Every finding on record at Wellbrooke of Avon

Based on record review and interview, the facility failed to hold ordered blood pressure medication when a resident's blood pressure was outside prescribed parameters for 1 of 6 residents reviewed (Resident 9) and failed to properly assess a Resident (Resident 96) for their ability to properly manage their own eye drops before they were kept at the bedside for 1 of 24 residents reviewed for medications at bedside.Findings include:.1. On 3/10/26 at 10:53 a.m., a record review was completed for Resident 9. She had the following diagnoses which included, but were not limited to, heart failure, and hypertension (high blood pressure). A physician order, dated 8/12/25, for carvedilol (medication for high blood pressure) 12.5 milligram (mg) administer 1 tablet two times daily for hypertensive heart disease with heart failure, hold if heart rate less than 60 or systolic blood pressure (SBP) less than 100. A physician order, current as of 3/10/26, for clonidine 0.1mg administer 1 tablet three times daily for essential hypertension, hold if SBP less than 140. Resident's Medication Administration Record (MAR), dated February 2026, indicated Resident 9 received carvedilol on 2/4/26 between 7 a.m. and 10:00 a.m., for a heart rate of 59, and on 2/17/26 for a heart rate of 59. Resident's MAR, dated February 2026, indicated Resident 9 received clonidine on 2/4/26 between 7:00 a.m. and 8:00 a.m., for a blood pressure of 109/65. Resident's MAR, dated March 2026, indicated Resident 9 received clonidine on 2/3/26 between 7:00 a.m. and 8:00 a.m., for a blood pressure of 138/66 and between 2:00 p.m. and 3:00 p.m. for a blood pressure of 139/78. On 3/5/26 she received clonidine between 7:00 a.m. and 8:00 a.m. for a blood pressure of 101/63 and between 2:00 p.m. and 3:00 p.m. for a blood pressure of 128/78. On 3/10/26 at 1:50 p.m., RN 3 indicated the medications should have been held due to blood pressure readings. On 3/11/26 at 11:12 a.m., the Director of Nursing (DON) indicated there was no policy for parameters. They followed the physician's orders. 2. On 3/10/26 at 10:15 a.m. Resident 96 was observed as she sat in a chair next to her bed. On the nightstand on the opposite side of the bed the resident was sitting on was an open bottle of Systane eye drops (artificial tears designed to provide temporary relief from dry, irritated, burning, or gritty eyes). On her rolling bedside table was an unopened box of the same brand eye drops. Resident 96 indicated that the eye drops were hers and that she used them because her eyes would get dry often. She indicated she had had them at her bedside since she arrived at the facility. On 3/11/26 at 10:42 a.m. Resident 96's medical record was reviewed.She was a rehab Resident whose diagnoses included but were not limited to chronic respiratory failure. Resident 96 was admitted to the facility on [DATE]. Upon review of Resident 96's assessments it was found that the record lacked a medication self-administration assessment for eye drops. Upon review of Resident 96's orders it was found that the record lacked an order to self-administer Systane eye drops. On 3/11/26 at 2:50 p.m. the Director of Nursing (DON) and the Executive Director (ED) indicated they would look for a medication self-administration assessment for Resident 96. On 3/12/26 at 9:30 a.m. the DON provided a copy of a medication self-administration assessment for Resident 96 dated 3/11/26 at 4:34 p.m. On 3/12/26 at 12:50 p.m. the DON indicated a Certified Nursing Assistant (CNA) had come to her before the assessment was requested, and that was when they started the process of getting the assessment completed. The DON indicated they would have been prompted to do a medication self-administration assessment when the resident asked to self-administer the eye drops, or when a staff member found the medications in a Residents room. 410 Indiana Administrative Code (IAC) 16.2-3.1-37

Based on observation and interview, the facility failed to refrigerate a medication until opened and failed to date nasal sprays and eye ointment when opened for 1 or 2 medication carts reviewed.Findings include: On 3/11/26 at 11:55 a.m., medication carts were observed with LPN 4. Resident 6 had fluticasone nasal spray (used for seasonal allergies) in the cart without a date to indicate when opened. Resident 40 had deep sea premium saline (used for nasal congestion) in the cart without a date to indicate when it was opened. Resident 61 had retaine PM ointment (used for dry eyes) without a date to indicate when opened. Resident 8 had latanoprost eye drops (used for glaucoma) in the cart. They were unopened with a label indicating to refrigerate until opened. On 3/11/26 at 12:00 p.m., LPN 4 indicated there were no dates indicating medications had been opened. She removed latanoprost from the medication cart. The facility did not provide a policy by the end of exit. 410 Indiana Administrative Code (IAC) 16.2-3.1-25(j)410 Indiana Administrative Code (IAC) 16.2-3.1-25(m)410 Indiana Administrative Code (IAC) 16.2-3.1-25(n)

Based on observations, interviews, and record reviews, the facility failed to ensure proper infection control practices were in place for 2 of 24 residents reviewed for infection control when a resident with a central line (a long, flexible tube inserted into a major vein in the neck, chest, or groin, extending to just above the heart) and a resident with a suprapubic urinary catheter were not in Enhanced Barrier Precautions (EBP) (an infection control strategy designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) (Residents 2 and 85) and the dressing for the central line was not changed per policy for 1 of 1 resident reviewed for central lines (Resident 2). Findings include:1. On 3/10/26 at 11:00 a.m. Resident 2 was observed as he lay in bed resting. Resident 2 had a central line inserted in his right chest, just under his clavicle. The dressing was a 4 by 4 gauze pad that covered the entire insertion site and the surrounding skin, with a clear adhesive dressing covering the gauze and adhering the dressing to his skin. The dressing was dated 3/9. At the time of that observation, there was no signage indicating Resident 2 was in EBP and there was no Personal Protective Equipment (PPE) (specialized clothing or gear, such as helmets, goggles, gloves, and masks) outside or inside of the resident's room. On 3/11/26 at 12:24 p.m. Resident 2 was observed as he lay in bed resting with his eyes closed. Resident 2's central line dressing was visible, and it appeared to be the same dressing as observed on 3/10/26. At the time of that observation an EBP sign was on Resident 2's door and a stacked three drawer caddy with PPE was outside of Resident 2's door. On 3/11/26 at 1:15 p.m. Resident 2's medical record was reviewed. Resident 2's diagnoses included but were not limited to necrotizing fasciitis (a rare, life-threatening flesh-eating bacterial infection that spreads rapidly, destroying muscle, skin, and fat tissue, often requiring emergency surgery and intravenous antibiotics) and gangrene (a life-threatening condition involving tissue death (necrosis) due to lack of blood flow or severe infection, often affecting limbs, fingers, or toes) of the left foot and osteomyelitis (a serious, often bacterial, infection of the bone causing pain, swelling, and fever). Resident 2 had an active order for his central line dressing to be changed every 5 days. Resident 2's medical record lacked an order for EBP. A progress note, dated 3/12/26 at 4:03 p.m., indicated Resident 2's central line dressing had been changed. On 3/12/26 at 2:49 p.m. a copy of a current facility policy titled, Catheter Insertion and Care- Central Venous Catheter Dressing Changes, dated 12/15 was provided. That policy indicated, .6. Change gauze dressings and TSM over gauze dressing every 48 hours. 7. An implanted vascular access port that is in use may be covered with either a transparent semi permeable [TSM] dressing or gauze dressing. 8. If gauze is used to support the wings of the access needle under a TSM dressing and does not obscure the insertion site it can be changed every five to seven days with the TSM dressing. On 3/13/26 at 12:30 p.m. the Infection Preventionist (IP) nurse indicated Resident 2's dressing had been changed in accordance with the facility's policy, and she indicated the order set for central line dressing changes was changed to align with the facilities policy and federal regulation. 2. On 3/10/26 at 10:14 a.m., two unidentified CNAs entered Resident 85's room and closed the door. There was no PPE equipment outside of the door, and no EBP sign posted on the resident's door. On 3/10/26 at 10:20 a.m., upon opening Resident 85's door, they indicated they were performing resident care, getting him washed and clothes changed. They were not observed to wear any PPE. Resident 85 was observed with a suprapubic catheter. The CNAs indicated, they weren't sure if Resident 85 was in EBP or not, because they had not seen a sign on his door and there was no PPE inside or outside of his room. On 3/11/26 at 11:40 a.m., Resident 85's record was reviewed. He was a newly admitted resident with diagnoses which included but were not limited to sepsis and acute kidney injury. He had a current physician's order for a suprapubic catheter. He had a comprehensive care plan initiated 3/9/26 which indicated staff should utilize PPE per facility policy during high contact ADL care which included dressing, hygiene and transfers. On 3/12/26 at 2:49 p.m. a copy of a current facility policy titled, Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 4/1/24 was provided. That policy indicated, .1. Enhanced barrier precautions (EBP) will be in place during high contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO [Multi-Drug-Resistant Organism] acquisition which include: ii. All residents with indwelling medical devices 1. Includes but not limited to: catheters, central lines,. 2. Personal protective equipment (PPE) should be used even if blood and bodily fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high contact care activities. May include face protection if splashes or sprays are anticipated during care 3. High contact care activities include but are not limited to: morning.ADL [Activities of Daily Living] care. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observations, interviews and record reviews, the facility failed to ensure essential kitchen equipment and associated systems were maintained in proper working order to prevent the potential contamination for 2 of 2 observations. Findings include:On 3/10/26 at 9:45 a.m., during an initial kitchen tour with the Assistant Director of Food Service, the freezer was observed. Inside the freezer unit, an apparent leak from the freezer compressor system was observed. Frozen droplets and ice cycles were observed on the piping coming in and out of the unit. There were drops and mounds of ice that had developed on top of carboard boxes that contained frozen bread in opened plastic wrap. The presence of frozen condensation above exposed food items indicated the freezer system may have been leaking or producing excess condensation. During an interview with the Assistant Director at that time, he indicated, he had not noticed the ice, and kitchen staff had not notified him of any ice build up either. During a follow up observation on 3/12/26 at 10:35 a.m., the pipes had been cleared of ice and reinsulated with new material, however, there were new droplets of freezing ice observed on the ceiling of the freezer, near the pipe and along the seal of the freezer wall. During an interview on 3/12/26 at 11:00 a.m., the Corporate Director of Plant Operation indicated, ice build up on freezer compressors was a common effect of the systems routine defrost process and staff should know to monitor and the unit to prevent ice build up. Kitchen staff were in the freezer on a daily basis and should have identified the ice build up to notify the facility Maintenance Director who could address the issues. On 3/12/26 at 12:49 p.m., the Administrator provided a copy of current facility policy titled, Storage Procedures, dated January 2025. The policy indicated, .Frozen food equipment is routinely cleaned and defrosted and free from garbage and other waste. Freezer doors should be opened as little as possible to prevent fluctuations of storage temperatures. 410 Indiana Administrative Code (IAC) 16.2-3.1-19(bb)

Based on interview and record review, the facility failed to ensure Medical Providers entered their visit assessments, summaries, and/or progress notes into the resident's medical records timely for facility staff access. Theis deficient practice had the potential to effect of 6 of 13 residents records reviewed, (Residents 1, 9, 12, 14, 16, and 99). Findings include: On 3/6/25 at 9:17 a.m., Residents 1, 9, 12, 14, 16, and 99's records were reviewed related to Medical Provider documentation into the electronic health record (EHR) for timely submission and access to facility staff as a part of resident's continuity of care. The following pattern of more than 3 business days late were noted: 1. Resident 1 was a long-term care resident who had resided in the facility for more than a year. The previous 6 months of physician documentation was reviewed. From 8/8/24 until 3/6/25, Resident 1 had 12 late entry physician's notes. Half were more than three business days late, the greatest discrepancy was a late note entered on 1/30/25 at 1:29 p.m., for a visit on 1/23/25 at 11:29 a.m. 7 days late. This visit included a new recommendation to start the resident on a topical anti-inflammatory for pain in her knee. 2. Resident 9 was a long-term care resident who had resided in the facility for more than a year. The previous 6 months of physician documentation was reviewed. From 8/1/24 until 3/6/25, Resident 9 had 9 (nine) late entry physician's notes. A late note entered 3/3/25 at 12:03 p.m., from a visit 4 days before on 2/27/25 at 12:02 p.m., included a new order related to moisture associated skin damage and candidiasis of female genitalia for fluconazole (an antifungal medication) weekly for 2 weeks and calmoseptine (a topical ointment to treat skin irritation). 3. Resident 12 was admitted on [DATE]. Since their admission, until 3/6/25, there were 12 late entry notes, 3 of which were more than 3 (three) business days late. 4. Resident 14 was a long-term care resident who had resided in the facility for more than a year. The previous 6 months of physician documentation was reviewed. From 8/1/24 until 3/6/25, Resident 14 had 15 late physician's notes, 6 were more than three business days late. 5. Resident 16 was admitted on [DATE]. Since their admission until 3/6/25, there were 25 late entry physician's notes, 10 were more than 3 business days late with the greatest discrepancy being; a note recorded 13 days late on 12/9/24 at 5:42 a.m., for a visit on 11/26/24 at 11:52 a.m. 6. Resident 99 was admitted on [DATE]. Since their admission, until 3/6/25, there were 5 late entry physician's notes, 1 being later than 3 business days. During an interview on 3/6/25 at 12:53 p.m., a contracted Nurse Practitioner (NP) Provider indicated, it would be impossible to have every document signed the day of the visit with as many patients and documents there were, but as a rule, it was his Provider's Practice to have notes signed and accessible in the EHR within 48 hours of the visit. During an interview on 3/7/25 at 12:41 p.m., the Home Office Clinical Support Nurse indicated, the facility policy did not give specific timelines for signing and uploading or making their documentation available to the nurses within a certain timeframe, but she expected notes to be up within three (3) business days. On 3/6/25 at 11:00 a.m., the Home Office Clinical Support Nurse provided a copy of current facility policy titled, Guidelines for Physician Services, reviewed 12/17/24. The policy indicated, . the resident's attending physician shall participate in the resident's assessment and care planning, monitor changes in the resident's medical status, and provide consultation or treatment as required by resident condition, regulations and or when consulted or called by the campus . position orders and progress notes shall be maintained in accordance with the OBRA regulations and campus policy At the time of the survey exit on 3/7/25 at 1:00 p.m., the Home Office Clinical Support Nurse provided an example of a Stand-Down Physician Visit Summary and indicated the summary was printed off and left at each nurses station at the conclusion of the providers visit. The summary and/or policy lacked documentation of how/if the Stand-Down was accessible to the nurses if the print out was lost/misplaced, if it stood in lieu of the signed physician note until it could be uploaded to the EHR, and/or the physician's signature at the time the Stand-Down was printed/distributed. 3.1-22(c)

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan related to recurrent Urinary Tract Infections (UTI) for a resident (Resident 4) who had seven UTI's in a 12-month period for 1 of 16 residents reviewed for care plans. Findings include: On 3/5/25 at 1:43 p.m. Resident 4's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, UTIs, chronic kidney disease, and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage). A physician note, dated 2/2/24, indicated on 1/29/24 the Resident was seen for dysuria (pain while urinating). A urine analysis (UA)(a test to determine if a UTI is present) and a C&S (culture and sensitivity)(a test to determine what antibiotic the infection is sensitive to) was ordered. It was found that the Residents UA was positive for E. Coli (a bacteria of the lower intestines commonly found in feces.). Macrobid (an antibiotic used to treat UTI)) was ordered to treat the UTI. A progress note, dated 2/7/24, indicated Resident 4 had completed her antibiotics and her dysuria had resolved. A physician note, dated 2/28/24, indicated on 2/23/24 a UA and C&S were ordered due to discomfort when urinating. It was found that the Residents UA was positive for E. Coli. Keflex (an antibiotic used to treat UTI) was ordered to treat the UTI. A physicians progress note, dated 3/5/24, indicated Resident 4 had completed her antibiotics and her dysuria had resolved. A progress note, dated 3/19/24, indicated Resident 4 had auditory hallucinations (hearing something that is not there) and confusion causing her to fall out of bed. An Interdisciplinary Team (IDT) note, dated 3/20/24, indicated a UA was ordered to rule out UTI. An infection control event, dated 3/26/24, indicated Resident 4 had a UTI and was ordered an antibiotic to be administered from 3/26/24 to 3/29/24. A physician progress note, dated 4/1/24, indicated on 3/25/24 the resident was ordered Ciprofloxacin (an antibiotic used to treat UTI) for a UTI caused by E. Coli in the urine. On 4/1/24 the symptoms had resolved. A progress note, dated 11/13/24, indicated a family member requested Resident 4 be tested for a UTI. Orders for a UA and C&S were placed. A physician progress note, dated 11/18/24, indicated it was found that the UA was positive for E. Coli. Macrobid was ordered to treat the UTI. A Nurse Practitioner (NP) note, dated 11/25/24, indicated Resident 4 had completed her antibiotics and her dysuria had resolved. A NP note, dated 12/20/24, indicated the Resident had burning with urination. Orders for a UA and C&S were placed. A progress note, dated 12/26/24, indicated Keflex was ordered until 12/30/24 to treat the UTI. A progress note, dated 12/31/24, indicated Resident 4 had finished her antibiotics and her dysuria had resolved. A physicians progress note, dated 1/6/25, indicated the UTI being treated on 12/26/24 was treated with four days of Keflex and seven days of extra strength Bactrim (an antibiotic used to treat UTI) with an end date of 1/2/25. on 1/2/25 Resident 4 continued to have UTI symptoms. Orders to extend the Bactrim to a ten-day course with an end date of 1/5/25 were placed. On 1/6/24 antibiotics were complete and dysuria had resolved. Resident 4's care plans were reviewed. The record lacked documention of a care plan for recurrent UTI's or the prevention of UTI's, only a general bowel bladder care plan indicating nurses would monitor signs and symptoms of UTI. On 3/7/25 at 1:30 p.m., a copy of a current facility policy titled, Comprehensive Care Plan Guideline, dated 12/17/24, was provided by the Minimum Data Set (MDS) support staff. The policy indicated, .2. Acute problems that arise with the resident and are expected to be resolved within a short time frame will be addressed on the event form specific for that problem. Address problems that become ongoing or chronic with a new comprehensive care plan . 3.1-35(a) 3.1-35(b)(1) 3.1-35(b)(2)

Based on observation, interview, and record review, the facility failed to ensure appropriate/effective interventions were in place to prevent the development of new open pressure and failed to ensure accurate documentation was detailed in the medical records for 2 of 2 residents reviewed for pressure ulcers (Residents 16 and 24). Finding include: 1. On 3/4/25 at 12:36 p.m., Resident 16 was observed. She was seated in a wheelchair with a pressure reducing cushion in place. Resident 16 indicated her bottom had been sore a couple weeks ago, but she thought it had cleared up. It still got a little sore and tender if she stayed up for too long. On 3/5/25 at 11:44 a.m., Resident 16's medical record was reviewed. She had diagnoses which included, but were not limited to, urinary tract infection (UTI), type 2 diabetes mellitus, muscle weakness, and pelvic and perineal pain. An admission minimum data set (MDS) assessment, dated 11/21/24, indicated Resident 99 admitted with a stage II (partial-thickness skin loss that presents as a wound with a red or pink wound bed) pressure ulcer on her coccyx. A nursing admission assessment, dated 11/15/24 at 5:16 p.m., indicated Resident 16 did not have any skin impairment upon admission and her Braden score (a series of questions scored to determine pressure ulcer risk) was 15, which indicated, she had a low to moderate risk of developing a pressure ulcer. A nursing admission progress note, dated 11/15/24 at 5:16 p.m., indicated there were no open areas and foam dressing was applied to her bottom for protection. A Dietitian admission progress note, dated 11/19/24 at 10:21 a.m., indicated, .noted pressure related impairment to coccyx on admission--will recommend fortified therapeutic diet, MVI [multivitamin infusion] with minerals and ProStat 30 cc BID to aid in wound healing The record lacked admission documentation of wound details (i.e. length, width, depth, tissue type etc .) until 12 days after admission when a Wound Observation Tool was opened. The first Wound Observation Tool was dated 11/27/24 at 11:38 a.m., and indicated the wound was a stage II pressure ulcer which measured 10 centimeters (cm) wide and 10 cm long with red, but blanchable wound edges. A second Wound Observation Tool, dated 12/9/24 at 8:54 a.m., indicated the wound was improved to 8 cm wide by 8 cm long with red but blanchable wound edges. A third Wound Observation Tool, dated 12/12/24 at 10:17 a.m., indicated the wound was stable and still measured 8 cm long by 8 cm wide, with red but blanchable wound edges. The Wound Observation Tools and/or would tracking lacked documentation the pressure ulcer had been resolved. A Dietitian progress note, dated 1/6/25 at 12:52 p.m., indicated Resident 16 had a coccyx pressure impairment present on admission, but it was resolved on 12/19/24. Resident 16's Treatment Record Administration (TAR) records were reviewed. Throughout December 2024, January 2025, and March 2025, Resident 16's TARs indicated a treatment was still being administered as ordered, Order Set: (Coccyx): cleanse wound with wound cleanser or normal saline, apply skin prep to peri-wound, and cover with foam (gentle or life) dressing change every 5 days, and was completed until 3/5/35. During an interview on 3/6/25 at 12:53 p.m., the Director of Nursing (DON) indicated Resident 16 had a wound upon admission, but it was healed in December 2024. She did not know why the order for wound treatments was still in place, but the Resident did not have an open area. 2. On 3/6/25 at 12:39 p.m., Resident 24 was observed. She was reclined in bed and propped on her right side. She indicated she had a pressure ulcer once, and sometimes her bottom still got sore. She did not believe she had a wound at that time. On 3/6/25 at 1:01 p.m., Resident 24's medical record was reviewed. She was a long-term care resident who was admitted on [DATE]. She had diagnoses which included, but were not limited to, chronic kidney disease, stage 3, morbid (severe) obesity due to excess calories and type 2 diabetes mellitus with diabetic peripheral angiopathy (disease/damage of the blood vessels). A nursing progress note, dated 12/10/24 at 7:30 p.m., indicated the CNA notified the nurse of a new open area to Resident 24's buttock. Upon the nurses' assessment, a small opening to her intergluteal cleft was noted. The DON and Nurse Practitioner (NP) were notified. The record lacked a New Wound/Skin Integrity Event. The record lacked documentation of additional wound details. A Medical Doctor (MD) progress note was entered into the record late, created on 12/15/24 at 11:10 a.m. effective for 12/11/24 at 11:10 a.m. The MD saw Resident 24 for dermatitis associated with moisture and a new wound, open to her buttock.Acute, unstable. [right] gluteal open wound w/ surround MASD. Suspect shearing [secondary to] moisture). The MD placed a new order for triad cream twice a day until the area was healed Resident 24's December TAR was reviewed and revealed the order was placed and discontinued on the date 12/11/24, with a comment: other but lacked details of what the comment was. A MD progress note was entered into the record late, created on 1/23/24 at 9:08 a.m. effective for 1/21/24 at 9:07 a.m. The MD note identically indicated, .Acute, unstable. [right] gluteal open wound w/ surround MASD [moisture associated skin damage]. Suspect shearing [secondary to] moisture). The MD placed a new order for triad cream twice a day until the area was healed Resident 24's January TAR was reviewed and revealed, an order to observe (buttocks) dressing to open area(s) every shift for draining on dressing and dislodgement, had been completed for every day. The record lacked documentation of the wound details related to the current treatments in place. A third MD progress note was entered into the record late; created on 2/12/24 at 10:24 a.m. effective for 2/7/24 at 10:24 a.m. The MD note identically indicated, .Acute, unstable. [right] gluteal open wound w/ surround MASD. Suspect shearing [secondary to] moisture). The MD placed a new order for triad cream twice a day until the area was healed Resident 24's February TAR was reviewed and revealed, an order to observe (Buttocks) dressing to open area(s) every shift for draining on dressing and dislodgement, had been completed for every day until it was discontinued on 2/7/25. The record lacked documentation of the wound details related to the current treatments in place and/or documentation the area was healed/resolved. During an interview on 3/6/25 at 1:45 p.m., the DON indicated she had just observed Resident 24 and there were no current open areas. At the time she was notified of what the nurse thought was an open area, the DON went to assess and found nothing there. There was no wound documentation at that time because there had been no wound to document. The DON did not know why the MD continued to address the area in the MD notes, and/or why the nurses continued to chart that treatments were completed. On 3/6/25 at 9:10 a.m., the Administrator (ADM) provided a copy of current facility policy titled, Pressure/Statis/Arterial/Diabetic Wound Guidelines, revised 4/16/24. The policy indicated, Purpose Statement: To provide weekly documentation of wound measurements and condition . 1. If skin as noted upon admission, admitting nurse should complete progress note assessment. IDT [Interdisciplinary team] should review this timely and wound nurse or designee complete an assessment and wound management. 2. If skin alteration occurs post admission follow the steps below: a. appropriate wound incident is completed by a RN/LPN in EHR [electronic health record]. b complete incident for each impaired area and assessment of the wound. C. all measurements are recorded in centimeters. d. IDT to review incident. Wound nurse/designee will add wound into wound management tool. e. Wound incident will remain open and EHR until wound management tool is initiated. 3. Document description of wound using: a. Length . b. Width . c. Depth . d. Exudates . e. Color . f. Odor . g. Wound margins . h. Surrounding tissue . i. Tunneling and/or undermining if applicable. 4. Re-assessment/measurement weekly . DHS/ADHS and/or designee to close/complete wound management PUSH tool 3.1-40

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 99) who had a history of falls, had an environment free from the potential for accidents when the rubber threshold of the shower was unattached and loose on the floor for 1 of 3 residents reviewed for accidents. Findings include: During an initial observation and interview on 3/4/25 at 11:00 a.m., Resident 99 indicated she was afraid of falling. She was observed as she sat in a wheelchair at the foot of her bed, with an over-bed table pulled in front of her. She had an immobilizer boot on her left foot and indicated she had broken her foot after a fall at home. Resident 99 indicated she often felt rushed, and staff told her not to hold onto the grab bars. She became tearful and indicated she was too afraid to fall because she could not see very well. Even when staff were there to help, she was afraid of falling especially in the bathroom because the rubber strip on the floor was loose. If she were on the toilet, the shower and stopper were on her left side, which was affected by her vision loss. She was afraid she would trip on it when she transferred because it was hard for her to see. On 3/4/25 at 11:05 a.m., Resident 99's bathroom was observed. There was a long white rubber threshold guard which separated the bathroom floor from the shower floor. The threshold had become detached from the floors and was loose to the touch. On 3/5/25 at 1:50 p.m., Resident 99's bathroom was observed. The rubber threshold remained in disrepair, loose on the floor. On 3/6/25 at 10:51 a.m., Resident 99's bathroom was observed, and the rubber threshold remained in disrepair, loose on the floor. During an interview on 3/6/25 at 10:54 a.m., Certified Nursing Aide, (CNA) 14 indicated Resident 99's bathroom shower stopper had been loose for about a week. Her wheelchair wheel had accidently dislodged it during a transfer when her wheel got stuck on it. CNA 14 did not know if it had been repaired yet. On 3/5/25 at 2:03 p.m., Resident 99's medical record was reviewed. She had diagnoses which included, but were not limited to, homonymous bilateral field defects on the left side (a condition where a person experiences vision loss on the left side of their visual field in both eyes), vascular dementia, history of falls, and a displaced fracture of cuboid bone of left foot. A hospital discharge summary, dated 2/17/25, indicated, .she very clearly tells me about the falls. She notes they occurred because of her chronic left homonymous hemianopsia as a sequela of previous stroke and she was attempting to get something off a table but couldn't see to her left side very well, became off balance, and fell Resident 99 had a comprehensive care plan dated 3/3/25 which indicated she was at risk for falls. Interventions included, but not limited to, .ensure the floor is free of liquids and foreign objects . On 3/6/25 at 11:00 a.m., Resident 99's bathroom was observed with the Assistant Director of Nursing (ADON). The ADON indicated, the rubber threshold was loose and could be trip hazard. The ADON would have Maintenance come and assess for repairs. On 3/6/25 at 9:10 a.m., the Administrator (ADM) provided a copy of current facility policy titled, Fall Management Program Guidelines, reviewed 12/17/24. The policy indicated, .Trilogy Health Services [THS] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures 3.1-45(a)

Based on observation and interview, the facility failed to date medications when opened for 1 of 3 medication carts reviewed. Findings include: On 3/6/25 at 10:53 a.m., the Renaissance ([NAME]) 1 B cart was observed. Resident 91 had an insulin pen, lantus 100 unit/milliliter (ml) in the medication cart and it lacked a date to indicate when it was opened. During an interview with the Assistant Director of Nursing Services (ADNS) on 3/6/25 at 11:00 a.m., he indicated that a nurse must have pulled the insulin pen from the refrigerator the night before and did not date it. A policy dated 11/18, titled, Medication Storage in the Facility was provided by the ADNS on 3/7/25 at 1:00 p.m. It indicated, .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on record review, and interview, the facility failed to ensure showers were provided for 1 of 1 residents reviewed for bathing preference (Resident B). Findings include: On 5/23/24 at 12:14 p.m., the medical record for Resident B was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to. Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke) affecting right dominant side. The point of care ADL (Activities of Daily Living) Report record, which was the documentation recorded by the Certified Resident Care Assistant (CRCA) indicated when the resident was provided a shower, a bed bath, or a partial bath: From 9/20/23 to 10/30/23 the resident was administered 2 showers. From 10/4/23 to 10/30/23 the resident was administered 5 showers. From 11/27/23 to 12/19/23 the resident was administered 6 showers. From 1/8/24 to 1/16/24 the resident was administered 3 showers. The documentation indicated in four months the resident received a total of 16 showers. The residents care profile, dated 4/13/22, indicated the resident's bathing preference was to be administered 2 showers per week. Showers were to be administered on the day shift on Monday and Wednesday. A care plan, dated 10/21/22, indicated the resident required staff assistance to complete ADL task completely and safely. An annual Minimum Data Set (MDS) assessment, dated 9/25/23, indicated the resident was dependent upon staff for all personal care. On 5/23/24 at 2:15 p.m., during an interview the Director of Nursing (DON) indicated the resident probably did not receive many showers because she was not safe. She did not recall if she required two persons to assist with showering. On 5/24/2024 at 11:13 a.m., the DON provided a document titled, Guidelines for Bathing Preference, dated 21/31/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose .to establish a personal preference bathing routine .Procedures .2. The resident shall determine their preference for bathing upon admission .a. Day of the week b. Time of day - morning or evening c. Type of bathing - tube, bed bath or shower .4. Bathing shall occur at least twice a week unless resident preference states otherwise This citation relates to complaint IN00434357. 3.1-38(a)(3)

Based on record review, interview, and observation, the facility failed to ensure a nurse aide was competent to safely transfer a resident while using a mechanical lift for 2 of 4 residents reviewed for mechanical lifts (Resident B). Findings include: 1. On 5/23/24 at 12:14 p.m., the medical record for Resident B was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke) affecting right dominant side. The medical record lacked a Physician order for use of mechanical lift for transfers. The resident was admitted to the hospital on 1/21/24 with diagnosis of sepsis, urinary tract infection (UTI), scalp hematoma, and laceration. A CT scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) indicated no evidence of acute intracranial hemorrhage (bleeding in the brain). A care plan, dated 10/21/22, indicated the resident required staff assistance to complete ADL (activities of daily living) tasks, completely, and safely. A Profile Care Guide, dated 4/13/22, indicated Resident B transferred by Hoyer (mechanical lift) with 2 staff. An annual Minimum Data Set (MDS) assessment, dated 9/25/23, indicated the resident was dependent upon staff for mobility and transfers. The facility investigation report, dated 1/21/24, at 6:50 p.m., indicated Certified Resident Care Assistant (CRCA) 3 was assisting Resident B into a lift pad. When the CRCA attempted to attach the mechanical lift pad to the lift device the resident slid out of the wheelchair and onto the floor and struck her head on the leg of the lift device. On 5/23/24 at 2:15 p.m., during an interview the Director of Nurses (DON) acknowledged Resident B did slide out of a wheelchair while the CRCA was assisting her. She indicated the resident was in the wheelchair and the aide had attached the top hooks of the lift pad but had not yet placed the hooks in the bottom of the pad. The resident had slid down in the chair to the edge of the seat. Before the CRCA could attach the pad the resident slid out onto the floor. She indicated the mechanical lift was a one person assist per guidelines. She indicated there was three residents currently utilizing a mechanical lift for transfers. On 5/23/24 at 2:51 p.m., during an interview CRCA 3 indicated he attached the lift sling of Resident (B) into the top part of the lift. He indicated the resident was slouched down in the wheelchair. The wheelchair moved backwards, and the resident slid out and fell on to the floor. The residents head landed on the bottom of the lift leg. The CRCA indicated he moved the wheelchair, placed a pillow under the residents head and left to find the nurse. The resident had a large bump on the back of her head and a skin tear on her arm. He would normally lock the wheelchair prior to beginning to assist the resident but had not locked the chair at that time. He indicated at the time they were very busy, so he was going to place the resident in the lift pad, attach it to the lift and go get someone for assistance. He normally used assistance of two persons when using the mechanical lift. He indicated after the incident he received training. Training included discussion of steps to use the lift and position the resident by staff with transfers. He indicated during training after the incident he did not return demonstration of the use of a mechanical lift device. On 5/23/24 at 3:45 p.m., during an interview, Registered Nurse (RN) 4 indicated she always used two persons to use the mechanical lift to position and transfer a resident On 5/23/24 at 3:46 p.m., during an interview, CRCA 5 indicated she always used two persons to use the mechanical lift to position and transfer a resident for safety reasons. On 5/23/24 at 3:48 p.m., during an interview, CRCA 6 indicated she always used two persons to use the mechanical lift to position and transfer a resident. On 5/24/24 at 10:42 a.m., Resident E was in bed sleeping. The bed was in low position, he was resting well no signs of pain. The staff indicated they were not going to get him up till later due to a decline in condition. The resident's profile care guide indicated the resident was to have 2 persons to assist with mechanical lift transfers. On 5/24/24 at 10:45 a.m., observed Resident C was resting in bed. She indicated the times she gets up varied and was determined by the CRCA assigned to care for her. She indicated the staff utilized the mechanical lift with two people to transfer her. The resident's profile care guide indicated the resident was to have 2 persons to assist with mechanical lift transfers On 5/24/24 at 10:52 a.m., observed Resident D was sitting up in wheelchair sitting on a grey lift pad with green edging. The pad was over the top of his head and covered his forehead and to the top of his eyes. He indicated only one staff person assisted with placing him in the lift pad and moving him with the mechanical lift. The residents profile care guide indicated; the resident was to have 2 persons to assist with mechanical lift transfers. 2. On 5/24/24 at 9:30 a.m., the medical record for Resident D was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength) following cerebral infarction (stroke) affecting right dominant side. The medical record lacked a Physician order for use of mechanical lift for transfers. The profile care guide, dated 8/18/23, indicated Resident D transferred with a Hoyer (mechanical Lift) with 2 staff. A care plan, dated 11/22/23, indicated Resident D had impairment in functional status related to CVA with hemiparesis. Interventions included but were not limited to. Approach Start Date: 11/22/2023, Provide assistance as needed with self-care and mobility functional tasks. A quarterly Minimum Data Set (MDS) assessment, dated 2/15/24, indicated the resident was dependent on staff for all mobility including transfers. On 5/24/24 11:52 a.m., during an interview CRCA 9, indicated she grabbed a lift pad when she was getting Resident D prepared to transfer from bed to chair. She did not know what size pad to use and went by the size of the resident. She acknowledged the lift pad being used by Resident D was very large and was over the top of the resident's head and forehead. She indicated the lift pad did not have a size on it. The Assistant Director of Nursing (ADON) observed CRCA 9 standing next to the resident and indicated to CRCA 9 the size was determined by the color on the trim. The ADON acknowledged the green trimmed lift pad was too large for the resident and obtained a yellow trimmed lift pad to apply to enable staff to reposition the resident. He indicated the yellow trimmed lift pad was the medium sized lift pad and indicated the size chart was on the back of the lift pad. On 5/24/24 12:10 p.m., observed Resident D being re-positioned to be lifted and re-positioned in the wheelchair. Observed CRCA 8 and CRCA 9 and the ADON prepare the resident to be repositioned. The resident was slouched down in the wheelchair and leaning to the side. The ADON instructed and assisted the CRCA's during preparation. Step by step instructions were verbally given by the ADON to the CRCA's assisting the resident. The green trimmed lift pad was removed, and the yellow trimmed lift pad was positioned under the resident. CRCA 9 positioned the mechanical lift legs to each side of the wheelchair. The ADON instructed CRCA 8 to lock the wheelchair. The CRCAs lifted and repositioned the resident in the wheelchair. The resident tolerated the procedure well. Both CRCA's indicated they used two staff to complete all mechanical lift transfers. , On 5/24/25 at 1:00 p.m., the medical records for Resident's C and E were reviewed. The profile care guide for each resident indicated both residents transferred by Hoyer (mechanical Lift) with 2 staff. On 5/23/2024 at 3:00 p.m., the DON indicated she did not have the manufacture guidelines for the mechanical lift currently used at the facility. She indicated she looked up the guidance. The DON provided an undated document titled, Section 1 -General guidelines, and indicated it was the guidelines provided by the manufacturer of Invacare mechanical lift. The document indicated, .Operating the lift .Although Invacare recommends that two assistants be used for all lifting preparation, transferring from, and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case .Using the sling .If the patient is in a wheelchair, secure the wheel locks in place to prevent the chair from moving forwards or backwards .Lifting the patient .When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem-otherwise, injury or damage may occur On 5/23/2024 at 3:07 p.m., the DON provided a document titled, Guidelines for residents utilizing a lift, dated 12/31/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures .2. If the resident requires the use of a lift device, this will need to be added to the resident plan of care that will be communicated to the caregiver .3. All devices are safe to be used by one staff member per manufacture guidelines. Staff should seek the assistance of a second person for those residents care planned for assistance of two with the lifting device or as needed for safe handling This citation relates to complaint IN00434357. 3.1-14(i)

Based on record review and interview, the facility failed to implement complete, person centered care plans for 4 of 4 residents reviewed for advance directive care plans (Residents 19, 26, 33 and 146). Findings include: 1. On 1/31/24 at 1:51 p.m., a record review was completed for Resident 19. She had the following diagnoses which included but were not limited to encephalopathy, urinary tract infection, heart disease, obesity, dementia, and low back pain. Resident 19 had an order for DNR (do not resuscitate). Resident 19's care plan indicated .Resident/resident representative have chosen the following advanced directives, residents 2 daughters are her health care representatives, code status reviewed. The care plan lacked resident specific choices and person centered information. 2. On 1/30/23 at 10:45 a.m., a record review was completed for Resident 26. He had the following diagnoses which included but were not limited to chronic pulmonary obstructive disease (COPD), respiratory failure, pneumonia, atrial fibrillation, and type 2 diabetes mellitus. Resident 26 had an order for DNR. Resident 26's care plan indicated, Resident/resident representative have chosen the following advanced directives. The care plan lacked resident specific choices and person centered information. 3. On 1/31/23 at 2:17 p.m., a record review was completed for Resident 33. She had the following diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD), respiratory failure, atrial fibrillation, Parkinson's disease, hypothyroidism and hyperlipidemia. She had an order for DNR. Resident 33's care plan indicated, Resident's/resident's representative decision regarding his/her advance directive will be honored. The care plan lacked resident specific choices and person centered information. 4. On 1/30/24 at 11:33 a.m., a record review was completed for Resident 146. She had the following diagnoses which included but were not limited to hemiplegia related to cerebral infarction, atrial fibrillation, obesity, type 2 diabetes mellitus, heart failure, and anxiety. She had an order for full code. Resident 146's care plan indicated, Resident/resident representative have chosen the following advanced directives including code status, daughter is POA. The care plan lacked resident specific choices and person centered information. During an interview on 1/30/24 at 3:35 p.m., the Minimum Data Set (MDS) Support indicated the company did not create care plan residents' code status in case it changed. They did not want conflicting information in the system until the next clinical care plan meeting. The nurses found residents' code status information under their banner, order or residents' documents. A policy titled, Comprehensive Care Plan Guideline, was provided by the Director of Nursing (DON) on 1/31/24 at 1:42 p.m. It indicated, Pertinent care plan approaches are communicated to the nursing staff per the Care Assist profile dependent on campus preference Comprehensive care plans need to remain current and accurate 3.1-35(c) 3.1-35(l)

Based on observation, interview, and record review, the facility failed to ensure a resident was wearing weather appropriate clothing when leaving the facility for 1 of 2 residents reviewed for dignity (Resident 104). Findings include: On 1/30/24 at 3:10 p.m., Resident 104's record was reviewed. He was admitted on [DATE]. An Inventory of Resident Personal Items showed Resident 104 had 3 shirts, 3 pants, and no jacket. No items were added or removed after admission. His diagnoses included, but were not limited to, weakness, chronic obstructive pulmonary disease (COPD), and hepatocellular carcinoma (liver cancer). His care plan, dated 1/25/23, indicated he had potential for complications, functional, and cognitive status decline related to respiratory disease: COPD. A physician order, dated 1/26/24, indicated Resident 104 had an oncology (cancer care) consultation appointment on 1/29/24 at 2:30 p.m. A Transportation Request form indicated Resident 104 was transported on 1/29/24 at 2:30 p.m. and returned at 2:50 p.m. He was transported by the facility bus for a physician appointment. It was completed by the facility Bus Driver (BD) 87. On 1/29/24 at 4:12 p.m., Resident 104 was observed to be assisted to exit the facility's bus by BD 87. He was in his wheelchair on the wheelchair lift. He did not have a winter coat on, but a tee shirt. Resident 104 indicated he was cold and he did not have a winter coat. The outside temperature was 34 degrees Fahrenheit (F), with a wind chill of 29 degrees F. A nursing progress note, dated 1/29/24 at 4:20 p.m indicated Resident 104 returned from an oncology appointment with a new order for oxycodone (narcotic analgesic) 5 mg, by mouth, every 6 hours, as needed (PRN) and a hospice (end-of-life care) referral. On 1/30/24 at 9:05 a.m., Resident 104 indicated yesterday he was returning from a doctor's appointment at a local hospital. He indicated the facility could have given him a blanket or something since he did not have a coat. His family was bringing his winter coat on 1/30/24. He indicated he was miserable without a coat. It was so cold on the bus, during the transport to the doctor's appointment, and the ride back. On 2/1/24 at 10:46 a.m., the Director of Nursing (DON) indicated she needed to educate the bus driver about transporting residents during winter weather because the resident should have had a blanket or something to be warm. On 2/1/24 at 12:18 p.m., the Assistant Director of Nursing (ADON) indicated the staff should have provided a blanket for Resident 104. A current policy, titled, Resident Rights, with no date, was provided with a resident admission packet after entrance conference. It indicated, The resident has a right to be treated with respect and dignity, including .The right to reside and receive services in the facility with reasonable accommodated of resident needs and preferences 3.1-3(a) 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident E) received appropriate and timely treatment after a fall with fracture for 1 of 4 residents reviewed for quality of care. Findings include: On [DATE] at 1:55 p.m., Resident E was initially observed. She was seated in a wheelchair in her room. During a general conversation, Resident E indicated she had been fine until she fell over Christmas and broke her wrist. She held up her arm and her wrist was observed in comparison to her left wrist. It was misshaped and swollen, and Resident E indicated she couldn't not move it as well as her other hand. Resident E indicated she had been standing at the end of her bed and her legs gave out. She knew immediately when she fell that it was broken, but no one believed her. She was not taken to the hospital until the following day. She indicated, it hurt very bad. During a follow up interview on [DATE] at 10:43 a.m., Resident E was asked about her accident. She gave consistent details and indicated, she had been standing at the end of her bed and her legs gave out. She fell down and knew immediately that her wrist was broken because, it hurt really bad, it was swollen and didn't look right. When asked how bad it hurt she indicated, pretty bad, I was able to fall asleep that night but woke up with it hurting a bunch of times. During a confidential interview it was indicated, family members had just been in for a visit on Christmas Eve and were concerned about Resident E's weakness. They shared their concern on the way out with the nurse (who no longer worked at the facility). Shortly after they left, around 5:00 p.m., family received a call from the nurse who told them Resident E had fallen but was fine. Resident E complained that her wrist hurt, but she was able to move it fine and family was led to believe it was no big deal. Family indicated it was a very traumatic experience for the resident and worst of all, the resident felt that no one believed her. Resident E still talked about the incident, and her wrist remained deformed. During a confidential interview it was indicated, on Christmas day family came back to visit Resident E. Family arrived in the afternoon around 3:30 p.m., and was horrified. Family had already been informed that Resident E had fallen the night before but had been led to believe everything was fine, so family had not rushed back in to see her or even thought an x-ray was warranted. However, upon family's arrival and observation of her arm, it was clearly broken. She was weak and could barely talk through the pain. She guarded her arm which was swollen, deformed, and bruised black and blue. Family ran out of the room to find a nurse but could not find anyone except an x-ray technician who was coming down the hall. The x-ray technician, who confirmed they were there for Resident E, was led to the room. The x-ray technician told the family they were not qualified to read the results and wait for the radiologist's results. But since Resident E still needed to get dressed, the technician advised the family to be very careful when moving her arm since it looked like a very bad break. Finally a nurse came in and told family it would be faster if they took her straight to the emergency room (ER) instead of waiting for an ambulance. At the hospital, Resident E was determined to be in acute hypoxic respiratory failure due to pneumonia. The fractured wrist was cast but did not require surgery. She was in such poor condition, hospital staff kept recommending hospice and family were very concerned it may have been the end. The family indicated Resident E had not received an x-ray sooner or been sent to the ER because they were told the x-ray was supposed to come on the 24th, but couldn't make it until the 25th. The family was told she was not in any pain so they did not think she needed to be seen, until they saw her the next day. Family was very upset they had not been given a full picture of Resident E's rapidly declining condition. Family indicated it was one of the most awful experiences Resident E had ever had. She was more or less back to her old self, but remained anxious about the accident. She often talked about it that she thought she might have died . During a confidential interview, it was indicated that a Certified Nursing Aide (CNA) who worked the evening of Resident E's fall had indicated they were surprised Resident E was not sent to the ER since the wrist was deformed and the resident complained of pain. During a confidential interview, it was indicated that the x-ray technician remembered Resident E's accident. The family had been there, and both family and Resident E were tearful. Resident E was in pain. Although they were not qualified to read the results of the x-ray, it was clearly broken and painful, so the technician advised the family not to move the arm if at all possible to avoid any further displacement. During an interview on [DATE] at 2:24 p.m., the DON indicated the nurse should have contacted the physician to let them know that x-ray would not be available until the following day to determine if Resident E should be sent out or get orders for care and monitoring in the meantime. The nurse on duty the evening of the fall and Resident E had personality clashes, and they were not fond of each other. During an interview on [DATE] at 11:18 a.m., the Medical Director (MD) indicated he vaguely remembered the accident when Resident E fall and broke her wrist. He could not say for sure if the facility called to notify him that the STAT (immediate) x-ray could not be obtained within the required timeframe. He indicated if the wrist was noticeably deformed, he would have given an order to splint the arm and closely monitor to ensure pulse was palpable until x-ray could be performed. During a confidential interview, it was indicated that Resident E's family had expressed their concern and grievances related to Resident E's treatment the night of the fall and the following day. The nurse who was on duty was not particularly fond of Resident E and Resident E did not like her. When the nurse called family to tell them about the fall she said, well, she had a fall but she's just being dramatic. Resident E told family the next day that the nurse did not even help her off the floor and just said, oh stop that, and get yourself up. Family indicated they came in on [DATE] to discuss their care concerns and spoke with the Social Service Director (SSD) particularly in order to make sure that nurse would not care for Resident E any longer. Family provided a copy of handwritten notes from a care plan meeting, dated [DATE], which indicated the following topics had been discussed (but were not limited to) .RUDE experience with the aide and [Name of the nurse on [DATE]], lack of communication Family indicated no follow up was provided. During an interview on [DATE] at 1:47 p.m., the SSD indicated she did not recall Resident E's family members complaining about anything related to her fall or customer care concerns related to nursing staff. On [DATE] at 10:59 a.m., Resident E's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, unspecified dementia, anxiety, post-traumatic stress disorder, repeated falls, and panic disorder. A nursing progress note, dated [DATE] at 6:00 p.m., indicated Resident E was found lying on the floor next to her bed and stated she had called 911 to come get her. She stated, that her right wrist was broken, but she was able to move it without problems. She did have an area that looked like a hematoma on her right wrist. The Nurse Practitioner (NP) was notified and a new order for a STAT x-ray was placed. A fall event, dated [DATE] at 5:11 p.m., indicated Resident E fell after transferring herself. She complained of right wrist pain on a scale of 3 of 10. The Event lacked documentation of 1st aide given, if any. A nursing progress note, dated [DATE] at 7:13 p.m., indicated the x-ray company called and even though they had received the STAT order, would not be able to perform the x-ray until the following day. The record lacked documentation that the MD had been notified that x-ray would not be available until the following day. A nursing progress note, dated [DATE] at 6:11 p.m., indicated x-ray arrived and stated the results were a fracture of the right wrist. Family was present and took Resident to the ER. The x-ray results, dated [DATE] at 5:21 p.m., indicated, an acute, approximately 4.1 mm impacted, distal radial metaphyseal (Colles') fracture, with sagittal oriented fracture line extending to the radiocarpal surface (with approximately 2 mm diastases at the radiolunate articular surface). A corresponding hospital record, dated [DATE], indicated, .[family at bedside] very emotional and stated the patient has gone downhill badly this past week . She was assessed and diagnosed with acute hypoxemic respiratory failure from aspiration pneumonia, dysphagia which required a diet downgrade to nectar thick and puree, a right wrist fracture resulting from a fall, and rhinovirus infection. Family submitted a picture that was taken on [DATE] at 3:52 p.m. of Resident E's right wrist. The wrist and hand were observed to be swollen and bruised. There was a visible angled deformity that caused her wrist to appear abnormally crooked. A corresponding message with the picture indicated, .it's really hurt and she said that they haven't done an x-ray. It's black and blue . On [DATE] at 10:39 a.m., the Clinical Consultant provided a copy of a post-fall investigation. An undated Timeline/Chronology of Event and Communication. The fall occurred on [DATE] at 5:11 p.m. and order for a STAT x-ray was placed. Just two hours later, on [DATE] at 7:13 p.m., the x-ray company called to inform the facility they could not obtain x-ray until the next day related to the holiday, and that the MD was updated, however lacked documentation of MD recommendations. Throughout the evening/night, Resident E received routine pain medication. On [DATE] at 5:21 p.m., x-ray was completed, and results concluded fracture of the right wrist. Resident E was sent to the ER. Immediate steps taken after the fall were, neurological checks and first aide although the record lacked documentation of what first aid was given. The timeline was signed by the Director of Nursing (DON) but remained undated. A care plan meeting observation, dated [DATE], was completed by the SSD but lacked documentation of family concerns. An SSD progress note, dated [DATE] at 8:43 a.m., indicated the SSD met with Resident E's family members and a hospice representative on [DATE].family is concerned about resident's decline and would like to hold off on hospice so resident could participate in therapy at this time. The note lacked documentation of care concerns related to nursing staff. The grievance log was requested and provided by the DON on [DATE] at 2:50 p.m. and lacked documentation of care concerns related to nursing staff for Resident E surrounding her fall with fracture. Resident E's comprehensive care plans were reviewed. She had a care plan initiated on [DATE] and last reviewed/revised on [DATE]. The care plan indicated, .Resident has a history of a traumatic experience or event. History of spousal abuse, per resident. Diagnosis of PTSD. Currently on a medication regime to alleviate depression, and dementia with delusions. Voices frequent, unspecific concerns with staff, states they don't seem to know that her back and wrist are broken despite evidence to the contrary . which lacked revision to include interventions or goals to reflect the fact her wrist had indeed been broken. On [DATE] at 2:45 p.m., the DON provided a copy of current, but undated, facility policy titled, Ordering Lab Testing. The policy indicated, .STAT lab testing is prioritized over routine testing and will be done in an expedited and timely manner . results for STAT testing are reported within 4 hours On [DATE] at 2:50 p.m., the DON provided a copy of current facility policy titled, Fall Management Program Guidelines, reviewed [DATE]. The policy indicated, .even the most vigilant efforts may not prevent all falls ad injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury . any orders received from the physician should be noted and carried out On [DATE] at 2:50 p.m., the DON provided a copy of current facility policy titled, Resident Concern Process, reviewed [DATE]. The policy indicated, .to provide a process for handling, tracking, and resolving customer concerns to provide excellence in customer service . enter the concern using the desktop icon labeled Resident Concern Form all concerns should be entered electronically . we never ask a family member to complete the form. Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution . Residents and/or their representatives have the right to voice grievances/concerns or recommendations without discrimination of reprisal. The campus will investigate reported concerns to resolve those concerns This citation relates to Complaint IN00414005. 3XXX,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure a Foley catheter bag (part of a urinary drainage system) was kept off the floor for a resident with a history of urinary tract infections (UTI) for 1 of 3 residents observed for closed urinary drainage system (Resident 39). Findings include: On 1/30/24 at 1:41 p.m., Resident 39's record was reviewed. Her diagnoses included, but were not limited to UTI, neuromuscular dysfunction of the bladder, and diabetes mellitus (blood sugar disorder). Her Foley care plan, dated 1/24/24, indicated the problem started on 9/1/23. The care plan goal was to keep the resident free from adverse effects from catheter use. The approaches included observation for signs of complication such as UTI and assist with catheter care and change Foley catheter per physician orders. Her other care plan goals indicated she would have her activities of daily living (ADL) needs met by staff and be free from burning and pain that interfered with comfort level. Her physician orders indicated Macrobid (antibiotic)100 milligrams (mg) capsule, twice a day, on 1/22/24 and 1/23/24. The indication for use was UTI. On 1/29/24 at 10:43 a.m., Resident 39 was observed in bed with her eyes closed. Her Foley bag was on the floor. On 1/31/24 at 2:15 p.m., Resident 39 was observed in bed with her eyes closed. Her Foley bag was on the floor. On 1/31/24 at 2:29 p.m., Registered Nurse (RN) 78 observed Resident 39's Foley bag on the floor. She indicated it should not be on the floor because it can lead to contamination and UTI. Resident 39 had a history of UTIs, and she would replace the Foley bag. On 1/31/24 at 2:38 p.m., RN 78 with the assistance of the Associate Director of Nursing (ADON) replaced the Foley bag with a clean one. Resident 39's hospital records were provided by Director of Nursing (DON), on 2/1/24 at 10:17 a.m. The emergency department (ED) hospital notes, dated 9/11/23, indicated she was brought in with a Foley with altered mental status (AMS). Her urinalysis (UA) indicated abnormal results and she was given gentamicin 320 mg (antibiotic), IVPB (intravenous piggyback) for a UTI. The ED hospital notes, dated 9/29/23, indicated the plan was for her to be treated for a bacterial UTI. She was given ceftriaxone 1 gram (antibiotic), IVPB, and would wait for urine bacterial cultures. The medication was changed to gentamicin 320 mg, IVPB. The ED hospital notes, dated 1/7/24, indicated she had an altered mental status likely due to UTI and dehydration. Her UA came back with abnormal results. Orders to give gentamicin 320 mg, IVPB. Bolus (rapid influx of fluids) 1000 mL (milliliters) LR (lactated ringers) and NS (normal saline), with NS running 100 mL/hour. A current policy, titled, Urinary Catheter Care, dated 12/31/22, was provided by the DON, on 2/1/24 at 10:17 a.m. A review of the policy indicated, .Overview To prevent infection of the resident's urinary tract .Be sure the catheter tubing and drainage bag are kept off the floor 3.1-41(a)(2)

Based on record review, observation and interview, the facility failed to dispose of a controlled medication after it had expired for a resident (Resident 17) for 1 of 2 medication storage rooms observed. Findings include: On 1/31/24 at 10:14 a.m. an observation was made of the refrigerated controlled lock box on the 100 hall. Inside the box contained lorazepam (anti-anxiety medication) belonging to Resident 17. Resident 17 had an order, dated 12/28/23, for lorazepam intensol schedule IV concentrate 2 milligrams per milliliter (mg/ml). Administer 0.25 ml orally, 30 minutes prior to a.m. care for agitation/anxiety. The lorazepam lacked a date that it was opened. The bottle should have been discontinued after being opened after 60 days. The label indicated the medication expired on 12/10/23. At the time of observation, the director of nursing (DON) indicated she would destroy the lorazepam and order a new bottle for the resident. A policy titled, Medication Storage in the Facility, was provided by the DON on 1/31/24 at 1:42 p.m. It indicated, .Expiration date of dispensed medications shall be determined by the pharmacist at the time of dispensing . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to appropriately assist a resident with eating for 1 or 2 residents observed for assistance with eating (Resident 6) and failed to complete correct hand hygiene during dining services for 2 of 2 dining observations (Resident 6 and 16). Findings include: 1. On 1/29/24 at 11:51 a.m., CRCA (Certified Resident Care Assistance) 25 was observed to touch the arms of the dining room chair with both hands and sat down. She gave Resident 6 a drink, put a napkin on her lap, and gave her another drink. She was observed to touch the chair with both hands again, pulled on the back of her shirt, and started to assist Resident 6 with eating. She provided several bites of food and gave her drinks. She put her right hand in her lap, then used her right hand to give the resident a drink. With her left hand she pulled the back of her shirt down again, scratched her left knee, and gave the resident another drink. She wiped the resident's mouth with a napkin. She adjusted the resident's clothes and necklace with her left hand. She touched the napkin with both hands. She held the chocolate pudding cup in her left hand and served with right hand. She adjusted Resident 6's necklace again, then continued assisting her with eating. She scratched her left thigh with her left hand, then used both hands to wipe chocolate pudding off of resident's sweater. Then, CRCA 25 pulled down the back of her shirt again, held the pudding with her left hand and continued assisting her with eating. 2 On 1/29/24 at 11:46 a.m., Dietary Aide (DA) 55 was observed to bring clean, adaptive plates from the kitchen. She washed her hands, turned the faucet off with her bare hands, then dried with paper towels. On 1/31/24 at 11:36 a.m., RN 85 was observed to put her bare hands on the wheelchair handles to move Resident 6, then she provided wrapped silverware to Resident 16. She did not do hand hygiene between residents. On 1/31/24 at 11:56 a.m., Division Dining Services Support indicated to complete hand hygiene, the staff should be let the water run, dry hands on paper towels, and turn the water faucet off paper towels. A current policy, titled, Guideline for Handwashing/Hand Hygiene, dated 12/31/23, was provided by the Director of Nursing (DON), on 2/1/24 at 10:31 a.m. A review of the policy indicated, .Handwashing is the single most important factor in preventing transmission of infection All health care worker shall utilize hand hygiene frequently and appropriately .Before/after preparing/serving meals, drinks .Wash well for at least 20 seconds .Rinse hands well under running water .Dry hands with paper towel(s) .Turn off faucet with paper towel to avoid recontamination hands from the faucet 3.1-21(i)(3)

A. Based on observations, interviews, and record reviews, the facility failed to ensure a resident received appropriate care and services to prevent complications with his biliary drainage catheter (a thin, hollow tube which is inserted into the liver through the skin which collects bile that is drained from the liver), which resulted in actual harm when a full physician order set with care instructions for flushing the tube was not re-initiated after a hospital stay and the tube became obstructed for 1 of 1 resident reviewed for biliary drainage catheter (Resident 13). B.Based on interviews and record reviews, the facility failed to ensure neurochecks were assessed after a resident fell for 1 of 1 resident reviewed for post fall procedure (Resident 98). C. Based on observations, interviews, and record reviews, the facility failed to ensure a resident, (Resident 197) received a comprehensive admission assessment to address a PICC dressing for 1 of 3 residents reviewed for new admissions. D. Based on observations, interviews, and record reviews, the facility failed to prevent the development of MASD (moisture associated skin damage) for a resident who was at risk for skin breakdown, which resulted in the development of a new wound that was not assessed in a timely manner for 1 of 4 residents reviewed for general skin conditions (Resident 47) . E. Based on observations, interviews, and record reviews, the facility failed to prevent the potential for complications/harm when a resident did not receive bladder scans and in/out catheterization as ordered for 1 of 4 residents reviewed for catheters (Resident D). Findings include: A. On 10/18/22at 2:55 p.m., Resident 13 was observed as he sat in his wheelchair (WC) beside his bed. At that time, he indicated he had recently returned from the hospital. He indicated, I wish I could have a new body, and pointed to the right side of his abdomen. It hurts. He pulled up his shirt and his biliary catheter tube was observed, the drainage bag rested on the WC pad beside him with a dark yellow fluid observed inside. Resident 13 indicated he was having a lot of trouble with the tube. During a continuous observation on 10/19/22 from 1:45 p.m., until 1:56 p.m., the following was observed: At 1:45 p.m., Resident 13 was observed as he sat in his WC beside his bed. His call light was illuminated at this time, and he indicated he wanted to lay down. The biliary drainage bag rested on his lap and contained a dark yellow fluid. At 1:47 p.m., Registered Nurse (RN) 8 answered Resident 13's call light and indicated she needed to get some assistance to transfer him into bed as she believed he was a two-person assist. At 1:49 p.m., RN 8 and Certified Nursing Assistant (CNA) 24 entered the room. RN 8 indicated Resident 13 had a lot of tubes, so they preferred to have him assisted by two people to not pull on the tubes. He has oxygen, a urinary catheter, and a biliary drain. CNA 24 indicated Resident 13 had been incontinent of bowel and she needed supplies to clean him up. RN 8 left the room to get supplies as requested. At 1:52 p.m., with RN 8 out of the room, CNA 24 positioned Resident 13 in his WC beside his bed. She removed his oxygen tubing, unlatched the catheter drainage bag from under the WC and tossed it onto the floor. CNA 24 stood behind Resident 13's WC, put her arms under his arm pits and assisted him to stand. He rocked forward several times, then shakily stood to his feet. As he stood his biliary drainage bag slid off his lap and hung to his knees. CNA 24 had to let go of one of Resident 13's arms to move around the WC which remained between them so that she could position herself in front of him and help him pivot to sit on the bed. As he turned, the biliary drainage bag was on the opposite side of the bed, and CNA 24 reached over and pulled it to the other side of the bed before Resident 13 sat on it. At 1:56 p.m., RN 8 re-entered the room and indicated, oh you already got him in bed. During an interview on 10/19/22 at 1:57 p.m., RN 8 indicated, usually transfer need to be completed with a gait belt in place in case they become unsteady. Resident 13 had just returned from the hospital and had not been evaluated by therapy yet, so he should have two people assist with a transfer, also because of all his tubes. During an interview on 10/19/22 at 1:57 p.m., CNA 24 indicated, before Resident 13 went to the hospital he was a 1-person assist so she thought it was ok to go ahead and transfer him. She indicated she didn't need a gait belt because she, had a good hold of him, even though she had to let go of him to come to the front of the WC, and to reposition his tubing. On 10/20/22 at 9:30 a.m., Resident 13 was observed. He sat in his WC beside the bed. There was a very pungent odor around him and he indicated he wanted to get laid down and cleaned up. He indicated he had a lot of pain and pointed to the area where his biliary drain was. He lifted his shirt. The dressing around the tube was observed at this time. There was a dark yellow/greenish stain at the center of the dressing around the tube, which spread outward in a more pink/reddish color. Resident 13 put his head in his hands and indicated, it hurts a lot. There was no date or initial on the dressing, and there was a white patch next to the dressing. On 10/20/22 at 10:26 a.m., RN 23 was notified of the drainage noted to Resident 13's dressing. At that time, she indicated, she was not familiar with Resident 13, she did not usually work that floor, she had just been pulled to that floor earlier that morning. RN 23 indicated she had put a lidocaine patch (a topical pain patch) on but that was it. She reviewed Resident 13's orders at this time and indicated there were no additional orders related to his biliary catheter besides monitor the drainage output and an order to cleanse the tubing. On 10/20/22 at 10:28 a.m., RN 23 entered Resident 13's room to assess the site. She observed the drainage around the tube, and indicated it was green in color, and more soiled than it should be. It appeared the dressing needed to be changed. Resident 13 indicated he was in pain, and RN 23 indicated she would bring him something for the pain. During an interview on 10/20/22 at 11:10 a.m., RN 23 indicated she had spoken with the ADON (Assistant Director of Nursing), who had called the NP (Nurse Practitioner). Resident 13 had been on several courses of antibiotics recently, so she was told to remove the dressing and observed the site for further signs/symptoms of infection. She prepared a medication cup of Resident 13's PRN (as needed) pain medication. On 10/20/22 at 11:30 a.m., (after allowing time for Resident 13's pain medication to become effective), RN 23 entered the room with supplies for a dressing change. She had a printed current physician order which indicated, cleanse tube area around tube with antibacterial soap and water or 1/2 water 1/2 hydrogen peroxide mixture daily. She indicated there were not specific orders or instruction for the dressing change, the order she had was the only order related the care/treatment of the biliary catheter beside monitoring for output. RN 23 failed to notify the physician and/or get clarifying orders for the dressing change before proceeding. When asked if she should notify the physician, she indicated, she had already spoken to the ADON. During the dressing change, which lasted approximately 30 minutes, Resident 13 expressed that he was still in a great deal of pain, especially as pressure, tugging, or wiping was completed around the site and to the tube. He clenched the bedsheets in his fists, he grimaced his face, and at one point, put his hand out to stop RN 23 and asked for a minute to catch his breath. The insertion site was observed have some redness around the tube, and Resident 13 indicated it was very tender. RN 23 finished the treatment, cleaned up her supplies and left the room. During an interview on 10/20/22 at 12:02 p.m., Resident 13 indicated the tube had been having a lot of trouble lately, he was not sure how often it was changed or should be changed. On 10/21/22 at 9:43 a.m., Resident 13 was observed as he sat in his WC beside his bed. He indicated he was feeling, ok, but still tired and in pain. The dressing from the previous day was observed in place, however there was a yellowish discharge noted to the center of the dressing surrounding the tube. During an interview on 10/21/22 at 11:26 a.m., RN 22 indicated he was not sure about Resident 13's dressing, but he had already been down to flush the catheter earlier that morning. When asked about the orders for flushing, RN 23 reviewed Resident 13's order set and indicated there was no order for flushing, and he had not noticed it before. RN 23 indicated it was important to flush the tube because if it was not, it could cause a build-up and that created pain for the resident. RN 23 indicated it appeared the flush orders had not been re-activated after his hospitalization , but it was something they had been doing before. On 10/21/22 at 11:38 a.m., RN 23 contacted the NP and received a new order to flush the biliary catheter twice a day, as before. During an interview on 10/24/22 at 10:33 a.m., the Medical Director (MD) indicated he was Resident 13's attending physician in the facility. Resident 13 had a chronically placed biliary catheter because he was a poor surgical candidate. With any type of tubes such at the biliary drain or urinary catheter, it was important to understand and adhere to transfer and positioning protocols to ensure the tubes aren't tugged on and become dislodged. Additionally, it was important to flush the tube to ensure it was patent and draining bile properly so that it did not get stopped up which could cause infection and would build up pressure also causing pain. On 10/19/22 at 10:00 a.m., Resident 13's medical record was comprehensively reviewed. He was a long-term care resident, admitted in 2019 with active diagnoses which included, but were not limited to; sepsis, unspecified severe protein-calorie malnutrition, urinary tract infection, other mechanical complication of bile duct prosthesis, displacement of bile duct prosthesis . He had physician orders which included, but were not limited to; a. cleanse tube area around tube with antibacterial soap and water or 1/2 water 1/2 hydrogen peroxide mixture daily, daily started 8/3/22. b. monitor biliary drain output every shift, started 4/11/22 The record lacked documentation of physician orders to monitor the dressing/incision site, and/or orders to flush for obstruction prevention. A nursing progress note, dated 5/1/22 at 7:40 a.m., indicated Resident 13's biliary tube had large amounts of green colored drainage. Resident was complaining of pain and discomfort. There was drainage at the insertion site of the tube, but no drainage was coming through the tube. 911 was called for transport to hospital. The corresponding hospital admission H&P (history and physical) dated 5/27/22 indicated, .apparently, the biliary drain had been pulled out approximately 6 to 8 cm [centimeters]. Patient does not know how this happened. Staff was unaware until today. Patient is having abdominal pain. He is unable to tell me how long he had been having abdominal discomfort or unwilling to elaborate on history. Apparently had a recent hospitalization between 5/1 and 5/7 for abdominal pain and biliary drain malfunction, which was replaced by IR [interventional radiology] on 5/3/22. He has chronic biliary drain secondary to common bile duct stricture from chronic pancreatitis. In either case upon my assessment, patient's only complaint is abdominal pain . I presume he does not want to communicate at present time considering his pain A nursing progress note, dated 5/24/2022 at 10:45 a.m., indicated, .received call from [Specialist Medical Doctor] regarding [Resident 13's] Biliary Drain. The physician explained he should have a routine exchange every 3 months with daily maintenance of 10 ml [milliliters] flush . he did not plan any more invasive procedure and [Resident 13] will have his biliary drain long term On 8/3/22 Resident 13 was sent back from the hospital after a routine biliary exchange with the following instructions, . Patient Education: a biliary catheter is a tube that drains bile. The tube goes through your skin and into your liver. It drains bile out of the body into a bag . Treatment/Procedure/Equipment (Home Care Orders) Flushing means rinsing your tube. This prevents it from getting blocked. Flush your tube 2 times a day with normal saline 10 ml, vigorously forward, without aspirating. Clean your tube/area around tube with antibacterial soap and water or 1/2 water 1/2 hydrogen peroxide mixture 0-1 times a day A nursing progress note dated 9/22/22 at 9:04 a.m., indicated Resident 13 had a fever and was sent to the ER and he was readmitted on [DATE] after being treated for sepsis, secondary to a UTI (urinary tract infection). On 10/04/22 at 1:29 p.m., Resident 13 was seen by the NP for follow up after his recent re-admission to address his common bile duct stone and biliary drain, which had been replaced 9/25. The NP gave instructions/orders to use sodium chloride 0.9 % (flush) injection syringe with alcohol swab cap, and to flush biliary drain with 10 cc two times a day However, the record lacked documentation that the flush orders had been initiated. On 10/16/22 at 7:15 p.m., Resident 13 was sent to the ER for after it was noted to have dislodged. The corresponding hospital discharge summary dated 10/16/22 indicated Resident 13's biliary drainage tube had become obstructed and was replaced. Upon his return, the record continued to lack documentation of physician orders to monitor the dressing/incision site, and/or orders to flush for obstruction prevention. A nursing progress note dated 10/22/22 at 2:25 p.m., indicated Resident 13's biliary tube had become dislodged again, and was sent to the ER. The corresponding hospital summary dated 10/22/22 indicated Resident 13 had been treated for an obstructed biliary drainage tube. here for evaluation of drainage around the biliary tube site that began this morning. Patient had this drain repositioned about 5 days ago and this morning noticed that it looked out of place and was draining, area is painful . attempted to contact Wellbrooke with no answer . tube replaced. The patient was given return precautions and instructions for follow up . instructions from care team: his biliary tube was replaced by IR today. Please be sure it doesn't get tugged on, pulled on, etc to avoid displacement again Resident 13's comprehensive care plans were reviewed and lacked documentation of a care plan for his biliary catheter. The record lacked documentation of orders or instructions for routine exchange. The record lacked documentation the physician had been notified of pain during the dressing change observation. On 10/19/22 at 1:48 p.m., the Director of Nursing (DON) provided a copy of current facility policy titled, Guidelines for Resident Transfers and Assistance, dated 5/10/17. The policy indicated, .to ensure the safety of residents and staff when performing mobility/transfer tasks . upon admission the admitting nurse and/or therapy department shall determine the type of transfer device needed as well as the amount of assistance required to assist with mobility based on observation and data collection. The following area will need to be observed: cognition, weight being status, resident's weight, upper and lower body strength, trunk stability, skin condition and mobility status During an interview on 10/25/22 at 10:28 a.m., the DON indicated there was no specific skills check off for nurses to complete related to biliary catheter care, however, if there was a question or concern with the biliary catheter system or procedure, the nurse should not continue until orders or treatments were confirmed with the MD. At this time she provided a copy of current facility policy titled, Biliary Drain Site Care and Dressing Change, dated 3/18/22. The policy indicated, Keep the skin around the drain clean and covered with 4 x 4 gauze dressing. The dressing should be changed per order by physician .DON provided last copies and indicated no skills check of for biliary tube .carefully remove the old dressing to avoid pulling on the drain. Note: soreness, redness, drainage or odor at the sire where the drain goes into the skin. If any of these signs are noted, change the dressing more frequently and contact the physician for further orders 37981 B. On 10/20/22 at 9:56 a.m., Resident 98 record was reviewed. She was admitted on [DATE]. A progress note, on 10/7/22 at 7:00 p.m., Registered Nurse (RN) 12 charted she was notified Resident 98 was on the floor. She was found face-down on the right side of her bed, between the bed and the window. Resident 98 was sitting in bed while eating dinner, when she slid out of bed and onto the floor. RN 12, an LPN (unidentified), and three RCAs (resident care assistants) (unidentified) lifted the resident back into bed using a Hoyer pad. Resident 98 had no apparent injuries. No loss of ROM (range of motion) or deformity noted to any extremity. She was PERRLA (pupils equal, round, reactive to light and accommodation). Her neuro status was at baseline. The Nurse Practitioner (NP), the DNS (Director of Nursing Services), and the family notified. A voicemail was left for family, requesting a return phone call. A fall mat was placed on the right side of bed and the bed was placed in position to facilitate safety. Her call light was within reach. On 10/7/222 at 9:25 p.m., RN 30 charted Resident 98 was encouraged and educated to sit up in a chair for meals to assist with ongoing safety related to prior fall. On 10/12/22 10:50 a.m., the Social Services Director (SSD) charted the initial care plan meeting was with herself, therapy, nursing, and the resident's daughter. The resident declined to attend. Discussion indicated the resident was refusing any out of bed activities due to fears of falling and statements of, I'm tired. Currently, on a low air-loss mattress and working with PT/OT (physical therapy/occupational therapy). She was refusing to work on any out of bed activities with them. She was total care for bed mobility and all ADLs and used a Hoyer lift. On 10/13/22 at 11:08 a.m., the DNS charted that the Interdisciplinary Team (IDT) met. Resident 98 was found on floor beside her bed. She had been on a low air loss (LAL) mattress, and she rolled off the side of bed. No injury was noted. Interventions were updated to include keeping bed at lowest position to facilitate safety and use of mat beside her bed. On 10/20/22 at 12:39 p.m., Resident 98's chart was reviewed. She was admitted on [DATE]. Resident 98's diagnoses included, but were not limited to, pressure ulcer of sacral region, stage 4 (full thickness skin loss with exposed bone, tendon or muscle) (primary diagnosis), protein calorie malnutrition, type 2 diabetes (blood sugar disorder), morbid (severe) obesity due to excess calories, necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin), acute candidiasis (yeast infection) of vulva and vagina and diarrhea (loose or liquid stool). Resident 98's fall care plan goal indicated she would be free from falls with major injury. Neuro checks were provided by the Assistant Director of Nursing Services (ADNS), on 10/19/22 at 1:31 p.m. Upon review the neuro checks were determined to be incomplete. a. The initial neuro check was completed on 10/7/22 at 7:00 p.m. b. The second neuro check after 15 minutes was completed on 10/7/22 at 7:15 p.m. c. The third neuro check after 15 more minutes was completed on 10/7/22 at 7:30 p.m. d. The fourth neuro check after 15 more minutes was completed on 10/7/22 at 7:45 p.m. e. The first neuro check after 30 more minutes was completed on 10/7/22 at 8:15 p.m. f. The second neuro check after 30 more minutes was completed on 10/7/22 at 8:45 p.m. g. The third neuro check after 30 more minutes was completed on 10/7/22 at 9:15 p.m. h. The fourth neuro check after 30 more minutes was completed on 10/7/22 at 9:45 p.m. i. The remaining neuro checks had dates and times but the assessments were blank: 1. On 10/7/22 at 10:45 a.m., (meant to be 10:45 p.m.) the assessment was blank. 2. On 10/7/22 at 11:45 p.m., the assessment was blank. 3. On 10/8/22 at 12:45 a.m., the assessment was blank. 4. On 10/8/22 at 1:45 a.m., the assessment was blank. 5. On 10/8/22 at 5:45 a.m., the assessment was blank. 6. On 10/8/22 at 9:45 a.m., the assessment was blank. 7. On 10/8/22 at 1:45 p.m., the assessment was blank. 8. On 10/8/22 at 5:45 p.m., the assessment was blank. 46414 C. On 10/18/22 at 2:55 p.m., Resident 197 was observed sitting up in her wheelchair. She was alert and oriented to person, place, and time. Resident 197 indicated she had a dressing on her right arm from a PICC (peripherally inserted central catheter). Resident 197 indicated the insertion site had become infected, and she was put on antibiotics at the hospital which she continued upon her arrival to the facility on [DATE]. The dressing was observed at this time. It was a bordered foam dressing, dated 10/12/22. Resident 197 indicated that the dressing had not been changed since she had gotten to the facility. On 10/18/22 at 3:00 p.m., RN (registered nurse) 12 and RN 13 came to resident 197's room to assess the dressing to resident 197's right arm. RN 12 indicated, since it was a PICC dressing site, they usually did not remove the dressing for up to 5 days. The dressing had been in place for 7 days. RN 12 removed the old dressing. The site was crusted over with no signs or symptoms of an infection. RN 12 indicated she would clean it and place a new dressing on resident 197's right arm. On 10/19/22 at 9:33 a.m., a comprehensive record review was completed for Resident 197. She had the following diagnoses which included, but were not limited to pulmonary fibrosis, cerebral ischemia, morbid obesity, vitamin B deficiency, vitamin D deficiency, hyperlipidemia, abnormal weight loss, diverticulosis of large intestine, essential hypertension, weakness, edema and adult failure to thrive. A nursing progress note dated 10/13/22 at 5:45 p.m., included an admission assessment of Resident 197 which included a complete head-to-toe assessment that did not make note of the PICC line dressing. An admission nursing Observation assessment was completed on 10/14/22. The dressing was not documented on the skin assessment. The record lacked documentation of physician orders for instructions/care for the dressing to her right arm. Although Resident 197 had an active physician order for Keflex (an antibiotic medication) 500 mg (milligrams) four times daily which ended on 10/16/22, there was no indication or diagnosis for it use. The record lacked documentation that neither a baseline or comprehensive care plan had been initiated to address the care requirements for the dressing on her arm. D. On 10/24/22 at 10:37 a.m., a comprehensive record review was completed for Resident 47. He had the following diagnoses but not limited to muscle weakness, cardiac murmur, nausea with vomiting, difficulty in walking, unsteadiness on feet, amnesia, pain, abnormal weight loss, cognitive communication deficit, generalized anxiety disorder, painful urination, and aftercare following joint replacement surgery. On 6/27/22 at 12:30 p.m., an Event document was created secondary to Resident 47 having sustained a laceration that measured 1.5 cm (centimeters) long by 1.5 cm wide to his left buttock. The Event note indicated the laceration was acquired due to moisture. Resident 47 had a physician's order dated 6/27/22 for Calmoseptine (methol-zinc oxide) 0.44-20.6% ointment three times daily, apply to buttocks with each episode of incontinence following perineal care. The record lacked further assessment of the area. On 10/24/22 at 2:55 p.m., the Assistant Director of Nursing (ADON) provided a record of a wound management note created 10/24/22 at 12:29 p.m. However, the documentation was backdated to 6/27/22. The late Event Note indicated on 6/7/22 the wound measured 1.5 cm long by 1.5 cm wide. On 7/5/22, the wound measured 0.5 cm long by 0.5 cm wide. The record lacked further documentation related to the wound on resident 47's left buttock. Resident 47's care plan lacked information related to the left buttock wound. E. On 10/18/22 at 10:31 a.m., Resident D was observed sitting up in her wheelchair. On 10/18/22 at 2:42 p.m., a comprehensive record review was completed for Resident D. She had the following diagnoses, which included, but were not to, hemiplegia and hemiparesis (paralysis/weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (unable or trouble speaking) following cerebral infarction, vitamin D deficiency, hyperlipidemia, restless leg syndrome, essential hypertension, constipation, retention of urine, urinary tract infection and weakness. Resident D admitted with an indwelling catheter on 10/5/22, but later received and ordered to discontinue the use of the catheter on 10/12/22 with instructions to complete a bladder scans every 8 hours and as needed if unable to void and in/out catheterize if residual in the bladder was greater than 250 milliliters (ml). The record lacked documentation that Resident D received bladder scans as ordered on 10/13/22, 10/14/22, 10/16/22, and 10/17/22. On 10/14/22 between 7:10 p.m. and 10:00 p.m., Resident D was noted to have 270 ml recorded from the bladder scan. The record lacked documentation indicating that an in and out catheterization was completed due to greater than 250 ml of residual. On 10/15/22 between 6:00 a.m. and 7:00 a.m., Resident D was noted to have 278 ml of residual urine recorded from the bladder scan. The record lacked documentation that an in and out catheterization was completed for Resident D. The record lacked that her bowel/bladder comprehensive care plan had been revised to reflect the removal of the catheter and bladder scans. On 10/24/22 at 12:12 p.m., the Administrator (ADM) provided a copy of current facility policy titled, Comprehensive Care Plans. The policy indicated, .Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan and .Comprehensive care plans need to remain accurate and current, new interventions will be added and updated during CCM meeting and newly recognized problems will have a care plan developed and added after CCM meeting On 10/25/22 at 10:28 a.m., the DON provided a copy of current facility policy titled, Physician- Provider Notification Guidelines, reviewed 12/1/21. The policy indicated, .to ensure the resident's physician or practitioner (may include NP PA or clinical nurse specialist) is aware of all diagnostic testing results or changes in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care This Federal tag related to Complaint IN00392899. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure a resident was not outside smoking at a smoke-free facility and did not sign out for a leave of absence when leaving the building for 1 of 1 resident reviewed for smoking (Resident 32) and failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed for accidents (Resident 14, 21, and 32). Findings include: 1. On 10/18/22 at 4:06 p.m., Resident 32 was observed outside the facility building smoking a cigarette. She was at the edge of the parking lot almost behind a car. No staff were with her. Resident 32 indicated she was a nurse and was alert and oriented x 4 (person, place, time, and event). She was not wearing a coat and indicated she needed to have her daughter bring her one. The temperature outside was 42 degrees. She was observed going directly back into the facility. Her smoking materials were not safely stored by the facility because the facility was smoking-free according to the Director of Nursing Services (DNS) during entrance conference. On 10/19/22 at 1:31 p.m., the receptionist indicated the Leave of Absence (LOA) books were at the nurse's station. On 10/19/22 at 1:37 p.m., Licensed Practical Nurse (LPN) 10 provided the [NAME] 1 LOA book where Resident 32 resided. A review of the LOA book, including every page and the front and back flaps revealed Resident 32 did not sign out LOA. She did not have a sign-out sheet in the LOA book. On 10/19/22 at 1:51 p.m., RN 23 indicated there was only one LOA book for the [NAME] 1 halls. On 10/19/22 at 1:59 p.m., Resident 32 indicated she had not signed out LOA when leaving the building. She indicated she was in the parking lot, smoking after lunch today. She usually takes a couple of puffs and discards the cigarette. On 10/19/22 at 2:07 p.m., LPN 10 indicated she was aware Resident 32 left the unit and she only found out a week ago that she was smoking. Resident 32 did not tell the staff each time she went out to smoke. She was non-compliant with it. She didn't sign out. LPN 10 thought that if Resident 32 signed out in the LOA book and left the property it was ok if she smoked. On 10/20/22 at 3:03 p.m., Resident 32's chart was reviewed. A progress note, dated 10/19/22 at 2:51 p.m., the Director of Social Services (DSS) indicated that Resident 32 was seen outside on facility property smoking on 10/19/22. The DSS and ADNS went to the resident's room to ask if she had cigarettes. She initially said, no. When she was told she was seen smoking, she indicated she did have smoking materials. The DSS asked the resident if she would provide her cigarettes and lighter for her family to pick up. She agreed and allowed the DSS to search her belongings for additional smoking supplies. None were found. The DSS asked how she was procuring her cigarettes, Resident 32 stated she ordered them off of Amazon. She was offered a nicotine patch, she refused stating she was allergic to the adhesive. The Nurse Practitioner (NP) will order nicotine gum to assist with cravings. Her family was notified that Resident 32 had smoking supplies in building and they will need them picked up. A new care plan was created on 10/20/22 at 3:30 p.m. The problem indicated Resident 32 demonstrated non-compliance with physician orders and/or plan of care as evidenced by smoking on facility property. The goal was stated as Resident 32's preferences would be honored to the extent that non-compliance with physician orders will not result in injury to self or others. On 10/19/22 at 3:43 p.m., Resident 32's record was reviewed. She was admitted [DATE]. Her smoking status indicated she was a former smoker. Her diagnoses included, but were not limited to, osteomyelitis (bone infection) of vertebra (spine), sacral and sacrocoocygeal (sacrum and coccyx), not facility acquired stage 4 pressures ulcers of the sacral region and left hip, and other chronic pain. Her medications included, but were not limited to, baclofen (muscle spasms), Dakin's solution 0.125% (treatment for stage 4 pressure ulcers), jantoven (warfarin) 4 mg (anticoagulant), and oxycodone-acetaminophen 5-325 mg (for pain relief). On 10/19/22 at 2:13 p.m., the Assistant Director of Nursing Services (ADON) indicated he was not aware Resident 32 was a smoker. The facility had no smoking assessment or smoking care plan because they are a smoke-free facility. They will probably request the family to pick up the smoking materials. Until then, we could keep them in the med cart. Smoking could have been an issue for her because of her pressure wounds she arrived with. On 10/19/22 at 2:47 p.m., the DNS indicated Resident 32 stated she had no cigarettes or matches or lighter. Resident 32 should not have put herself and others at risk with smoking. The DNS indicated the resident should have signed-out before leaving the building. On 10/19/22 at 3:05 p.m., the DNS indicated a note was put in Resident 32's chart. The DNS indicated the resident told her, she was ordering cigarettes on Amazon. The Director of Social Services Director (DSS) searched the resident's room. The resident was offered a nicotine patch and she refused it. The facility will be ordering nicotine gum for her. It should arrive tomorrow. Her daughter was coming to take all her money and bill fold. Resident 32 indicated to the DSS that she was caught smoking. 46414 2. On 10/17/22 at 2:18 p.m., Resident 14 was observed lying in bed. He was able to answer yes and no questions only. His hands were tremoring during the observation. His bedside table was not within reach. He did not have an indwelling catheter as ordered. On 10/18/22 at 9:26 a.m., Resident was observed lying in bed. His bedside table was not within reach. Resident 14 able to answer yes and no questions. His hands were observed to be tremoring. On 10/18/22 at 2:52 p.m., a comprehensive record review was completed. Resident 14 had the following diagnoses but not limited to schizophrenia, parkinson's disease, UTI (Urinary Tract Infection), PE (Pulmonary Embolism), dementia, mood disorder, psychotic disorder, anxiety, hypothyroidism, vitamin deficiency, hyperlipidemia, bladder neck obstruction and reflux uropathy, benign prostatic hypertrophy, unspecified fall, and age-related cognitive decline. Resident 14 admitted to the facility on [DATE]. He admitted with an indwelling catheter. Prior to discharging to the facility, the resident's healthcare representative expressed concerns about resident having an indwelling catheter, indicating that he would pull the catheter out. On 10/18/22 at 1:35 p.m., during an interview with the DNS, she indicated that prior to resident admitting, he had hand restraints at the hospital due to attempting to pull his catheter out at the hospital. The DNS informed the hospital that resident would have to be restraint free for at least 24 hours before he could be admitted to the facility. A progress note dated 9/20/22 at 7:30 p.m., indicated that resident 14 was observed lying in bed with his indwelling catheter on the floor. Inside the bathroom, the nurse noticed blood in the bathroom along with blood-soaked clothing. Resident 14 was bleeding from his urethra. The nurse documented that resident 14 was observed to have an abrasion to the top of his head measuring 3.0cm by 2.0 cm. Resident 14 was sent to the hospital for evaluation. Resident 14's discharge paperwork indicated that the emergency room staff questioned a fall due to the abrasion on his head, therefore, completed a CT scan of his head. The emergency room phoned the nurse at the facility, and she was unsure if resident 14 fell or not. He was found in bed and bleeding was observed in the bathroom. The emergency room replaced the indwelling catheter and sent resident 14 back to the facility. On 10/20/22 at 11:05 a.m., during an interview with the ADNS, he indicated that resident did not have a fall. He indicated that resident did have an abrasion to his head. The record lacked an event or investigation in the origin of the abrasion on his head. The ADNS indicated that the abrasion should have had an event and investigation to find out what caused the abrasion on his head. On 10/20/22 at 11:20 a.m., the ADNS provided a copy of an event with the creation date of 9/20/22 at 7:30 p.m. The event was recorded on 10/20/22 at 10:57 a.m. On 10/21/22 at 11:13 a.m., during an interview with the ED and DNS regarding resident 14's abrasion. The ADNS providing a copy of an event that was completed on 10/20/22 and a lack of documentation into the origin of the abrasion. No further information was provided. 3. On 10/24/22 at 9:59 a.m., Resident 21 was observed sitting up in her wheelchair and leaning to her right side, resting on the arm of the chair. Resident was not wearing a wander guard. RN 12 assessed resident 21 for a wander guard and could not find one on her person or wheelchair. RN 12 indicated that she would get one and place it on resident 21. On 10/24/22 at 10:12 a.m., a comprehensive record review was completed for resident 21. Resident 21 had the following diagnoses but not limited to chronic obstructive pulmonary disease, hypertension, hypertensive heart disease with heart failure, hypothyroidism, vitamin B deficiency, other specified depressive disorders, major depressive disorder, restless leg syndrome, peripheral autonomic neuropathy, vascular dementia, insomnia, altered mental status, difficulty in walking, repeated falls, lack of coordination, abnormal weight loss, age-related physical debility, and chronic pain. A quarterly nursing observation dated 9/28/22 indicated that resident was at risk for elopement due to a history of elopement seeking, attempts to leave the campus, exhibits periods of pacing, agitation or wandering toward an exit, and resident wanders. Resident 21 had orders to have a wander guard and to check placement and function of the device. Resident 21 had a care plan dated 4/14/22, addressing risk for elopement. An intervention dated 4/12/22 indicated for resident 21 to have a wander guard and to check placement and function as ordered. Observed an elopement binder at the front desk. It included a profile of resident 21. The picture was pixilated and resident 21's face was unrecognizable. Included in the binder were other residents who were no longer residing in the facility. A policy titled Guidelines: Elopement Risk Assessment and Prevention date 9/28/16 was provided by the DNS on 10/25/22 at 2:06 p.m., it indicated .each resident will be assessed for elopement risk upon admission, quarterly and with change in condition. An elopement risk binder with be kept at a secure location known to staff that contains a resident elopement risk profile about each resident who may be at risk for elopement. Facilities with wander alert detection systems should place a wander alert bracelet on the resident . 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure enough medication was administered to manage pain resulting in harm when the resident was in acute pain and yelling out during a wound treatment for 1 of 2 residents reviewed for pain management (Resident 98). Findings include: On 10/20/22 at 9:56 a.m., Resident 98 record was reviewed. She was admitted on [DATE]. A progress note, dated 10/6/22, indicated Resident 98 was seen by the Nurse Practitioner (NP) 28 at 10:41 a.m. Her findings included, but were not limited to, the resident was seen for an initial visit related to an infected sacral wound. The resident was in the hospital due to a fall and developed the sacral wound. Went to the extended care facility (ECF) for rehabilitation, her wound got worse, she went back to the hospital but refused a surgical debridement. She was admitted to this facility with 2 intravenous (IV) antibiotics for ongoing wound care. The resident did not have osteomyelitis. Upon examination, resident indicated minimal pain, no fever, cough, or shortness of breath. On 10/9/22 at 11:47 a.m., Registered Nurse (RN) 23 charted Resident 98 had a yellow running discharge from her vagina while changing her dressing. Resident complained of pain and itching. She notified the Nurse Practitioner (NP) 28 and received orders for Diflucan (antifungal) 100 mg daily for 7 days and Nystatin (antifungal) cream. On 10/13/22 at 11:08 a.m., the DNS charted that the Interdisciplinary Team (IDT) met. The wound to Resident 98's sacrum was reviewed. Resident was admitted with a Stage 4 ulcer with osteomyelitis (bone infection). She completed all the IV antibiotics per the physician's orders. The wound continued to have moderate amounts purulent drainage. The wound bed was 75% slough (dead tissue that needs to be removed) and 25% necrosis (dead tissue). Her treatments continued with Dakin's solution (strong, topical antiseptic) and ABD pad per her physician's orders. The peri-wound was macerated (tissue broken down at the cellular level) due to very frequent loose jelly like stools. Resident continues on low air loss (LAL) mattress and multivitamins. A new order was received to give Pro-Mod (oral protein supplement) and Ensure (nutritional supplement). On 10/20/22 at 12:54 p.m., Resident 98's physician's orders were further reviewed. Starting on 10/04/22, give 1 tablet of hydrocodone-acetaminophen 5-325 mg PRN for pain 4 times a day. This order was open ended. Starting on 10/4/22, the order indicated to encourage the resident to turn and reposition while in bed three times a day from 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 6:00 a.m. This order was open ended. Starting on 10/4/22, a daily pain assessment should have been completed between 7:00 a.m. to 3:00 p.m. This order was open ended. Starting on 10/4/22, a pressure reducing mattress and pressure reducing cushion to Resident 98's wheelchair. These orders were open ended. Starting on 10/5/22, cleanse sacral wound with wound cleanser or normal saline (NS), apply skin prep to peri-wound, apply Dakin's moistened gauze and cover with island dressing as needed (PRN). Change when dressing becomes dislodged or soiled. Resident 98's diagnoses included, but were not limited to, pressure ulcer of sacral region, stage 4 (full thickness skin loss with exposed bone, tendon or muscle) (primary diagnosis), protein calorie malnutrition, type 2 diabetes (blood sugar disorder), morbid (severe) obesity due to excess calories, necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin), acute candidiasis (yeast infection) of vulva and vagina and diarrhea (loose or liquid stool). On 10/20/22 at 12:39 p.m., Resident 98's care plans were reviewed. The care plans were dated 10/12/22. Resident had a sacral pressure ulcer, stage IV. The staffing approaches included, but were not limited to, administer analgesics (pain relief) per MD (medical doctors) order, assess and record the condition of the skin and surrounding skin of the pressure ulcer, observe for and report signs of pain related to pressure, encourage fluids unless contraindicated, and observe and report signs of infection (like localized pain, redness, swelling, tenderness, drainage, odor, and fever). Resident was at risk for skin breakdown related to decreased mobility, weakness, incontinence, chronic venous insufficiency (decreased blood flow), necrotizing fasciitis, and history of vaginitis. The staffing approaches included, but were not limited to, avoid shearing skin during positioning, turning, and transferring, pressure reducing mattress to the bed, pressure reducing cushion to the wheelchair, encourage and assist to turn and reposition for comfort and as needed, use moisture barrier product to perineal area as needed, float heels as needed, conduct weekly skin assessment and pay particular attention to bony prominences, keep linens clean and dry, keep resident as clean and dry as possible, minimize skin exposure to moisture, and use a lifting device as needed for bed mobility. Resident demonstrated hearing loss. The staffing approaches included, but were not limited to, hearing aids as indicated, refer to Speech Therapy for evaluation of need for communication device as appropriate, refer to physician to assess for wax buildup, and monitor for changes in hearing, refer to audiologist for a hearing evaluation as needed, ensure resident is near the activity leader/speaker during activities of interest and care-giving, use written communication as needed, and communicate with resident in a clear, concise manner. Increase volume to ensure resident receives the message. On 10/20/22 at 4:48 p.m., LPN 14 indicated Resident 98's dressing would be changed during the night due to her soiling it after a bowel movement (BM). He would be checking her around midnight. On 10/21/22 at 12:02 a.m., LPN 14 provided hydrocodone-acetaminophen 5-325 mg for Resident 98. At first, she refused. After a sip of cold water, she accepted the pain medication. He was talking loudly directly in her ear because she was hard of hearing (HOH). The resident was able to hear and understand him. He asked her to drink all the water so the medication would work faster. Resident 98's response was, please don't hurt me. She had a worried look on her face. On 10/21/22 at 12:34 a.m., LPN 14 indicated he did not do wound measurements. The wound team did the wound assessments and measurements. On 10/21/22 at 12:35 a.m., Resident Care Assistant (RCA) 29 was observed in in Resident 98's room putting on gloves. On 10/21/22 at 12:36 a.m., LPN 14 indicated he would be discarding the soiled dressings and lightly salt the wound with 4 x 4 Dakin's, then lightly pack the wound with 4 x 4 Dakin's-soaked gauze and use abdominal (ABD) pads and tape. On 10/21/22 at 12:39 a.m., RCA 29 tried to tell Resident 98 we were going to change your dressing. Resident 98 indicated she could not hear her. RCA 29 did not clarify or speak directly into her ear. She stopped talking to her. On 10/21/22 at 12:40 a.m., 12:42 a.m., 12:43 a.m., and 12:44 a.m., Resident 98 used a loud, pleading voice, Why me? LPN 14 and RCA 29 were in the room. They did not speak with her. On 10/21/22 at 12:47 a.m., Resident 98 indicated loudly, in a pleading voice, she should not have to go through this. LPN 14 was talking to her, but not in her ear. She indicated loudly, I cannot hear you. On 10/21/22 at 12:48 p.m., Resident 98 had a teary, worried expression and loudly pleaded, Lord Jesus, help me! On 10/21/22 at 12:47 a.m., LPN 14 washed his hands with no concerns and put on gloves. He told Resident 98 he was going to put the head-of-the-bed (HOB) down and turn her on her side. On 10/21/22 at 12:49 a.m., Resident 98 indicated she did not know what he was saying. As she was turned, she made loud groaning sounds. On 10/21/22 at 12:51 a.m., LPN 14 indicated to the resident, she had had a BM and he needed to clean her up. He indicated he was sorry. Resident 98 responded in a loud voice, you are not sorry. On 10/21/22 at 12:52 a.m., LPN 14 indicated the soiled dressing was, dated 10/20/22, with no time or initials. He indicated the area below her dressing was an open area of skin where her BM was, acid was eating her skin. The area was observed to be a large, raw, open skin area with several spots of blood. LPN 14 used A and D ointment for that area. Resident was openly crying now. On 10/21/22 at 12:56 a.m., LPN 14 removed the soiled dressing and washed his hands. On 10/21/22 at 12:57 a.m., after putting on clean gloves, LPN 14 used his gloved, dry gauze covered finger to wipe inside the deep area of the wound but not in the undermined areas. He did not use normal saline (NS) or wound cleanser. Resident 98 was calling out in pain. He changed gloves, did not wash his hands, and used skin prep around wound. Resident 98 was continuing to call out in pain. LPN 14 changed gloves, did not wash his hands and placed a Dakin's-soaked gauze in the wound. He used sterile cotton swabs to push the dressing up to the wound edges, but not in the undermined area. He changed gloves, did not wash his hands, and placed another Dakin's-soaked gauze in wound with sterile cotton swabs. It was pushed against the wound edges but did not enter the undermined area. He changed gloves, did not wash his hands, and placed ABD pads over the wound. He put A and D ointment on the raw, open area of skin under the ABD with a gloved finger. Resident 98 was continuing to cry out for help from Jesus. On 10/21/22 at 1:03 a.m., LPN 14 placed tape over the ABD pads. He indicated in a normal (not loud) voice to Resident 98, we are almost done and thank you for your patience. He did not talk in her ear. She did not respond. He was observed dating the dressing. He used scissors, there was no observation of them being cleaned, to cut the tape slightly at the distal mid-portion nearest to the rectum. He indicated he used alcohol wipes or sanitizer wipes to clean the scissors if we have them. He indicated those were his personal scissors and he was observing leaving them in the gauze squares box. On 10/21/22 at 1:05 a.m., LPN 14 and RCA 29 placed a clean disposable brief on Resident 98. When she was turned from side and side, she continued to call out in pain. The staff continued to reposition and re-centered her on the bed. On 10/21/22 at 1:09 a.m., LPN 14 indicated to the resident, we are going to pull you up in bed now. Resident 98 indicated loudly, what are you saying? He did not speak into her ear. After she was pulled up in bed, she called out loudly, how long Lord? On 10/21/22 at 1:11 a.m., LPN 14 was observed to clean his scissors in the resident's bathroom with water only. He placed them in the gauze squares box with the 4 x 4s. Then washed his hands. On 10/21/22 at 10:51 a.m., Resident Care Assistant (RCA) 15 indicated she was finishing a bed bath for Resident 98. She indicated when she turned Resident 98 to clean her back, she was screaming. On 10/21/22 at 10:38 a.m., the Assistant Director of Nursing Services (ADNS) indicated Licensed Practical Nurse 14 was probably trying to hurry with the sacral wound dressing change because the Resident 98 was in pain and did not take the time to clean or dress the undermined portions of the wound. On 10/25/22 at 4:50 p.m., NP 28 indicated Resident 98 refused surgical debridement when she was at the hospital, prior to coming to the facility. She had no report from the staff that the resident had been uncomfortable or in pain with dressing changes. She discontinued the order for scheduled Tylenol. She talked to Resident 98's daughters frequently. They had not reported she was in pain; we can increase her Norco to 2 pills prior to a dressing change. The staff could have reviewed the planned procedure into the resident's ear for her understanding before doing the dressing change. NP indicated she talked with the resident frequently. On 10/25/22 at 7:25 p.m., the Medical Director indicated while Resident 98 was in the hospital, the surgical team wanted to debride her wound, but the resident refused. She had a complicated wound and may not survive it. We relied on wound care experts because she had necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin). He believed her to have hyper-responses to pain, but the pain medications had room to be increased for possible pain relief. For this wound, she would almost need conscious sedation (combination of medicine to help her to relax, a sedative, and to block pain, an anesthetic) to change the dressing without pain. Long term acute care might a better option than long term care. On 10/26/22 at 1:13 p.m., NP 28 indicated she discontinued the scheduled Tylenol per Resident 98's family request and had now increased the dose of scheduled Norco from, 5/325 mg to 7.5/325 mg four times a day. The family had wanted the Norco to be PRN (as needed) because when she took it in the hospital, she was loopy. The resident indicated she had pain with the dressing change. Scheduled Tylenol twice a day with Norco 30 min prior to twice a day dressing changes. If it is a PRN dressing change, then give Tylenol 30 minutes prior to the dressing change. The daughter indicated her mom complained of pain, but not severe. She believed the Resident's pain was mostly when she was moved or turned. She indicated she had not been in the resident's room during a dressing change. A current policy, titled, Dressing Changes, dated 5/11/22, was provided by the ED, on 10/24/22 at 12:02 p.m. A review of the policy indicated, .To ensure measure that will promote and maintain good skin integrity while maintaining standard measures that will minimize/control contamination .Dispose of gloves in plastic bag or trash can. Wash hands with soap and water .If using scissors make sure, it is clean with antiseptic after contact with soiled dressings. Remove gloves and discard. Wash hands with soap and water 3.1-37(a)

Based on interview and record review the facility failed to ensure communication of health care, accurate assessments, and validation of a resident's ability to self-catheterize resulting in hospitalization for urosepsis for 1 of 1 resident reviewed for hospitalization (Resident #113) and 1 of 1 resident reviewed for communication of health care related to [MEDICAL TREATMENT] (Residents #60). Findings include: 1. Resident #113's closed record was reviewed on 12/11/2015 at 2:04 p.m. The record indicated Resident #113 had been hospitalized , for other than a planned elective surgery, within 30 days of his admission to the facility. Resident #113 had [DIAGNOSES REDACTED]. An Admission Assessment for Functional Status for Elimination, dated 6/23/2015, indicated Resident #113 utilized an indwelling catheter as a bladder appliance and the facility should provide catheter care per protocol. A care plan, dated 6/24/2015, indicated Resident #113 utilized a Foley catheter for [MEDICAL CONDITION] and [MEDICAL CONDITION] with a goal to have no difficulty with urination. A care plan, dated 6/24/2015, indicated Resident #113 had [MEDICAL CONDITION] with [MEDICAL CONDITION] and required an indwelling urinary catheter. The care plan indicated Resident #113 had been willing to have his Foley catheter removed and his output should have been monitored when the attempt was made. Current interventions included staff stimulating the resident to void when the catheter was removed. An admission Minimum Data Set (MDS) assessment, dated 6/30/2015, indicated Resident #113 was admitted with an indwelling urinary catheter and required extensive assistance with one staff member for toileting and extensive assistance with two staff members for transfers. A physician's order, dated 6/26/15, indicated Resident #113 should receive Foley catheter care every shift. This order was discontinued on 7/13/2015. A physician's assessment, dated 7/6/2015, indicated Resident #113 had been concerned about his existing catheter and wanted to see his urologist. The assessment and plan indicated the facility would make an appointment for Resident #113 with the urologist. The record did not include a progress report or physician's orders from the urology appointment on 7/10/2015. A nursing note, dated 7/10/2015 at 8:29 p.m., indicated, Resident is alert and oriented and able to voice needs and wants .continent of bowel and bladder The record did not indicate a physical assessment to determine if bladder was distended and did not indicate monitoring of urinary output after the catheter was removed. A nursing note, dated 7/10/2015 at 4:21 a.m., indicated, Resident is alert and oriented to person, place, and time .Had Foley catheter removed on 7/10/15, continent of bowel and bladder, minimal assist with ADL's and transfers The record did not indicate a bladder assessment and did not indicate monitoring of urinary output after the catheter was removed. A nursing note, dated 7/11/2015 at 8:30 p.m., indicated, Resident alert and oriented to person, place and time, able to voice needs and wants .continent of bowel and bladder The record did not indicate a bladder assessment and did not indicate monitoring of urinary output after the catheter was removed. A nursing note, dated 7/12/2015 at 11:00 p.m., indicated, Resident reported on 7/12/2015 at 10 p.m. that during self cathing urine showed presence of blood. Resident reported to writer that his Foley catheter was removed on 7/10/15 by urologist. Urologist also instructed resident to self cath every evening to ensure bladder is empty to prevent infection. Facility did not receive any documentation from MD (physician) office appointment and facility was unaware of MD instruction to self cath daily .Spoke with wife who accompanied resident to appointment and she confirmed the information that was provided by the resident. Wife could not confirm if any documentation was received from that appointment. An Elimination Circumstance and Reassessment form, dated 7/12/2015 at 10:00 p.m., indicated Resident #113 had his indwelling Foley catheter discontinued by the urologist on 7/10/2015 and the staff were to monitor his urinary output related to [MEDICAL CONDITION]. The assessment indicated Resident #113 had a change in his continence status and urine color, clarity, consistency of urine should be assessed with [REDACTED]. A Change in Condition Report, dated 7/13/2015 at 3:57 a.m., indicated, Resident rang call light because he was freezing, upon entering the room, nurse observed resident shaking uncontrollably. A base line temp (temperature) of 98.6 degrees Fahrenheit (oral) at 2:50 a.m. 2 [MEDICATION NAME]/apap 5/325 milligram (mg) given per order. 3:00 a.m. oral temp of 99.3 degrees Fahrenheit. 3:05 a.m. oral temp of 100.5 degrees Fahrenheit. Resident's shakiness at this time had eased enough to attempt vitals: B/P (blood pressure) 142/64, Pulse 80 and bounding. Respirations 20 and rapid. Was unable to attain O2 (oxygenation) sats due to resident's unsteady hands. On call (physician) notified, and resident sent to hospital per MD (physician). A hospital Admission History and Physical, dated 7/13/2015, indicated Resident #113 had presented to the hospital with complaints of fever and shakiness. The impression and plan indicated Resident #113 had an admitting [DIAGNOSES REDACTED]. A hospital note, dated 7/14/2015, indicated Resident #113 was admitted on [DATE] with a complaint of fever, chills, nausea, and confusion. He had an admission white blood cell count of 900 (normal range 4,500 to 10,000). Resident #113 had positive blood and urine cultures for Escherichia coli (bacteria). The assessment indicated Resident #113 had a [DIAGNOSES REDACTED]. During an interview on 12/15/2015 at 2:48 p.m., the Director of Nursing (DON) indicated Resident #113 had his Foley catheter removed during his urologist appointment on 7/10/2015 at 11:30 a.m. She indicated the facility had not followed up with the urologist's office for new orders after he returned to the facility with his Foley catheter removed. She indicated she expected her nursing staff to follow up with the doctor's office for new orders if the resident returned to the facility without them. She indicated the facility had been unaware that Resident #113 had been instructed by the urologist to perform self catheterization in the evenings. She indicated she could not provide documentation from the urologist appointment or the facility, that Resident #113 had been provided the education to perform self catheterization. She indicated she would expect her nursing staff to perform urinary assessments and monitor the resident's voiding each shift after the discontinuation of his Foley catheter. During an interview on 12/16/2015 at 10:53 a.m., the DON indicated she could not provide documentation that Resident #113's urine had been monitored during the day or evening shift on 7/11/2015. She indicated the facility did not have parameters of output amount after a Foley catheter is discontinued. She indicated she expected her staff to document each shift that Resident #113 was able to void after the removal of his Foley catheter on 7/10/2015. 2. Resident #60's record was reviewed on 12/15/15 at 8:30 a.m. Resident #60 had a [DIAGNOSES REDACTED]. A physician order, dated 9/25/15, indicated [MEDICAL TREATMENT] three times a week. The record lacked indication the facility had communicated, either verbal or written, with the [MEDICAL TREATMENT] provider after Resident #60 returned from [MEDICAL TREATMENT] visits. During an interview on 12/16/2015 at 9:45 a.m., Licensed Practical Nurse (LPN) #15 indicated the facility did not have a form of communication, either verbal or written, with the [MEDICAL TREATMENT] provider when Resident #60 returned from her [MEDICAL TREATMENT] visits. During an interview on 12/16/15 at 10:53 a.m., the Director of Nursing indicated the facility did not have a system which ensured routine communication between the [MEDICAL TREATMENT] provider and the facility after [MEDICAL TREATMENT] visits. During an interview on 12/16/15 at 1:28 p.m., [MEDICAL TREATMENT] Provider Care Coordinator #17 indicated if the facility would send a communication form they would fill it out and send it back with Resident #60. She indicated otherwise they would call if they had significant issues or the resident was sent to the emergency room . A [MEDICAL TREATMENT] policy, identified as current by the Director of Nursing on 12/16/15 at 1:10 p.m., indicated, .To provide guidelines for communication and partnership of [MEDICAL TREATMENT] Providers and the campus . A report (may be written or verbal) shall be requested from the [MEDICAL TREATMENT] Provider so that will alert the campus regarding: tolerance to procedure, vital signs, medications administered, other information deemed necessary for the ongoing provision of care. Upon return from the [MEDICAL TREATMENT] Provider the campus shall: Provide ongoing monitoring of the shunt site for signs of complication. Review the [MEDICAL TREATMENT] Provider paperwork for any necessary follow up requirements A Urinary Catheter Care policy identified as current by the DON on 12/15/15 at 4:09 p.m., indicated, . To prevent infection of the resident's urinary tract .Maintain an accurate record of the resident's daily output, per campus guidelines .determine if changes in daily urinary catheter procedures have been made (e.g., review of care plan, receipt of oral instructions from nurse supervisor, physician orders) A Guidelines for Removal of a Foley Catheter policy identified as current by the DON on 12/16/15 at 1:16 p.m., indicated, .To provide guidelines for the approved method of removing a Foley catheter .Determine if the resident is on intake or output before discarding urine .Verify that there is a physician's order for this procedure. Review the residents care plan to assess for any special needs of the resident .Services are provided to restore or improve normal bladder function to the extent possible, after the removal of the catheter, and a resident with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer prevention interventions were evaluated and revised to prevent a resident who was admitted without a pressure ulcer from developing a stage 3 (full thickness skin loss) and two stage 2 (partial thickness/loss of skin layers) for 1 of 1 resident reviewed for pressure ulcers (Resident #69). Finding includes: During an interview on 12/10/15 at 12:16 p.m., Registered Nurse (RN) #10 indicated Resident #69 had a stage 3 (full thickness skin loss) pressure ulcer on his right buttock, and stage 2 (partial thickness/loss of skin layers) pressure ulcers on bilateral heels. On 12/14/15 from 11:07 a.m. to 11:35 a.m., a pressure dressing change to the stage 3 pressure on the resident's buttock was observed with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #16. Resident #69 was observed to have an incontinence diaper on while lying on his back on the low air loss mattress. The open area had pink edges and a brown hard center. No drainage was observed from the wound. The ADON indicated the open area measured 3 centimeters (cm) long by 3 cm wide and had more eschar than previously measured. On 12/14/15 from 11:51 a.m. to 12:16 p.m., a pressure dressing change to the stage 2 pressure on Resident #69's right heel was observed with the ADON and LPN #16. Resident #69 was observed lying on his back with his right hip propped up on a pillow on the low air loss mattress. The open area on the right heel had a bright red center, and a moderate amount of serosanguinous (containing or relating to both blood and the liquid part of blood) drainage. The bottom of the foot had a white sticky substance surrounding the wound. The ADON indicated the open area measured 3 cm in length by 5.8 cm in width x 0.1 cm in depth. On 12/14/15 from 12:17 p.m. to 12:26 p.m. a pressure dressing change to the stage 2 pressure on Resident #69's left heel was observed with the ADON and LPN #16. The open area had red tissue with three small areas of black tissue, and a small amount of serosanguinous drainage. The ADON indicated the open area measured 3 cm in length by 2.5 cm in width. The ADON requested LPN #16 to go get gauze and inform the physician she was changing the treatment for [REDACTED].#69's left heel due to an increased amount of eschar. On 12/15/15 at 1:30 p.m., Resident #69's record was reviewed. The admission skin assessment, dated 10/8/15, stated the resident had the following skin impairment risk factors: decreased activity level, and immobility. The physician orders [REDACTED].#69's pressure ulcers, dated 10/8/15 to 11/1/15, included but were not limited to: barrier cream to back right flank, regular diet with pureed consistency and thin liquids, high compression hose to assist in BLE (bilateral lower extremity) [MEDICAL CONDITION] management daily, and, resident to lay down daily after lunch to rest. The admission Minimum Data Set (MDS) assessment, dated 10/15/15, indicated Resident #69 was at risk for pressure ulcers, had no unhealed pressure ulcer, and was an extensive assist of two for bed mobility, transfer, and toileting. The MDS indicated the resident was an extensive assist of one for dressing, eating, bathing, and personal hygiene. The MDS indicated the resident was frequently incontinent of bladder and occasionally incontinent of bowel. The care plan, dated 10/17/15, for risk of skin break down stated, Assist/remind me with turning and repositioning when I am in bed. The form titled, Pressure Wound Circumstance, dated 11/2/15 at 6:53 p.m., indicated stage 2 pressure ulcers were found on Resident #69's bilateral heels. The form indicated the measurements of the each pressure ulcer were 6 cm in length by 6 cm in width. The form stated the contributing factors to the development of the pressure ulcer included the following: dementia, incontinence, immobility. The form stated the following interventions were in place: pressure reducing device for chair and bed, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressing, applications of ointments/medications other than to feet, application of dressing to feet. The form indicated the resident had [DIAGNOSES REDACTED]. The physician orders [REDACTED].#69's stage 2 pressure ulcers on his bilateral heels, dated 11/2/15 to 11/22/15, included but were not limited to: barrier cream to back right flank, heel cushion boots at all times, bilateral [MEDICAL CONDITION] wraps, bilateral [MEDICAL CONDITION] wraps to lower extremities therapy to mange and change three times a week. The 30 day MDS, dated [DATE], indicated Resident #69 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 and was cognitively intact. The MDS indicated the resident was at risk of pressure, had had two unhealed stage 2 pressure ulcers. The MDS indicated the resident was frequently incontinent of bladder and occasionally incontinent of bowel. The nursing progress note, dated 11/11/15, stated, .stage 2 pressure ulcers to bilateral heels. Right heel pressure ulcer intact, measure 6 cm x 9 cm. Blister is larger than previous assessment. Left heel pressure ulcer no change measuring 6 cm x 6 cm. The nursing progress note, dated 11/23/15 at 11:53 p.m., stated, Resident noted with open area to his R (right) lateral buttock at the distal end, presents as a stage 3 pressure ulcer. Site measures approximately 4 cm x 0.8 cm x 0.2 cm New orders for [MEDICATION NAME] (ointment) to wound bed, cover with fluffed gauze, cover with dry dressing. The note stated, Resident is to be without briefs when in bed. The physician orders [REDACTED].#69's stage 3 pressure ulcer on his right buttock, dated 11/23/15 to 12/15/15, included but were not limited to: cleanse right buttock wound with normal saline and apply skin prep to periwound and cover with [MEDICATION NAME], and apply Hydrogel to right heel pressure ulcer. The form titled, Pressure Wound Circumstance, dated 11/24/15, indicated Resident #69 had a stage 3 pressure ulcer on his right buttock, and it measured 4 cm in length by 0.8 cm in width by 0.2 cm in depth. The form indicated the pressure area was discovered on 11/23/15. The form stated the contributing factors to the development of the pressure ulcer included the following: incontinence, immobility, and contractures. The form stated the following interventions were in place: pressure reducing device chair, pressure reducing device for bed, turning/repositioning program, pressure ulcer care, dressings, and applications of ointments/medications. The Interdisciplinary team (IDT) note, dated 11/24/15 at 10:30 a.m., stated, IDT review of stage 3 pressure ulcer to right buttock. Wound assessed 11/23/15 with charge nurse. Patient sleeps on Flow T pressure reduction mattress. The note indicated therapy was to evaluate the resident's current, enhanced foam wedge cushion, in his wheelchair and replace it with a Roho cushion. The note indicated the resident was an extensive assist for repositioning and transfers, and was incontinent of bladder. The notes indicated Resident #69 was to be turned and repositioned every two hours while in bed and not wear incontinence briefs while in bed. The nursing progress note, dated 12/1/15 at 5:35 p.m., stated, weekly wound evaluation of Stage 3 pressure ulcer to right buttock. Wound has deteriorated. Wound measures 4 cm x 3 cm x 0.2 cm. Wound bed is 75% soft brown eschar (dead tissue) .New order noted to change treatment to twice weekly Santyl (enzymatic [MEDICATION NAME] ointment) to aid in debridement of eschar/slough. Broda chair ordered this evening for OT (occupational therapy) to trial positioning in new chair with ROHO cushion in the AM. The 60 day MDS, dated [DATE], indicated the resident had a BIMS score of 13 out of 15 and was cognitively intact. The MDS indicated the resident was at risk for pressure ulcers, had two unhealed stage 2 pressure ulcers, and one stage 3 pressure ulcer. The MDS indicated the resident was occasionally incontinent of bladder and always continent of bowel. The nursing progress note, dated 12/8/15 at 12:00 p.m., stated, Stage 3 pressure ulcer to right buttock measures 3.5 cm x 2.8 cm x 0.2 cm. Wound bed is 75 % soft brown eschar . He is unable to turn or reposition himself in bed and is assisted by staff for transfer needs with a mechanical lift only as he cannot bear any weight due to contractures, pain, muscle spasms and cognitive impairment. During an interview on 12/14/15 at 9:30 a.m., LPN #16 indicated she was Resident #69's nurse, but was unaware if she was the one that did Resident #69's dressing change. During an interview on 12/14/15 at 10:46 a.m., LPN #16 indicated she would perform all dressing changes. During an interview on 12/14/15 at 12:36 p.m., the Assistant Director of Nursing (ADON) indicated all of Resident #69's pressure ulcers were acquired at the facility. She indicated the resident obtained heel pressure areas by rubbing his heels on the mattress as his legs continued to contracture. She indicated his pressure ulcer on his buttock was due to pressure with contracture and sliding and it was a stage 3 when it was found. She indicated prior to his pressure ulcers the resident was on a composure mattress and it was changed to a low air loss mattress after the pressure areas developed. During an interview on 12/14/15 at 2:01 p.m., the ADON indicated the following interventions were in place prior to the development of pressure ulcers on Resident #69's feet: encourage fluids, physical and occupational therapy, turning and reposition, keep resident clean and dry, keep linens wrinkle free, passive range of motion (PROM) exercises for his contractures, and a foot board on wheelchair. She indicated the foot board on the wheelchair was to stop the resident from pulling his feet back as his legs contracted, but it was discontinued because the resident was rubbing his heels against it. During an interview on 12/15/15 at 2:53 p.m., Certified Nursing Assistant (CNA) #1 indicated Resident #69 was to be repositioned every 2 to 3 hours and was to only wear incontinence briefs while up in the wheelchair. She indicated the resident required extensive assist with movement and repositioning and was unable to reposition himself. During an interview on 12/16/15 at 10:06 a.m., the ADON indicated Resident #69's ankle boots were ordered after the stage 2 pressure areas developed on his heels. She indicated prior to the development of the stage 2 pressure ulcers Resident #69's care plan stated to turn and reposition and did not specify how often. She indicated prior to the development of pressure ulcers there was no order to turn and reposition or a timed CNA task to turn and reposition the resident. She indicated Resident #69 now was to be turned every two hours and repositioned. She indicated she determined the efficacy of wound interventions with weekly assessments including: measurements, pain levels, and signs of infection. She indicated if signs of deterioration such as increased eschar, signs or symptoms of infection, or an increased size she would change treatment plans and revise the care plan interventions. On 12/15/15 at 12:28 p.m., the Executive Director provided the current policy titled, General Wound and Skin Care Guidelines. The policy stated, Turn/reposition residents who are immobile according to their care plan requirements .use a lift sheet to prevent shearing of skin .use pillows or wedges for positioning to avoid skin on skin contact .evaluate the need for a pressure reduction surface for bed/chair and the need for the elbow protectors and/or heel floats. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to utilize a gait belt during the transfer of resident, which resulted in a resident falling and sustaining a head injury that required emergency room evaluation/treatment and hospitalization . This deficient practice affected 1 of 3 residents reviewed for accidents (Resident B). Findings include: Resident B's record was reviewed on 11/13/2014 at 10 a.m. Resident B had [DIAGNOSES REDACTED]. A Minimum Data Set assessment tool (MDS), dated [DATE], indicated she had cognitive impairment with a Brief Interview for Mental Status score (BIMS) of 9 out of 15 and required the physical assistance of staff for transfers. A nurse's noted, dated 10/22/2014 at 6:51 a.m., indicated Resident B fell while being transferred by a Certified Nursing Assistant (CNA). This note indicated the CNA stated "she was unable to keep her from falling." This note indicated Resident B was "shaken up" by the incident. This note indicated Resident B sustained a "large" hematoma (bruise) to the top right corner of her forehead. The hematoma had a "small" abrasion in the center with a "moderate amount of bleeding" noted. This note indicated Resident B complained of pain and required narcotic pain medication. An untimed physician's telephone order, dated 10/22/2014, indicated the physician was notified and gave orders to send Resident B to the emergency room to be evaluated and treated. Review of an Emergency Department physician progress notes [REDACTED]. A radiology report, dated 10/22/2014 at 10:38 a.m., indicated Resident B had an "acute" left "C1 (cervical) lamina fracture." An Admission History and Physical Note, dated 10/22/14 at 3:04 p.m., indicated Resident B was "found to have a C1 fracture and transferred to (hospital named) for further evaluation...." During an interview on 11/13/2014 at 12:00 p.m., CNA #1 indicated that she had transferred Resident B from a wheelchair to her recliner and Resident B lost her balance and fell . She indicated she failed to use a gait belt while transferring Resident B. She indicated she was aware that a gait belt should have been utilized as an intervention to prevent falls. During an interview on 11/13/2014 at 2:55 p.m., the Director of Nursing (DON) indicated all residents should be transferred with the use of a gait belt. She indicated CNA #1 failed to utilize a gait belt at the time Resident B fell and sustained a head injury. The DON indicated Resident B was transferred to the emergency room and admitted to the hospital after evaluation of her head injury. A policy titled "Gait Belt Transfers" identified as current by the DON on 11/13/2014 at 1:30 p.m., indicated "Gait belts are provided to assist staff to safely transfer or ambulate residents...Unless otherwise noted in the resident's care plan, a gait belt should be utilized for all residents during manual transfers...." This Federal tag relates to complaint IN 385. 3.1-45(a)(2)