, indicated the resident had a suspected deep tissue injury (blister) to the ball of the left foot which measured 3 cm in length and 3.5 cm in width with no depth. The skin grid pressure sheet, dated 4/30/21, indicated the resident had a stage 2 pressure ulcer to the left buttock which measured 2.5 cm in length and 1.5 centimeters in width with no depth. The clinical record lacked documentation of turning and repositioning or elevation of the heels prior to the acquisition of the wounds. On 5/4/21 at 11:27 a.m., the Director of Nursing indicated she felt the pressure ulcers were the result of her decline in the disease process. On 5/4/21 at 5:08 p.m., the Regional Director of Clinical Operations provided a current copy of the document titled Skin Care & Wound Management Overview dated 5/30/19. It included, but was not limited to, Definition .A pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction .The facility staff strives to prevent resident .skin impairment .Procedure .Evaluate for consistent implementation of interventions This Federal tag relates to Complaint IN 010 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure a resident (Resident R), dependent on staff for bolus feedings, received all ordered feedings, which resulted in a significant weight loss for 1 of 3 residents reviewed for weight loss. Findings include: The clinical record for Resident R was reviewed on 12/21/20 at 12:23 p.m. [DIAGNOSES REDACTED]. The 11/29/20 quarterly MDS (Minimum Data Set) assessment indicated severely impaired cognition and required an extensive, one person physical assistance with feeding. The care plan, dated 10/6/20, indicated the resident was at risk for nutritional decline due to NPO (nothing by mouth) and was dependent with tube feeding and water flushes per physician's orders [REDACTED]. The December 2020 Medication Administration Record [REDACTED]. Review of the video footage on 12/21/20 at 2:47 p.m., indicated the resident did not receive the bolus feeding and water flushes on 12/12/20 at 4:00 p.m. or 8:00 p.m., 12/13/20 at 12:00 a.m., 12:00 p.m., or 8:00 p.m., and 12/14/20 at 8:00 p.m. The bolus feedings and water flushes were initialed by staff as given on the medication administration record. The weight summary report indicated the resident weighed 121.5 pounds on 12/8/20 and 116 pounds on 12/15/20, a weight loss of 5.5 pounds in one week. The dietary nutritional assessment, dated 12/21/20, indicated the resident has had a significant weight loss of 7 pounds (5.7%) over a 30 day period. During an interview on 12/23/20 at 2:58 p.m., Staff Member 7 indicated on 12/5/20, a case of 24 cartons of the Vital 1.5 was placed in the resident's room. On 12/12/20, there were still 8 cartons left in the case which had been marked prior to placement. In the seven day time frame the resident would have used 35 cartons if she had received the ordered daily amount. On 12/23/20 at 4:31 p.m., the Director of Nursing provided a current copy of the document titled Administering Bolus Enteral Nutrition via [DEVICE] dated 10/27/2009. It included, but was not limited to, Gastrostomy tube: a type of feeding tube .that terminates into the stomach with an external connection for the purpose of hydration/enteral feeding .Policy .It is the policy of this facility to provide resident centered care by providing enteral feeding and hydration fro residents unable to tolerate oral feedings This Federal tag relates to Complaint IN 678 3.1-44(a)(2)

Based on record review and interview, the facility failed to ensure a resident who was positive for COVID-19 was assessed, monitored and provided necessary care and treatment in accordance with professional standards of practice during a decline in condition with shortness of breath and decreased oxygenation, and failed to ensure the physician was notified of the decline in condition. At the time of the resident's decline, a facility nurse administered oxygen via a non-rebreather mask without physician orders [REDACTED]. The next documentation in nursing notes was two days later, when the same nurse discontinued all oxygen without notifying the physician or receiving orders to do so, which was followed by the resident's death. This deficient practice affected 1 of 3 residents reviewed for quality of care. (Resident B) This deficient practice resulted in immediate jeopardy. The immediate jeopardy began on 4/28/20 at 12:00 a.m. when a resident was experiencing a decline in condition, the nurse did not notify the physician and obtain orders for the resident's care and treatment, and the facility did not monitor and assess the resident for the following two days. On 4/30/20, the nurse acted independently and discontinued all oxygen, again without notifying the physician or obtaining orders for care, and the resident progressively declined to death 7 hours and 45 minutes later, again with no care or monitoring documented during that time. The Health Facility Administrator, Director of Nursing, and Regional Nurse were notified of the immediate jeopardy on 5/04/20 at 4:33 p.m. The immediate jeopardy was removed on 5/12/20, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record of Resident B was reviewed on 5/05/20 at 11:00 a.m. Resident B's [DIAGNOSES REDACTED]. A nurse's note, dated 3/13/20 at 3:55 p.m., indicated the resident had been admitted to the facility. The care plan, dated 3/16/20, indicated the resident was a full code. A physician's orders [REDACTED]. The care plans lacked documentation of any changes to advanced directives including, but not limited to, do not resuscitate, palliative care, or comfort measures only. The Admission MDS (Minimum Data Set) assessment, dated 3/20/20, indicated the resident was moderately cognitively impaired. A nurse's note, dated 4/24/20 at 5:10 p.m., indicated the resident had new orders for COVID-19 testing. The nurse's note, dated 4/26/20 at 4:28 p.m., indicated the resident was COVID-19 positive. The nurse's note, dated 4/28/20 at 12:00 a.m., documented by LPN 6 as a late entry on 4/30/20 at 1:36 a.m., indicated the resident had an O2 sat (oxygen saturation) of 64% (normal range is greater than 90%). O2 (oxygen) was started at 2 LPM (liters per minute) via nasal cannula, with no improvement. The resident was displaying diaphragmatic breathing, and had rhonchi (abnormal continuous low pitched, rattling lung sounds) throughout the lungs. The O2 was increased to 5 LPM via a face mask, and the resident's O2 saturation raised to 84%. The resident was then changed to a non-rebreather mask and the oxygen was increased to 10 LPM. The resident's O2 saturation rose to 89%. The clinical record lacked documentation of notification to the physician of the resident's decline in condition, or the initiation of oxygenation therapy. The nurse's note, dated 4/28/20 at 1:36 a.m., documented by LPN 6 as a late entry on 4/30/20 at 1:43 a.m., indicated the resident's condition was guarded. O2 continued at 10 LPM via non-rebreather mask, with O2 saturation remaining around 80-85% as the resident continued to display a diaphragmatic breathing pattern. The resident's breathing was labored and had rhonchi throughout the lung fields. There was no documentation in nurses' notes between 4/28/20 at 1:36 a.m. and 4/30/20 at 1:00 a.m. The nurse's note, dated 4/30/20 at 1:00 a.m., documented by LPN 6, indicated the resident continued with diaphragmatic breathing. O2 saturation was down to 64% as O2 continued at 10 LPM via non-rebreather mask. The resident appeared to be weak and tired. The nurse asked the resident if he was tired of fighting, and whether he wanted to let go and go to heaven. The resident indicated he did, and the nurse removed all supplemental oxygenation. The clinical record lacked documentation of any notification to the physician of the resident's continual decline or the discontinuation of oxygenation therapy, and any physician's orders [REDACTED]. There was no further documentation by LPN 6 after 1:00 a.m. on 4/30/20. A nurse's note, dated 4/30/20 at 8:45 a.m., documented by the day shift nurse, LPN 7, indicated the resident had passed away. At this time, the physician was notified of the resident's death. The clinical record lacked documentation of any respiratory assessments from the time the oxygen administration was started, to the time of the resident's death. Review of a social media post, made by LPN 6 on 5/01/20, indicated, I just want y'all to know the hardest thing I've ever done in [AGE] years start a patient on O2 for 4 days 12 LPM. with a non-rebreather mask and I asked him on day 4 if he's tired he said yes I said do you want me to take all this off for you and let you go and fly with the angels and he said yes I took it all off of him I went in the hallway and I cried and I let him go and he passed away 1 hour and 45 minutes after I left. During an interview on 5/04/20 at 12:30 p.m., LPN 4 indicated a non-rebreather mask would only be utilized for a resident if a physician ordered it. During an interview on 5/04/20 at 4:42 p.m., the DON and the Regional Nurse both indicated they could not locate documentation of notification of the physician regarding the resident's decline in condition, or any orders to administer or discontinue any oxygenation. During an interview on 5/05/20 at 10:37 a.m., LPN 6 indicated she had started oxygen on the resident when his sats (oxygen saturation) were in the 70's. They had standing orders for up to 5 LPM (liters per minute) of O2. She put him on 5 LPM via a mask, but it only brought the resident's sats up to 77. She then increased it to 10 LPM via a non-rebreather mask. She told the resident's daughter, who was the POA, the oxygen was only .prolonging the inevitable. The daughter had told her if it was her father's wishes she could remove the mask. She later removed the oxygenation. She did not speak with the physician because she was taking care of over 40 COVID patients and the week that I had had was terrible and that is one thing I forgot to do was call the doctor. She indicated they only had standing orders for up to 5 LPM of O2. The physician did not give the order to start the oxygen or to use the non-rebreather mask, she was just trying to keep the resident's sats (oxygen saturation) up. The physician did not give an order to discontinue the oxygenation. On 5/05/20 at 11:56 a.m. a subsequent interview with LPN 4 indicated she provided the care during day shift on 4/28/20 and 4/29/20 for the resident, and he had been on the non-rebreather mask at 12 LPM when she came on to the shift, but he hadn't been in any distress during her care. She had assumed the other nurse who started the oxygen would have notified the physician and gotten an order to start the oxygen. On 5/05/20 at 12:10 p.m., interview with LPN 7 indicated LPN 6 had told her the resident wasn't doing good, and he wanted the O2 off and family wanted it off, so she took the oxygen off. LPN 6 did not tell her if she had notified the doctor. LPN 7 assumed LPN 6 had notified the doctor, because LPN 6 had removed the oxygen. LPN 7 said she would not have taken the oxygen off without contacting the doctor first. LPN 7 indicated she was absolutely not aware the doctor wasn't notified. During an interview on 5/05/20 at 2:43 p.m., APRN (Advanced Practice Registered Nurse) 9, who practiced under the direction of the resident's attending physician/facility Medical Director, indicated the last time she had seen the resident was on 4/28/20. She indicated the resident's oxygen saturations were in the low to mid 80's (percent), and she had wanted to send the resident out to the hospital. The resident had told her he wanted to go to the hospital, but the nurse told her she had discussed it with the family and they did not want him to be sent out. She did not believe he was of sound mind. She did not personally speak with the daughter. During an interview on 5/05/20 at 3:23 p.m., the Medical Director, who was also the resident's attending physician, indicated he did not recall any discussion about the resident's care. He was not made aware of the resident's decline or the oxygen administration and removal until 5/04/20. During an interview on 5/05/20 at 4:22 p.m., the Regional Nurse indicated once the physician sees the resident, the APRN would have to write the orders on a paper order and the nurse would transcribe and place in the electronic record. She did not see any orders for oxygenation in the electronic record for the resident. No orders had ever been transcribed into the resident's medical record to administer or discontinue oxygenation. She could not locate any notification or discussion with the physician regarding the continued decline after the APRN's visit on 4/28/20, or the nurse's decision to discontinue the oxygenation. During an interview on 5/06/20 at 9:43 a.m., the resident's family member indicated on 4/27/20 she started getting calls to let her know the resident was declining around 8:00 p.m. LPN 6 had told her the resident would not keep his mask on. She talked to him on a video call and asked him to keep the mask on, he nodded his head up and down, but she could tell he was tired. It was said to her that he kept taking the oxygen off. She told LPN 6 she could remove it, but try to put it back on him later when he calmed down. On the night of the 28th, they snuck her in the exit door of the 400 hall to see her father. He had the mask in place, and was barely opening his eyes. She asked him to keep the mask on. After she left, the nurse called her and said he was not doing well. The nurse told her if they sent him out to the hospital they would just be doing the same things they were already doing at the facility, so the family member told them to let him stay there and not send him out. LPN 6 called her back and said the resident was not keeping the mask on, and she told the nurse to let him calm down and put it back on. The nurse told her she would try to keep putting it on him, but she could not force him to keep it on. The next time a nurse called her, it was LPN 7 to tell her, her father had passed away at 8:52 a.m. on the morning of 4/30/20. During interview on 5/08/20 at 11:37 a.m., the DON indicated the nurse's notes on 4/28/20 were late entries, but the note on 4/30/20 at 1:00 a.m. was not a late entry. It should have shown up on the 24 hour report she monitors daily. She did not remember seeing it or discussing it with the clinical team. She indicated she had no reason she could provide as to why it was not discussed and it was definitely something they should have discussed, with someone at 64% oxygen saturation on 10 LPM of oxygen. The DON indicated they would have assessed the patient before morning meeting even started, and she would have called the doctor herself. The Oxygen-Medical Gas Use policy and procedure, last revised 12/21/18, was provided by the DON as the current policy and included, but was not limited to, .I. Oxygen Safety . b. Oxygen will be ordered by a physician or other authorized provider . II. Residents Receiving Oxygen a. Will have a physician/provider's order for the oxygen including route of administration, liters per minute, and frequency of use The Physician Notification for Change in Condition Reporting Policy and Procedure, last revised 8/1/16, was provided by the DON as the current policy and included, but was not limited to, . 1. Unless there are documented extenuating circumstances, the nurse will report CICs (change in conditions) based on the following criteria for reporting to the physician/provider .Report immediately .Oxygen Saturation, 90% . Abrupt onset of wheezing, rales or rhonchi .abrupt shortness of breath with pain, fever, or respiratory distress Review of the Indiana Administrative Code, Title 848, Indiana State Board of Nursing Article 2 Standards for the Competent Practice of Registered and Licensed Practical Nursing included the following: 848 IAC 2-3-2 Responsibility as a member of the health team Sec. 2. The licensed practical nurse shall do the following: (1) Function within the legal boundaries of practical nursing practice based on the knowledge of statutes and rules governing nursing. (2) Accept responsibility for individual nursing actions and continued competence. (3) Communicate, collaborate, and function with other members of the health care team to provide safe and effective care . 848 IAC 2-3-3 Unprofessional conduct Sec. 3. Nursing behaviors (acts, knowledge, and practices) failing to meet the minimal standards of acceptable and prevailing licensed practical nursing practices, which could jeopardize the health, safety, and welfare of the public shall constitute unprofessional conduct. These behaviors shall include, but are not limited to, the following: (1) Using unsafe judgment, technical skills, or inappropriate interpersonal behaviors in providing nursing care. The immediate jeopardy that began on 4/28/20 was removed on 5/12/20 when the facility completed staff education, an audit of all residents in the building to ensure physician notification had been completed if needed, all residents were assessed for change of condition, and extended the 24 hour review to 72 hours to ensure late entries would be monitored. Noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because continued monitoring was needed. This Federal tag relates to Complaint IN 579. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and interventions were in place to prevent a severely cognitively impaired resident (Resident C), who was assessed by the facility as an elopement risk, fall risk and COVID-19 positive, from exiting the facility unsupervised. She was missing for more than three hours when she was found 2.8 miles away from the facility. Although the facility assessed the resident as at risk for elopement, no interventions and/or increased supervision had been implemented to attempt to protect the resident from elopement. The facility also failed to ensure staff responded promptly to the 200 hall door alarm when the resident exited. This affected 1 of 2 residents reviewed for elopement. This deficient practice resulted in immediate jeopardy. The immediate jeopardy began on 5/02/20 when a cognitively impaired resident with dementia, who was also a fall risk, exited the facility unsupervised and was missing for more than three hours when she was found 2.8 miles from the facility. The resident exited the 200 hall fire door which alarmed for 8 minutes before a staff member responded. The Health Facility Administrator, Director of Nursing, and Regional Nurse were notified of the Immediate Jeopardy on 5/04/20 at 4:33 p.m. The immediate jeopardy was removed on 5/11/20, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record for Resident C was reviewed on 5/04/20 at 11:00 a.m. [DIAGNOSES REDACTED]. The hospital discharge note, dated 3/11/20 at 3:37 p.m., indicated Resident C had fallen, and had been brought to the hospital and admitted for further evaluation. The patient had been confused as well as a poor historian with an underlying history of [MEDICAL CONDITION] and behavioral issues. The cognitive assessment completed by the nurse on 3/11/20 indicated the resident was unable to report the correct year, month, or day of the week. The admission observation tool, dated 3/11/20 at 7:22 p.m., indicated the resident had risk factors for elopement and/or unsafe wandering. There were no other elopement assessments completed for the resident. Fall observation tools indicated the resident had fallen on 3/18/20. The admission MDS (Minimum Data Set) assessment, dated 3/20/20, indicated the resident had severely impaired cognition, had a history of [REDACTED]. The Social Services note, dated 3/20/20 at 8:12 a.m., indicated the resident had [DIAGNOSES REDACTED]. She had difficulty making decisions and keeping focus on what was being said. She jumped from one thing to another, such as could she have chicken, could she have soup, she needed shoes, and so on. She was alert and able to answer some questions. When asked what year it was, she said March 20, however did not know the day of the week. When asked to repeat three words, she changed the subject and never did repeat the three words. The clinical record lacked documentation of a plan of care and interventions related the resident's elopement risk. The skilled documentation notes, dated 3/13/20, 3/14/20, 3/15/20, 3/16/20, 3/21/20, 3/22/20, 3/23/20, 3/24/20, 3/25/20, 3/26/20, and 3/28/20 indicated Resident C had poor decision making skills and required cues and supervision. The nurse's note, dated 4/26/20 at 2:54 p.m., indicated Resident C had been educated to stay in her room to prevent spread of infection and to wear a mask if out in hall. The resident continued to come out in hallways with her mask not on appropriately. The resident had been educated on the proper way to wear the mask. The resident continued to wear her mask over her mouth with her nose not covered. Education had been provided throughout shift. A progress note, dated 4/30/20 at 12:32 p.m., indicated the resident tested positive for COVID-19. The nurse's note, dated 5/02/20 at 10:24 a.m., recorded as a late entry on 5/03/20 at 10:39 a.m., indicated at 6:58 p.m., RN 5 walked to the nurse's station area from the 300 hall and heard an alarm sounding. RN 5 assessed the situation to find the door at the end of the 200 hall sounding. He went out the 200 hall door and made a visual sweep of the area, entered back into the facility, and began a head count of the residents on the hall. CNA (Certified Nursing Assistant) 8 entered the hall through the zippered barrier wall and was informed of the situation. They continued with room searches and head counts. It was quickly determined that Resident C was absent from her room. CNA 8 had interacted and assisted the resident back to her room and shut the door at approximately 6:42 p.m. All the rooms and floors were searched, and a silver alert was called. The nurse's note, dated 5/02/20 at 8:32 p.m., recorded as late entry on 5/3/20 at 8:30 p.m., indicated staff had alerted RN 5 of the code silver (missing resident) due to the resident unable to be accounted for. RN 5 had been on the 500 hall and exited through the 500 hall door with other staff at which time staff split up to complete a visual sweep of the facility grounds. The staff were unable to find the resident. Staff were informed to, once again, complete a head count and were instructed to look at each resident's face in bed to ensure the resident was not lying in another resident's bed due to the resident may have been confused due to all the room changes and the placement of the zipper wall barrier. The local police were notified of possible elopement, and the resident's medical condition of COVID-19 positive had been provided. The Executive Director was also informed and all policy and procedures were currently being followed. An organized search was implemented and the maintenance director contacted to view the video footage to help establish the whereabouts of the resident along with a detailed time frame. A progress note, dated 5/02/20 at 10:14 p.m., indicated the facility was notified by the police that the resident was found at her home, and the resident refused to return to the facility. On 5/04/20 at 1:45 p.m., during an observation of the video footage of the 200 hall on 5/02/20, Resident C was observed to exit her room and ambulate to the end of the 200 hall. She pressed the egress bar of the fire door at 6:50 p.m., which initiated the alarm. After 15 seconds, the door opened and the resident exited the facility. The resident walked around the building and at 6:56 p.m., ambulated to the right on the sidewalk, off the facility premises. At 6:58 p.m., RN 5 was observed to walk to the end of the hall and turn the alarm off and then exited the door. During an interview on 5/04/20 at 2:19 p.m., the Director of Nursing indicated the resident was an elopement risk, did not have an elopement care plan in place, did not have a Wander guard bracelet on and should have, and staff should have responded immediately to the 200 hall alarm. During a telephone interview on 5/06/20 at 10:35 a.m., Resident C's sister indicated the resident had arrived at her home around 8:00 p.m. on 5/02/20. She had not spoken with her sister for several days but had attempted multiple times, over the course of several days, to reach the facility so she could talk with her. She was aware her sister tested positive for COVID-19. Resident C informed her sister she had left the facility and had been walking when someone had stopped and given her a ride to her sister's office. When Resident C realized her sister was not at the office, she received another ride from someone who dropped her off at her sister's house. Resident C and her sister visited out on the porch and then Resident C walked to her home which was 4 blocks away. Resident C's sister had decided to go check on her sister and found the police at Resident C's home. She informed the police that Resident C was inside. On 5/04/20 at 1:17 p.m., the Director of Nursing provided a current copy of the document titled Elopement Prevention, dated 4/20/17. It included, but was not limited to, Definition .Elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident/patient at harm or injury .Policy .The facility strives to prevent resident/patient elopement .Procedure . (a) All new admissions that are at risk for elopement will have interventions put into place immediately until further assessment is complete. Interventions may include, but are not limited to .Environmental modifications to prevent undetected exit such as wander alerts, door alarms .Increased frequency of resident observation rounds . (b) Any resident/patient admitted who is cognitively impaired and can self-ambulate is considered an elopement risk until determined otherwise On 5/04/20 at 1:17 p.m., the Director of Nursing provided a current copy of the document titled Elopement Prevention and Management Overview, dated 5/30/19. It included, but was not limited to, Definition .Elopement is defined as when a resident/patient leaves the premises or safe area without authorization and/or any necessary supervision and places the resident/patient at harm or injury. Unsafe wandering is defined when a resident/patient enters an area that is physically hazardous .Policy .The interdisciplinary team plans the least restrictive interventions to promote mobility and safety and to meet the individualized needs and goals of the resident .Procedure .Identify resident/patients who are at a risk for elopement .Determine elopement risk factors .Develop and document individualized interventions to manage risk factors .Communicate risk factors and interventions to the caregiving staff The immediate jeopardy that began on 5/02/20 was removed on 5/11/20 when the facility completed staff education on elopement prevention/management and risk factors that put residents at risk for elopement, wander/elopement assessments on all residents, and elopement drills with staff response. Noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had participated in the elopement drills and continued monitoring was needed. This Federal tag relates to Complaint IN 579. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident, who was positive for COVID-19 and experiencing an acute decline in condition with labored breathing and decreased oxygenation, was free from abuse. The resident was deprived of necessary care and services, when a facility nurse independently discontinued all supplemental oxygen without any contact with the physician, which was followed by no other care and services provided for the resident through the time of his death 7 hours and 45 minutes later. This deficient practice affected 1 of 3 residents reviewed for abuse. (Resident B) This deficient practice resulted in immediate jeopardy. The immediate jeopardy began on 4/30/20 at 1:00 a.m. when a facility nurse removed all supplemental oxygen from Resident B, and the resident progressively declined to death with no care or monitoring documented during that time. The Health Facility Administrator, Director of Nursing, and Regional Nurse were notified of the immediate jeopardy on 5/08/20 at 2:50 p.m. The immediate jeopardy was removed on 5/12/20, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record of Resident B was reviewed on 5/05/20 at 11:00 a.m. Resident B's [DIAGNOSES REDACTED]. A nurse's note, dated 3/13/20 at 3:55 p.m., indicated the resident had been admitted to the facility. The care plan, dated 3/16/20, indicated the resident was a full code. A physician's orders [REDACTED]. The care plans lacked documentation of any changes to advanced directives including, but not limited to, do not resuscitate, palliative care or comfort measures only. The Admission MDS (Minimum Data Set) assessment, dated 3/20/20, indicated the resident was moderately cognitively impaired. A nurse's note, dated 4/24/20 at 5:10 p.m., indicated the resident had new orders for COVID-19 testing. The nurse's note, dated 4/26/20 at 4:28 p.m., indicated the resident was COVID-19 positive. A nurse's note, dated 4/28/20 at 12:00 a.m., documented by LPN 6 on 4/30/20 at 1:36 a.m. as a late entry, indicated the resident had an O2 sat (oxygen saturation) of 64% (normal range is greater than 90%). O2 (oxygen) was started at 2 LPM (liters per minute) via nasal cannula, with no improvement. The resident was displaying diaphragmatic breathing, and had rhonchi (abnormal continuous low pitched, rattling lung sounds) throughout the lungs. The O2 was increased to 5 LPM via a face mask, and the resident's O2 saturation raised to 84%. The resident was then changed to a non-rebreather mask and the oxygen was increased to 10 LPM. The resident's O2 saturation rose to 89%. The nurse's note, dated 4/28/20 at 1:36 a.m., documented by LPN 6 on 4/30/20 at 1:43 a.m. as a late entry, indicated the resident's condition was guarded. O2 continued at 10 LPM via non-rebreather mask, with O2 saturation remaining around 80-85% as the resident continued to display a diaphragmatic breathing pattern. The resident's breathing was labored and had rhonchi throughout the lung fields. There was no documentation in nurses' notes between 4/28/20 at 1:36 a.m. and 4/30/20 at 1:00 a.m. The nurse's note, dated 4/30/20 at 1:00 a.m., documented by LPN 6, indicated the resident continued with diaphragmatic breathing. O2 saturation was down to 64% as O2 continued at 10 LPM via non-rebreather mask. The resident appeared to be weak and tired. The nurse asked the resident if he was tired of fighting, and whether he wanted to let go and go to heaven. The resident indicated he did, and the nurse removed all supplemental oxygenation. The clinical record lacked documentation of any notification to the physician of the resident's continual decline or the discontinuation of oxygenation therapy, and any physician's orders [REDACTED]. There was no further documentation by LPN 6 after 1:00 a.m. on 4/30/20. A nurse's note, dated 4/30/20 at 8:45 a.m., documented by the day shift nurse, LPN 7, indicated the resident had passed away. At this time, the physician was notified of the resident's death. Review of a social media post, made by LPN 6 on 5/01/20, indicated, I just want y'all to know the hardest thing I've ever done in [AGE] years start a patient on O2 for 4 days 12 LPM. with a non-rebreather mask and I asked him on day 4 if he's tired he said yes I said do you want me to take all this off for you and let you go and fly with the angels and he said yes I took it all off of him I went in the hallway and I cried and I let him go and he passed away 1 hour and 45 minutes after I left. During an interview on 5/04/20 at 4:42 p.m., the DON and the Regional Nurse both indicated they could not locate documentation of notification of the physician regarding the resident's decline in condition, or any orders to administer or discontinue any oxygenation. During an interview on 5/05/20 at 10:37 a.m., LPN 6 indicated she had started oxygen on the resident when his sats (oxygen saturation) were in the 70's. They had standing orders for up to 5 LPM (liters per minute) of O2. She put him on 5 LPM via a mask, but it only brought the resident's sats up to 77. She then increased it to 10 LPM via a non-rebreather mask. She told the resident's daughter, who was the POA (power of attorney), the oxygen was only .prolonging the inevitable The daughter had told her if it was her father's wishes she could remove the mask. She later removed the oxygenation. She did not speak with the physician because she was taking care of over 40 COVID patients, and the week that I had had was terrible, and that is one thing I forgot to do was call the doctor. She indicated they only had standing orders for up to 5 LPM of O2. The physician did not give the order to start the oxygen or to use the non-rebreather mask, she was just trying to keep the resident's sats (oxygen saturation) up. The physician did not give an order to discontinue the oxygenation. On 5/05/20 at 12:10 p.m., interview with LPN 7 indicated LPN 6 had told her the resident wasn't doing good, and he wanted the O2 off and family wanted it off, so she took the oxygen off. LPN 6 did not tell her if she had notified the doctor. LPN 7 assumed LPN 6 had notified the doctor, because LPN 6 had removed the oxygen. LPN 7 said she would not have taken the oxygen off without contacting the doctor first. LPN 7 indicated she was absolutely not aware the doctor wasn't notified. During an interview on 5/05/20 at 2:43 p.m., APRN (Advanced Practice Registered Nurse) 9, who practiced under the direction of the resident's attending physician/facility Medical Director, indicated the last time she had seen the resident was on 4/28/20. She indicated the resident's oxygen saturations were in the low to mid 80's (percent), and she had wanted to send the resident out to the hospital. The resident had told her he wanted to go to the hospital, but the nurse told her she had discussed it with the family and they did not want him to be sent out. She did not believe he was of sound mind. She did not personally speak with the daughter. During an interview on 5/05/20 at 3:23 p.m., the Medical Director, who was also the resident's attending physician, indicated he did not recall any discussion about the resident's care. He was not made aware of the resident's decline or the oxygen administration and removal until 5/04/20. During an interview on 5/05/20 at 4:22 p.m., the Regional Nurse indicated no orders had been transcribed into the resident's medical record to administer or discontinue oxygenation. She could not locate any notification or discussion with the physician regarding the continued decline after the APRN's visit on 4/28/20, or the nurse's decision to discontinue the oxygenation. During an interview on 5/06/20 at 9:43 a.m., the resident's family member indicated on 4/27/20 she started getting calls to let her know the resident was declining around 8:00 p.m. LPN 6 had told her the resident would not keep his mask on. She talked to him on a video call and asked him to keep the mask on, he nodded his head up and down, but she could tell he was tired. It was said to her that he kept taking the oxygen off. She told LPN 6 she could remove it, but try to put it back on him later when he calmed down. On the night of the 28th, they snuck her in the exit door of the 400 hall to see her father. He had the mask in place, and was barely opening his eyes. She asked him to keep the mask on. After she left, the nurse called her and said he was not doing well. The nurse told her if they sent him out to the hospital they would just be doing the same things they were already doing at the facility, so the family member told them to let him stay there and not send him out. LPN 6 called her back and said the resident was not keeping the mask on, and she told the nurse to let him calm down and put it back on. The nurse told her she would try to keep putting it on him, but she could not force him to keep it on. The next time a nurse called her, it was LPN 7 to tell her, her father had passed away at 8:52 a.m. on the morning of 4/30/20. During an interview on 5/08/20 at 9:23 a.m., the DON indicated she found out about the incident regarding LPN 6's actions sometime after 9:00 a.m. on 5/04/20, when the Executive Director (ED) made her aware he had started an investigation. After making appropriate notifications to authorities, the physician, family, and ISDH, she began reviewing the record. She had not been aware of the documentation in the medical record prior, because it had been made as a late entry, and it had not shown up on her 24 hour report she reviewed daily. They knew the resident was sick and not doing well, but she had never been notified of the oxygen. The facility did not have any standing orders for oxygen. The DON indicated adding oxygen was a change in condition, and the physician would have to be notified. She did not question his death because they knew he was COVID positive, and the APRN had said it would most likely take him. The facility had not considered it an unexpected death. During an interview on 5/08/20 at 10:50 a.m., the ED indicated early in the morning on 5/04/20 between 7:30 a.m. and 8:00 a.m., a staff member called and said a social media post had concerned the staff member. The ED had the screenshot of the post sent to him and began his investigation on 5/04/20 between 8:00 and 10:00 a.m. Part of the problem was the nurse made a late entry, so it did not show up on the 24 hour report. The ED indicated late entries were not the facility's goal, and they tried to educate not to do that. During a subsequent interview on 5/08/20 at 11:37 a.m., the DON indicated the nurse's note on 4/30/20 at 1:00 a.m., was not a late entry. It should have shown up on the 24 hour report she reviewed daily. She did not remember seeing it, or discussing it with the clinical team. She had no reason she could provide as to why it was not discussed, and indicated it was definitely something they should have discussed. The INDIANA Abuse & Neglect & Misappropriation of Property policy and procedure, last revised 4/01/19, was provided by the DON as the current policy and included, but was not limited to, .Abuse . In Indiana, the willful infliction of injury , unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful: In Indiana, the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm The policy did not identify the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being as abuse. The immediate jeopardy that began on 4/30/20 was removed on 5/12/20 when the facility audited all residents for abuse and staff education was completed, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because continued monitoring was needed of staff who were working more than 40 hours per week, picking up additional shifts, and/or working the COVID unit. This Federal tag relates to Complaint IN 579. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure adequate pain relief was in place, prior to wound debridement, which resulted in unnecessary pain for 4 of 4 residents reviewed for pain. (Residents E, G, and H) Findings include: 1. The clinical record for Resident E was reviewed on [DATE] at 1:11 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 12/26/19, indicated the resident's cognition was mildly impaired. The plan of care, dated 4/25/19, indicated the resident was at risk for pain related to wounds, with interventions to anticipate need for pain relief and evaluate effectiveness of pain interventions. Review of the December 2019, January 2020, and February 2020 medication administration records indicated the resident was to receive Tylenol (pain medication) 650 mg every 4 hours as needed for mild pain. The administration records lacked documentation of the administration of the pain medication. Review of the wound evaluation reports for Resident E indicated the resident was seen by Wound Physician 10 on 12/3/19, [DATE], 1/24/20 and 2/12/20. The wound debridement (removal of damaged tissue) was performed to the venous ulcer of the right lower calf with each visit. During a confidential interview on [DATE] at 11:44 a.m., Staff Member 2 indicated two to three weeks ago during wound debridement Resident E had yelled out in pain and the wound physician just kept on cutting and did not stop. During a confidential interview on [DATE] at 11:45 a.m., Staff Member 3 indicated in the recent past she had heard Resident E yell out in pain when the wound physician was in his room and she continued to cut on him. On [DATE] at 12:41 p.m., Resident E was observed resting in bed with his eyes open. He indicated when the wound doctor comes in, she picks at his leg and then starts cutting on his leg. It was painful and he told her, but she kept on going and did not numb his leg before cutting on it. He had not received any pain medication prior to his treatments. On [DATE] at 1:22 p.m., the Director of Nursing indicated she was unaware of any residents with complaints of pain during wound debridement and would follow up with interviews. The wound physician was scheduled to come in on Tuesdays, but sometimes the days change and we do not know exactly what time she will be here which made it hard to pre-medicate. During an interview on [DATE] at 1:40 p.m., LPN (Licensed Practical Nurse) 4 indicated she did remember, but not sure of the date, when Resident E had told LPN 5 that the doctor did not numb him prior to cutting on him. She did not report it because she thought LPN 5 was going to fill out a grievance form. On [DATE] at 3:35 p.m., the Director of Nursing indicated her resident interviews confirmed residents were having increased pain during wound care. During an interview on 2/18/20 at 1:58 p.m., LPN 5 indicated she had never heard Resident B yell out in pain during debridement of his wound. She could tell by his facial expression after the wound doctor treated him that he was in pain. Wound Physician 10 always left pools of blood on the bed. She had not filled out any grievances for the resident since he had refused pain medication in the past. The clinical record and care plan lacked documentation of the resident's refusal of pain medication and/or evaluations for pain or discomfort prior to, during, and after treatment. 2. The clinical record for Resident F was reviewed on [DATE] at 3:17 p.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 12/25/19, indicated the resident's cognition was intact. The care plan, dated 6/21/19, indicated the resident was at risk for pain related to a pressure wound, and to anticipate the need for pain relief and respond immediately to any complaints of pain. Review of the wound evaluations indicated Resident F was seen by Wound Physician 10 on 12/3/19, [DATE], 1/24/20, and 2/12/20. The resident's wound was debrided on 2/12/20 and chemical cauterization (burning of granulation tissue) was completed on 1/24/20. During an interview on [DATE] at 2:20 p.m., Resident F indicated she did have pain when the physician cuts on her wound, but it was not unbearable. The physician did not numb her wound prior to treatment and she could feel it when the doctor cuts on it. She had not received any pain medication prior to treatment. During an interview on [DATE] at 2:30 p.m., LPN 7 indicated she did round with the wound physician and made sure she numbed them prior to deriding the wounds. If a resident did have pain, it would have been subtle for me not to see. During a confidential interview on [DATE] at 2:32 p.m., Staff Member 6 indicated she had observed the resident in pain during wound care with the physician. She was asked to provide assistance for incontinence care so the wound physician could treat the resident's wound. After the resident was cleaned, she rolled the resident on her side and the wound physician just stuck the blade in her wound without numbing her. Resident F was moaning with her face in the pillow. The wound looked like it was a beefy red color. She just started cutting around the edge of the wound and LPN 7 was in there and did not say anything. The clinical record lacked documentation of an evaluation of pain prior to, during, and after treatment. 3. The clinical record for Resident G was reviewed on 2/18/20 at 11:28 a.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 1/13/20, indicated the resident's cognition was intact. The care plan, dated 11/19/19, indicated the resident was at risk for pain related to impaired skin integrity and to administer [MEDICATION NAME] per orders and give one half hour before treatments of care. Review of the wound evaluations indicated Resident G was seen by Wound Physician 10 on [DATE], 1/24/20 and 2/12/20 with wound debridement performed with each visit. During an interview on [DATE] at 1:40 p.m., LPN 4 indicated she did follow the wound physician last week and went in the room with her during treatments and made sure she numbed the resident. She did, however, get called away and the wound physician had went in to Resident G's room without her. She heard the resident say something was hurting. She walked in the room and the physician had started cutting the slough from the venous wound. The LPN reached in her pocket for the [MEDICATION NAME] (ester local anesthetic used as a topical pain reliever) and numbed the resident. During an interview on [DATE] at 2:48 p.m., Resident G indicated the wound physician did not numb her wound prior to cutting on her. She has had a pain level as high as 9 out of 10 when the wound physician was cutting on her and it was very painful. She had finally started asking the wound physician if she would be cutting and scraping on her wound to numb it before she starts. She had not received any pain medications prior to treatments in the past. The clinical record lacked documentation of an evaluation of pain prior to, during, and after treatment. 4. The clinical record for Resident H was reviewed on 2/18/20 at 10:30 a.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 1/28/20, indicated the resident's cognition was intact. The care plan, dated 6/6/18, indicated the resident had an alteration in skin integrity related to an [DIAGNOSES REDACTED] of the scalp and to assess for pain/comfort every shift, as needed, prior to dressing changes and medicate per physician orders. Review of the wound evaluations indicated Resident H was seen by Wound Physician 10 on 11/12/19, 11/19/19 and [DATE] with scissors used to surgically excise devitalized tissue from the scalp on 11/12/19 and 11/19/19. During a confidential interview on [DATE] at 2:32 p.m., Staff Member 6 indicated Resident H would tell her she could not sleep because her head was sore due to the doctor pulling scabs off her head and cutting on her head. The wound doctor told her she had to cut them off so they could drain and heal. Staff Member 6 informed the resident that she could refuse to let the doctor treat her if the treatments were causing that much pain. During an interview on [DATE] at 2:58 a.m., the resident was observed resting in bed with her eyes open. She indicated, at one time, the wound doctor cared for all her wounds but she has since told her she did not want her touching her again. She never numbed her before and would cut off the scabs on her scalp, along with healthy tissue, with a scissors. She would almost scream when she cut on certain areas of her scalp. She would never numb the areas and would cut and cauterize. She never told me what she was doing and then lay that hot wand on my scalp. I dreaded when she would come in and she would never listen to what you were telling her. When she would cauterize the resident's scalp, her pain level would be at least a 9 or 10. LPN 9 was there with the resident once and she tried to comfort the resident. The resident was not given any pain medications prior to treatments. The clinical record lacked documentation of an evaluation of pain prior to, during, and after treatment. On [DATE] at 3:55 p.m., the Director of Nursing provided a current copy of the document titled Slough Treatment dated 5/30/19. It included, but was not limited to, Removal of this tissue is necessary for wound healing .Procedure .Evaluate resident .for pain/discomfort prior to, during and post dressing change On [DATE] at 3:55 p.m., the Director of Nursing provided a current copy of the document titled Pain Management and assessment dated [DATE]. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents This Federal tag relates to Complaints IN [AGE]0 and IN [AGE]7 3.1-37(a)

Based on observations, record review, and interview, the facility failed to identify timely and prevent a stage 3 or 4 pressure ulcer that was identified as a shear, which resulted in a stage 4 facility acquired pressure ulcer and failed to ensure treatments were administered as ordered by the physician for 2 of 7 residents reviewed for pressure ulcers. (Residents 100 and 13) Findings include: 1. The clinical record for Resident 100 was reviewed on 12/4/19 at 12:00 p.m. The resident's [DIAGNOSES REDACTED]. A care plan, initiated on 6/18/19, indicated the resident had an area of shearing (deep layers of tissues resulting in cell deformation and cell death caused by friction) to the right thigh. The care plan lacked documentation of preventative interventions. The non-pressure skin grid assessment, dated 7/16/19, indicated the resident had a new non-pressure area to the right thigh, described as shear, which measured 2 cm in length by 2 cm in width, and 0.1 cm in depth. The wound was 50% granulation and 50% slough (dead tissue). On 7/23/19 the treatment was changed to Santyl, calcium alginate, and a bordered foam dressing daily. The Quarterly MDS (Minimum Data Set) Assessment, dated 7/27/19, indicated the resident was moderately cognitively impaired, had physical behaviors towards others, and rejection of care 1 to 3 days. The resident required extensive assistance of two staff members with transfers and bed mobility. He did not have a pressure ulcer or any open wounds. The resident was at risk of developing a pressure ulcer and did not have a turning and repositioning program. The skin/wound note, dated 8/14/19, indicated the results of a pelvis X-ray recommended further evaluation with a bone scan was indicated if osteo[DIAGNOSES REDACTED] was clinical concern. On 8/20/19 the wound measured 3 cm in length by 3 cm in width and 2 cm in depth, with 30% granulation, 40% slough, and 30% necrotic (dead) tissue. The wound now had an odor. On 9/10/19 the Skin grid pressure assessment indicated the wound was now classified as an unstageable pressure ulcer (full thickness tissue loss covered by slough or eschar) to the right ischium, which measured 4 cm in length by 4 cm in width, and 5 cm deep, with 50% granulation and 50% necrotic tissue. The hospital report, dated 9/20/19, indicated .consistent with small focal area of osteo[DIAGNOSES REDACTED] in the right ischial tuberosity deep to the right ischial decubitis skin ulcer . On 9/24/19 the wound measured 4 cm in length, 2 cm in width, and 5 cm in depth and was now classified as a stage 4 pressure ulcer (exposing underlying muscle, tendons, catilage ,or bone), with 80% granulation, 20% fascia, and had signs of infection including odor. The nurse's note, dated 9/24/19, indicated the Wound Care physician gave new orders for a PICC (peripherally inserted central catheter) line placement and antibiotics to treat osteo[DIAGNOSES REDACTED], as well as wound vac placement to the right gluteal fold with suction at 125. The care plan, dated 9/25/19 and revised and resolved on 11/24/19, indicated the resident had osteo[DIAGNOSES REDACTED]. Interventions included, but were not limited to, wound treatment as ordered. The Quarterly MDS assessment, dated 10/27/19, indicated the resident had a stage four pressure ulcer. The most recent physician's orders [REDACTED]. The clinical record lacked documentation of any refusals of care or resistance to care from 7/2/19 to 12/5/19. During an observation of wound care on 12/5/19 at 11:13 a.m., LPN (Licensed Practical Nurse) 12 entered the resident's room to provide wound care. The resident was rolled onto the left side. There was a moderate amount of pink and brown drainage, which had soaked through the brief and the draw sheet. The brief was removed. A slight odor was noted. There was no dressing in place, and the wound was not packed. The right ischium wound was measured to be 2 cm (centimeters) in length, 2.2 cm in width, and 3.8 cm in depth. The wound bed was noted to be covered in white tissue. The sides of the wound were pink. During an interview on 12/4/19 at 11:23 a.m., the DON (Director of Nursing) indicated the resident's wound had started as a shear and later progressed. The wound care physician had reclassified the wound as a pressure ulcer in September. During an interview on 12/5/19 at 11:13 a.m., LPN 12 indicated the resident's treatment had not been in place. It could have fallen off, but it was not in the resident's brief. One of the CNAs (Certified Nursing Aides) might have removed it due to soilage. During an interview on 12/9/19 at 11:05 a.m., the RDCO (Regional Director of Clinical Operations) indicated, They need their treatments in place. We need to follow physician orders. If becomes dislodged or is soiled, they (CNAs) need to tell their nurse immediately. 2. During an observation on 12/4/19 at 1:25 p.m., Resident 13 was assisted back to bed after lunch. The resident had a pillow under her knees, but her heels were not floated properly off bed. CNA 13 lifted the sheet off the resident's feet and took off her footies. Resident 13 had a reddened area on the left heel. The resident was observed to not have her pressure relieving boots on. During an observation on 12/5/19 at 8:22 a/.m., The resident was observed in bed laying on her back with her heels directly on the bed. The resident did not have her pressure relieving boots on as ordered. The resident's clinical record was reviewed on 12/4/19 at 8:30 a.m. The resident's [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. Apply skin prep topically daily. Turn and reposition every 2 hours, float heels on pillows while abed, daily wound assessment pressure area to left heel document abnormalities in progress notes, resident to wear (pressure relieving boots) .while abed and in w/c for prevention . The current care plans for the resident indicated, .actual impairment to skin integrity r/t pressure wound to left heel. The wound will show signs of healing and will not develop an infection. Educate resident, family, and caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. .(pressure relieving boots) .while abed or in wheelchair. Float heels while abed .Pressure reduction mattress, (pressure relieving boots) .on while abed or in wheelchair .Turn and reposition every two hours while abed . A Quarterly MDS (Minimum Data Set) assessment, dated 8/28/19, indicated the resident's cognition was moderately impaired. The Wound Evaluation and Management Summary, dated 3/18/19, indicated the resident had an unstageable DTI (Deep Tissue Injury) to the left heel. The wound measured 1 cm x (by) 1 cm x 0.2 cm with moderate serous exudate, 50% slough and 50% granulation tissue. The wound treatment was for Alginate Calcium once daily with a foam dressing, recommend air boot, Removed necrotic tissue and establish the margins of viable tissue . The Wound Evaluation and Management Survey, dated 12/3/19, indicated the resident had an unstageable DTI to the left heel 0.4 cm x 0.4 cm x 0.1 cm. There was no exudate and 100% dermis. Recommendations were for skin prep once daily, air boot, and [MEDICATION NAME] (antibiotic) 100mg twice daily by mouth. The dietary note, dated 12/3/19, indicated Wound f/u (follow up): Stage III area to left heel remains stable per wound nurse. No other skin issues noted. Wound MD follows weekly. Treatment in place as ordered . During an interview on 12/9/19 at 9:20 a.m., LPN 8 indicated when staff floated a resident's heels we put a pillow underneath the legs so that the heels are off the bed. We turn the residents every 2 hours or more if needed. For prevention we do things like monitor the skin, nutrition and hydration. During an interview on 12/9/19 at 12:50 p.m., CNA 14 indicated if the resident had a wound they were propped up with a pillow so they were not laying on the pressure area. For the resident's heels they would put a pillow under the legs and float the heels off the bed. A policy and procedure titled, Skin Care & Wound Management revised on 5/30/19, was presented by the Regional Director of Clinical Operations included, but was not limited to, Prevent resident or patient skin impairment and to promote the healing of existing wounds . Skin care and wound management programs include but is not limited to . Implementation of prevention strategies to decrease the potential for developing pressure ulcers . Treatment . 3. Obtain physician's orders [REDACTED]. Document treatment on the Treatment Administration Record (TAR) . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure the safety of a resident (Resident D), which resulted in a blister/burn, secondary to frostbite from liquid oxygen spillage from a portable oxygen tank and failed to provide appropriate education of the dangers of liquid oxygen prior to the incident for 1 of 3 residents reviewed for accidents. Findings include: On 12/9/16 at 9:20 a.m., Resident D was observed to have a reddened area to the left upper anterior (front) thigh, approximately 9 cm (centimeters) long and 8 cm wide. This area was missing the top layer of skin. Within the reddened area were two areas, with a brown/yellowish discoloration, with one measuring approximately 2 cm by 2 cm (upper area) and the other measuring approximately 3 cm by 5 cm. LPN (Licensed Practical Nurse) 3 indicated the areas were slough (yellow fibrinous tissue). During an interview on 12/8/16 at 1:35 a.m., Resident D indicated I didn't know it would burn me like that. His portable oxygen tank fell off the back of his wheelchair and he picked it up and placed the tank in his lap, for about 10 minutes, until he could find someone to place it back on the wheelchair. During an interview on 12/8/16 at 2:00 p.m., LPN 3 indicated her understanding of the incident was the resident flipped the switch on the side of the portable oxygen tank, which released the liquid oxygen out of the bottom of the tank and the tank was in his lap. During an interview with CNA (Certified Nursing Assistant) 4 on 12/9/16 at 12:05 p.m., she indicated the resident removed the portable oxygen tank from the back of his wheelchair and placed it on his lap and she removed it from the resident's lap and placed it back on the wheelchair. She did not know how long the portable oxygen tank was on his lap or if liquid oxygen was seeping out of the bottom of the tank. During an interview on 12/9/16 at 12:08 p.m., RN (Registered Nurse) 5 indicated It (blister) was not there when we got him up after breakfast. The DON (Director of Nursing) was here the next day and I told her about the blister and what I had done. The aides laid Resident D down around 3:30 p.m. and 4:00 p.m. and that was when she was informed of the blister. During an interview on 12/9/16 at 9:50 a.m., the Director of Nursing indicated staff had witnessed Resident D place the portable oxygen tank in his lap, but when interviewed he denied putting the tank in his lap. On 12/13/16 at 3:37 p.m., Physician 6 returned a call which was placed to her on 12/9/16 at 10:10 a.m. She indicated, prior to the residents appointment on 12/1/16, facility staff had informed her that the blister on the resident's thigh was from liquid oxygen from a portable oxygen tank and .The blister was a result of frostbite. The clinical record for Resident D was reviewed on 12/8/16 at 11:30 a.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 7/21/16, indicated a BIMS (Brief Interview of Mental Status) score of 15, which signified intact cognition. The clinical record lacked documentation of any education provided to Resident D regarding the dangers of liquid oxygen prior to the incident. The nurses' note, dated 11/26/16 at 11:06 a.m., created on 11/27/16 at 11:07 a.m., included, but was not limited to, the following: .Called to resident room by aides. When putting resident to bed, blistered area was noted to from of left thigh. Blister was not present when resident was put in w/c (wheelchair) this AM. Unable to ascertain cause of blister at this time. NP (nurse practitioner) notified . The Weekly Skin Alteration Report, dated 11/26/16 at 5:00 p.m., included, but was not limited to, the following: .(Resident D's name) .Skin Condition Information .Is this a new .area .Yes .Site .Left thigh (front) .Describe .blister .Assessment of Wound .Size in CM (centimeters) .7.0 x 6.0 (7 centimeters by 6 centimeters) . The nurses' note, dated 11/28/16 at 10:35 a.m., included, but was not limited to, the following: .Call received form (sic) (physician's name) that stated she got a panic call from rsd. (sic) (resident) POA(Power of Attorney)/aunt regarding lt (left) thigh blister. (name of physician) wants to see 12/1/2016 . The IDT (Interdisciplinary Team) note, dated 11/28/16 at 11:52 a.m., included, but was not limited to, the following: .IDT SKIN ALTERATION ROOT CAUSE REVIEW: Large fluid filled blister noted to resident's left thigh. Resident unaware of how blister was obtained. Staff report seeing resident placing respiratory equipment on his lap which may have contributed to the blister forming .Resident to f/u (follow up) with wound surgeon on 12/01/2016 . On 12/9/16 at 11:00 a.m., the Director of Nursing provided a copy of the handwritten investigation. It included, but was not limited to, the following: .(Resident D's name) .11/26/16 Found lg (large) blister (sic) front thigh. Patient interviewed and denies knowledge of cause. Patient is alert/oriented and intervable (sic) .Interviewed staff on duty (plus sign) regular caregiver. No one has dirct (sic) knowledge of cause. One CNA reports that she observed (resident's first name) holding his oxygen tank (portable) .Re-interviewed (resident's first name) again about this, he denied he denied (sic) burning area. He kept changing focus to Could I get more pain medicine for this. NP (Nurse Practitioner) notified of pain concerns. Pain medication is on board (c with line over it) (with) routine/PRN (as needed). Education provided not to touch O2. Education provided to (resident's first name) to not touch area, do not rupture blister esp (especially) after manipulating ostomy bag. Voiced understanding (continued to request pain meds (medications) or alcohol to ease pain .I am unable to determine cause of blister, patient seem (sic) less than cooperative in determing (sic) cause . On 12/9/16 at 11:00 a.m., the Director of Nursing provided a copy of the hospital physician progress notes [REDACTED].(Resident D's name) .Wound #15 Left, Anterior Upper Leg (sic) fluid filled bulla is a Bulla and has received a status of Not Healed. Initial wound encounter measurements are 9.5 cm (centimeters) length x (by) 9cm width, with an area of 85.5 sq (square) cm .General Notes: Large fluid filled bulla noted .pt (patient) states it has been there since last week .he thinks it is from a burn but is uncertain .This wound is a result of frostbite from the liquid oxygen tank .Assessment .He has a frostbite injury on his left anterior thigh where he pulled his liquid oxygen onto his lap. I talked to his nurse at his nursing home after his and (sic) called an (sic) upset about the blistering . The incident report, dated 12/9/16, included, but was not limited to, the following: .Description added .12/9/2016 .(Resident D's name) was found with a blister to thigh on 11/26/2016, (sic) I interviewed the patient that date and he does not know what happened. Denied injury or event .is alert and oriented and able to participate in interview. Facility did not feel that it met guidelines for reporting at that time. He recently told his Physician that he felt it was a frostbite burn from his liquid oxygen. Facility at this time based on his new statement felt that it met the guidelines for reporting .Type of Injury .Fluid filled blister to left thigh, received information on 12/8/2016 from (physicians name) .Follow up appointment 12/1/2016 at Wound care Center .During that appointment he told physician it was frostbite . This Federal tag relates to Complaint IN 207 3.1-45(a)(1)