Every finding on record at West Bend Nursing and Rehabilitation

Based on observation and interview the facility failed to prepare food under sanitary conditions in 1 of 1 kitchens. This had the potential to affect 66 out of 67 residents who ate food prepared in the kitchen.Finding includes: During a tour of the kitchen on 3/9/2026 at 9: 38 A.M. with the Culinary Manager (CM) the following was noted:-the wall around the handwashing sink was dirty with brown and yellow spots and drips-3 stainless steel skillets were black and brown colored greasy skillet on both the inside and outside surfaces-and the top of 2 water heaters were covered with dust and debris. During an interview on 3/9/2026 at 9:48 A.M., the CM indicated the wall near the handwashing sink should have been cleaned, they probably should order new frying pans, and the top of the water heaters should have been free of dust and debris. On 3/13/2026 at 10:05 A.M. a current policy, dated 6/2025 and titled Kitchen Cleanliness, was provided by the ED. The policy indicated, .A clean, sanitary, and safe kitchen environment will be maintained at all times to ensure the health and well-being of our residents, staff, and visitors. All kitchen areas, including food preparation surfaces, equipment, storage areas, walls, and floors must be cleaned regularly and kept free of debris, spills, and potential contaminants 410 IAC (Indicana Administrative Code) 16.23.1-21(i)(3)

Based on observation, interview and record review, the facility failed to maintain a sanitary environment on the 200 Unit for 1 of 3 Units whose environment was observed. (200 Unit)During a continuous observation of the 200 Unit's environment on 3/6/2025 from 9:30 A.M. until 3:30 P.M., and during an environment tour with the Housekeeping Supervisor (HS) on 3/13/2025 at 11:00 A.M., the following was observed:-Two ceiling air vents above the 200 Unit Medication Cart had a heavy build up of dust.-A heavy build up of dust on the blinds and window sills of rooms 208, 216 and 218.-room [ROOM NUMBER] had a dried brown substance on the wall in the corner of the room.-The toilet in room [ROOM NUMBER] had a brown stains inside the bowl 3/6/2026 and had hard water stains on 3/13/2025 inside the bowel.-Used towels and wash clothes were on the floors in the bathroom of rooms 208, 216, 212 and 220. During an interview with the HS on 3/13/2025 at 1:20 A.M., the HS indicated toilets should be cleaned daily, even for residents who are always incontinent and the build-up in the toilet of room [ROOM NUMBER] was from the hard water. The HS indicated the blinds and window sills should be cleaned and air vents in the hallway should have been dusted every week. If Housekeeping found towels/washcloths on the floor, the facility would investigate to see if the resident had placed the towel/washcloth on the floor or if the staff had placed the towel/washcloth on the floor. If it was found the staff had been placing the dirty towels/washcloths on the floor, the HS would talk with the nursing staff. On 3/13/2025 at 11:30 A.M., the Executive Director provided a policy dated, 12/2021 and titled, Daily Cleaning Procedure and identified it as the policy currently used by the facility. The policy indicated, .Daily Resident Rooms .clean and disinfect the restroom .Extra duties for Resident Rooms and all common areas .Monday: High dust room, including bathrooms, wall hangings, TVs and ceilings. Tuesday: Wipe down walls where dirt and food debris is apparent .Fridays: Window treatments, including window blinds, clean/dust window sill On 3/13/2025 at 11:30 A.M., the Executive Director provided a policy dated, 12/2021 and titled, Restroom Cleaning Procedure and identified it as the policy currently used by the facility. The policy indicated, .6. Clean toilet bowl and exterior of toilet 410 IAC 16.2-3.1-19(e)

Based on interview and record review, the facility failed to ensure a resident's responsible party was notified timely of new medication and the risks and benefits of the medication, prior to administration of the medication, for 1 of 3 residents reviewed for notification, (Resident B). Finding includes: On 6/18/25 at 9:43 A.M., a telephone interview with the Social Service Director (SSD) at a local dialysis center indicated Resident B received dialysis at the dialysis center on Mondays, Wednesdays and Fridays and had received dialysis for several months. The SSD indicated the facility had notified the dialysis center, on 3/14/25, that Resident B had been prescribed Ativan (a central nervous system depressants which slows down the nervous system and is used to treat anxiety) before his dialysis appointments. The dialysis SSD indicated Resident B had been coming to dialysis treatments, lethargic and out of it over the past few weeks and, on 5/28/25, she had notified the Director of Nursing and requested a discontinuation of the Ativan medication. The dialysis SSD indicated there was a note in the resident's communication book that indicated the resident had been figgity at an appointment, on 2/14/25, and there was no further documentation of negative behaviors during dialysis treatments. During an interview on 6/18/25 at 10:20 A.M., the facility Memory Care Director indicated, on 3/13/25, she was directed by the Director of Nursing to call the facility's Psychiatric Nurse Practitioner to request an order for medication to calm the resident while he received dialysis. The Memory Care Director indicated she had called and made the request to the Psychiatric Nurse Practitioner, who then prescribed Ativan 0.5 mg to be taken by mouth every Monday, Wednesday and Friday before leaving the facility for dialysis. The Memory Care Director indicated, on 3/13/25, during a telephone Care Plan meeting with the resident's responsible party, the resident's medications were reviewed but the addition of Ativan was not discussed. The Memory Care Director indicated she had not notified Resident B's responsible party that the resident was receiving Ativan at the time of the initial administration on 3/10/25. During an interview with the Assistant Director of Nursing, on 6/18/24 at 10:30 A.M., she indicated she had not notified Resident B's responsible party that Ativan had been prescribed for anxiety prior to dialysis treatments. The Assistant Director of Nursing indicated, on 3/13/25, during a telephone Care Plan meeting, she had listed the resident's medications, and that Ativan must have been mentioned, but it had not been discussed with the responsible party. , During an interview, on 6/18/25 at 11:00 A.M., with the Director of Nursing, she indicated the only documentation of notification to the resident's responsible party regarding the order to start Ativan was in the resident care plan note, on 3/13/25. The Director of Nursing indicated she had not notified Resident B's responsible party that Ativan had been prescribed. Resident B's clinical record was reviewed on 6/19/25 at 10:00 A.M. Diagnoses included but were not limited Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety. A physician's order dated from 3/11/25 to 5/28/25, indicated Ativan tablet 0.5 mg was to be administered by mouth once a day on Monday, Wednesday, and Friday before dialysis for the diagnosis of adjustment disorder with anxiety. Review of the Medication Administration Record (MAR), indicated Resident B had received Ativan 0.5 mg every Monday, Wednesday, and Friday from 3/10/25 to 5/28/25. Review of Resident B's Care Plan Summary, dated 3/13/25 at 1:19 P.M., indicated medications were reviewed with Resident B's responsible party and she was aware of the risks associated with the medications and had no concerns. On 6/18/25 at 10:01 A.M., the Administrator provided a policy titled, Resident Change of Condition, dated 11/2018, and indicated it was the current facility policy. The policy indicated, It is the policy of this facility that all changes in resident condition will be communicated to the .responsible party .The nurse in charge is responsible for notification of .responsible party prior to end of assigned shift when a significant change in the resident's condition is noted .Documentation will include time and [responsible party] response . This citation relates to Complaint IN00460484. 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from chemical restraint related to medication administered for the purpose of calming the resident prior to off-site dialysis treatments, for 1 of 3 residents reviewed for chemical restraints, (Resident B). Finding includes: During an observation, on 6/17/25 at 10:18 A.M., Resident B was in the common area of the Memory Care unit seated upright, alert and watching the activities of the other residents in the area. The resident was well-groomed and nicely dressed. The resident showed no signs of any negative behaviors. During an observation, on 6/18/27 at 9:48 A.M., Resident B was in the common area of the Memory Care unit, seated in a chair along with other residents in the area. Resident B was clean, well dressed, appeared alert and showed no signs of negative behaviors. During an interview, on 6/18/25 at 9:43 A.M., with the Social Service Director (SSD) from a local dialysis center, she indicated Resident B received dialysis at the dialysis center on Mondays, Wednesdays, and Fridays, and had been receiving dialysis treatments for several months. The SSD indicated the facility had notified the dialysis center, on 3/14/25, that Resident B had been prescribed Ativan (a central nervous system depressants, which slows down the nervous system and is used to treat anxiety), before his dialysis appointments. The dialysis SSD indicated Resident B had been coming to dialysis, lethargic and out of it over the past few weeks and, on 5/28/25, she had notified the Director of Nursing and requesedt a discontinuation of the Ativan. The dialysis SSD indicated there was only one note in the resident's communication book that indicated the resident had been figgity at an appointment ,on 2/14/25, and there was no further documentation of negative behaviors during his dialysis treatments. During an interview, on 6/18/25 at 10:20 A.M., the Memory Care Director indicated, on 3/10/25, she was directed by the Director of Nursing to call the facility's Psychiatric Nurse Practitioner to request an order for medication to calm the resident while he received dialysis treatments. The Memory Care Director indicated she had called and made the request to the Psychiatric Nurse Practition,, who then prescribed Ativan 0.5 mg to be taken by mouth every Monday, Wednesday, and Friday before leaving the facility for dialysis treatments. The Memory Care Director indicated Resident B was very pleasant and easily redirected, though he could get agitated if he was seated for long periods of time. She indicated the facility always sent a Certified Nursing Assistant (CNA) to sit with the resident during dialysis treatments. The Memory Care Director indicated it was reported to her, on 2/14/25, that Resident B had been figgity at his appointment and had pulled at his infusion port. The Director of Memory Care indicated there had been no other reports of figgiting or behaviors that she had been aware of for Resident B. The Director of Memory Care indicated no assessments had been completed by the facility or the Psychiatric Nurse Practitioner to determine the resident's medical need for the Ativan medication and there were no assessments completed following the administration of the medication. The Memory Care Director indicated she had observed no behaviors in the resident that would warrant the need for Ativan. During an interview with the Assitant Director of Nursing, on 6/18/24 at 10:30 A.M., she indicated the facility did not start psychotropic medications, such as Ativan, unless they had documented, unwanted behaviors or anxieties demonstated by the resident for at least three days. Unwanted behaviors were then reported to the Psychiatric Nurse Practitioner who determined the necessary treatment. The Assistant Director of Nursing indicated there was no supportive documentation regarding Resident B, and the Psychiatric Nurse Practitioner had not assessed the resident before prescribing Ativan. During a telephone interview on 6/18/25 at 10:40 A.M. on the Assistant Director of Nursing's telephone, the Psychiatric Nurse Practitioner indicated on 3/10/25, she had initiated a new order for Ativan 0.5 mg to be administered to Resident B, before dialysis on every Monday, Wednesday, and Friday, due to a report from the Director of Nursing that the dialysis center had requested Resident B have something to address his restlessness and anxiety during dialysis. The Psychiatric Nurse Practitioner indicated the medication was discontinued, on 5/28/25, at the request of the dialysis center because the resident was lethargic. During an interview with the Director of Nursing, on 6/18/25 at 11:00 A.M., she indicated in March the dialysis center had reached out to her to report agitation in the resident, and felt he may have needed something to help him to relax. The Psychiatric Nurse Practitioner had ordered Ativan 0.5 mg to be administered by mouth before dialysis appointments. The Director of Nursing indicated no further concerns had been communicated to the facility, until 5/28/25, when the dialysis center indicated Resident B was too groggy to complete his treatments. She indicated the Ativan had been discontinued, at that time, at the request of the dialysis center. The Director of Nursing indicated there had been no behavioral assessments completed by the nursing staff or the Psychiatric Nurse Practitioner prior to the initiation of the medication and there were no follow-up assessments to address the resident's response to the Ativan or to monitor for any adverse side effects. Resident B's clinical record was reviewed on 6/19/25 at 10:00 A.M. Diagnoses included but were not limited Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety. Review of the resident's dialysis communication book from 2/1/25 to 6/16/25, indicated on 2/14/25 the resident was figgity and pulling at his dialysis port. No other entries concerning negative behaviors had been communicated. A note from the dialysis center, dated 5/29/25, was provided by the dialysis center on 6/18/25 at 10:07 A.M. The note indicated the dialysis center had notified Resident B's responsible party that the CNAs sitting with the resident to dialysis were frequently leaving him unattended and that the resident had arrivedto dialysis lethargic due to Ativan. The note indicated the responsible party was not aware of the Ativan use and that he had been active and moving during her visits at the facility. She had reported she felt the Ativan was an appropriate substitution for a sitter. A physician's order dated from 3/11/25 to 5/28/25, indicated Ativan tablet 0.5 mg was to be administered by mouth once a day on Monday, Wednesday, and Friday before dialysis for the diagnosis of adjustment disorder with anxiety. Review of the Medication Administration Record (MAR), indicated Resident B had received Ativan 0.5 mg every Monday, Wednesday, and Friday from 3/10/25 to 5/28/25. On 6/17/25 at 1:42 P.M., the Administrator provided a policy titled, Psychotropic Management, dated 9/24, and indicated it was the current facility policy. The policy indicated, .It is the policy .to ensure that a resident's psychotropic medication regimen helps promote the resident highest practicable mental, physical, and psychosocial well-being .A psychotropic drug is any drug that affects the brain activities associated with mental process and behavior. These drugs include .Anti-anxiety [drugs] .Prior to initiating a psychotropic medication, and assessment by the .prescriber will be made of the resident including other potential causes of the behavior; as will as non pharmacological interventions that have been attempted. Symptoms and therapeutic goals must be clearly documented prior to initiating or increasing a psychotropic medication .diagnoses alone do not necessarily warrant the use [of] these medications . This citation relates to Complaint IN00460484. 3.1-3(w) 3.1-26(k)(l)(o)

Based on interview and record review, the facility failed to ensure a comprehensive plan of care was created timely related to anit-anxiety medication use for 1 of 3 residents reviewed for care plans, (Resident B). Finding includes: During an interview on 6/18/25 at 10:20 A.M., the Memory Care Director indicated on 3/10/25, she was directed by the Director of Nursing to call the facility's Psychiatric Nurse Practitioner to request an order for medication to calm the resident while he received dialysis. The Memory Care Director indicated she had called and made the request to the Psychiatric Nurse Practitioner, who then prescribed Ativan 0.5 mg to be taken by mouth every Monday, Wednesday, and Friday before leaving the facility for dialysis. Resident B's clinical record was reviewed on 6/19/25 at 10:00 A.M. Diagnoses included but were not limited, Alzheimer's disease, vascular dementia, chronic kidney disease and adjustment disorder with anxiety. A physician's order, dated from 3/11/25 to 5/28/25, indicated Ativan tablet 0.5 mg to be administered by mouth once a day on Monday, Wednesday, and Friday before dialysis for the diagnosis of adjustment disorder with anxiety. Review of the Medication Administration Record (MAR), indicated Resident B had received Ativan 0.5 mg every Monday, Wednesday, and Friday from 3/10/25 to 5/28/25. The care plans for Resident B's included, but where not limited to, Psychotropic Drug Use, Resident is at risk for adverse side effects related to use of psychotropic medication-Anxiety, intitiated on 5/16/25. During an interview with the Assitance Director of Nursing, on 6/18/24 at 10:30 A.M., she indicated a care plan should have been initiated for Ativan use immediately after it was ordered but was not done. During an interview, on 6/18/25 at 11:00 A.M., with the Director of Nursing, she indicated a care plan should have been initiated for Ativan use, when the Ativan was prescribed, but was not done. On 6/17/25 at 1:42 P.M., the Administrator provided a policy titled Psychotropic Management, dated 9/24, and indicated it was the current facility policy. The policy indicated, .It is the policy .to ensure that a resident's psychotropic medication regimen helps promote the resident highest practicable mental, physical, and psychosocial well-being .Symptoms and therapeutic goals must be clearly documented prior to initiating or increasing a psychotropic medication . According to an article published by the National Library of Medicine, dated 4/10/23, regarding Care Planning and the Nursing Process, .Planning .is where goals and outcomes are formulated that directly impact patient care based on EDP [Evidenced Based Practice] guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs . Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. This citation relates to Complaint IN00460484. 3.1-35(a)

Based on observation, interview and record review, the facility failed to store and serve food in a sanitary manner in the pantries, dining rooms, kitchen and kitchenettes. This had the potential to affect 57 of 57 residents who consumed food from the kitchen, pantries, dining rooms and kitchenettes. Findings include: 1. During the initial kitchen tour with the Culinary and Nutrition Manager (CNM) on [DATE] at 9:45 A.M., [DATE] at 8:30 A.M., [DATE] at 11:20 A.M. and [DATE] at 8:40 A.M. the following was observed: - the 6 burner gas range had a thick buildup of a black substance on all burner grates and below the grates. -there was a build up of grease on the stainless backsplash surrounding the gas range. -there was a build up of grease on the wall next to the gas burners. -A ceiling vent had a black substance that looked like mold above the stainless steel prep table behind the ovens. -The handwashing sink was dirty with a red colored dried substance on the wall by the soap dispenser. -Two ovens had a build up of a black substance on the inside, and both ovens had a buildup of grease and food debris on the outside. -The floor was dirty in the cooking area, dishwashing room and the dry storage room. During an interview on [DATE] at 8:45 A.M., the CDM indicated the cooking equipment, walls, floors, and ceiling vents were dirty and needed to be cleaned. He indicated the staff utilized a check list to clean the kitchen. 2. During an observation of meal service in the 2nd Floor Dining Room on [DATE] at 11:58 A.M., the following was observed: - The black four burner range had food debris on all four burners. - The inside of the oven had a build up of grease and food debris. During an interview on [DATE] at 12:00 P.M., Qualified Medication Aide 10 indicated the top of the range and inside of the oven were dirty and should be cleaned. She indicated it was the kitchen's job to clean the range and oven. During an interview with the Housekeeping Supervisor (HS) on [DATE] at 9:44 A.M.,she indicated it was the kitchen's responsibility to clean out the oven in the 2nd floor Dinning Room. 3. During an observation of meal service in the Main Dining Room on [DATE] at 12:10 P.M., the following was observed: -A Puddle of water was under the ice machine. -The ice machine had a buildup of lime on the inside. -The wall behind the ice machine was dirty and had a brown substance splattered down the wall. -4 out of 14 chairs had a buildup food debris on the arms of the chairs. During an interview on [DATE] at 8:45 A.M., the CDM indicated the ice machine needed to be delimed and it was the kitchen's responsibility to delime the inside of the ice machine. During an interview with the Housekeeping Supervisor (HS) on [DATE] at 9:44 A.M., the HS indicated it was Housekeeping's responsibility to clean the dining room table, chairs and floors. During an interview with the Maintenance Director (MD) on [DATE] at 9:05 A.M., the MD indicated the ice machine had been leaking. 4. During an observation of the Cottage's kitchenette on [DATE] at 1:44 P.M., the following was observed: -A Clear container with 24 packs of single serve hot chocolate with no expiration dates. -A Clear container with packaged condiments that had no use by date. The container had 14 packets of tartar sauce, 12 packets of mild hot sauce, 2 packets of syrup and 2 packets of barbeque sauce. One packet of mild hot sauce was leaking an orange substance onto the other single serve condiment packages. During an interview on [DATE] at 1:45 P.M., LPN 6 indicated he was not able to identify when the hot chocolate or individual packets of condiments should be discarded. He indicated one of the hot sauce packets was leaking and all the packets should be thrown away. LPN 6 indicated it was the nursing staff's responsibility to throw away undated or expired food in the unit pantries and kitchenettes. 5. During an observation of the 100 Hall Unit Pantry on [DATE] at 10:50 A.M., the following was observed: -A cake, dated [DATE], with no resident identifying information. -A package of sliced turkey with no opened on or use by date. -5 single serve yogurt containers with an expiration date of [DATE]. -Two Zip Lock bags containing M & M candies with no resident identifying information and no opened on or use by date. -A half a stick of butter with no resident identifying information and no opened on or use by date. -There wasa large amount of a black substance that looked like mold on the bottom of the refrigerator. During an interview on [DATE] at 10:53 A.M., LPN 7 indicated the cake and yogurt were expired and should be thrown away. She indicated the sliced turkey, M & M candies and the half a stick of butter should have contained resident identifying information, the date the food was opened and the date the food should be discarded. She indicated the mold on the bottom of the refrigerator should not be there and the mold should be cleaned. She believed the nursing staff was responsible for cleaning out the pantry refrigerators. 6. During an observation of the kitchenette in the Activities Room on [DATE] at 1:45 P.M., the following was observed: -A one Gallon Ziploc bag of pizza sauce, dated [DATE]. -A one Gallon Ziploc bag of pizza sauce, dated [DATE]. -A Large block of butter with no opened on or use by dates. -A large Ziploc bag of shredded cheese, dated [DATE]. -The electric range had 4 burners and all 4 burners and their pans below the burners were dirty. -Inside of the oven had burnt on food debris. During an interview on [DATE] at 1:48 P.M., Activates Assistant (AA) 8 indicated the left overs should be thrown away 7 days after opening, but if there was no opened on date, the food should be thrown away immediately. AA 8 indicated it was Housekeeping's responsibility to clean the range, oven and refrigerator. During an interview on [DATE] at 10:00 A.M., the CDM indicated it was the kitchen's responsibility to clean all of the ranges, ovens and refrigerators in the building, including on the units and in the kitchenettes. On [DATE] at 9:22 A.M., the Executive Director indicated the facility did not have a policy for maintaining the kitchen and the kitchen equipment, but the facility followed the Food and Drug Administration's (FDA) Food Code as a guide. During an interview on [DATE] at 10:30 A.M., the Corporate Nurse indicated the facility used the FDA Code as a guide for maintaining the kitchen, dining rooms, unit pantries and kitchenettes. On [DATE] at 9:15 A.M., the [NAME] President of Operations supplied a cleaning schedule for the kitchen and identified the cleaning schedule as the one currently used by the facility. The cleaning schedule indicated, .Ranges cleaned daily, Ovens cleaned on Saturday, ceiling vents cleaned monthly, sweep and mop floors daily . 3XXX,d+[DATE](3)

Based on observation, interview and record review, the facility failed to 1 of 1 staff (LPN 2) met professional standards regarding signing off dressing changes for 1 of 3 residents reviewed for wounds. (Resident 42) Finding includes: During an observation and interview on 12/3/2024 at 9:41 A.M., Resident 42 indicated that she was supposed to get her dressing changed daily, and it had not been completed for two days. She had asked the evening shift to do it, but no one had completed her dressing change. The dressing covering the resident's left above the knee amputation revision wound was dated 11/30/2024. When Resident 42 pulled back the dressing, there was a large amount of reddish- brown thick drainage, an opening in the center of wound and erythema around the whole surgical site. During an observation and interview on 12/3/2024 at 10:12 A.M., LPN 2 indicated the dressing to the left leg was ordered to be changed daily, but the current dressing was dated 11/30, 4 days prior. LPN 2 indicated Resident 42 had went out of the building with a friend on 12/1/2024 and 12/2/2024 and had requested the dressing change to be completed later in the day, when she returned from her outings. A record review was completed for Resident 42 on 12/4/2024 at 2:00 P.M. Diagnoses included, but were not limited to: chronic hematogenous osteomyelitis, left femur-distal, infection following a procedure, chronic obstructive pulmonary disease, chronic diastolic heart failure, acquired absence of left leg above the knee and acquired absence of right leg above the knee, peripheral vascular disease, and atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs. A Physician Order, dated 11/27/2024 indicated the following: - left surgical above the knee wound to cleanse with wound wash, dry, apply skin prep then xeroform to wound bed and cover with an abdominal dressing and wrap with kerlix dressing. A Current Care Plan, dated 10/30/2024, indicated impaired skin integrity related to a surgical wound, with the following intervention of treatment as ordered. A Treatment Administration Record, for December, dated 12/1/2024 - 12/4/2024, indicated the dressing was documented as changed on 12/1/2024 and 12/2/2024. During an interview on 12/4/2024 at 3:18 P.M., LPN 2 indicated she had not changed Resident 42's dressing and the dressing changes should not have been signed off as completed on the TAR for 12/1/2024 and 12/2/2024. On 12/4/2024 at 3:40 P.M., a policy was requested but one was not provided. 3.1-50(a)(2)

Based on interview and record review, the facility failed to provide a copy of the Bed Hold Policy to residents when admitted to the hospital for 2 of 2 residents reviewed for hospitalization . (Residents 4 and 16) Findings include: 1. A record review was completed on 10/3/2024 at 2:10 P.M. for Resident 4. Diagnoses included, but were not limited to chronic obstructive pulmonary disease, respiratory failure and heart failure. A Significant Change Minimum Data Set (MDS) assessment, dated 10/23/2024, indicated Resident 4's cognition was intact. On 10/5/2024 at 6:15 P.M., Nursing Progress Notes indicated Resident 4 was found unresponsive. After an assessment and notification to the physician, Resident 4 was sent to the emergency room . Her husband was notified by phone of the transfer but the record lacked documentation that the Bed Hold Policy was provided to the resident or her husband. During an interview on 12/05/24 at 2:16 P.M., the ED indicated there was no documentation of the transfer paperwork, including the Transfer/Discharge form for Resident 4. 48145 2. During an interview on 11/3/2024 at 10:31 A.M., Resident 16 indicated she had been to the hospital in the last four months and did not recall receiving a bed hold policy. A Nursing Progress note, dated 9/19/2024 at 6:30 P.M., indicated Resident 16 was sent to the Emergency Department (ER) due to lower back pain and vomiting. A Nursing Progress note, dated 9/19/2024 at 7:49 P.M., indicated the Director of Nursing, Resident 16's family and Primary Care Physician were notified the resident was being transferred to the ER. A Nursing Progress note, dated 9/20/2024 at 6:25 A.M., indicated Resident 16 was admitted to the hospital. A Nursing Progress note, dated 10/4/2024 at 7:48 P.M., indicated Resident 16's family was concerned about the resident's health and requested the resident be sent to the hospital for evaluation. A Nursing Progress note, dated 10/4/2024 at 8:00 P.M., indicated after assessing the resident, the nurse called Emergency Services and the resident was transported to the hospital. The record lacked the documentation that a bed hold policy was provided to the resident in conjunction with Resident 16's transfer to the hospital on 9/20/2024 and 10/4/2024. During an interview on 12/5/2024 at 2:16 P.M., the Administrator (ED) indicated the record lacked copies of transfer paperwork, which included the notice of transfer and bed hold policy paperwork. On 12/5/2024 at 2:30 P.M., the ED provided the policy titled, Bed Hold Policy, dated 11/2017 and indicated it was the policy currently being used by the facility. The policy indicated Purpose of Policy: Provide guidance to facility staff for holding a bed for a resident transfer. 2. The residents will be provided the bed hold policy at the time of the hospital transfer or therapeutic leave. 4. The facility staff will document the notification to the resident and resident representative of the bed hold policy on the Emergency Resident Transfer Form 3.1-12(25)(A)(B)

Based on interview and record review, the facility failed to ensure residents were free from antibiotic medication used for an excessive duration for 1 of 6 residents reviewed for unnecessary medications. (Resident 41) Finding includes: A record review was completed on 12/5/2024 at 10:00 A.M. for Resident 41. Diagnoses included but were not limited to: acute osteomyelitis of left ankle and foot and stage 2 pressure ulcer on left heel. An Admission Minimum Data Set (MDS) assessment, dated 10/7/2024, indicated Resident 41's cognition was intact and he received antibiotic medication. Current Physician Orders included, but were not limited to, cephalexin (an antibiotic) ordered on 11/28/2024, 500 milligrams by mouth every 8 hours for a urinary tract infection. The antibotic was to have been completed and discontinued on 12/4/2024. A lab report, dated 11/30/2024, indicated a urine specimen showed no bacterial growth as the final result. The facility did not notify the Nurse Practioner, on 11/30/2024 of the need to discontinue the antibiotic treatment. An Event note, dated 12/5/2024, indicated the antibiotic was discontinued by the Nurse Practitioner due to no growth in the resident's urine, 5 days after the lab result was received. During an interview on 12/6/2024 at 1:14 P.M., the Infection Preventionist indicated it was normal to stop antibiotics due to the lab results from 11/30/2024. On 12/3/2024 at 1:00 P.M. a current policy, dated January 2023 and titled, Antibiotic Stewardship Program was provided by the Executive Director. The policy indicated, .The facility shall establish key elements for antibiotic prescribing and a system to monitor and manage antibiotic use 3.1-48(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident received fresh ice water per his preference for 1 of 3 residents reviewed for hydration. (Resident 21) Finding includes: During an observation and interview, on 12/4/2024 at 12:05 P.M., Resident 21 indicated he had did not have fresh ice water delivered daily to his room. He indicated he desired to have fresh ice water in his room. He indicated the last date he had water delivered was on 11/13 and 11/29. During an observation and interview, on 12/4/2025 at 1:16 P.M., Resident 21 indicated staff did not pass water and he had to go to the nurse's station and to ask for it in order to have a drink of water. During an observation on 12/5/2025 at 9:42 A.M., there was no cup of water in Resident 21's room. A record review was completed on 12/4/2024 at 2:11 P.M., for Resident 21. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following nontraumatic intracerebral hemmorrhage affecting left dominant side, type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 9/26/2024, indicated resident required set up assistance for eating and had upper and lower body range of motion impairment to one side of his body. A Quarterly Hydration Review assessment, dated 11/11/2024, indicated Resident 21 required assistance with food and fluids. A current Care Plan, dated 6/26/2024, indicated Resident 21 required assistance or monitoring of nutrition, hydration and elimination. The plan did not address the resident's desire to have fresh ice water in his room. During an interview on 12/5/2024 at 9:43 A.M., CNA 11 indicated she only provided water to residents' that wanted it and she did not just leave water in resident's rooms for them. She indicated that Resident 21 could do things for himself. On 12/9/2024 at 10:00 A.M., the Administrator provided a policy titled, Hydration Management, revised on 11/2017, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of American Senior Communities to ensure that each resident is offered sufficient fluid intake to maintain proper hydration. 4. Hydration plans will be reviewed at a minimum of quarterly to determine if plan is still needed or requires revision. 9. Fresh water or other preferred beverages will be passed to all residents, unless medically contraindicated, on each shift . 3.1-46(b)

Based on observation, interview, and record review, the facility failed to ensure acceptable infection control standards were maintained during a surgical dressing change for 1 of 1 resident observed for a dressing change. (Resident 42) Finding includes: During an observation of a dressing change, on 12/3/2024 at 10:12 A.M., LPN 2 removed the soiled dressing from Resident 42's wound. LPN 2 then removed her gloves, pulled another pair of gloves out of her uniform pocket, donned them and proceeded to clean the resident's wound. Prior to starting the dressing change, LPN 2 had laid the supplies for the dressing change on the residents bed without placing a barrier between the resident's bed and the clean dressing supplies. A record review was completed for Resident 42 on 12/4/2024 at 2:00 P.M. Diagnoses included, but were not limited to: chronic hematogenous osteomyelitis, left femur-distal, infection following a procedure, chronic obstructive pulmonary disease, chronic diastolic heart failure, acquired absence of left leg above the knee and acquired absence of right leg above the knee, peripheral vascular disease, and atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs. During an interview on 12/3/2024 at 10:28 A.M., LPN 2 indicated she should have washed her hands after she had removed the soiled dressing and she should have cleaned off the bedside table and placed a barrier down for the dressing supplies. On 12/3/2024 at 2:48 P.M., the DON provided a policy titled, Dressing Change Clean Technique (Incision or Wound), revised 10/2024, and indicated the policy was the one currently used by the facility. The policy indicated .8. Set up clean field with dressing change supplies and other necessary equipment. 10. Removed old dressing from the resident and put directly in trash receptacle. 11. Remove gloves and discard. 12. Perform hand hygiene . 3.1-18(a)

Based on observation, interview, and record review, facility failed to ensure a resident received a treatment per the physician order for 1 of 3 resident's reviewed for skin condition. (Resident 42) Finding includes: During an observation and interview, on 12/3/2024 at 9:41 A.M., Resident 42 indiated she was supposed to have gotten her dressing changed daily, but it had not been done for the past two days. She indicated she had requested the evening shift staff to complete it, but no one had came to change the dressing. The dressing on her left above the knee amputation site was dated 11/30/2024. The dressing was loose and a large amount of reddish-brown thick drainage was noted when the resident pulled back the edge of the dressing, the center of the wound had an opened area and the tissue around the wound and incision was red. A record review was completed for Resident 42 on 12/4/2024 at 2:00 P.M. Diagnoses included, but were not limited to: chronic hematogenous osteomyelitis, left femur-distal, infection following a procedure, chronic obstructive pulmonary disease, chronic diastolic heart failure, acquired absence of left leg above the knee and acquired absence of right leg above the knee, peripheral vascular disease, and atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs. A Current Care Plan, dated 10/30/2024, indicated impaired skin integrity related to a surgical wound, with the following intervention of treatment as ordered. A Physician Order, dated 11/27/2024 indicated the following: -left surgical above the knee wound to cleanse with wound wash, dry, apply skin prep then xeroform to wound bed and cover with an abdominal dressing and wrap with kerlix dressing. During an observation and interview on 12/3/2024 at 10:12 A.M., LPN 2 indicated the dressing to the left leg was ordered daily but the current dressing was dated 11/30., four day prior LPN 2 indiated Resident 42 went out with a friend during the day, on 12/1/2024 and 12/2/2024, and requested the dressing changes be completed when she had returned from her outings. During an interview on 12/4/2024 at 3:18 P.M., LPN 2 indicated she had not passed on in report to the evening shift that Resident 42 needed her dressing change completed when she returned from her leave of absence on 12/1/2024 and 12/2/2024. The dressing was not changed, even though the TAR (Treatment Record) had been inaccurately signed as completed on 12/1/2024 and 12/2/2024. A Nursing Progress note, dated 12/1/2024 at 1:15 P.M., indicated Resident 42 had requested her dressing to remain in place as she was going out of the building with a friend On 12/5/2024 at 8:53 A.M., the DON indicated that they did not have a policy on following physician orders was just the standard of practice. 3.1-37(a)

Based on interview and record review, the facility failed to provide a copy of the Notice of Transfer/Discharge form when residents were transferred and admitted to an acute care facility for 2 of 2 residents reviewed for hospitalization . (Residents 4 and 16) Findings include: 1. A record review was completed on 10/3/2024 at 2:10 P.M. for Resident 4. Diagnoses included, but were not limited to chronic obstructive pulmonary disease, respiratory failure and heart failure. A Significant Change Minimum Data Set (MDS) assessment, dated 10/23/2024, indicated Resident 4's cognition was intact. On 10/5/2024 at 6:15 P.M., Nursing Progress notes indicated Resident 4 was found unresponsive. After an assessment and notification to the physician, Resident 4 was sent to the emergency room . Her husband was notified by phone of the transfer but the record lacked documentation that the Notification of Transfer/Discharge form was provided to the resident or her husband. During an interview on 12/05/24 at 2:16 P.M., the ED indicated there was no documentation of the transfer paperwork, including the Transfer/Discharge form for Resident 4. 48145 2. During an interview on 11/3/2024 at 10:31 A.M., Resident 16 indicated she had been to the hospital in the last four months. A Nursing Progress note, dated 9/19/2024 at 6:30 P.M., indicated Resident 16 was sent to the Emergency Department (ER) due to lower back pain and vomiting. A Nursing Progress note, dated 9/19/2024 at 7:49 P.M., indicated the Director of Nursing, Resident 16's family and the Primary Care Physician had been notified of the resident's transfer to the ER. A Nursing Progress note, dated 9/20/2024 at 6:25 A.M., indicated Resident 16 was admitted to the hospital. A Nursing Progress note, dated 10/4/2024 at 7:48 P.M., indicated Resident 16's family was concerned about the resident's health and requested the resident be sent to the hospital for evaluation. A Nursing Progress note, dated 10/4/2024 at 8:00 P.M., indicated after assessing the resident, the nurse called Emergency Services and the resident had been transported to the hospital. The record lacked the documentation that a transfer/discharge assessment and forms had been completed in conjunction with Resident 16's transfer to the hospital on 9/20/2024 and 10/4/2024. During an interview on 12/5/2024 at 2:16 P.M., the Administrator (ED) indicated the record lacked copies of transfer paperwork, which included the notice of transfer and bed hold policy paperwork. On 12/5/2024 a policy was requested regarding documentation of a transfer/discharge assessment and one was not provided prior to the survey exit. 3.1-12(a)(6)(A)

Based on interview and record review, the facility failed to have Care Plan meetings with residents and/or their representatives timely for 2 of 3 residents whose Care Plan meetings were reviewed. (Residents 47 & 38) Findings include: 1. During an interview on 12/03/2024 at 2:13 P.M., Resident 47 indicated he had not been to a Care Plan meeting with the staff. Resident 47's record review was completed on 12/4/2024 at 1:23 P.M. Resident 46 had a Minimum Data Set (MDS) assessment completed on the following dates: -11/19/2024 Quarterly MDS assessment -8/21/2024 Significant Change MDS assessment -5/31/2024 Quarterly MDS assessment -5/14/2024 Quarterly MDS assessment -3/19/2024 Annual MDS assessment -1/2/2024 Quarterly MDS assessment There was no documentation a Care Plan meeting with Resident 47 had been conducted following any of the MDS assessments, except after the 2/18/2024 Annual MDS assessment. During an interview on 12/5/2024 at 2:34 P.M., the Social Services Director indicated she had met with Resident 47 regularly, but had not had a Care Plan meeting with him following his MDS assessments. During an interview on 12/6/2024 at 8:45 A.M., the Executive Director indicated Resident 47 had not received Care Plan meetings regularly after his MDS assessments. 47419 2. During an interview on 12/4/2024 at 10:45 A.M., Resident 38 indicated she had not met with staff about her care plan in a long time. A record review was completed on 10/5/2024 at 2:30 P.M. for Resident 38. Diagnoses included, but were not limited to, hypertension, general anxiety disorder and depression. An Annual Minimum Data Set (MDS) assessment, dated 11/6/2024, indicated Resident 38's cognition was intact. Resident 38's record lacked the documentation a Care Plan meeting had been conducted on a quarterly basis with Resident 38 and/or her representative from 6/6/2024 through 12/5/2024. During an interview on 12/05/24 at 2:45 P.M., the Social Service Director (SSD) indicated that she had not held any formal care plan meetings with Resident 38 and should have had them after quarterly assessments were completed on 8/14/2024 and on 11/6/2024. On 12/5/2024 at 3:00 P.M. a current policy, dated 8/2023, and titled, IDT Comprehensive Care Plan Policy was provided by the SSD. The policy indicated, .During the meeting all IDT members promptly meet with resident and/or representative at the bedside, or resident's desired location, at the time mutually agreed upon by SS, IDT, resident and/or representative 3.1-(d)(2)(B)

Based on observation, interview, and record review, the facility failed to properly store refrigerated medications in 1 of 3 medication refrigerators that were observed for drug storage (Cottage Unit). Finding includes: An observation of the medication refrigerator on the Cottage Unit was completed on 12/7/2023 at 8:18 A.M. The medication refrigerator's freezer had a heavy built-up of ice that was melting and causing water to accumulate in a red bin containing resident's medications. During an interview, completed on 12/7/2023 at 8:23 A.M., the Director of Nursing indicated there was water dripping onto resident's medications in the refrigerator, and there should not be. On 12/7/2023 at 10:30 A.M., the Director of Nursing provided a policy, with a revision date of 7/21/2022, and titled, Storage and Expiration Dating of Medications and Biologicals,. The Director Nursing indicated it was the policy currently being used by the facility. The policy indicated, .This Policy sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles .11. Facility should monitor refrigerated storage for evidence of moisture and condensation (humidity) and may consult with the pharmacy regarding medication integrity 3.1-25(m)

Based on record review and interview, the facility failed to create a person-centered care plan for 2 of 25 residents whose care plans were reviewed (Residents 1 and 55). Findings include: 1. A record review was completed on 12/7/2023 at 11:39 A.M. Resident 1's diagnoses included, but were not limited to: anxiety disorder, Non-Alzheimer's dementia, pseudobulbar affect, adjustment disorder with mixed anxiety and depressed. Resident 1's current physician orders included, but were not limited to: Lexapro 20 mg (milligram) tablet oral once a day for depression, and Valium 2 mg tablet 3 times a day for anxiety disorder. A current care plan, dated 2/24/2017, and revised, on 8/22/2018, indicated Resident 1 was displaying signs and symptoms of depression, such as trouble sleeping, feeling tired and having little energy, crying, and tearfulness. Resident 1 indicated she felt bad about herself and had trouble concentrating. Interventions included, but were not limited to: Offer encouragement and support to the the way Resident 1 feels, encourage activities of interest, encourage family support, and involvement. During an interview, on 12/7/2023 at 3:45 P.M., the Director of Nursing indicated Resident 1's care plan was not person centered, but should have been. 38845 2. A record review was completed on 12/6/2023 at 3:42 P.M. Resident 55's diagnoses included, but were not limited to anxiety, depression, dementia and traumatic brain dysfunction. A Quarterly MDS (Minimum Data Set) assessment, dated 9/26/2023, indicated Resident 55 had no mood or behavior issues. Resident 55's current medication list included, but were not limited to: Lexapro (Antidepressant) and Lorazepam (Benzodiazepines). A current care plan, dated 6/13/2023, indicated the resident was at risk for signs and symptoms of anxiety. Worried facial expressions, repetitive movements, insomnia, reports of anxiety. Resident may become verbally aggressive with other residents. Has a diagnosis of Generalized Anxiety disorder. The interventions included: Encourage activities of interest. Encourage family support and involvement. Encourage resident to verbalize fears and anxiety, offer validation and reassurance. Maintain calm environment, move to quiet area. Medications per MD order, and Psych (psychiatric) services as appropriate- resident declined. A current care plan, dated 6/13/2023, and last reviewed on 10/2/2023, indicated the resident was at risk for signs/symptoms of depression. Sad facial expression, withdrawal, decreased appetite, tearfulness, insomnia, verbalization of depression, etc. PHQ-9 (Patient Health Questionnaire) states feeling tired and feeling fidgety/restless. The interventions included: Encourage activities of interest. Encourage family support ad involvement. Allow the resident to express feelings and frustrations offer validation and support. During an interview, on 12/8/2023 at 12:00 P.M., the Director of Nursing indicated the care plans were not person centered with interventions and should have been. On 12:10 P.M., the Director of Nursing provided the policy titled, IDT Comprehensive Care Plan Policy. The policy indicated .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person--centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process. The care plan must include measurable goals and resident specific interventions based on resident needs and preferences 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure oxygen was provided as ordered, change oxygen equipment and ensure oxygen equipment was dated for 1 of 1 resident reviewed for oxygen use (Resident 52). Finding includes: During an observation, on 12/04/2023 at 11:45 A.M., Resident 52 had undated oxygen tubing and an undated humidification bottle in her room and the oxygen storage bag was dated 11/10/2023. During an observation, on 12/05/2023 at 9:11 A.M., Resident 52 had undated oxygen tubing and an undated humidification bottle in her room and the oxygen storage bag was dated 11/10/2023. During an observation, on 12/6/2023 at 5:55 A.M., no date was found on the oxygen tubing and the humidification bottle was undated and the oxygen tubing bag was dated 11/10/2023. During an observation, on 12/06/223 at 11:18 A.M., no date was on the oxygen tubing or humidification bottle and oxygen storage bag dated 11/10/2023 with staff observed in resident's room. During an interview, on 12/06/2023 at 3:06 P.M., LPN 5 indicated that Resident 52's oxygen tubing and humidification bottle should have been changed and dated on Sunday night per the Physician Order. LPN 5 looked at the oxygen tubing, humidification bottle, and oxygen storage bag and indicated that the oxygen tubing and humidification bottle should have been dated, and the bag should have been changed at the same time. LPN 5 indicated that the oxygen bag was dated 11/10/2023 and should have been changed out. A record review was completed, on 12/07/2023 at 11:10 A.M., and indicated Resident 52's diagnoses included, but were not limited to: chronic respiratory failure with hypoxia, dementia, cor pulmonale, pulmonary hypertension due to lung diseases and hypoxia. A Physician's Order, dated 5/12/23, indicated to change oxygen tubing and humidification bottle, and clean concentrator and filter once a week on Sunday. A Physician's Order, dated 7/19/2023, indicated Resident 52 had continuous oxygen at two liters per nasal cannula. On 12/8/2023 at 9:00 P.M., the Director of Nursing provided an undated policy titled Oxygen Therapy and Devices and indicated that this was the current policy used by the facility.Oxygen devices .(1) nasal cannula .(e) Change out weekly and as needed .(f) place in bag when not in use On 12/8/2023 at 9:00 A.M., the Director of Nursing provided an undated policy titled Oxygen Concentrator and indicated that this was the current policy used by the facility.daily maintenance (1) Check the water level in the humidity bottle and change the bottle as needed every seven days 3.1-47 (a)(6)

Based on record review and interview, the facility failed to ensure that a Physician Order indicated a Do Not Resuscitate (DNR) as indicated upon admission by the resident and legal representative for 1 of 2 residents reviewed for Advance Directives (Resident 43). Finding includes: A record review was completed, on 12/07/2023 at 8:43 A.M., and indicated diagnoses included, but were not limited to: Alzheimer's disease, dysphagia, anxiety, and depression. A current Physician's Order, dated 3/28/2023, indicated Resident 43 had a Full Code status ordered. A signed POST (Physician's Orders for Scope of Treatment) form dated 9/7/2023 indicated Resident 43 had a Do Not Resuscitate status. A care plan, dated 9/29/2023, indicated Resident 43's legal representative had formulated a Do Not Resuscitate with POST orders. Resident and legal representative preferences regarding advanced directives would be honored. Assess for change in condition as indicated and ensure that the POST form would be completed fully and integrated in Physician's Orders and ensure that POST form is sent to the hospital with resident if hospitalized . During an interview, on 12/07/2023 at 10:11 A.M., LPN (Licensed Practical Nurse) 6 indicated that there was a discrepancy between the Physician's Order for Resident 43's code status and the POST form. LPN 6 indicated she was unsure why there was a discrepancy and indicated Resident 43 had been admitted as a Full Code status and the orders should have been updated when the POST form was changed. LPN 6 indicated that the orders and the POST form should have been the same. On 12/8/2023 at 9:00 A.M., the Director of Nursing provided a policy titled Advanced Directives-POST, DNR, Health Care Rep dated 1/2016 and indicated this was the current policy used by the facility. The policy indicated .If a resident has a valid Advanced Directive, the facility's care will reflect the resident's wishes as expressed in the Directive, in accordance with state law .(2) Information about any Advanced Directives already in place will be gathered as part of the admission process. Executed Advanced Directives will be documented in the medical record. Advanced Directives which reflect medical care and treatment will be documented as a physician's order .Implementing/Maintaining a POST form .(3) If the individual decides to revoke or change the POST form, the resident's attending physician should be notified and appropriate changes to the physician's orders should be obtained as soon as possible to ensure that the resident's wishes are accurately reflected in the plan of care 3.1-4(5)

Based on interview and record review, the facility failed to protect a residents' right to be free from sexual abuse by a resident for 1 of 3 residents reviewed for abuse, (Resident C). Findings include: On 2/09/23 at 11:31 A.M., the Executive Director (ED) provided a facility reported incident, Incident Number 686, dated 2/01/23. The report indicated on 2/01/23 around 7:00 P.M., staff were rounding in the Memory Care Area and found Resident D in bed with Resident C attempting to put his had down Resident C's brief. Staff immediately redirected Resident D and assisted him out of the bed and escorted him back to his room. A Head-to-Toe assessment was completed on Resident C, finding Resident C's brief remained in tact and fastened. Resident C did not show any signs or symptoms of psychosocial distress. On 2/09/23 at 11:47 A.M., the clinical record for Resident C was reviewed. Resident C was admitted on [DATE] with diagnoses that included but were not limited to Alzheimer's disease. The most recent comprehensive Minimum Data Set (MDS) was a quarterly assessment dated [DATE], and indicated Resident C was severely cognitively impaired, required extensive assistance for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Resident C was totally dependent on staff for locomotion on and off the unit, and for bathing. The resident utilized a wheelchair for mobility. The MDS listed diagnoses that included but were not limited to, Alzheimer's disease, dementia, anxiety, and depression. On 2/09/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was most recently admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia with behavioral disturbances. The most recent comprehensive MDS was a quarterly assessment, dated 1/26/23, and indicated Resident D was severely cognitively impaired, exhibited intermittent signs of inattention, disorganized thinking, and altered levels of consciousness indicated by lethargy, difficult to arouse, and startling easily. The resident did not exhibit any behaviors to impact others during the 7 day assessment period. Resident D required limited assistance of 1 person to walk in the room and in the corridor and did not require a mobility device. The MDS listed diagnoses that included but were not limited to stroke and dementia. On 2/10/23 at 10:30 A.M., during an interview conducted with the ED she indicated it was inappropriate for Resident D to be in Resident C's bed. She indicated the facility policy directed the action to be a form of abuse, so reported the incident to the State Agency within 2 hours of the occurrence. A policy, titled Abuse Prohibition, Reporting, and Investigating, dated 1/23 was provided by the Executive Director on 2/09/23 at 2:50 P.M., and indicated it was the current policy. The policy indicated, .It is the policy .to provide each resident with an environment that is free from abuse .This includes but is not limited to .sexual abuse .Definitions/Examples of Abuse .Sexual Abuse-Nonconsensual sexual contact of any type with a resident. Examples may include but not limited to .touching . This Federal tag related to complaint IN00401263. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to implemented a Care Plan for a resident who required feeding assistance, for 1 of 3 residents reviewed for feeding assistance, (Resident B). Finding includes: On 2/10/23 at 12:13 P.M., during an observation of Resident B, the resident was in his bed with the head of the bed elevated and sitting up in preparation of the lunch meal, and with a Hospice nurse at the bedside. During an interview with the Hospice Nurse at that time, she indicated the resident required feeding assistance for all meals and that the resident spilled much of his food if he was not assisted. On 2/10/23 at 12:15 P.M., during an observation and interview, Resident B was set-up and awaiting the lunch tray. During an interview with the Executive Director at that time, she indicated Resident B required feeding assistance from the staff. On 2/10/23 at 12:30 P.M., during an observation of Resident B, the resident was being fed by Qualified Medication Aide (QMA) 3. During an interview with QMA 3, he indicated resident would sometimes feed himself, but was supposed to be fed by staff. On 2/13/23 at 10: 41 A.M.,during an interview with Social Service Director, she indicated on 1/27/23 there was a family Care Plan meeting with Resident B's family member and it was determined at that time that staff need to feed the resident and that resident Care Plans should be followed. On 2/13/23 at 2:20 P.M., the clinical record for Resident B was reviewed. Resident B was most recently admitted to the facility on [DATE] with diagnoses that included but were not limited to hemiplegia (paralysis to one side of the body) following a stroke, dysphasia (difficulty in swallowing), and contracture of the left hand. A Minimum Data Set (MDS) dated [DATE], for a quarterly assessment indicated Resident B was moderately cognitively impaired, exhibited no behaviors, required extensive assistance of 2 people for bed mobility, transfers, toileting, extensive assistance of 1 for dressing, personal hygiene, total dependence for locomotion on and off the unit, and bathing. The resident required supervision for eating. Resident B was receiving hospice services. Resident B's current care plans included but were not limited to, the resident's experience of weight loss in the past, dated 5/12/22. The Care Plan indicated staff were to monitor food intake at meals. A Care Plan for nutritional status was initiated on 10/02/19 and updated on 12/02/22, instructing staff to assist with eating as needed and to monitor food intakes. A CarePlan Summary dated 12/02/22, indicated in Culinary Instructions, .discussed that when nurse does round she sees resident getting assistance with meals. Did speak with floor staff in regards to assisting res, [Resident B], not sitting tray in room without having staff ready to assist with meal . A CarePlan Summary dated 1/27/23, indicated in Culinary Instructions, .States staff should be feeding him [Resident B] .Nursing to offer to feed Review of Resident B's point of care documentation for meal assistance from 1/01/23 to 2/12/23 indicate the resident did not receive feeding assistance on the follow dates and times: 1/01/23 lunch: Independent 1/02/23 lunch: Independent 1/03/23 breakfast and lunch, no documentation 1/06/23 lunch: Independent 1/07/23 lunch: No documentation 1/09/23 breakfast: Independent 1/10/23 breakfast: Independent 1/18/23 breakfast: Independent 1/22/23 breakfast: Independent 1/22/23 lunch: No Documentation 1/24/23 lunch: No Documentation 1/25/23 breakfast and lunch, no documentation 1/27/23 lunch: Independent 1/28/23 breakfast: Supervision 1/29/23 breakfast: Supervision 1/30/23 supper: No documentation 1/31/23 breakfast: Supervision 2/01/23 breakfast: Supervision. Lunch and supper, no documentation 2/04/23 supper: No Documentation 2/05/23 breakfast: Independent 2/06/23 breakfast: Supervision. Lunch, no documentation 2/07/23 breakfast, lunch, supper: no documentation. 2/08/23 breakfast, lunch: no documentation. Supper, supervision 2/09/23 breakfast, supper: no documentation 2/11/23 breakfast supper: no documentation 2/12/23 breakfast: no documentation Review of Resident B's Vitals Report for meal intake amounts from 1/01/23 to 2/12/23 indicated no meal intake documentation on the follow dates and times: 1/01/23 breakfast 1/02/23 lunch 1/03/23 breakfast and lunch 1/04/23 breakfast and lunch 1/05/23 breakfast and lunch 1/06/23 lunch 1/07/23 breakfast and lunch 1/08/23 dinner 1/10/23 lunch 1/12/23 lunch 1/18/23 lunch 1/19/23 breakfast and lunch 1/20/23 lunch 1/24/23 lunch 1/26/23 lunch 1/28/23 lunch 1/29/23 dinner 1/30/23 breakfast and lunch 1/31/23 breakfast 2/01/23 breakfast and lunch 2/02/23 dinner 2/03/22 breakfast 2/05/23 lunch 2/06/23 breakfast 2/07/23 breakfast and dinner 2/08/23 breakfast and lunch 2/09/23 lunch 2/10/23 breakfast and lunch 2/11/23 lunch A policy titled, IDT [Inter Disciplinary Team] Comprehensive Cafe Plan Policy, dated 10/19 and indicated as the current policy was provided by the Executive Director on 2/13/23 at 9:15 A.M. The policy indicated, .The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning . This Federal tag relates to complaint IN00400525. 3.1-35(g)(2)

Based on observation, interview and record review, the facility failed to prevent the worsening of, follow physician's orders and effectively treat a Stage 4 pressure ulcer to a resident's coccyx for 2 of 5 residents reviewed for pressure ulcers in a total sample of 6 residents who met the criteria for pressure ulcers. (Resident B and Resident I) The immediate jeopardy began on 10/3/18 when the facility failed to ensure a resident received timely assessment and treatment of [REDACTED]. The Administrator, Director of Nursing and Corporate Nurse were notified of the immediate jeopardy on 12/27/18 at 4:55 P.M. The immediate jeopardy was removed on 12/31/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: 1. The clinical record for Resident B was reviewed on 12/26/18 at 1:57 P.M. A MDS (Minimum Data Set) assessment, dated 6/19/18, indicated she did not currently have a pressure ulcer, but was at risk for developing pressure ulcers. A Braden pressure ulcer risk assessment, dated 7/2/18, indicated Resident B was at high risk for developing a pressure ulcer. [DIAGNOSES REDACTED]. A Progress Note, dated 6/16/18 at 9:12 P.M., indicated Resident B was admitted to the facility with a redness noted to coccyx and skin was intact. She was a one assist with transfers and used a wheelchair for ambulation. A Progress Note, dated 6/19/18 at 10:38 A.M., indicated Resident B was sent to the local hospital for emergency room evaluation. A Progress Note, dated 7/2/18 at 7:12 P.M., indicated Resident B returned to the facility with a open area noted to her coccyx. A Wound Note, dated 7/3/18, indicated Resident B had a Stage 2 pressure area to coccyx measuring 4.2 cm (centimeters) x 1.3 cm x no depth with 100% [MEDICATION NAME] tissue noted to wound base, outside wound edges with pink and normal. A Physician Telephone Order, dated 7/3/18, indicated the wound nurse had received a telephone order from the Primary Care Physician for [MEDICATION NAME] once daily, cleanse area to coccyx with wound wash, pat dry, apply lanteseptic and cover with adherent dressing. A Physician Telephone Order, dated 7/5/18, indicated the wound nurse had received a telephone order from the Primary Care Physician for [MEDICATION NAME] once daily, cleanse area to coccyx with wound wash, pat dry, apply [MEDICATION NAME] and cover with adherent dressing. A care plan for risk of skin breakdown, dated 7/3/18, indicated Resident B's risk factors included but were not limited to, inability to respond meaningfully to pressure-related discomfort, skin is often but not always wet, linen must be changed at least once a shift, chair fast, ability to change and control body position was very limited, at risk for shearing due to complete lifting without sliding against the sheets was impossible and she frequently slid down in bed and chair and required frequent repositioning and [DIAGNOSES REDACTED], contractures and agitation leading to almost constant friction. A Care Plan Summary, dated 7/18/18, indicated Resident B, her husband, the nurse from P.A.C.E., the social worker and dietician were present for family care conference. There was no documentation the pressure ulcer to Resident B's coccyx was discussed. A care plan for impaired skin integrity, dated 7/23/18, indicated wound to coccyx that was present on admission. The interventions included, but were not limited to, notify physician of change in wound such as worsening or signs of infection, observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth, and turn and reposition every two hours. New interventions were added on 10/9/18 to float heels and Pro Mat Plus (mattress) and on 10/23/18 a wound vac to coccyx. A Physician Telephone Order, dated 7/23/18, indicated the wound nurse had received a telephone order from the Primary Care Physician for a roho cushion to be applied to resident's wheelchair. A Wound Note, dated 7/24/18 and created 7/30/18, indicated Resident B had a Stage 2 pressure ulcer that measured 4 cm x 1.5 cm x no depth with light serous drainage and wound status was declining. There was no documentation available that Resident B's Primary Care Physician was notified of the change in wound. A Physician Telephone Order, dated 7/26/18, indicated the wound nurse had received a telephone order from the Primary Care Physician for [MEDICATION NAME], cleanse coccyx with wound wash, pat dry, apply [MEDICATION NAME], and cover with adherent dressing twice daily. A PRN Medication Administration History, dated 8/1/18- 8/31/18, indicated Resident B had an order for [REDACTED]. An order of turn and reposition resident every 2 hours was started on 8/22/18. There were no orders to or documentation completed for observation of wound to coccyx for signs or symptoms of infection. A Progress Note, dated 8/10/18 at 10:58 A.M., indicated Resident B required assistance with bed mobility, transfers, eating and toilet use. A Progress Note, dated 8/23/18 at 4:24 P.M., indicated the Nurse Practitioner from P.A.C.E was updated on Resident B's wound. A PCP (Primary Care Provider) Progress Note, dated 8/23/18, indicated the Nurse Practitioner was notified that Resident B had a Stage 3 pressure area that the facility was providing wound care for. A recommendation for a referral to the wound clinic was made for wound management. A Telephone Note, dated 8/24/18 at 4:14 P.M., indicated the case manager of P.A.C.E. was made aware of the Stage 3 coccyx pressure on this day from the wound nurse at facility. It was the same Stage 2 wound Resident B had admitted with on 7/2/18 and was noted to have slough on 8/22/18 and measured 3.9 cm x 1.5 cm x 0.1 cm, resident had roho cushion and broda chair since last week and derma float mattress was started on 7/18/18. Resident was receiving 2 cal supplement twice weekly and would be started on protein supplement 30 ml twice daily per Nurse Practitioner. A Physician Telephone Order, dated 8/27/18, indicated the wound nurse had received a telephone order from the Resident's primary care physician for [MEDICATION NAME] twice daily, cleanse coccyx with wound wash, pat dry, and apply [MEDICATION NAME] and alginate and cover with adherent dressing. A Wound Note, dated 8/28/18, indicated Resident B had a Stage 3 pressure ulcer that measures 4 cm x 1.7 cm x 0.1 with 40% [MEDICATION NAME], 50% granulation and 10% slough with pink/normal surrounding tissue and wound status declining. The were no changes made to care plan to alleviate pressure to coccyx area. The Medication Administration History, dated 9/1/18 -9/31/18, indicated the order for turn and reposition every 2 hours had been charted late 95 times and had missing documentation 23 scheduled times. [MEDICATION NAME] was received as needed on 5 occasions for pain to coccyx. Tylenol was ordered as 650 mg twice a day for wound to coccyx on 9/17/18 to 9/26/18 when [MEDICATION NAME] was ordered 50 mg twice daily. There were no orders or documentation available for observation of wound to coccyx for signs or symptoms of infection. A Progress Note, dated 9/8/18 at 9:31 P.M., indicated Resident B was sent to the local hospital for an emergency room evaluation. A physician progress notes [REDACTED]. If signs of infection persisted despite treatment of [REDACTED]. A Progress Note, dated 9/11/18 at 5:48 P.M., indicated Resident B was admitted back to the facility from the hospital with a open area to coccyx and no complaint of pain or discomfort. A Wound Note, dated 9/12/18 and created 9/18/18 indicated Resident B had a pressure area that measured 5.7 cm x 2.8 cm x 0.4 with 40% slough to wound base and [DIAGNOSES REDACTED] noted around wound. A Progress Note, dated 9/15/18 at 1:35 P.M., indicated Resident B had treatment completed to coccyx with no complaint or non-verbal indicators of pain. A Progress Note, dated 9/20/18 at 12:14 P.M., indicated Resident B's weight was 168 lbs (pounds) and her BMI (Body Mass Index) was 25.4, indicating she was slightly overweight per guidelines. Resident B was currently on Pro-Stat Max 30 ml (milliliters) twice daily and Two Cal 240 ml three times daily to aide in wound healing and a recommendation for Pro-Stat to be increased to three times a day was made. A Progress Note, dated 9/24/18 at 10:45 P.M., indicated Resident B denied any pain except for pain at her wound site. The Wound Clinic Note, dated 9/26/18, indicated Resident B was admitted to facility in (MONTH) and had developed a pressure ulcer over her sacrum. The wound measured 6.4 cm x 2.6 cm x 1.9 cm with a lot of slough present, some surrounding [DIAGNOSES REDACTED] (redness). The wound was staged at a Stage 3 pressure injury. There was debridement to the wound to remove necrotic tissue. Resident B's diabetes was apparently well controlled. The physician indicated he wanted to recheck sed rate and c-reactive protein to see if they were improving and would consider MRI of pelvis. A Physician Order, dated 9/26/18 at 10:09 A.M., indicated order for Santyl, dampened gauze and ABD pad daily, transport by stretcher only to appointments, no pressure to coccyx, low air loss mattress, alternating pressure, up in chair for meals and showers only with 30 min maximum time. A Physician Order, dated 9/26/18 at 10:20 A.M., indicated the wound clinic had ordered an [MEDICATION NAME], Pre-[MEDICATION NAME], C-Reactive Protein, Sedimentation Rate and Hemoglobin A1C. A Progress Note, dated 9/26/18 at 11:02 P.M., indicated Resident B voiced pain to her coccyx due to open area. A bari-bed was delivered. A Physician Telephone Order, dated 9/26/18, indicated a LPN (Licensed Practical Nurse) 2 had received a telephone order for [MEDICATION NAME] 50 mg (milligrams) twice daily for moderate pain associated with Stage 3 pressure ulcer to coccyx. A Progress Note, dated 9/27/18 at 12:25 P.M., indicated Resident B had an average meal consumption of 60-80% of breakfast, 40-60% of lunch and 60-80% of dinner, consumed 97% of 2 cal over the last seven days. Resident B's weight was 167 lbs. A Progress Note, dated 9/30/18 at 12:09 P.M., indicated Resident B was not hungry for breakfast and she requested to lay back in bed, she required extensive assist of two with transfers. Tylenol was given for pain. The Medication Administration History, dated 10/1/18 - 10/31/18, indicated the order for turn and reposition every 2 hours had been documented late 51 times up to 10/14/18 and 4 missing documentation's. A Progress Note, dated 10/2/18 at 1:27 P.M., indicated treatment of [REDACTED]. The Wound Clinic Note, dated 10/3/18, indicated the wound size was 5.5 cm x 2.6 cm x 1.6 cm with a large amount of necrotic material present and bone was able to be palpated. Wound was classified as Stage 4, excisional debridement was done down to the bone, removing some pieces of bone and necrotic material. The bone tissue was sent for tissue culture and MRI of pelvis was ordered. A Physician's Order, dated 10/3/18, indicated treatment order was Santyl every day with gauze fluffed and covered by ABD (abdominal) pad, MRI (Magnetic Resonance Imaging) ordered, culture and sensitivity sent, Infection Disease Consult and resident to transport by stretcher only to appointments. Resident was to only be up 30 minutes at a time for meals and showers only. There was no documentation to indicate the MRI was scheduled, follow up on culture and sensitivity or consult for Infectious Disease physician was completed. The Culture of the wound fragments from the coccyx wound, dated 10/3/18, indicated Resident B's coccyx wound was positive for proteus mirabilis [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus). A Progress Note, dated 10/4/18 at 1:51 P.M., indicated Resident B complained of moderate pain to the coccyx and she continued on scheduled pain medication. A Care Plan Summary, dated 10/5/18, indicated the guardian for Resident B was present for the Family Care Conference. There was no documentation that the wound progression was discussed or new orders that had been received from the wound clinic for Infectious Disease consult. A Progress Note, dated 10/7/18 at 4:18 A.M., Resident B complained of discomfort to her back. A Physician Order, dated 10/9/18, indicated a verbal order for a Pro Mat plus Air Mattress. A Wound Note, dated 10/9/18 and created 10/15/18, indicated Resident B had a Stage 4 pressure ulcer that measured 5.5 cm x 2.5 cm x 1.7 cm with 50% slough noted to wound bed and [DIAGNOSES REDACTED] noted to surrounding tissue and wound status was declining. There was no documentation available for communication with the Primary Care Physician or wound clinic in regards to changes in the condition of wound. A Progress Note, dated 10/11/18 at 10:05 P.M., indicated Resident B complained of moderate pain during treatment to coccyx. A Progress Note, dated 10/14/18 at 3:15 P.M., indicated Resident B presented with lethargy, poor appetite and elevated temperature and pulse. She was diaphoretic and disoriented and oxygen saturation was 88%. Resident B's temperature was still elevated one hour after Tylenol was given. The Physician Communication Tool, dated 10/14/18, indicated Resident B was being transferred to the local hospital for temperature of 100.3 and pulse of 112, with the problem seemed to be infection. The Emergency Department Physician Evaluation, dated 10/14/18, indicated Resident B was sent the ER (emergency room ) for altered mental status. Upon physical examination Resident B's temperature was 99.1 and her pulse was 88. She had a large foul smelling high-grade Stage 4 decubitus sacral ulcer with blackness noted around edges. Her white cell blood count was 14,000 (range 4,000 to 11,000). The [DIAGNOSES REDACTED]. A Wound Care Evaluation Note, dated 10/15/18 at 11:19 A.M., indicated Resident B had a Stage 4 pressure ulcer the presented with exposed bone and a piece of loose bone, but the necrotic slough was holding it from being removed. Debridement was painful and caused some bleeding, so it was stopped. A physician progress notes [REDACTED].M., indicated a large open wound to the sacrum with bone exposure and foul smelling with purulent drainage. A physician progress notes [REDACTED].M., indicated the ulcer to the sacral area was around 8 cm x 8- 10 cm deep with gray colored dead tissue with a bad odor. A Consultant for the Infectious Disease Physician, dated 10/17/18 at 10:30 A.M., indicated that a few days prior to hospital admission Resident B started having increased confusion and she was found to have a significant enlargement of the sacral area after admission with exposed bone. A swab culture from 10/3/18 [MEDICAL CONDITION], proteus (causes 90% infection in humans and found widely distributed in soil and water) and bacillus fragillis (part of normal mircobiota of the human colon, but can cause infection into other surrounding tissues). Imaging was done that confirmed destruction to bone with acute osteo[DIAGNOSES REDACTED]. Resident was to be seen by surgery and resident indicated the overall pain to her buttocks had not improved. A wound culture was done on 10/14/18 from decubitus ulcer the was positive for Gram-Positive Cocci, Gram Positive Rods, proteus and acinetobacter (bacteria found in soil and water, rarely occurs outside the healthcare setting and spread by person-to-person contact or by contaminated surfaces). The urine culture from 10/14/18 was positive [MEDICAL CONDITION]. The impression and plan indicated Resident B was admitted for alteration in mental status likely due to acute osteo[DIAGNOSES REDACTED] of the sacrum and coccyx. The MRI imaging confirmed the [DIAGNOSES REDACTED]. Overall poor chance of fully treating with antibiotics due to open exposure of underlying bone. The impression and plan was [DIAGNOSES REDACTED]. An Operative Report, dated 10/17/18, indicated Resident B underwent the debridement of sacral decubitus ulcer with placement of a wound vac-assisted closure. Using electrocautery to divide skin, subcutaneous fat, some muscle and fascia was removed all the was around the area of the wound and the necrotic tissue at the base of the wound. The wound then had good healthy-appearing tissue with good blood flow. An area right at the tip of the coccyx was inflamed. Tissue was sent for culture and wound vac was applied. The local hospital Discharge Summary, dated 10/20/18, indicated Resident B's primary [DIAGNOSES REDACTED]. Resident B was continue 6 week course of IV antibiotics. Follow up order was to follow up with Infectious Disease, primary care and vascular surgery. A Wound Note, dated 10/22/18 and created on 10/23/18, indicated Resident B had pressure ulcer measuring 9 cm x 5 cm x 4.5 cm with moderate drainage, and [DIAGNOSES REDACTED] was noted to outside edges of wound. The wound was noted to be declining. A Wound Note, dated 10/30/18, indicated Resident B had pressure ulcer measuring 10 cm x 6 cm x 3.5 cm with moderate drainage, and outside edges of wound were noted to be dark purple or rusty discoloration and [DIAGNOSES REDACTED]. The Medication Administration History, dated 11/1/18 - 11/30/18, indicated there were no orders or documentation available for monitoring the wound to coccyx for signs and symptom of infection or worsening. The Wound Clinic Notes, dated 11/29/18, indicated the wound measured 9.0 cm x 2.1 cm with adherent slough noted throughout most of the wound, brown purulent material drained from the wound as it was debrided out. A Progress note, dated 11/30/18 at 9:28 P.M., indicated Resident B had a running a fever of 101.5 at 6:00 P.M. and emesis was noted. The Medication Administration History, dated 12/1/18 - 12/31/18, indicated there were no orders or documentation available for monitoring the wound to coccyx for signs and symptom of infection or worsening. A Progress Note, dated 12/4/18 at 9:55 A.M., indicated Resident B was noted to be diaphoretic. There was no physician notification noted for change in condition. A Wound Clinic Note, dated 12/6/18, indicated the post debridement measurement of the wound was 10.1 cm x 6.1 cm x 2.5 cm. The physician indicated he advised the facility reschedule the appointment with Infectious Disease that they missed. There was no documentation available for follow up with Infectious Disease. The Emergency Transportation Note, dated 12/16/18 at 11:53 P.M., indicated Resident B's temperature was 102. The Progress Note, dated 12/16/18 at 12:22 P.M., Resident B was not alert when nurse entered room, struggling with breathing sounds of fluid. Kussmal breathing noted. Head of bed to highest position, breathing treatment ineffective. Resident B sent out to local hospital. A Nursing Narrative Note from local hospital, dated 12/16/18 at 12:30 P.M., indicated Resident B had a large sacral wound noted to her coccyx the size of a softball, wound was tunneling and bone was visualized. A strong foul odor was coming from the wound. The wound vac was not attached and dressing was soaked in stool so it was removed. A Consultation, dated 12/16/18 at 4:59 P.M., indicated Resident B present to the ER with fever, altered mental status and dyspnea. resident underwent [REDACTED]. She was then transferred to the ICU (intensive care unit). The Wound Note from local hospital, dated 12/17/18 at 11:27 A.M., indicated a Stage 4 pressure ulcer over sacrum/coccyx that measured 9.2 cm x 5.5 cm x 3.2 cm with tunneling at 11 o'clock at 2.5 cm, 3 o'clock at 0.8 cm and 9 o'clock at 1.3 cm. During an interview, on 12/26/18 at 2:20 P.M., the legal guardian for Resident B indicated staff did not turn the resident every two hours as they should been and she feels the bedsore should have never progressed the way it has if she had been receiving the care she should have During an interview, on 12/28/18 at 2:30 P.M., the Nurse Practitioner from P.A.C.E. and working under Resident B's primary care physician indicated the was no notification of a wound on Resident B until the Nurse Practitioner made a visit to the facility on [DATE]. During an interview, on 12/28/18 at 2:45 P.M., the Medical Records Nurse from P.A.C.E. indicated that all information and notification to the resident's primary care physician was to go through P.A.C.E. She indicated that from 7/2/18 to 8/23/18 there were no physician notifications documented on the updates of Resident B wounds. She indicated the facility had been educated previously proper routes of communication with the physician and that all information needed to be communicated through P.A.C.E. During an interview, on 12/28/18 at 3:00 P.M., the RN (Registered Nurse) from local hospital indicated Resident B present to ER with a wound vac in on sacral region, the edges the dressing were rolled up and the sponge was soaked in fecal matter. The wound had a very bad smell, was tunneling and bone was present. Wound was cleaned with normal saline and continued to have a large amount of brown purulent drainage. During an interview, on 12/28/18 at 5:00 P.M., the Corporate Nurse indicated there was no documentation available for the follow through of the 10/3/18 order from the wound clinic for a MRI and Infectious Disease Consult. During an interview, on 12/28/18 at 5:17 P.M., the DON indicated he was not aware that Resident B had a bone culture positive [MEDICAL CONDITION] from 10/3/18 culture. He indicated he was not aware of the resident'[MEDICAL CONDITION] [DIAGNOSES REDACTED]. He indicated that only dressing change education was completed with staff and there was not education provided for wound assessments. During an interview, on 12/28/18 at 5:27 P.M., the Wound Nurse indicated she was not aware of the orders from 10/3/18 for the MRI and Infectious Disease consult. She indicated she was not aware the resident had a positive bone culture [MEDICAL CONDITION] on 10/3/18. She indicated she was aware that all notifications had to go through P.A.C.E. and the DON was keeping the NP updated with changes via text and receiving orders that way. She indicated that she had never spoke with the Primary Care Physician regarding the condition changes of the resident and the wound. She indicated that she only talk to the NP when she was in the facility. 2. During an interview, on 12/29/18 at 12:00 P.M., the DON (Director of Nursing) indicated that during a skin sweep of the building, Resident I was noted to have worsening of a pressure area that was noted. During an observation, on 12/29/18 at 12:30 P.M., Resident I presented with large sacral dressing dated 12/29/18 to coccyx region with a large amount of brown drainage noted through the exterior portion of the the dressing. There was a foul odor noted upon entering Resident I's room. The dressing was removed per DON (Director of Nursing) and a large unstageable pressure ulcer was noted to the resident buttocks that involved the right and left buttock. Brown dry eschar was noted to center of the wound and [DIAGNOSES REDACTED] (redness) was noted to the surrounding tissue of the wound. During an interview, on 12/29/18 at 12:53 P.M., the Wound Nurse indicated wound to Resident I's coccyx area was staged at a Stage 3 pressure ulcer because the wound had slough on it. She indicated the slough and the presence of granulation tissue on a pressure area was the criteria was Stage 3 pressure areas. She was unaware of the facility policy for wound staging. She indicated Resident I was admitted to the facility on [DATE] with a Stage 2 noted to his left buttocks and had an order for [REDACTED].>The clinical records for Resident I were reviewed on 12/29/18 at 1:30 P.M. The [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 12/19/18, was incomplete. The following sections were not completed as of 12/31/18: Sections A, D, E, G, GG, H, I, J, L, M, N, O, P, Q and Z. The Admission Observation, dated 12/12/18 at 12:35 P.M., indicated Resident I had an open area to left buttocks, no measurements available to review. A Braden Scale for Predicting Pressure Sore Risk, dated 12/12/18 at 1:54 P.M., indicated Resident I was at risk for pressure area development with a score of 18. A care plan, dated 12/13/18, indicated Resident I had a pressure area to coccyx that was present on admission. The interventions included, but were not limited to, assess for pain, assess wound weekly, notify physician of worsening of wound or for signs of infection and observe of signs of infection (redness, pain, drainage, malodorous drainage, fever and increase in size/depth of wound). A care plan, dated 12/14/18, indicated Resident I was at risk for skin breakdown due to resident's ability to respond meaningfully to pressure-related discomfort was slightly limited, responds to verbal commands but can't always communicate discomfort or need to be turned or has some sensory impairment that limits the ability to feel pain/discomfort, skin is often moist and linen must be changes at least once a shift, chair-fast and resident's ability to change and control body position was very limited (unable to make frequent or significant changes independently The interventions included, but were not limited to turn and reposition every 2 hours, barrier cream and pressuring reducing mattress to chair. A Progress Note, dated 12/13/18 at 1:37 P.M., indicated Resident I received a new order for antiseptic to buttocks every shift. A Wound Note, dated 12/13/18 at 1:48 P.M., indicated Resident I had a Stage 2 pressure ulcer to left buttocks that measured 1.5 cm (centimeters) x 1.5 cm x 0 depth, with 96% [MEDICATION NAME] tissue noted to wound base. A Progress Note, dated 12/17/18 10:15 A.M., indicated an aide found an open area on Resident I's buttocks that measured 1.5 cm x 1 cm. A Wound Noted, dated 12/18/18 at 11:52 A.M., indicated Resident I had a Stage 2 pressure ulcer to left buttocks that measured 1.5 cm x 1 cm with no depth, and 100% [MEDICATION NAME] tissue was noted to wound base. A Progress Note, dated 12/23/18 at 4:32 A.M., indicated Resident I had an episode of vomiting and his buttocks was very red and sore. There was no physician notification noted. A Progress Note, dated 12/23/18 at 1:58 P.M., indicated Resident I had redness noted to buttocks. A Progress Note, dated 12/24/18 at 12:59 P.M., indicated Resident I had eschar tissue noted to left buttocks and resident was non-compliant with lying down to take pressure of his buttocks. A Progress Note, dated 12/25/18 at 6:43 A.M., indicated that Resident I slept in his wheelchair on and off. A Progress Note, dated 12/25/18 at 1:58 P.M., indicated eschar tissue was noted to buttocks. There was no physician notification or treatment changes noted. A Progress Note, dated 12/26/18 at 1:33 A.M., indicated that Resident I's buttocks wound was bleeding. A Progress Note, dated 12/26/18 at 9:16 P.M., indicated Resident I had a temperature of 100.6 and pulse was 124 and CBC (Complete Blood Count) was ordered. The laboratory result, dated 12/27/18, indicated Resident I had a WBC (white blood cell) count of 17.6 (reference range was 4.5 to 11.5) A Progress Note, dated 12/27/18 at 1:17 P.M., indicated the NP (Nurse Practitioner) was in to see Resident I and examined him. There were no progress notes available from NP. A Progress Note, dated 12/17/18 at 12:30 P.M., indicated Resident I had a Stage 2 pressure ulcer to left buttocks, no changes were noted in weight and no nutrition recommendations were made. A Progress Note, dated 12/28/18 at 1:03 P.M., indicated NP was in to assess wound and resident was to continue to use roho cushion in wheelchair/ (per care plan roho cushion was placed to wheelchair on 12/26/18). The Progress Note from NP, dated 12/28/18, indicated Resident I had a gradual decline in condition with wound to coccyx that staff reported had eschar which was reported earlier in the week with orders given to notify wound nurse and keep pressure off bottom as much as resident would allow and draw labs. Today staff reported area is loosening with drainage around area and WBC was elevated. Resident's weight was 221 lbs (pounds), height was 68 inches and BMI (Body Mass Index) was 33.6. A large area to bottom with black hard eschar to middle of coccyx area with edges pink with approximately 0.5 cm depth. The pressure ulcer was staged at an Unstageable to coccygeal region. A new order for Keflex 500 mg ice daily for seven days was ordered and to continue [MEDICATION NAME] for debridement of eschar and promote wound healing. A Progress Note, dated 12/28/18 at 7:18 P.M., indicated the daughter of Resident I was notified of the worsening of wound to buttocks and the current interventions were air mattress to bed (per care plan placed on bed on 12/27/18), roho cushion to wheel chair, and laying resident down between meals, multivitamin and oral protein supplements. A Wound Note, dated 12/29/18 at 10:31 A.M., indicated Resident I had a Stage 3 pressure ulcer to coccyx that measured 8 cm x 5 cm with no depth, drainage was moderate, 60 % slough was noted to wound bed and [DIAGNOSES REDACTED] was noted to surrounding wound tissue. The wound had declined, left buttock wound had spread onto coccyx area. A Progress Note, dated 12/29/18 at 3:57 P.M. indicated the NP was in to assess Resident I's wound due to increase drainage and a foul odor. NP recommended to increase the antibiotic dose. A Progress Note from NP, dated 12/29/18, indicated she was requested to revisit Resident I. She indicated Resident I's wound did have a odor that was not noted on earlier examination and eschar was soft with increased drainage. A large area on bottom with black eschar, boggy in nature to middle of coccyx area with edges pink and approximately depth of 0.5 cm. The wounds approximate measurements were 10 cm x 5 cm with 80 % eschar. The order was changed to Santyl for wound treatment once daily, a Foley catheter was anchored to help with wound healing and Keflex was increased to 1000 mg twice daily due to the odor in the wound. There was no order present for wound culture. During an interview, on 12/29/18 at 1:04 P.M., the DON indicated the pressure area to Resident I's coccyx was a Stage 3 because the wound base was fully covered by eschar. He indicated that pressure ulcer assessment and document was to be completed every seven days and that Resident I had wound documentation completed on 12/18/18 and not again until 12/29/18. During an interview, on 12/31/18 at 1:45 P.M., the Wound Nurse indicated she was not made aware of the decline in Resident I's pressure area. She indicated she was not aware of decline until the skin sweep of facility was completed on 12/28/18. On 12/29/18 at 11:48 A.M., the Resident Change of Condition policy was reviewed, and indicated .Any sudden or serious change in a resident's condition manifested by a marked change in

Based on record review and interview, the facility failed to assess and provide catheter care to a resident who was experiencing decreased urine output in an indwelling catheter bag and leaking urine around catheter tubing which resulted in a distended bladder palpable to the naval and urine retention of 2000 ml (milliliters). (Resident B) The immediate jeopardy began on 12/14/18 when the facility failed to ensure catheter care was provided to a resident with an indwelling catheter that resulted in hospitalization to the ICU (intensive care unit) with a distended bladder, acute UTI [MEDICAL CONDITION]. The Administrator, Director of Nursing and Corporate Nurse were notified of the immediate jeopardy on 12/27/18 at 4:55 P.M. The immediate jeopardy was removed on 12/31/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview, on 12/27/18 at 4:06 P.M., the CNA (certified nurse aide) 4 indicated she had reported to RN 5 on 12/14/18 that Resident B's catheter was not working and urine was leaking around the catheter. She indicated she noticed the resident's belly was swelling, the catheter bag was not filling up and the resident's bed was soaking wet. She indicated she placed a depends adult diaper on the resident. She indicated the nurse told her it was just sweat from the resident and nothing was wrong with the catheter. She indicated she then reported the catheter concerns to LPN 6 that the catheter was not working and LPN 6 responded she was not going to change the catheter because she didn't want to and she was tired of everyone passing the buck. CNA 4 indicated she called the DON (Director of Nursing) on 12/17/18 and informed him of her concerns regarding the catheter not draining properly. The clinical record for Resident B was reviewed on 12/26/18 at 1:57 P.M. A MDS (Minimum Data Set) assessment, dated 10/5/18, indicated resident currently had a catheter and [DIAGNOSES REDACTED]. A care plan for indwelling catheter for [DIAGNOSES REDACTED]. During an interview, on 12/27/18 at 4:20 P.M., RN 5 indicated that CNA 4 did make her aware of the catheter concerns and that she did not change the catheter at that time. She indicated she passed it on to the next shift nurse to address. During an interview, on 12/27/18 at 4:30 P. M, the DON indicated CNA 4 told him on 12/17/18 of complications with Resident B's catheter, but the resident was already at the hospital. The Vitals Report, dated 12/1/18- 12/28/18, indicated Resident B's urine output on 12/14/18 was small. Prior to this, the average output from 12/1/8-12/14/18 was large. There are no assessments available to review for the condition of the catheter or the resident. The Emergency Transportation Report, dated 12/16/18 at 11:53 A.M., indicated when EMS (emergency medical service) arrived Resident B was found laying in supine position (on her back). Loud, gurgling sounding, rhonchi (rattling lung sounds) could be heard from the door way. A foul and pungent urine smell was noted in the room. A Foley catheter bag was noted, hanging on the side of the bed. Resident B was wearing a depends adult diaper that was saturated in urine and resident's bed sheets were saturated in urine. The RN (Registered Nurse) from the facility advised the resident had been altered since yesterday, but the RN could not give any information. The RN advised she had never dealt with the resident before and was unable to find any previous notes about her present condition in resident's medical file. A Nursing Narrative Note from the local hospital, dated 12/16/18 at 12:45 P.M., indicated Resident B presented to the ER with a Foley catheter was in place and it was not draining and her bladder was distended to basketball size. Old catheter was removed and new one was placed with large amount of urine return and urine was foul in smell. A Nursing Narrative Note from the local hospital, dated 12/16/18 at 1:43 P.M. indicated 2000mL of dark yellow urine with foul smell drained from catheter. During an interview, on 12/28/18 at 3:00 P.M., the admitting nurse for the 12/16/18 at 12:25 P.M. ER admission indicated Resident B presented to the ER unresponsive and was intubated by 12:35 P.M. She indicated the catheter bag was not draining effectively and the resident's bed sheets had brownish yellow urine stains on the sheet that extended out to the edges of the sheet and the resident. She indicated a strong ammonia smell was present. The bladder was palpated to be the size of a basketball and RN indicated she had never seen a bladder that distended. The Emergency Department Physician Evaluation, dated 12/16/18, indicated Resident B did have a bladder that percusses to the navel and was palpable to the navel. The diagnostic impression [MEDICAL CONDITION] and possible acute UTI [MEDICAL CONDITION] versos sacral decub [MEDICAL CONDITION]. Resident B was admitted to the hospital ICU (Intensive Care Unit) on 12/16/18. A hospital consultation note, dated 12/16/18, indicated .Chief Complaint: Altered mental status .She presented to the ED (Emergency Department) from her nursing home where she had been difficult to arouse after reportedly having been at her baseline .She was also suffering a fever .She underwent intubation. She was resuscitated and give [MEDICATION NAME]/[MEDICATION NAME] (IV antibiotics used for severe infections). She was transferred to the ICU where she remains minimally responsive off sedation TMAX (Temp max): 103.9 F, BP (blood pressure): 87/41 On 12/29/18 at 11:40 A.M, review of the Bowel and Bladder Program policy, received from the DON on 12/28/18 at 2:00 P.M., indicated .Indwelling Urinary Catheters .It is recommended that catheter care be performed every shift or as indicated per physician orders [REDACTED]. This Federal tag relates to Complaint IN 152 & IN 830. 3.1-41(a)(2)

Based on interview, observation and record review, the facility failed to ensure a comprehensive assessment and care plan reflected a safe transfer process for 1 of 4 residents reviewed for transfers. This deficiency resulted in 1 resident sustaining a tibia/fibula fracture on her right leg during a transfer. (Resident D) Finding includes: On 9/12/18, during the initial tour, Resident D was observed in the activity room. She was sitting in a Broda chair with a green cast to her right foot/ankle. Her toes were exposed and had no discolorization and were not observed to be swollen. On 9/12/18 at 11:16 A.M., a review of the clinical record for Resident D was conducted. The resident's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated 7/11/18, indicated the resident was rarely/never understood, was total dependence with transfers (Full staff performance of an activity with no participation by resident) with 1 person physical assist, she was totally dependant with bathing, she had limited Range of Motion (ROM) on 1 side of her lower extremity, no history or current falls and had a life expectancy of less han 6 months. A Care Plan, dated 6/11/13, for Activities of Daily Living (ADL) indicated the resident had a self care deficit related to her dementia. The interventions included, but were not limited to: a Broda chair for ambulation, extensive assist of 2 persons with transfers. A Care Plan, dated 8/29/18, indicated resident had a fracture to right tibia/fibula with cast to affected area. Interventions included but were not limited to: observe for pain, notify physician of change to affected area, utilize Hoyer lift for all transfers and observe for skin redness, or irritation under and around cast, assess toes for swelling cap refill and notify MD of abnormal findings. A facility reported incident, #318, indicated Resident D was sent to a local emergency room (ER), on 8/29/18, for non-verbal signs and symptoms of right leg pain and change in appearance of leg. Resident was evaluated in ER and had a fracture of her tibia/fibula. Staff were interviewed and there were no concerns. The Director met with hospice and no concerns noted from their staff. Due to her cognitive deficit, the resident was unable to discuss event. The incident details indicated other resident interviews were conducted with no concerns and facility staff were interviewed to determine who and when bruising was observed. There was no documentation indicating the staff were interviewed on how the resident was being transferred. A Hospice note, dated 8/23/18 indicated the following: skin was frail with left anterior foot having a new purple colored bruise that extends over entire anterior surface of foot, left great toe is dark purple. Resident able to move toe without grimacing but does have grimacing with repositioning, transfers and showering. Resident was very rigid in all extremities. Coordinated care with facility nurse, no needs at this time. Phoned resident's daughter with update and she indicated the facility had lost her mothers shoes. A Hospice note, dated 8/27/18, indicated the following: resident had occasional groan-facial grimace. The resident had bruising of left and right medial leg, was pale and skin had poor turgor. Resident had increased symptoms of pain including yelling out, grimacing and pulling away when socks were removed to assess feet. Left anterior foot light purple, left great toe remains dark purple, new bruising to right foot noted today by facility staff. Facility CNA indicated resident had no discoloration today until after lunch. Now had right medial & anterior foot purple areas, tender to touch, with trace [MEDICAL CONDITION]. Resident was not transferred with Hoyer lift, was transferred by staff. Has bed to Broda chair transfer. New order to start [MEDICATION NAME] 50 milligrams 1 tab twice a day, and use Tylenol three times a day as needed and will continue to monitor. Coordinated care with agency nurse at the facility. A Client Coordination Report from Hospice, dated 8/28/18, indicated facility nurse reported resident had a temp this A.M. of 100.1 and was given Tylenol. The bruise to left foot and great toe remain dark purple, skin warm to touch, right shin and foot cool to touch. [MEDICATION NAME] was given for pain. The resident continued to yell out when area was touched. Physician was contacted for possible x-ray or Doppler of left extremity. Discussed possible ischemia of leg, would be emergent care at hospital if POA (Power of Attorney) decides to do so, or comfort medications at the facility. POA was contacted and verbalized desire to send to hospital. Hospice note, dated 8/29/18, indicated the resident was returned and was found to have spiral fracture of tibia/fibula. Resident to be a Hoyer lift from this day forward. A x-ray, dated 8/28/18 at 7:43 P.M., indicated acute fractures of the proximal right fibula and mid-distal right tibia with no [MEDICAL CONDITION]. During an interview, on 9/12/18 at 4:10 PM, CNA (Certified Nurses Aide) 3 indicated before Resident D's injury/fracture the resident was a 1 person transfer and now she was a 2 person lift with a Hoyer. During an interview, on 9/12/18 at 4:13 P.M., QMA (Qualified Medication Aide) 4 indicated Resident D was currently a Hoyer lift transfer with 2 staff persons and prior to fracture she was a 1 person transfer. On 9/12/18 at 4:35 P.M., Regional Support RN indicated resident was on hospice so wouldn't be part of the quarterly review for transfers. However, a review of the resident's transfer status would be conducted if staff were reporting the resident was difficult to transfer or not at same level of care. She indicated there was no documentation indicating resident was a difficult transfer. During an interview, on 9/12/18 at 4:45 P.M., the MDS Coordinator indicated Resident B was to be a 2 person transfer as documented on the care plan. During an interview, on 9/13/18 at 9:33 A.M. CNA 6 indicated she had assisted the hospice aide with transferring the resident to her Broda chair and they did not use a Hoyer lift, prior to the fracture. During an interview on 9/13/18 at 9:39 A.M., Hospice Aide 8 indicated prior to Resident D's injury/cast she was transferred with a facility CNA, a 2 person transfer. She indicated she was a small lady and could lift her over the Broda chair's stationary arm rests. The Hospice Aide indicated the resident was dead weight. On 9/13/18 at 9:45 A.M., the Director of Therapy indicated Resident D had not been evaluated for transfers since (MONTH) of (YEAR) and resident had contractures at bilateral knees. She said hospice residents were not usually evaluated for transfers. On 9/13/18 at 10:10 A.M., an interview was conducted with the MDS Specialist, the MDS Coordinator and the Regional Support RN. The MDS Coordinator indicated the 7-day look back period from 7/5/17 through 7/11/18 indicated Resident D was totally dependent and needed a one person assist with transfers. She indicated she just documents on the MDS Assessment what the staff inputs during their daily charting. She indicated she did not update the care plan to indicated the resident was a 1 person assist with transfers. The MDS Specialist indicated since the resident was in a Broda chair it should of red flagged the MDS Coordinator to educated staff regarding their input about transferring the resident and 2 persons were needed to transfer the resident into and out of a Broda chair. The Regional Support Nurse indicated the look back period did not match the plan of care and education was needed for the staff,as they were not following the plan of care, to transfer the resident with 2 persons. During a telephone interview, on 9/13/18 at 10:40 A.M., Resident D's daughter indicated she had witnessed staff transferring her mother with 2 persons and with 1 person. She indicated her mother's knees were fixed in angle (contracture) and when they used just 1 person she felt they were not transferring her safely. A policy regarding transfers was requested but never received. On 8/13/18 at 1:14 P.M., the Regional Support RN provided a policy titled Resident Assessment (RAI) Care Area Assessment Completion (CAA) dated 1/2016, and indicated the policy was the one currently used by the facility. The policy indicated .Assessment information will used to develop, review, and revise the resident's plans of care to provide services to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being .1. After completing the MDS portion of the comprehensive assessment, the next step is to further identify and evaluate resident's strengths, problems, and needs This Federal tag relates to complaint IN 437. 1-35(g)(1) 1-35(g)(2)

Based on record review and interview, the facility failed to ensure that residents were assessed and appropriate interventions were in place to prevent the development of Stage 3 and unstageable pressure ulcers in 2 of 4 residents reviewed for pressure ulcers. (Resident #56 and Resident #62) Findings include: 1. The clinical record for Resident #56 was reviewed on 4/20/17 at 1:00 P.M. The [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 1/4/17, indicated Resident #56 had a BIMS (Brief Interview for Mental Status) score of 12, moderate cognitive impairment. Resident's functional status indicated he required extensive assist of one with bed mobility, transfers, and personal hygiene and was at risk for pressure area development. Progress notes from emergency room visit, dated 12/17/16, indicated resident was had incurred stage 3 [MEDICAL CONDITION] by space heater because of his [MEDICAL CONDITION] and sensory deficit. He has [MEDICAL CONDITION] secondary to motor vehicle accident, and has not been able to have adequate sensation to that area. A care plan, dated 12/21/16, for skin risk for breakdown or further skin breakdown due to skin breakdown indicated a goal that resident would be free of skin breakdown. The interventions included, but were not limited to, assess and document skin condition weekly, incontinent care as needed, pressure reducing mattress to bed and pressure relieving cushion to w/c (wheelchair), and turn and reposition every 2 hours. Resident Progress Note, dated 12/23/16 at 9:02 P.M., indicated an open area was noted to right hip measuring 5.5 cm (centimeters) x 3 cm x 0.1 cm. Wound Management Note, initiated 12/27/16 at 5:08 P.M., indicated area to right hip was identified on 12/27/16 measuring 5.3 cm x 3 cm with no depth at a Stage 2 with [MEDICATION NAME] tissue noted. On 1/3/17, wound to right hip measured 5 cm x 3.1 cm at a Stage 3 with slough present in 50% of the wound. Note indicated resident was to turn and reposition self. No documentation available for education with resident regarding turning and repositioning. A care plan for impaired skin integrity, dated 12/27/17, indicated resident had area to right hip with interventions that included, but were not limited to, assess wound weekly, observe sign of infection, pressure reducing cushion and mattress on bed. No changes were made to care plan after pressure area worsened to stage 3. Wound Assessment notes from wound clinic, dated 1/11/17, resident required debridement to wound on right hip. Measurement from wound clinic indicated 4.7 cm x 2.8 cm x 0.3 cm. Wound Assessment notes from wound clinic, dated 1/18/17 at 2:45 P.M., indicated a Stage 3 pressure area to left trochanter measured 2.7 cm x 3.2 cm x 0.2 cm with 67% eschar was debrided, new measurement was 2.7 cm x 3.2 cm x 0.2 cm. Note indicated resident was to self offload. No documentation available for education with resident regarding offloading. No updates to care plan where made regarding off loading. Resident Progress Note, dated 1/18/17 at 5:52 P.M., indicated resident returned from wound clinic with new orders for area noted to his left trochanter. Wound Management note, created 1/19/17 at 1:34 P.M., indicated area to right hip was first identified on 1/18/17. Measurements from 1/19/17 indicated Stage 3 pressure area 2.7 cm x 3.2 cm x 0.3 cm with 50% slough. Resident Progress Note, dated 1/19/17 at 11:51 A.M., indicated DON (Director of Nursing) had discussed overhead trapeze and roho (air filled mattress) overlay to assist resident in positioning self. During an interview, on 4/21/17 at 3:35 P.M., the DON indicated that all mattresses in facility are pressure reducing, and no changes where made in mattresses until after the the development of the second Stage 3 pressure area. He indicated the Stage 3 pressure to left hip was first observed at wound clinic. He indicated on 1/19/17 a overlay roho mattress was applied to bed and an overhead trapeze was placed to assist with repositioning. The DON did indicate Resident #56 did have [DIAGNOSES REDACTED]. He indicated nursing staff and aides were to make observations to skin daily during ADL (activities of daily living) care giving recent pressure areas and [DIAGNOSES REDACTED]. On 4/21/17 at 2:00 P.M., the DON provided the Skin Management Program policy, dated 9/2016, and indicated the policy was the one currently used being used by the facility. The policy indicated, . Prevention: . 3. offloading devices will be used .7. all residents who required assistance with mobility will be encouraged and assisted to turn and reposition every two hours .6. designated wound nurse will review and document on any new alterations in skin integrity the following business day to determine root cause . 2. A clinic record review was conducted on 04/19/17, at 11:38 PM, for Resident #62 and indicated an admission date of [DATE]. Her [DIAGNOSES REDACTED]. A review of the admission MDS assessment, dated 10/18/16, indicated no unhealed pressure ulcers were present and she was at risk for development of pressure ulcers. The most current MDS, dated [DATE], indicated a BIMS score could not be completed with Resident #62. A review of wound records indicated the pressure ulcers were not present at admission/re-entry. The records indicated 6 pressure areas developed since admission. Pressure area 1, 2, and 3 were first observed on 03/14/17, pressure area 4 was first observed on 02/24/17, pressure area 5 was first observed on 02/22/17, and pressure area 6 was first observed on 11/20/17. A review of care plans for Resident #62 indicated a care plan for actual impaired skin integrity and risk for skin impairment with interventions. Per LPN #11, wounds were measured and staged as follows: 1. coccyx - 0.3cm x 0.4 cm x 0 cm, stage 2. Pink/red base. Initially measured 2cm x 2cm x 0cm. 2. Right lateral calf - 9 cm x 3.1 cm x <0.1 cm, unstageable. Eschar and slough. Initially measured 8.7cm x 2cm x 0cm. 3. Right lateral heel - 4 cm x 4 cm x <0.1 cm, unstageable. Eschar. Initially measured 4cm x 4cm x 0cm. 4. Left ankle - 1.9 cm x 1.6 cm x 0.1 cm, stage 3. Pink with slough. Initially measured 1cm x 1.2cm x 0cm. 5. Left medial heel - 3.5 cm x 2.6 cm x <0.1 cm, unstageable. Eschar. Initially measured 4.7cm x 3cm x 0cm. 6. Left lateral heel - 1.4 cm x 1.8 cm x <0.1 cm, unstageable. Eschar. Initially measured 1.5cm x 1cm x 0cm. During an interview on 04/20/17, at 9:15 AM, LPN #11 indicated the Left medial heel and Left lateral heel are 2 separate wound areas. A review of physician orders [REDACTED]. No order was present for pressure area 5. A review of weekly skin observations was completed on 04/21/17, at 2:50 PM, indicated the weekly skin assessment was not routinely being documented as the policy indicated. A policy was provided by the DON (Director of Nursing) on 04/21/17 at 8:15 AM, titled Skin Management Program, dated 09/2016, and indicated this was the policy currently used by the facility. The policy indicated .treatment order will be obtained .Residents will have a skin assessment completed no less than weekly by the licensed nurse 3.1-40(a)(1)

Based on observation, record review and interview, the facility failed to ensure a resident who was established as a known elopement risk was provided adequate supervision to prevent elopement which resulted in the resident leaving the facility through the second story chapel window for 1 of 5 residents reviewed for elopement. (Resident B) The resident left the facility at 6:51 A.M. on 9/15/15. The facility was unaware of the resident's whereabouts until the morning of 9/18/15, when family called to notify the facility of the resident's location. This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 9/14/15 when the resident began to exhibit escalating exit seeking behavior. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy on 9/18/15 at 4:30 P.M. The Immediate Jeopardy was removed on 9/22/15, but noncompliance remained at the lower scope and severity of no harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On 9/18/15 at 8:30 A.M., an Incident Report, dated 9/16/15 at 10:19 A. M., was reviewed. The Incident Report indicated that while rounding to escort residents to breakfast, the charge nurse noticed Resident B was missing from his room. The charge nurse had noted seeing Resident B earlier in the morning. The Charge Nurse, RN #4, then notified the Executive Director and initiated a Code Silver (a means to alert staff that a elderly resident cannot be located), a search of the interior and exterior parameters of the facility and grounds was conducted. When Resident B was not found, the facility then called the South Bend Police Department. The police department arrived at the facility and began an investigation into the elopement of Resident B. On 9/18/15 at 11:00 A. M., the clinical record for Resident B was reviewed. Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, dated 7/3/15, indicated Resident B had a Brief Interview for Mental Status (BIMS) score of 5, indicating he was severely cognitively impaired. A Nursing Progress note, dated 9/14/15 at 10:15 A.M., indicated .Shortly after breakfast, resident noted to be upset and stated he wanted to go home see his friend because he is dying. Resident stated he was going to leave facility. Staff offered to walk with resident to console him. Resident refused and became aggressive with staff. Resident attempted to hit staff. This writer intervened. Resident stated he was going to throw the chair at the window and leave the facility. MD (Medical Doctor) notified and order received to send resident to ER (emergency room ). Call placed to 911. Policeman and paramedics arrived at facility. After much encourage (sic), resident agreed to be taken to ER for evaluation A Nursing Progress note, dated 9/14/15 at 1:14 P.M., indicated .Resident displayed agitation and aggression this morning, becoming verbally and physically aggressive towards staff. 911 was called to request resident be admitted for inpatient stay. Hospital reported resident could not be admitted at the time and would be returning to facility. Upon return to facility resident was calm, however, continued to walk around building. Resident continued to be on 15 minute safety checks due to exit seeking behaviors An Interdisciplinary Team (IDT) progress note, dated 9/15/15 at 2:49 P.M., indicated . IDT reviewed new and worsening behavior. Behavior: Resident was noted to become verbally and physically aggressive towards staff. Resident continued to actively exit seek and would not be redirected. Resident B stated he had a friend in the hospital. No reported friend in the hospital, staff attempted to comfort and encourage resident regarding thoughts about his friend, however, he refused to be comforted. Resident B remained on 15 minute safety checks. At 8 AM on 9/15/15, resident was noted to have eloped from the building. A code silver was called and staff and authorities have continued to attempt to locate resident. Family and MD (Medical Director) aware. Assessment: Upon assessment the environment was quiet. Resident's roommate passed away over the weekend. Although the two did not appear close, it is possible that roommate's death triggered some trauma for Resident B. Resident B's family was also in to visit on 9/10/15. Resident reported he thought he was going home and since that time (9/10/15) he cut off his wanderguard and refused to have it placed back on. Staff attempted to explain the importance of wanderguard, however, resident continued to refuse. 15 minute safety checks initiated due to exit seeking behaviors. Resident was unable to be calmed although many different staff members with good rapport attempted to talk to resident. 911 was called and resident was escorted by police to ER for evaluation. IDT called report to (hospital) to request inpatient stay, however, hospital was unable to admit at that time. Resident B was sent back to the facility. Resident B has dx of dementia with behavioral disturbances, depressive disorder, and Alzheimer's disease. Resident B has most recent BIMS score of 5(severe cognitive impairment), however Resident B will often refuse to answer questions asked. This could be related to cognitive impairments, intelligence, (Resident B is illiterate) or personality. No recent medication changes have taken place. Resident will periodically refuse medication, however, he can often be redirected and will then take medications. Root cause: IDT discussed that root cause could be related to seeing family members and having roommate recently pass as a trigger. Resident B has history of eloping two years ago in the fall. Intervention: At the time of behavior 911 was called after several attempts to calm resident. Resident sent to ER (emergency room ) for evaluation, however, was not admitted as requested. Resident continued on 15 minute safety checks. IDT recommends to continue efforts with authorities and staff to search for resident to secure safety. Upon resident's return he will be placed on secured unit. IDT will continue discussion proper placement upon return to facility A Care Plan with a problem start date of 10/26/13, indicated, . Resident has history of elopement episode and at times will actively exit seek. Resident remains an elopement risk. Resident removed wanderguard on 9/10/15 and refused to have it replaced. Order remains, staff to continue to attempt to place wanderguard as able and will remain on 15 minute safety checks until wanderguard is able to be replaced .Long Term Goal .Resident will not exit facility unsupervised thru next review .Approaches: All facility exits secured . Wanderguard per order .Coat hat and suitcase stored outside of his room .(Encourage resident and family to keep personal snacks in the kitchen rather than in his room to promote increased supervision and discourage time spent out of his room) .(Encourage participation in activity outside of his room) On 9/18/15 at 2:30 P.M., an interview was conducted with CNA (Certified Nurse Aide) #2. CNA #2 indicated he was working the morning of 9/15/15 and that he provided care for Resident B. CNA # 2 indicated Resident B was awake earlier than usual that morning and pacing the halls, CNA #2 indicated he observed Resident B sitting in his chair in the hallway then Resident B would get up, walk to the end of the hallway, turn around and come back, walk into his room then come back out into hallway and sit in his chair, then he would stand up and repeat the sequence. CNA #2 indicated the Executive Director has spoken to Resident B around 6:30 A.M. CNA #2 indicated he last saw Resident B between 7:40 A.M. and 7: 45 A.M. CNA #2 indicated he was asked by RN #1 to accompany her to administer Resident B's morning medications and that is when they discovered he was not in his room. On 9/18/15 at 3:05 P.M., during an interview, RN #1 indicated that she had gotten report about 6:00 A.M. the morning of 9/15/15 and that Resident B had been peeking around the corner and approached her asking if he could leave. RN #1 indicated she asked the Executive Director to talk to him as he was pointing at her and getting in her face. She further indicated after the ED talked to Resident B, he seemed to settle down. Between 7:30 A.M., to 7:45 A.M., Resident B was observed pacing. He would sit down in his chair then get up walk the hall and go into his room and come out again repeating the pacing sequence. At 8: 00 A.M. RN #1 felt uncomfortable going to Resident B's room alone so she indicated she had asked CNA #2 to accompany her to administer Resident B's medications. When CNA #2 entered Resident B's room he was not found. RN #1 indicated at that time the facility began searching for Resident B and a code silver was called. On 9/19/15 at 12:00 P.M., a family member was interviewed. The family member indicated she found the resident at another family members house. He went from a friends house to a family members home. She indicated the resident had told her, he left the facility at night by going through the chapel windows and he jumped off the roof. He told her he did not use a ladder. He indicated he walked to the south side of town to a friends house. The family member indicated this would have been 3 to 4 miles. On 9/21/15 at 10:30 A.M., video footage of channel 7 and 8 (cameras that were positioned and recording events for the hallway Resident B resided on) were reviewed with the Corporate Nurse, the Executive Director and the Director of Nursing Services. The Corporate Nurse indicated there was a 38 minute lapse of time between the time shown on the film and the actual time of day. To get the correct time, 38 minutes should be added to the time on the footage. This is consistent throughout the footage. The video indicated the following events with recorded times: . 5:21 A.M. Resident B is seen sitting in a chair outside his room .5:37 A. M. He was observed with his winter coat and red ball cap on .5:40 A.M. was observed talking to RN #1 .5:42 A.M. Observed in the hallway talking to Executive Director .5:43 A.M. Observed in chair .5:45 A.M. Observed walking into his room and back to hallway with his hat and coat on .5:48 A. M. Talking to nurse near nurses station, this was not in cameras view . 5:51 A.M. Resident walked the hallway then proceeded back to his room .5:57 A.M. Walked hallway to nurses station and returned to chair .6:03 A.M. Walked back down the hallway and returned to room .6:10 A.M. Observed sitting in his chair outside of his room .6:12 A.M. Resident stood up and was visualized walking into the chapel This observation indicated the resident was not on a secured unit. On 9/21/15 at 11:15 A.M., the Executive Director and Director of Nursing Services were interviewed. The Director of Nursing Services indicated 6:12 A.M. was the last time Resident B was visualized in the facility. He further confirmed the actual elopement time was 6:51 A.M. and not 7:55 A.M. that was previously reported to ISDH. On 9/21/15 at 11:40 A.M., A Safety Check List - 15 Minute form, dated 9/15/15, and provided by the Director of Nursing Services on 9/20/15 at 3:50 P.M. was reviewed. The Safety Checklist Form indicated Resident B had been checked on at 7:00 A. M., 7:15 A.M., 7:30 A.M. and 7:45 A.M. On 9/21/15 at 12:20 P.M., a second interview was conducted with the Director of Nursing Services. The Director of Nursing Services indicated he became aware that the Safety Check List indicated Resident B was checked at 7:00 A.M., 7:15 A.M., 7:30 A.M., and 7:45 A.M. on 9/18/15, when he began reviewing Resident B's chart. He further indicated the nurse who documented the 15 minute checks had been suspended pending an investigation. The Immediate Jeopardy that began on 9/14/15 was removed 9/22/15, when through observation, record review, and interview, staff had completed education related to elopement, updated the clinical records of residents deemed at risk for elopement and secured windows and exits of the facility. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of on-going monitoring and assessment. This Federal tag relates to Complaint IN 617. 3.1-45(2)

Based on record review and interview, the facility failed to ensure licensed staff initiated cardiopulmonary resuscitation (CPR) when the resident was found non-responsive and without pulse or respirations, and the resident expired. The deficient practice affected 1 of 3 residents reviewed related to potential need for CPR in a sample of 9 residents. (Resident #E) The Immediate Jeopardy began on [DATE] when facility staff failed to initiate CPR for Resident #E who was found unresponsive and without a pulse. The facility Administrator and the Director of Nursing were notified of the immediate jeopardy on [DATE] at 5:00 p.m. The immediate jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: The closed record for Resident #E was reviewed on [DATE] at 10:00 a.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The [DATE] Nursing Progress Notes indicated an entry was electronically made at 8:56 p.m. The entry was made by LPN#1. The entry indicated the CNA called the writer to Resident #E's room and the resident "was on the floor, non-responsive, no pulse/no HR (heart rate), CNA went to get RN, 911 was called, paramedics stated pt (patient) was deceased at 7:50 pm, family and MD are aware." The admission Face Sheet indicated the resident's resuscitation status was listed as "Full Code". This indicated CPR was to be initiated if the resident was found without pulse or respirations. An Observation note, completed on [DATE], and titled "Psychosocial/Social History Update" indicated the resident's Advanced Directive was for CPR to be initiated. The Observation note was made by Social Service staff. The note also indicated there had been no change in the resident's cognition or ability to communicate and the resident had no language or hearing deficits. The ,[DATE] Physician order [REDACTED]." This order was initially written on [DATE]. A current care plan initiated on [DATE] indicated Resident #E chose to have life sustaining measures. The care plan interventions included for staff to honor the resident's choice and initiate CPR by trained persons. Review of a list of the nursing employees who worked the evening shift on [DATE] was compared to a list of nursing staff with current CPR certification. There were six nursing staff members with current CPR certification working the evening shift on [DATE]. The six staff members included RN #1 and LPN #1. A First Aid CPR Nursing Skills Validation form was received from the Staff Development Nurse on [DATE] at 12:56 p.m. The form had an original date of ,[DATE] and the date ,[DATE] typed under the ,[DATE] date. During interview at this time, the Staff Development Nurse indicated this was the current procedure staff was trained on. The form indicated staff were to check for response or gently shake the victim, ask the victim if they are OK, tell someone to call 911 and get an AED (automatic defibrillator device), open airway and check for breathing ,[DATE] seconds by looking at chest, listening, and feeling, give 2 breaths with looking for chest to rise, check for carotid pulse ,[DATE] seconds, locate compression point, make sure victim is on his back and give 30 compressions 1 to 1 ,[DATE] inches at a rate of 100 per minute, give 2 breaths, continue to do compressions/breathing cycles for 5 cycles and recheck for a pulse. The form also indicated once CPR is initiated it must be continued until EMS (Emergency Medical Services) arrives or physician is present and provides an order to discontinue. When interviewed on [DATE] at 11:55 a.m., the DON (Director of Nursing) indicated Resident #E was a Full Code. The DON indicated that she was aware the CPR had not been initiated by any facility staff. The DON indicated she spoke with LPN#1 and the LPN indicated she was aware of Resident #E's code status and she did not initiate CPR because the resident had no pulse and no heart rate. The DON indicated 911 was called and when they arrived they began the appropriate measures including CPR. The DON indicated the paramedics ceased CPR at the facility. The DON indicated it was close to end of the shift when she obtained interviews from staff and LPN#1 was placed on suspension then came into the facility the next day and placed a note under her door indicating she had resigned. The DON indicated the resident was a full code and CPR should have been initiated for Resident #E as that was his code status. When interviewed on [DATE] at 12:06 p.m., the facility Administrator indicated she was informed of the above incident on the night it occurred. The Administrator indicated she was informed staff found the resident with no pulse and no respirations and 911 was called. The incident was reviewed further the next day and the Administrator indicated staff did not follow all the protocols for CPR. The Administrator indicated LPN #1 did have current CPR certification. When interviewed on [DATE] at 12:08 p.m., the Director of Nursing indicated CNA #1 was off duty when she found the resident. The DON indicated she interviewed CNA #1 and CNA #1 indicated she went into the resident's room and found the resident on the floor and called out for the nurse who was in the hallway. When interviewed on [DATE] at 1:20 p.m., the DON indicated she interviewed RN #1 and RN #1 indicated the off duty CNA came upstairs and he came downstairs and assessed Resident #E. RN #1 indicated he assessed the resident and checked the vital signs. RN #1 indicated LPN #1 did not tell him Resident #E was a full code. When interviewed on [DATE] at 4:05 p.m., the Director of Nursing indicated the First Aid CPR Nursing Skills Validation form is the guideline used for care of residents who are full code status. The past noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: The LPN who did not initiate CPR for the resident was suspended and did not return to work at the facility after [DATE]. The RN who was called to the resident's room was educated by the DON on [DATE]. The RN was inserviced on CPR procedures also on [DATE] before he was allowed to work that day. The facility initiated inservices on CPR and measures to be taken upon finding a resident without vital signs for all staff, including the contracted construction workers who are completing renovations in the facility. The inservicing was completed for all staff except those on extended Family Medical Leave and those who work PRN on a rare basis. The facility implemented a system to more readily identify the Code Status of each resident. The name labels of resident who were to have CPR initiated were change to green and the chart labels for the other residents remained white. Green dots were placed on the room doors and green arm bands were placed on the residents who were to have CPR initiated. Interviews were completed with nursing and non-nursing staff members and the interviewed staff identified knowledge of the procedures they were inserviced on. Observations were made of green labels on charts, green dots on room name plates, and green wrist bands on residents. The facility also reviewed the CPR status of the employees to verify current CPR status of the employees. This federal tag relates to Complaint IN 244. 3XXX,[DATE](a)