Brickyard Healthcare - Richmond Care Center

Based on interview and record review, the facility failed to file a grievance for a resident with missing clothing for 1 of 1 resident reviewed for grievances. (Resident 34)Findings include:The clinical record for Resident 34 was reviewed on 12/4/25 at 2:34 p.m. The diagnoses included, but were not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (brain tissue death caused by a blockage in a blood vessel) affecting right dominant side and dry eye syndrome.The Quarterly Minimum Data Set (MDS) assessment, dated 10/20/25, indicated Resident 34 was cognitively intact for daily decision making.During an interview on 12/3/25 at 11:45 a.m., Resident 34 indicated he had two sweaters that came up missing approximately three months ago. One sweater was gray, had cost over $100.00, and meant a lot to him because his step-daughter had given it to him. The other sweater was green and he had gotten it last Christmas. Resident 34 indicated he told the Executive Director (ED) about a month ago and was told that they would look for them and get back with him and if he had to, they would be replaced. Resident 34 indicated no one had been back in to follow up on the missing items.Grievances were reviewed for the last six months and no grievances were filed for Resident 34's missing sweaters.During an interview with the ED on 12/4/25 at 2:18 p.m., The ED indicated Resident 34 had mentioned something to him about missing sweaters as he was passing by one day. The ED indicated Resident 34 told him he spoke with Laundry/Housekeeping Aide 2 about the missing sweaters and indicated Laundry/Housekeeping Aide 2 told him she spoke with Resident 34's wife, so I figured it was handled. The ED indicated he did not follow up with Resident 34 and indicated he should have filled out a grievance for these missing items.During an interview with Laundry/Housekeeping Aide 2 on 12/4/25 at 2:27 p.m., they indicated Resident 34 did tell them that he had missing sweaters and his wife went into the laundry room with her and they still could not be found. Laundry/Housekeeping Aide 2 indicated she spoke with the ED and he indicated to her he would follow up with Resident 34. Laundry/Housekeeping 2 indicated she never heard anything else about the missing sweaters after that and indicated she should have filled out a grievance form when she was first told about the missing items.The Resident and Family Grievances policy was provided by the ED on 12/4/25 at 2:50 p.m. It indicated,.8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member.10. Procedure:.b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form.c. Forward the grievance form to the Grievance Official as soon as possible.e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances.12. The facility will make prompt efforts to resolve grievances. 3.1-7(a)(2)

Based on observation, interview and record review, the facility failed to ensure fluids were available and within reach and failed to ensure call lights were within reach for 3 of 3 residents reviewed for accommodation of needs (Resident 41, Resident 10 and Resident 5). Findings include:1. During an observation and interview on 12/02/2025 at 2:08 p.m., Resident 41 was lying in bed. The resident's call light was out of reach, on recliner underneath a blanket. The call light was activated for a test. CNA 2 came in the room and indicated he was responsible to ensure Resident 41 had her call light within reach. CNA 2 indicated he assisted Resident 41 to lay down and the roommate requested something and he forgot to give Resident 41 her call light. CNA 2 provided the resident with her call light. During the observation Resident 41 had no fluids available in her room. During an observation on 12/03/2025 at 2:33 p.m., Resident 41 had no fluids available in room. Resident 41's mouth and lips were dry and her lips were sticking to her teeth. Resident 41 indicated she would like to have something to drink, sometimes the staff gave her fluids and sometimes they did not. Resident 41 activated her call light. During an observation and interview on 12/03/2025 at 2:40 p.m., CNA 1 came into Resident 41's room, the resident requested something to drink. CNA 1 indicated she did not know why the resident did not have fluids available. CNA 1 provided the resident with a Styrofoam cup of ice water with a straw. Resident 41 took two large drinks of the water independently and indicated it tasted good. Review of the clinical record of Resident 41, on 12/04/2025 at 11:26 a.m., indicated the resident's diagnoses included, but were not limited to, history of urinary tract infection, muscle weakness, age related debility, chronic kidney disease, constipation and major depression. The physician's recapitulation for Resident 41, dated December 2025, indicated the resident diet order was thin liquids and encourage fluids as allowed by resident every shift (original date 11/25/25). The care plan for Resident 41, dated 11/26/25, indicated the resident had a urinary tract infection and was on antibiotics. The interventions included, but were not limited to, encourage adequate fluid. The care plan for Resident 41, dated 12/4/25, indicated the resident had the potential for dehydration related to diuretic medication use. The goal was to maintain moist mucous membranes. 2. During an observation and interview on 12/02/2025 at 2:36 p.m., Resident 10 was lying in her bed, the call light was behind the head board of her bed on the floor. The roommates call light was activated. CNA 2 came into the resident's room and indicated CNA 5 was taking care of Resident 10 and was on break. CNA 2 indicated he told CNA 5, before she went on break, to ensure all the residents she was caring for had their call lights available. CNA 2 provided Resident 10 with her call light. Resident 10 did not have water available, she had a cup of coffee on her bedside table out of reach. During an observation on 12/05/2025 at 1:23 p.m., Resident 10 was eating an drinking independently. During an interview with Resident 10 on 12/08/2025 at 10:47 a.m., the resident indicated it happened frequently that she did not have water available and sometimes her call light was out of reach. Resident 10 indicated when this happened she would have her roommate use her call light for her, if her roommate was in the room when that happened. The resident was observed to not have fluids in her room at this time except for a small medication cup with water in it. Review of the clinical record for Resident 10 on 12/08/2025 at 10:51 a.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, anemia, anxiety, arthritis, hypertension, muscle weakness and dementia. The quarterly Minimum Data Set (MDS) for Resident 10, dated 11/1/25, indicated the resident was moderately impaired for daily decision. The resident required set up only for drinking. The bowel care plan for Resident 10, dated 5/19/25, indicated the resident was at risk for constipation related to medication use and decrease mobility at times. The interventions included, but were not limited to, call bell in within reach, remind to use as needed and encourage fluids. The bowel and bladder care plan for Resident 10, dated 5/19/25, indicated the resident was at risk for alteration in elimination of bowel and bladder related to urinary and bowel incontinence. The interventions included, but were not limited to, call bell within reach, remind to use call bell as needed and encourage fluids. The hydration care plan for Resident 10, dated 5/19/25, indicated the resident was at at risk for alteration in hydration related to needing some set up with fluids, required reminded at times to increase fluids. The intervention included, provide, encourage and assist with fluids as needed. 3. During an observation and interview on 12/03/2025 at 10:40 a.m., Resident 5 did not have fluids available in his room. The resident indicated it happened occasionally that staff did not provide fluids to him. The resident activated his call light and requested something to drink from the staff. Review of the clinical record of Resident 5 12/05/2025 at 10:24 a.m., indicated the resident's diagnoses included, but were not limited to, depression, muscle weakness, diabetes, anxiety and vitamin deficiency. The physician's order for Resident 5, dated December 2025, indicated the resident was to receive a regular diet with thin liquid. The quarterly MDS assessment for Resident 5, dated 10/31/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident required set up for eating and drinking fluids. During an observation on 12/5/25 at 12:50 p.m., Resident 5 was drinking independently in his room. The hydration policy provided by the Director Of Nursing (DON) on 12/8/25 at 10:20 a.m., indicated the facility would offer each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The protocol included, but were not limited to, ensure beverages were available and within reach. The call light policy provided by the DON on 12/8/25 at 10:25 a.m., indicated the facility would ensure a call light was at each residents bedside. Staff would ensure the call light was within reach of the resident and secured. The call system would be accessible to residents while in their bed. 3.1-3(v)(1)

Based on observation, interview and record review, the facility failed to ensure care plan interventions were implemented for a resident's call light to be within reach and failed to implement a touch call light for a resident at high risk for falls for 1 of 2 residents reviewed for care plan implementation of interventions. (Resident 41). Finding include:During an observation and interview on 12/02/2025 at 2:08 p.m., Resident 41 was lying in bed, the resident's call light out of reach, on recliner underneath a blanket, the call light was activated for a test. CNA 2 came in the room and indicated he was responsible to ensure Resident 41 had her call light within reach. CNA 2 indicated he assisted Resident 41 to lay down and the roommate requested something and he forgot to give Resident 41 her call light. CNA 2 provided the resident with her call light. During an observation and interview on 12/04/2025 at 2:34 p.m., Resident 41 was lying in bed with her call light. CNA 3 verified Resident 41 did not have a pad touch call light. Review of the record of Resident 41 on 12/04/2025 at 11:26 a.m., indicated the resident's diagnoses included, but were not limited to, history of urinary tract infection, muscle weakness, age related debility, chronic kidney disease, constipation and major depression. The fall care plan for Resident 41, dated 8/5/25, indicated the resident was at risk for falls related to deconditioning and history of falls. The interventions included, but were not limited to, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and touch pad call light. The quarterly Minimum Data Set (MDS) assessment for Resident 41, dated 10/15/25, indicated the resident was moderately impaired for daily decision making. The resident required substantial/maximal assistance with transfers, the resident did not ambulate. The resident had one fall with injury since prior assessment. The fall risk assessment for Resident 41, dated 11/9/25, indicated the resident was at high risk for falls. The fall prevention policy provided by the Director Of Nursing (DON) ON 12/8/25 at 10:20 a.m., indicated the resident would be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The protocol included, but were not limited to call light and frequently used items were within reach, provide interventions that address unique risk factors and alternate call system access. 3.1-35(b)(1)

Based on observation, interview and record review the facility failed to provide routine dental service for a resident with improper fitting dentures for 1 of 3 residents reviewed for dental services (Resident 5). Finding include:During an observation and interview on 12/03/2025 at 10:49 a.m., Resident 5 indicated he had dentures but they were too big and they were in his bathroom. The resident indicated he would like to have dentures that fit. He did not have problems with eating but did miss things like corn on the cob that he could not eat due to not having dentures that fit. The resident did not remember the last time he wore his dentures and they had not fit him for a long time. The resident's dentures were observed in the bathroom in a denture cup with the resident's name on them, the resident was observed with no dentures in his mouth. Review of the clinical record for Resident 5 on 12/05/2025 at 10:24 a.m., indicated the resident's diagnoses included, but were not limited to, depression, muscle weakness, diabetes, anxiety and vitamin deficiency. The last dental note for Resident 5, dated 11/2/23, indicated the resident was edentulous, had poor oral hygiene and was recommended for routine dental exams. The annual Minimum Data Set (MDS) assessment for Resident 5, dated 5/27/25, indicated the resident had no natural teeth and was edentulous. The quarterly MDS assessment for Resident 5, dated 10/31/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident required set up for eating and drinking fluids. The care plan for Resident B, dated 11/25/25, the resident has potential for oral problems related to edentulous status. The interventions included, but were not limited to, coordinate arrangements for dental care, transportation as needed/as ordered. The physician recapitulation for Resident 5, dated December 2025, indicated the resident may see the dentist. During an interview with the Social Service Director (S.S.D.) on 12/4/25 at 3:32 p.m., she indicated she was responsible to ensure Resident 5 was seen by a dentist. see ancillary services. During an interview with the S.S.D. on 12/5/25 at 9:55 a.m., she indicated she was unable to find any documentation that Resident 5 had seen a dentist since 11/2/23. The S.S.D. was going to contact the dental company to see if they had any further documentation. During an interview with S.S.D. on 12/5/25 at 2:04 p.m., she indicated there was no documentation that the facility had contacted the dentist to schedule an appointment for Resident 5 after his last dental appointment in November 2023. The dental service policy provided by the Director Of Nursing (DON) on 12/8/25 at 10:15 a.m., the DON indicated the facility would assist residents in obtaining routine and emergency dental services. Routine dental services meant an annual inspection of the oral cavity for sings of disease, minor partial or full denture adjustments, taking impressions for dentures and fitting dentures. 3.1-24(a)(1)

Based on observation, interview, and record review, the facility failed to offer a resident his elbow splint, per the restorative nursing plan, for 1 of 2 residents reviewed for positioning and mobility. (Resident 1)Findings include:The clinical record for Resident 1 was reviewed on 12/2/25 at 2:10 p.m. His diagnoses included, but were not limited to, contractures and right-side hemiplegia. The Restorative Nursing PROM (Passive Range of Motion) program care plan, dated 1/3/24 and revised 12/2/25, indicated the resident participated in the program due to contractures and decreased range of motion. The goal was for him to tolerate PROM to his RUE (right upper extremity) and PROM/Stretch of his right upper extremity elbow and hand, for three sets of up to 15 repetitions in preparation for donning splint. An intervention indicated, Splint/Brace: Assistance with Splint or brace (Splint to elbow, carrot or palm guard) The resident was to wear the orthotic elbow extension splint and carrot or palm to RUE for up to 2 or more hours daily, 6 days per week. The staff responsible for this intervention was the RNA (restorative nurse aide.) The tasks section of the electronic health record indicated the above intervention was not completed eight of the last 30 days. There was no documentation to indicated he refused or was unavailable.An observation and interview with Resident 1 were conducted in his room on 12/4/25 at 2:28 p.m. He was not wearing an elbow splint. He indicated he did not use an elbow splint, only the carrot for his hand. There was no elbow splint visible in his room.An interview was conducted with UM (Unit Manager) 5 on 12/4/25 at 2:35 p.m. She indicated the therapy department was responsible for implementing the restorative nursing program, including PROM and splint application. The TD (Therapy Director) created the program and RNA 8 implemented it. An interview was conducted with the TD on 12/4/25 at 2:38 p.m. The TD indicated therapy oversaw the restorative nursing/PROM program at the facility, and RNA 8 implemented it. An interview was conducted with RNA 8 on 12/4/25 at 2:38 p.m. She indicated she began working at the facility as the restorative aide in March, 2025. Resident 1 had a carrot and palm protector for his right hand. He liked the carrot better than the palm protector and he used it about four hours a day, six days a week. He did not use any splints at all, and she did not offer an elbow splint to Resident 1, as she was unaware that he had one. An observation of Resident 1 and his belongings was made in his room with the TD and RNA 8 on 12/4/25 at 2:38 p.m. The TD retrieved Resident 1's elbow splint from a nightstand behind Resident 1's bed.The Restorative Nursing Programs policy was provided by the DON (Director of Nursing) on 12/5/25 at 9:50 a.m. It indicated, Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include: b. Splint or brace assistance.The Restorative Nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented.The discharging therapist, Restorative Nurse, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan.3.1-42(a)(2)

Based on interview and record review, the facility failed to initiate the continuation of care, related to the administration of a resident's comfort eye drops, for 1 of 1 resident reviewed for Quality of Care. (Resident 9) Findings include: The clinical record for Resident 9 was reviewed on 12/2/25 at 2:00 p.m. Her diagnosis included, but was not limited to, cataracts. The impaired visual function care plan, revised 7/6/25, indicated the goal was for the resident to have no indications of acute eye problems through the next review date. An intervention was to arrange consultation with the eye care practitioner as required. The physician's orders indicated she may see an ophthalmologist and/or optometrist, starting 9/4/25. An interview was conducted with Resident 9 on 12/2/25 at 2:01 p.m. She indicated she saw the optometrist a couple of weeks ago, who ordered eye drops for her, but she had not yet begun receiving them. The Plan section of the optometry consultation note, dated 11/14/25, indicated the resident received a new medication order for Refresh Dry Eye Therapy solution, one drop in both eyes, twice daily for indefinitely. The Action Required By Nursing Home Staff section of the note indicated there were new orders. The physician's orders in the clinical record did not include an order for Refresh eyedrops. An interview was conducted with the SSD (Social Services Director) on 12/4/25 at 1:05 p.m. She indicated she was responsible for residents seeing the eye doctor. Their provider last came on 11/14/25. The SSD reviewed Resident 9's 11/14/25 optometry consultation note and orders from the electronic health record. She indicated she was unsure what happened with the Refresh eyedrops, as she did not see an order for them. Nursing were responsible for administering them. An interview was conducted with the DON (Director of Nursing) on 12/4/25 at 1:16 p.m. She indicated nursing did not receive orders or consultation notes from the eye doctor. Only social services received them. She did not generally know who the eye doctor saw when they came. An interview was conducted with UM (Unit Manager) 5 on 12/4/25 at 1:24 p.m. She indicated the eye doctor gave orders to the SSD, who gave the orders to nursing. She was unaware of the Refresh eye drop orders for Resident 9. An interview was conducted with Resident 9 on 12/4/25 at 1:21 p.m. She indicated she still hadn't begun receiving the eye drops. Her eyes felt like they had sand in them. The Hearing and Vision Services policy was provided by the DON on 12/4/25 at 1:38 p.m. It indicated, The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: a. Obtaining history from medical records, the family, and the resident regarding hearing and vision abilities.c. Ongoing monitoring of sensory problems; d. Care plan development and implementation. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to be knowledgeable of behavioral health interventions for 1 of 5 residents review for behavioral health management. (Resident E) Findings include: The clinical record for Resident E was reviewed on 11/24/2025 at 4:20 p.m. The medical diagnoses included Wernicke's Encephalopathy (neurological symptoms caused by biochemical lesions of the central nervous system) and Substance Abuse Disorder. A Quarterly MDS, dated [DATE], indicated Resident E was independent with transferring and walking. A care plan, dated 5/1/2025, indicated Resident E had behavioral issues of grabbing staff in appropriate areas, wanting to lay head on other residents' shoulders, and self-pleasuring in the room with his roommate present. The interventions included, but were not limited to, administer medications, monitor for effectiveness, anticipate the needs of the resident, to keep appropriate distance when communicating with the resident to allow space for the resident to remain focused on the conversation and redirect if the resident attempts to lay on a staff members shoulder, and to redirect the resident when attempting to grab/touch inappropriate areas. A care plan, dated 9/24/2025, indicated Resident E was at high risk of inappropriate behaviors of making loud inappropriate comments to staff and other residents. Interventions included encouraging Resident E to avoid making inappropriate comments and providing appropriate directions for the resident to engage in activities that he enjoys. A staff management solution system, provided on 11/25/2025 at 3:00 p.m., indicated the resident's behaviors interventions was for staff to do the educating Resident E to avoid inappropriate and/or sexual behaviors, arranging to receive mental health services, providing the opportunity to express mental health needs to staff, observation of mental health, providing opportunities to identify mental health needs, and to offer activities to redirect to activities. During an interview with SSD, on 11/24/2025 at 5:20 p.m., she indicated she was not aware of Resident E's self-pleasure behaviors. She was not aware of any new interventions when Resident E obtained a roommate and did not increase supervision. She believed Resident E had a private room per his preference, not as a behavior management tool. During an interview with CNA 3, on 11/25/2025 at 10:50 a.m., she indicated she had worked with Resident E often, but not always. She stated he had some behaviors that needed redirection, but she was not sure the last time he had them or what exactly they were. She had heard .other staff talk about. the behaviors. She was unaware of the interventions to keep distance when interacting with Resident E. During an interview with LPN 4, on 11/25/2025 at 11:30 a.m., she indicated she was unaware of any behaviors management interventions for Resident E. If he had behaviors, she would use the baseline intervention of assuring his safety and then notify the DON/ED. She was unaware of needing to redirect, monitor, or keep distance when interacting with Resident E. During an interview with CNA 5, on 11/25/2025 at 1:30 p.m., she indicated she had worked with Resident E the whole time he was here, but he did everything himself, so he didn't require much help. CNA 5 was unaware of any behavioral management interventions for Resident E to include redirecting and keeping distance when communicating to Resident E. A policy entitled, Behaviors Health Services, was provided by the Director of Nursing on 11/25/2025 at 12:00 p.m. The purpose of the policy was to ensure all residents received behavioral health services to assist in reaching and maintaining their highest level of mental and psychosocial function and well-being. The policy indicated to .utilize MDS and care area assessments.Assess and develop a person-centered care plan. and .share concerns to the intradisciplinary team.The deficient practice was corrected on 11/14/2025, after the facility implemented a systemic plan of staff education, auditing, and monitoring to ensure implementation of the in-servicing was monitored related to behaviors. This citation relates to Intakes 2674247 and 2674760. 3.1-43(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 2 of 5 residents reviewed for abuse (Resident D and Resident F) were free from sexual abuse from a resident with known inappropriate behaviors (Resident E), resulting in inappropriate touching (Resident D); and psychological harm of feeling upset and gross (Resident F). Finding included:1.The clinical record for Resident E was reviewed on 11/24/2025 at 4:20 p.m. The medical diagnoses included, but were not limited to, Wernicke's Encephalopathy and Substance Abuse Disorder. A Quarterly minimum data set assessment (MDS), dated [DATE], indicated Resident E was independent with transferring and walking. A care plan, dated 5/1/2025, indicated Resident E had behavioral issues of grabbing staff in appropriate areas, wanting to lay head on other residents' shoulders, and self-pleasuring in the room with his roommate present. Interventions included, but were not limit to, administer medications, monitor for effectiveness, anticipate the needs of the resident, to keep appropriate distance when communicating with the resident to allow space for the resident to remain focused on the conversation and redirect if the resident attempts to lay on a staff members shoulder, and to redirect the resident when attempting to grab/touch inappropriate areas. A care plan, dated 9/24/2025, indicated Resident E was at high risk of inappropriate behaviors of making loud inappropriate comments to staff and other residents. Interventions included encouraging Resident E to avoid making inappropriate comments and providing appropriate direction for resident to engage in activities that he enjoys. A behavior note, dated 8/7/2025, indicated Resident E was found self-pleasuring in the room with his roommate and yelling vulgarities. A behavior note, dated 8/7/2025, indicated Resident E was making inappropriate sexual comments in front of other residents. A behavior note, dated 8/7/2025, indicated Resident E had an intervention of being .moved to new room in which he can self-pleasure with privacy. A psychiatry progress note, dated 9/22/2025, indicate Resident E was asking other residents for fellatio (the practice of performing oral sex on a male). Per the facility census, Resident E had a roommate (Resident F) move-in on 10/30/2025. A social service progress note, dated 11/4/2025, indicated staff report Resident E was making .comments about kissing and going to another resident's room. A psychiatry visit note, dated 11/4/2025, indicated no new intervention for Resident E and .no concerns by staff . A Social Service note, dated 11/14/2025 at 9:50 a.m., indicated they met with .resident in his room as to address concerns reported by staff during smoke break. SSD educated resident on the importance in avoiding inappropriate verbal behaviors. Resident continued to make inappropriate comments to staff. SSD reminded resident to avoid verbal comments that are inappropriate in nature . A nursing progress note, dated 11/14/2025, indicate Resident E's roommate (Resident F) stated .he does not feel safe in same room with [Resident E], that he [Resident E] will ask him [Resident F] to suck his di*k, Resident E would watch him when toileting and make inappropriate comments regarding his butt, and roommate (Resident F) wants to be moved to another room. During an interview with SSD, on 11/24/2025 at 5:20 p.m., she indicated she was not aware of Resident E's self-pleasure behaviors. She was not aware of any new interventions when Resident E obtained a roommate and did not increase supervision. She believed Resident E had a private room per his preference, not as a behavior management tool. During an interview with LPN 4, on 11/25/2025 at 11:30 a.m., she indicated she was unaware of any behavior management interventions for Resident E. If he had behaviors, she would use the baseline intervention of assuring his safety and then notify the DON/ED. She was unaware of needing to redirect, monitor, or keep distance when interacting with Resident E. During an interview with CNA 5, on 11/25/2025 at 1:30 p.m., she indicated she was unaware of any behavioral management interventions for Resident E. The clinical record for Resident F was reviewed on 11/24/2025 at 4:45 p.m. The resident's diagnosis included, but were not limited to, spinal stenosis and major depressive disorder. A Quarterly MDS Assessment, dated 10/6/2025, indicated Resident F was cognitively intact, needed partial/moderate assistance for dressing, was independent with chair transfer and locomotion with a manual wheelchair, and ambulation not attempted due to safety concerns.A care plan, dated 1/30/2024 and revised on 11/17/2025, indicated Resident F had depression and anxiety. The interventions included, but were not limited to, mental health services and nursing facility staff to provide supportive counseling.During an interview, on 11/24/2025 at 2:35 p.m., Resident F reported his former roommate (Resident E) was inappropriate with him. On three different occasions, Resident E had asked Resident F to show Resident E his penis. Resident F indicated Resident E would . make comments about my butt and try to watch me in the bathroom. These comments made Resident F upset and feel gross and .I don't want [Resident E] as my roommate.During an interview, on 11/25/2025 at 12:10 p.m., DON indicated there were no additional interventions put into place or increased supervision when Resident F was moved into Resident E's room on 10/30/2025. 2. A statement by Staff Member 7, dated 11/14/2025 (with no time documented), indicated that Resident E was observed to be acting suspicious around the center hall where Resident D's room was located. A nursing progress note, dated 11/14/2025, indicate two residents were yelling out. When the residents were asked why they were yelling out, resident Resident D indicated Resident E had touched him inappropriately. The clinical record for Resident D was reviewed on 11/25/2025 at 11:05 a.m. The medical diagnoses included intellectual disabilities and anxiety. A Quarterly MDS Assessment, dated 11/6/2025, indicated Resident D was cognitively impaired, needed partial to moderate assistance with dressing and transferring, and was independent with locomotion in a wheelchair. A care plan, dated 9/17/2025, indicated Resident D used medication to help manage a diagnosis of anxiety. The interventions included, but were not limited to, monitoring medication and psychiatry evaluation. A nursing progress note, dated 11/14/2025, indicated Resident D .indicated to staff that another resident had touched him inappropriately. The other resident was immediately removed from the situation and the accused resident placed on 1:1 [one staff to one resident supervision] immediately.A written statement, dated 11/14/2025, was signed by Resident D. The statement indicated, . [Resident E] came into his [Resident D's] room around 8 pm and touched him [Resident D] down there pointing to his private part. He touched me under my pants (clothes) with his hand. I told him to stop. A policy entitled, Abuse, Neglect, and Exploitation, was provided by the Director of Nursing on 11/25/2025 at 12:00 p.m. The purpose of the policy was to protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy indicated the facility would work toward preventing abuse by, .Establishing a safe environment.identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors. The deficient practice was corrected on 11/14/2025, after the facility implemented a systemic plan of staff education, auditing, and monitoring to ensure implementation of the in-servicing was monitored related to abuse. This citation relates to Intakes 2674247 and 2674760.3.1-27(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document a resident's death, the notification of a resident's death to the physician, family, responsible party, disposition of the resident's body, personal possessions, medications, or a complete and accurate notation of the resident's condition preceding the resident's death in the clinical record for 1 of 1 resident reviewed for death (Resident B).
Findings include:
During an interview with the Director of Nursing (DON) on [DATE] at 12:20 p.m., she indicated Resident B died, on [DATE], on day shift. The facility did not document anything about the resident's death in the clinical record because the facility's legal department did not want anything documented as a late entry.
During an interview with Licensed Practical Nurse (LPN) 5 on [DATE] at 1:23 p.m., they indicated, on [DATE], a Certified Nurse Aide (CNA) came and got her and said they needed her help on the other unit with Resident B. LPN 5 checked Resident B's code status when she got to the unit and he was a Do Not Resuscitate (DNR) code status. When LPN 5 entered Resident B's room, Registered Nurse (RN) 6 was there checking for the resident's pulse and reported she could not find a pulse. LPN 5 then checked Resident B for a pulse and respirations, and he did not have a pulse or respirations.
During an interview with RN 6 on [DATE] at 1:45 p.m., she indicated she was not caring for Resident B, on [DATE], when he died. Qualified Medication Aide (QMA) 7 came to RN 6's office to get her. When RN 6 got to Resident B's bedroom, he was lying on the bed, he had no pulse, one eye closed and one eye open and fixed, and he had no respirations. RN 6 requested LPN 5 to come to the resident's room and verify that he did not have a pulse or respirations.
During an interview with CNA 8 on [DATE] at 3:23 p.m., she indicated, on [DATE], she was caring for Resident B when he died. CNA 8 indicated she went to check on Resident B and found him lying in his bed with a plastic bag over his head. CNA 8 removed the bag and felt the resident's chest to see if it was moving and it was not. CNA 8 ran and got help.
The clinical record for Resident B was reviewed on [DATE] at 11:05 a.m. The diagnoses included, but were not limited to, dementia, psychotic disturbance, bipolar disorder, depression, suicidal ideations, and anxiety disorder. The resident's code status was DNR.
The last documentation in Resident B's clinical record, dated [DATE] at 9:00 a.m., indicated the Social Service Director (S.S.D.) went to the resident's room to complete a psychosocial assessment. The resident was fully dressed and asleep in the recliner. The S.S.D. also noted that the resident's room was clean and orderly.
During an interview with the [NAME] President of the facility, on [DATE] at 12:07 p.m., they indicated the facility team made the decision not to document Resident B's death, on [DATE], in the clinical record and the legal department agreed. The facility did this to ensure accuracy of documentation due to it was a high stress situation.
The documentation in the medical record policy provided by the DON, on [DATE] at 2:15 p.m., indicated each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation shall be accurate, relevant, and complete. Documentation shall be timely and in chronological order.
This citation relates to Complaint IN00454495.
3.1-50(a)(1)
3.1-50(a)(2)
3.1-50(j)(1)
3.1-50(j)(2)
3.1-50(j)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who required more than limited assistance with transfers received adequate assistance and supervision to prevent accidents related to only one staff person assisting during a transfer without the utilization of gait belt and ensure the resident's wheelchair was free from sharp objects resulting in the resident requiring 18 sutures to the left lower leg for 1 of 3 residents reviewed for accidents (Resident C).
This deficient practice was corrected on 2/28/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff to ensure residents were transferred safely, conducted an audit of all residents' wheelchairs to ensure they were free from any sharp objects, and conducted audits on safe transfers and wheelchair safety with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review.
Findings include:
The clinical record for Resident C was reviewed on 3/5/25 at 9:45 a.m. The diagnoses included, but were not limited to, metabolic encephalopathy, chronic kidney disease, anxiety disorder, congestive heart failure, vascular dementia, and acute respiratory failure. The resident was admitted to the facility on [DATE].
The fall risk assessment for Resident C, dated 1/31/25, indicated the resident was at high risk for falls.
The plan of care for Resident C, dated 1/31/25, indicated the resident was at high risk for falls due to medication use. The interventions included, but were not limited to, determine the resident's ability to transfer.
The admission Minimum Data Set (MDS) assessment for Resident C, dated 2/3/25, indicated the resident utilized a wheelchair. The resident required substantial/maximal assistance (helper does more than half the effort) to sit to stand and transfer from chair to bed. The resident did not ambulate.
The plan of care for Resident C, dated 2/10/25, indicated the resident had an activity of daily living (ADL) performance deficit related to limited mobility and cognitive loss. The interventions included, but were not limited to, the resident required extensive assistance of 1-2 staff to transfer. At the time of increased weakness, a sit to stand lift may be utilized, initiated on 2/18/25.
A progress note for Resident C, dated 2/18/25 at 7:30 p.m., indicated the nurse was called to the resident's room by another nurse who reported the resident needed to go to the hospital. Upon entering the room, a very large skin tear was observed to the resident's left lower leg. Emergency Medical Services (EMS) was called. Pressure was applied to the wound with towels until EMS arrived and applied a pressure dressing.
The hospital emergency department note for Resident C, dated 2/18/25 at 9:08 p.m., indicated the resident presented to the emergency room with a left leg laceration from the Extended Care Facility (ECF). The resident was being transferred from the wheelchair to the bed and her leg was injured by the bed frame versus the wheelchair causing a left lower leg laceration. The resident complained of worsening pain to the left leg wound when touched or movement of the left lower extremity. The resident was given a tetanus shot and lidocaine. The laceration length was 18.5 centimeters (cm) long and was closed with 18 sutures.
A statement from Certified Nurse Aide (CNA) 1, dated 2/18/25, indicated she went to get the sit to stand mechanical lift to transfer Resident C. Resident C asked if she (CNA 1) would let her stand with the bar and the CNA explained that she was told the resident was supposed to utilize the sit to stand lift. The resident asked the CNA not to use it because it hurt her. The CNA scooted the wheelchair beside the bed and got in front of the resident and put both arms under the resident's arms and counted to three. When the resident sat down on the bed she started to cry. The resident put her hand down to her leg and the CNA seen the tear to the resident's leg. The CNA ran to the nurse and told the nurse to call 911 and she needed help.
A statement from Licensed Practical Nurse (LPN) 2, (no date), indicated she was alerted there was an emergency in Resident C's room. The resident's left outer leg was bleeding profusely. CNA 1 indicated the resident's leg got caught while she was transferring her. The resident was currently on her way to the hospital.
A statement from LPN 3, (no date) at 7:25 p.m., indicated staff had alerted her there was an emergency in Resident C's room. The resident had a wound on the left leg with a gaping hole and flapping skin.
During an observation and interview with Resident C on 3/5/25 at 10:24 a.m., the resident was sitting in a wheelchair with a bandage around her left lower leg. When queried about what happened to her left leg the resident indicated a girl was trying to help her from the wheelchair to the bed. She lifted the resident up underneath her arms and tried to put Resident C into the bed and when the resident turned around, she lost her balance and fell into the bed and hit her left leg on the leg of the bed. The resident began crying and indicated it hurt really bad, and she had to go to the hospital. The resident rated her current pain of the left leg at medium, a 5 on the 1-10 pain scale.
During an interview with the Therapy Manager on 3/5/25 at 11:10 a.m., they indicated Resident C had been assessed prior to the incident on 2/18/25. Resident C fluctuated between three different ways of transferring. The resident fluctuated between a two person transfer, a sit to stand mechanical lift, and a sling mechanical lift (Hoyer lift). The therapy manager indicated it was not good practice to transfer a resident by lifting them under their arms and a gait belt should have been utilized unless a resident was independent. The CNA should have been utilizing two staff for the transfer on 2/18/25.
During an interview with the Director of Nursing (DON) on 3/5/25 at 11:32 a.m., she indicated the facility investigation into the incident, on 2/18/25, with Resident C indicated it was the resident's wheelchair that caused the skin tear. The wheelchair was missing a rubber/plastic piece and there was a sharp metal edge exposed. The DON indicated CNAs were supposed to utilize gait belts during transfers and only in an emergency situation would it be acceptable to lift a resident under their arms.
During an interview with the DON on 3/5/25 at 12:44 p.m., she indicated CNA 1 must have obtained, during shift report, that the resident was to be utilizing a sit to stand lift.
During an interview with the DON on 3/5/25 at 1:00 p.m., she verified Resident C did not have a care plan on how she was supposed to be transferred until the incident on 2/18/25.
The safe resident handling/transfer policy provided by the DON, on 3/5/25 at 12:45 p.m., indicated the facility would ensure residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident. Handling aides may include gait belt, transfer boards, and other devices. Resident lifting and transferring would be performed according to the resident's individual plan of care.
The accidents and supervision policy provided by the DON, on 3/5/25 at 2:15 p.m., indicated the resident environment would remain as free of accident hazards as was possible. Each resident would be provided with adequate supervision and assistive devices to prevent accidents. Accident refers to any unexpected or unintentional incident, which resulted in an injury to a resident.
This citation relates to Complaint IN00453938.
3.1-45(a)(1)
3.1-45(a)(2)

Based on interview and record review, the facility failed to obtain physician orders to crush medications for 3 of 5 residents reviewed for medication administration.
Findings include:
1. The clinical record for Resident L was reviewed on 11/7/2024 at 1:30 p.m. The medical diagnoses included diabetes.
During an interview with Resident L, on 11/6/2024 at 1:15 p.m., they indicated they take their medication crushed since they were admitted to the facility.
The physician orders did not reflect an active order to crush medications as needed.
2. The clinical record for Resident O was reviewed on 11/7/2024 at 1:40 p.m. The medical diagnoses included diabetes.
The physician orders did not reflect an active order to crush medications as needed.
3. The clinical record for Resident P was reviewed on 11/7/2024 at 1:45 p.m. The medical diagnoses included chronic obstructive pulmonary disease.
The physician orders did not reflect an active order to crush medications as needed.
During a confidential staff interview completed during the survey, the staff member indicated they crush medications based on nursing judgement. Resident L, Resident O, and Resident P take their medications crushed and have since the staff member has worked with them. The staff member verified Resident L, Resident O, and Resident P do not have orders to crush medications.
An interview with Registered Nurse (RN) 1, on 11/6/2024 at 1:41 p.m., indicated they had issues with medication not being able to be crushed, but the pharmacy was unaware of the resident taking medications crushed because of not having physician orders when they review medications. RN 1 stated they provided the Director of Nursing Services (DNS) and the Executive Director (ED) with a list of residents that take crushed medications, but no orders have been obtained for those residents.
A blank nursing report sheet was provided by the DNS on 11/7/2024 at 2:30 p.m. The document indicated Resident L, Resident O, and Resident P received crushed medications.
A policy, entitled Medication Administration, was provided by the ED on 11/6/2024 at 10:20 a.m. The policy indicated, .Crush medications as ordered .
This citation relates to Complaint IN00446364.
3.1-25(b)

Based on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document self-administration of medications were clinically appropriate for 1 of 6 residents reviewed for medication administration. (Resident T)
Findings include:
The clinical record for Resident T was reviewed on 11/8/24 at 10:20 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, dry eye syndrome, and chronic viral hepatitis.
An Annual Minimum Data Set (MDS) assessment, completed 9/18/24, indicated she was cognitively intact for daily decision making.
On 11/6/24 at 10:55 a.m., Resident T had one blue oblong pill sitting in a medicine cup at the bedside. Resident T indicated she did not want the pill, but did not tell the nurse she didn't, so it was left at the bedside.
During an observation of Resident T on 11/7/24 at 11:47 a.m., one bottle of Visine eye drops was sitting on the bedside table. Resident T indicated, a nurse just left it here one time, so she just left it.
During an interview on 11/7/24 at 11:53 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident T should not have any medications at the bedside and was not sure who left it there. LPN 3 indicated Resident T cannot have any medications left at the bedside nor self-administer medications.
During an interview on 11/8/24 at 1:58 p.m., the Director of Nursing Services (DNS) indicated Resident T had not had a self-administration of medication order or care plan in place for self-administration of medications.
On 11/12/24 at 12:05 p.m. a Resident Self-Administration of Medications Policy was provided by Unit Manager. The policy indicated, .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely
This citation relates to Complaint IN00446364.
3.1-11(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a proper code status order and care plans were in place for 2 of 4 residents reviewed for code status and care plans. (Resident EE & Resident GG)
Findings include:
1. The clinical record for Resident EE was reviewed on 11/8/24 at 1:55 p.m. The diagnoses included, but were not limited to, essential tremor, peripheral vascular disease, and chronic respiratory failure.
Resident EE had a Physician Orders for Scope and Treatment (POST) form dated 4/29/24. The form indicated Resident EE was a Do Not Resuscitate (DNR). Resident EE had a physician order for DNR status placed on 7/30/24. An Advance Directive care plan, initiated 12/7/23, indicated Resident EE was a full code.
During an interview with the Director of Nursing Services (DNS) on 11/8/24 at 1:50 p.m., she indicated Resident EE had a full code care plan because it had not been updated properly.
2. The clinical record for Resident GG was reviewed on 11/8/24 at 12:30 p.m. The diagnoses included, but were not limited to, diabetes mellitus, depression, and chronic ischemic heart disease.
The clinical record indicated Resident GG was admitted to the facility on [DATE]. No POST form, code status order, or code status care plan were present in the clinical record.
During an interview with the DNS on 11/12/24 at 12:25 p.m., she indicated Resident GG had not made her mind up yet about her code status. So, we treat them as a full code, and nothing is documented in the Electronic Health Record (EHR) until we get everything signed and completed.
A Communication of Code Status Policy provided by the Unit Manager, on 11/12/24 at 12:04 p.m., indicated the following, .It is policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .2. When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to . a. Full Code, b. Do Not Resuscitate .4. The designated sections of the medical record are: Orders Section
This citation relates to Complaint IN00446364.
3.1-4(f)(5)

Based on interview and record review the facility failed to provide privacy for residents' medical condition by taking pictures and videos on personal cell phones for 2 of 4 residents reviewed for privacy (Resident KK and Resident W).
Findings include:
During an interview with Licensed Practical Nurse (LPN) 5 on 11/8/24 at 10:40 a.m., she indicated she had called the on-call Nurse Practitioner (NP) about Resident KK's wound on her leg, and they responded with continuation to monitor the area. LPN 5 indicated she was a new nurse and did not feel comfortable with that. LPN 5 took a picture of the wound on her cell phone and sent it to the Director of Nursing Services (DNS) to get her opinion. LPN 5 indicated she did not send the picture to anyone else and deleted the picture off her phone.
During an interview with LPN 4 on 11/8/24 at 2:41 p.m., she indicated she did take a video of Resident W and sent it to the DNS. LPN 4 indicated she was working third shift, and Resident W had a total change in condition. The resident was making a snoring sound, breathing weird, hitting himself, banging on his chest, banging on the walls and tore up his bedroom. This was out of character for the resident. LPN 4 indicated she had tried to call the DNS and when she did not answer she video tapped Resident W and sent it to the DNS. LPN 4 indicated she wanted the DNS to understand how serious the situation was. LPN 4 indicated she did not send the video to anyone else, and she deleted it from her cell phone.
During an interview with the DNS on 11/12/24 at 12:13 p.m., she indicated the facility previously had the capability to send pictures of wounds via the electronic health record system and they no longer had that option. LPN 5 and LPN 4 did send the DNS a picture and video of residents because the nurses did not feel like the provider was responding appropriately about these situations and wanted my help. The DNS indicated Resident W was delusional and having hallucinations on the video. Resident W was yelling and hitting himself. LPN 4 had called the on-call Nurse Practitioner (NP), and she gave an order for Ativan (antianxiety medication), and it did not help Resident W. That was why LPN 4 called her and sent the video to her.
The resident photograph policy provided by the Executive Director, on 11/6/24 at 10:20 a.m., indicated taking photographs and/or videos of residents was a violation of the residents rights' to privacy and confidentiality.
This citation relates to Complaint IN00446364.
3.1-3(o)

Based on interview and record review, the facility failed to ensure an order and care plan were in place for a resident receiving hospice services for 1 of 3 residents reviewed for hospice. (Resident DD)
Findings include:
The clinical record for Resident DD was reviewed on 11/6/24 at 1:26 p.m. The diagnoses included, but were not limited to, anxiety disorder, diabetes mellitus, and chronic pain syndrome. Resident DD's hospice binder indicated he was placed on hospice on 9/15/24. The clinical record indicated there was not an order for hospice nor a hospice care plan in the Electronic Health Record (EHR).
During an interview with the Director of Nursing Services (DNS) on 11/7/24 at 10:29 a.m., they indicated Resident DD's physician put a one-time order in for a hospice services consult for one day only, then the order fell off the EHR after that day, and an order was not put in after that.
An interview with the DNS on 11/8/24 at 10:00 a.m., they indicated the facility recently switched over their care plan library for auditing purposes, on 10/28/24, and all of the old care plans were disappearing.
A hospice care plan, dated 11/7/24, indicated interventions to coordinate plan of care with hospice services and to obtain physician order and appropriate referral.
A Coordination of Hospice Services Policy was provided by the Executive Director (ED) on 11/6/24 at 2:40 p.m. The policy indicated the following, .the facility and hospice provider will coordinate a plan of care and will implement interventions .5. The facility will monitor and evaluate the resident's response to the hospice care plans
This citation relates to Complaint IN00446364.
3.1-37(a)

Based on observation and interview, the facility failed to ensure open medication bottles were dated in 2 of 2 medication carts observed for medication storage and four open, un-identified medications laying in medication drawers in 2 of 2 medication carts observed.
Findings include:
During an observation of Extended Care Unit (ECU) Medication Cart 1 with Registered Nurse (RN) 1, on 11/6/24 at 9:45 a.m., several medication bottles were noted not to have open dates marked on the bottles. Bottles included: one 236 milliliter (ml) Guaifenesin, one 433 ml Enulose, three Polyethylene Glycol 3350 8.3 ounce (oz) bottles, one 473 ml Milk of Magnesia, three 355 ml oral simethicone, one 473 ml Guaifenesin, two Almacone bottles, one 236 ml Dermal Wound Cleanser, and one 10 ml Refresh Optive Advanced. One Fluticasone Propionate inhalation powder was noted to not have a resident label or dates labeled on it. One half of a loose orange oblong pill was laying in the medication drawer.
During an interview on 11/6/24 at 9:45 a.m., RN 1 indicated she was unsure where the open pill came from, and it should have been discarded if not used. RN 1 indicated when a new medication bottle is opened, they were to put an open date and expiration date on them.
During an observation of the ECU Medication Cart 2 with Licensed Practical Nurse (LPN) 2 on 11/6/24 at 10:00 a.m., one loose blue pill was noted in medication drawer. LPN 2 indicated she was unsure who's medication it was or where it came from, and open medications should not be stored in the medication cart. One Albuterol 90 microgram (mcg) inhaler with spacer was noted laying in the bottom drawer with no resident label on it. LPN 2 indicated, she was unsure who the medication belonged to, and it should be labeled. LPN 2 discarded all loose and unidentified medications.
During an observation of the ECU Medication Cart 2 with LPN 2 on 11/6/24 at 10:00 a.m., several medication bottles were noted not to have open dates labeled on them. Bottles included: one 473 ml Enulose, four Guaifenesin 473 ml bottles, one Max Tussin 300 ml bottle, one Milk of Magnesia 473 ml bottle, one 8.3 oz. Polyethylene Glycol, and one Potassium Chloride 10% 473 ml bottle. LPN 2 indicated when a bottle was opened, the open date should be recorded on them.
During an interview with the Director of Nursing Services (DNS) on 11/8/24 at 1:20 p.m., they indicated nursing puts the open date and the dispose date anytime a new medication bottle is opened. The DNS indicated they keep a binder at the nurses' stations that has what the discard time lengths should be for different medications.
A Medication Storage Policy provided by the Executive Director, on 11/6/24 at 11:22 a.m., indicated the following, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations .8. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, or deteriorated medications with worn, illegible, or missing labels
This citation relates to Complaint IN00446364.
3.1-25(j)
3.1-25(o)

Based on interview and record review the facility failed to follow-up with monitoring and have an indication for use on a one-time order for Ativan (antianxiety medication) for a resident who was experiencing an acute change in condition for 1 of 3 residents reviewed for change in condition (Resident W).
Findings include:
During an interview with Licensed Practical Nurse (LPN) 4 on 11/8/24 at 2:41 p.m., she indicated she did take a video of Resident W and sent it to the Director of Nursing Services (DNS). LPN 4 indicated she was working third shift, and Resident W had a total change in condition. The resident was making a snoring sound, breathing weird, hitting himself, banging on his chest, banging on the walls and tore up his bedroom, which was out of character for the resident. LPN 4 indicated she had tried to call the DNS and when she did not answer she video tapped Resident W and sent it to the DNS, on 10/18/24 around 2:30 a.m. LPN 4 indicated she wanted the DNS to understand what a serious situation that was. LPN 4 indicated she did not send the video to anyone else, and she deleted it from her cell phone.
During an interview with the DNS on 11/12/24 at 12:13 p.m., she indicated LPN 4 did send the DNS a video of Resident W because the nurse did not feel like the provider was responding appropriately about the situation and wanted my help. The DNS indicated Resident W was delusional and having hallucinations on the video. Resident W was yelling and hitting himself. LPN 4 had called the on-call Nurse Practitioner (NP), and she gave an order for Ativan (antianxiety medication), and it did not help Resident W. That was why LPN 4 called her and sent the video to her.
Review of the record of Resident W, on 11/12/24 at 10:36 a.m., indicated the diagnoses included, but were not limited to, opioid dependence, hypertension, muscle weakness, and fatigue.
The admission Minimum Data Set (MDS) assessment, dated 9/30/24, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident did not have hallucinations, delusions, or behaviors.
A progress note for Resident W, dated 10/18/24 at 3:32 a.m., indicated the resident had been in his room since early A.M., around 1:30 a.m., with altered mental status. The resident was standing with eyes rolling in the back of his head, laying on the couch halfway, screaming out, stating that someone was going to push him off his bed if he got on it. The resident was beating on his chest and face with his fists, while seemingly being asleep. The resident was not getting any better, only worse. This nurse sat resident down numerous times to keep him safe and prevent him from falling. There was nothing that was helping the situation. The on-call provider was notified, and the DNS was notified.
A progress note for Resident W, dated 10/18/24 at 3:37 a.m., indicated the Nurse Practitioner (NP) response was to administer Ativan two milligrams (mg); one dose.
The clinical record did not indicate what the Ativan two milligrams was utilized for or indication of follow up if the Ativan was effective or not effective for Resident W.
A progress note for Resident W, dated 10/18/24 at 6:52 a.m., indicated the resident was thrashing on the couch uncontrollably, vital signs were normal, and was unable to answer questions appropriately. The writer suspects resident had taken unprescribed medication. The NP was called, and an order was received to send the resident to the emergency room.
A progress note for Resident W, dated 10/18/24, indicated since around midnight the resident had been thrashing, yelling, hitting himself, eyes rolling back in head and general disoriented to person, time, and place. The resident had refused care of his cellulitis this past week and could be septic although his vital signs were normal. The resident became very disoriented, combative with staff, and hitting himself. Ativan two mg was given, around 2:00 a.m., with little effect on his demeanor. The resident was experiencing hallucinations and agitation. The resident was disoriented with mental status changes, usually this resident was very kind and respectful and was currently yelling and hitting himself. The resident was unable to answer if he had taken any substance that he was not supposed to or why his condition suddenly spiraled out of control. The resident was being transported to the emergency room. The progress note was electronically signed by NP 2.
A progress note for Resident W, dated 10/18/24 at 7:10 a.m., indicated the fired department was at the facility to transport the resident, NP 2 was in the resident's room as well.
The hospital records for Resident W, dated 10/18/24, indicated the resident was admitted to the local hospital with toxic encephalopathy (sudden, severe change in mental function) secondary to cocaine and amphetamine use. The resident had left the long-term care facility yesterday and when he returned, he was altered and confused. The resident remained in the emergency room for several hours, with attempts at metabolizing, but despite this he remained quite sleepy and had to be placed on oxygen. Given the prolonged period of observation in the emergency department, still without return to baseline I do feel that patient will warrant further inpatient management.
The provision of physician ordered services policy provided by the Executive Director, on 11/12/24 at 3:00 p.m., indicated the purpose of this policy was to provide reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.
This citation relates to Complaint IN00446364.
3.1-48(a)(3)
3.1-48(a)(4)

Based on observation, interview, and record review the facility failed to utilize smoking aprons during smoking for safety of the residents as assessed for 3 of 3 residents reviewed for smoking safety (Resident J, Resident Z and Resident BB).
Findings include:
1. During an observation on 11/7/24 at 11:43 a.m., Resident J was outside smoking with other residents and a staff member. Resident J did not have on a smoking apron.
During an interview with Resident J on 11/7/24 at 12:00 p.m., he indicated he did not wear a smoking apron when smoking. Resident J indicated the smoking apron was only for residents who drop things and were not safe during smoking.
Review of the record of Resident J, on 11/8/24 at 2:18 p.m., indicated the diagnoses included, but were not limited to, chronic respiratory failure, difficulty walking, chronic obstructive pulmonary disease, diabetes, heart failure and dependence on nicotine.
The plan of care for Resident J, dated 7/9/24, indicated the resident was at risk for smoking related injury. The interventions included, but were not limited to, provide a smoking apron while smoking.
The Quarterly Minimum Data Set (MDS) assessment for Resident J, dated 8/29/24, indicated the resident was cognitively intact for daily decision making.
The smoking and safety assessment for Resident J, dated 10/29/24, indicated the resident was lethargic/falls asleep easily during task or activities. The intervention included, but were not limited to, utilize a smoking apron.
2a. During an observation of the designated smoking area, on 11/6/24 at 11:41 a.m., Resident Z and Resident BB were smoking without a smoking apron in place.
The clinical record for Resident Z was reviewed on 11/8/24 at 10:46 a.m. The diagnoses for Resident Z included, but were not limited to, flaccid hemiplegia (neurological condition with a loss of voluntary movement in a limb) affecting left non-dominant side, dependence on supplemental oxygen, and vascular disease.
An Annual Minimum Data Set (MDS) assessment, dated 9/17/24, indicated Resident Z was cognitively intact and had limited range of motion of upper extremity on one side and utilized a wheelchair for ambulation.
A Smoking and Safety assessment provided by the Director of Nursing Services (DNS), on 11/8/24 at 9:30 a.m., indicated Resident Z had limited or no Range of Motion (ROM) in arms or hands and was to utilize a smoking apron.
During an interview on 11/7/24 at 1:50 p.m., Resident Z indicated she occasionally wore a smoking apron and was aware that she was supposed to at all times. Resident Z indicated she had never had any burns while smoking.
2b. The clinical record for Resident BB was reviewed on 11/8/24 at 10:47 a.m. The diagnoses included, but were not limited to, essential hypertension, hypothyroidism, and chronic obstructive pulmonary disease (COPD).
A Quarterly MDS assessment, dated 10/2/24, indicated Resident BB had moderate cognitive impairment and was wheelchair dependent for mobility.
A Smoking and Safety assessment provided by the DNS, on 11/8/24 at 9:30 a.m., indicated Resident BB was to utilize a smoking apron.
During an interview on 11/7/24 at 1:46 p.m., Resident BB indicated he would wear a smoking apron every now and then, when you guys were here. Resident BB indicated he was aware that he was supposed to utilize a smoking apron at all times while smoking. He indicated he had never been burned while smoking but he had gotten ashes on his clothing that caused burn holes in his clothing.
During an interview on 11/6/24 at 11:41 a.m., the DNS indicated the facility does a smoking assessment on all residents who smoke. That assessment assesses their abilities to safely smoke. If a resident triggers for not being able to smoke without a risk, they will trigger for a smoking apron to be worn. If they do not trigger, then they are not required to wear one.
A Resident Smoking Policy was provided by the Executive Director (ED) on 11/6/24 at 10:20 a.m. The policy indicated the following, .it is the policy of the facility to provide a self and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents .6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all .10. All safe smoking measures will be documented on each resident's care plan
This citation relates to Complaint IN00446364.
3.1-45(a)(2)

3. During an observation on 9/9/24 at 11:35 a.m., Resident C was lying in bed, the bilateral heels were flat on the bed, and the resident had a brief on.
During an observation on 9/9/24 at 2:29 p.m., Resident C was lying in bed, the bilateral heels were flat on the bed, and the resident had a brief on.
During an observation and interview with Resident C on 9/10/24 at 1:59 p.m., the resident was lying in bed, the bilateral heels were flat on the bed, and the resident had a brief on. Resident C indicated she was not supposed to wear a brief in bed because she had skin issues on her bottom.
During an observation on 9/11/24 at 2:52 p.m., Resident C was lying in bed, the bilateral heels were flat on the bed, and the resident had a brief on.
During an observation and interview with Resident C on 9/12/24 at 1:17 p.m., the resident was lying in bed, the bilateral heels were flat on the bed, and the resident had a brief on. The resident indicated her feet hurt and she would like to have cushioned boots on.
During an observation and interview on 9/12/24 at 1:20 p.m., CNA 2 lifted Resident C's heels off the bed and there was no redness. CNA 2 provided incontinent care to the resident and the resident's bottom had a red rash covering the entire buttocks region. CNA 2 indicated they had been applying the house cream on the resident's bottom.
During an interview with Registered Nurse (RN) 1 on 9/12/24 at 1:29 p.m., they indicated Resident C had returned from the local hospital with the rash and the facility had been applying the house cream to it.
Review of the clinical record of Resident C, on 9/11/24 at 2:15 p.m., indicated the diagnoses included, but were not limited to, congestive heart failure, pneumonia, dementia, chronic obstructive pulmonary disease, hypertension, anxiety, dysphagia, and history of pressure ulcer to the right buttock.
The plan of care for Resident C, dated 8/11/23, indicated the resident was at risk for skin impairment. The interventions included, but were not limited to, float heels at all times while in bed.
A physician order for Resident C, dated September 2024, indicated the resident was not to have a brief on while in bed. The resident was to have a weekly skin review every Monday, on day shift, with a full set of vital signs.
A Quarterly MDS assessment for Resident C, dated 7/13/24, indicated the resident was moderately impaired for daily decision making. The resident was always incontinent of her bladder and bowels.
A skin assessment for Resident C, dated 7/29/24, indicated the resident had a pre-existing rash.
A skin assessment for Resident C, dated 8/5/24, was not completed and was blank.
A skin assessment for Resident C, dated 8/12/24, indicated a rash like skin issue.
A skin assessment for Resident C, dated 8/19/24, indicated a rash like skin issue.
A skin assessment for Resident C, dated 8/26/24, indicated skin intact.
A skin assessment for Resident C, dated 9/2/24, indicated skin intact.
A skin assessment for Resident C, dated 9/9/24, indicated the resident had a rash.
During an interview with the DNS on 9/12/24 at 2:00 p.m., they indicated the nurses were responsible to ensure pressure relieving devices for Resident C's heels were in place. The DNS indicated Resident C was not to have a brief on while in bed and was communicated to the CNAs by the resident's Kardex.
The Kardex for Resident C provided by the DNS, on 9/12/24 at 3:00 p.m., indicated the resident was to have heels floated at all times while in bed and not to have a brief on while in bed.
During an interview with Licensed Practical Nurse (LPN) 4 on 9/13/24 at 1:15 p.m., they indicated, 7/23/24, was the last day of treatment for Resident C's rash. LPN 4 would have the Nurse Practitioner (NP) look at it today for a treatment. LPN 4 provided the last treatment order for Resident C.
A physician order for Resident C, dated 7/23/24, indicated the resident was ordered clotrimazole-betamethasone 1-0.05 % cream (antifungal cream) to be applied two times a day to the buttocks for a rash for 14 days. This indicated the resident had not a treatment implemented for her rash since 8/6/24.
This citation relates to Complaint IN00440948.
3.1-37(a)
2. The clinical record for Resident 44 was reviewed on 9/11/2024 at 11:20 a.m. The medical diagnoses included chronic respiratory failure and chronic obstructive pulmonary disease.
A Quarterly MDS assessment, dated 8/29/2024, indicated Resident 44 was cognitively intact, did not have behaviors, and received diuretics in the seven days prior to the assessment.
A dehydration care plan, initiated on 7/9/2024, indicated Resident 44 was at risk for fluid imbalance due to diuretic use. An intervention indicated to record Resident 44's weight per order and notify physician of weight gains/losses.
A physician order, dated 5/5/2024, indicated to notify Resident 44's provider of a weight gain of three pounds in 24 hours or a weight gain of five pounds in one week.
A physician order, dated 5/15/2024, indicated to obtain daily weights for Resident 44 before eating or drinking.
Resident 44's weight record, dated 8/1/2024 through 9/12/2024, indicated a weight gain of three of more pounds within 24 hours 11 times.
Review of the progress notes, on 9/12/2024, indicated Resident's 44 provider was notified three times a weight gain of three or more pounds between 8/1/2024 through 9/12/2024.
During an interview, on 9/12/2024 at 2:30 p.m., the DNS indicated they could not locate where a provider was notified of Resident 44's weight gain for eight incidents between 8/1/2024-9/12/2024. The DNS indicated the direct care nursing staff were responsible for obtaining daily weights and notifying appropriate providers if indicated.
During an interview on 9/12/2024 at 3:00 p.m., the DNS indicated physician orders should be followed as written unless clinically contraindicated.
A policy entitled, Weight Monitoring, was provided by the DNS on 9/12/2024 at 9:48 a.m. The policy indicated unless ordered at an increased frequency based on clinical needs, all residents would be weighed monthly.
1. Based on observation, interview, and record review, the facility failed to follow physician orders for obtaining daily and monthly weights for 2 of 2 residents reviewed for weights. (Resident 6 and 44).
2. Based on observation, interview, and record review, the facility failed to have accurate skin assessments, follow physician orders for no brief while in bed, and have heels floated for 1 of 3 residents reviewed for skin. (Resident C)
Findings include:
1. The clinical record for Resident 6, reviewed on 9/9/24 at 2:19 p.m., indicated diagnoses included, but were not limited to, schizophrenia, muscle weakness, cognitive communication deficit, diabetes mellitus, and abnormal weight loss.
During an observation on 9/9/24 at 11:47 a.m., Resident 6 was lying back in bed. Her legs were uncovered, and they were red and swollen.
A quarterly Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident 6 was cognitively intact, had limited extremity impairment to both lower extremities, and required a wheelchair for mobility.
A physician order, dated 2/23/24, indicated a monthly weight to be obtained on the 16th of every month.
A progress note, dated 3/14/24, indicated Resident 6 asked about the swelling in her legs and lack of leg strength and there was minimal swelling to both lower legs.
A review of weights was obtained and documented 2/29/24- 172.6 pounds (lbs.), 7/10/24- 178.2 lbs., 7/31/24- 178.2 lbs., 8/1/24- 189.4 lbs., and 9/10/24- 179 lbs. This indicated Resident 6 was not weighed for four months and a re-weigh was not obtained after an abnormal weight was obtained, on 8/1/24.
A progress note, dated 8/3/24 at 7:16 a.m., by Registered Dietician (RD) 7 indicated a weight of 189.4 reviewed with a 6.3 % weight increase. MD [Medical Director] and family notified. Suspect outlier weight, rec [recommend] re-weigh for verification.
A progress note, dated 8/12/24 at 3:45 p.m., by RD 9 indicated weight gain may be due to edema and to observe Resident 6 for weight increase and decrease with the absence and /or presence of edema.
A progress noted, dated 9/10/24 at 5:41 p.m., by the Director of Nursing Services (DNS) indicated a re-weight was collected and ace wraps (a compression bandage) were to be on bilateral lower extremities every morning and off at bedtime.
A care plan provided by the DNS, on 9/12/24 at 11:12 a.m., indicated Resident 6 had a history of significant weight changes with interventions, dated 9/11/22, for weights as ordered.
During an interview with the DNS on 9/12/24 11:15 a.m., indicated she delegates to the certified nurse aides (CNAs) to obtain weights for residents as ordered by the physician. The DNS indicated when an abnormal weight was obtained, a re-weight was done.

Based on interview, observations, and record review, the facility failed to ensure Resident 44 had a self-administration of medications assessment completed for 1 of 1 resident reviewed for self-administration of medications.
Findings include:
The clinical record for Resident 44 was reviewed on 9/11/2024 at 11:20 a.m. The medical diagnoses included chronic respiratory failure and chronic obstructive pulmonary disease.
A Quarterly Minimum Data Set (MDS) assessment, dated 8/29/2024, indicated Resident 44 was cognitively intact and did not have behaviors.
A self-administration care plan, initiated on 9/10/2024, indicated an intervention of completing a self-administration assessment per the facility's protocol.
During an interview and observation, on 9/5/2024 at 11:21 a.m., indicated Resident 44 had two medication nasal sprays. Resident 44 indicated they kept the two medicated nasal sprays on the over-bed table, staff knew about the medicated nasal sprays, and staff told them to just keep the medicated nasal sprays in one spot.
During an interview on 9/5/2024 at 11:30 a.m., QMA 6 indicated Resident 44 utilized over the counter nasal sprays that the family provided, and Resident 44 kept at the bedside.
During an observation on 9/10/2024 at 1:55 p.m., Resident 44 had two medicated nasal sprays on the bedside table.
A self-administration assessment, dated 9/10/2024 at 6:29 p.m., indicated that Resident 44 was fully capable of self-administration for nasal decongestants.
A policy entitled, Resident Self-Administration of Medications, was provided by the Director of Nursing Services on 9/12/2024 at 9:40 a.m. The policy indicated, .A resident may only self-administer medications after the facility's intradisciplinary team has determined which medications may be self-administered safely .the opportunity to self-administer medications during the routine assessment .
3.1-11(a)

Based on observation, interview, and record review, the facility failed to provide fresh water daily for 1 of 1 resident reviewed for hydration. (Resident C)
Findings include:
During an observation and interview with Resident C on 9/9/24 at 11:30 a.m., the resident had two cups of thickened juice on the bedside table and no water. Resident C indicated she liked juice but would like to have fresh water every day also.
During an observation on 9/10/24 at 1:59 p.m., Resident C had a cup of thickened coffee and a cup of thickened juice. The resident did not have any water.
During an observation and interview with Resident C on 9/11/24 at 2:52 p.m., the resident had a cup of thickened coffee and juice. The resident did not have any water. Resident C indicated she had not had any water in the last five days.
During an observation on 9/12/24 at 1:17 p.m., Resident C had a cup of thickened coffee and a cup of thickened juice. The resident did not have any water.
Review of the clinical record of Resident C, on 9/11/24 at 2:15 p.m., indicated the diagnoses included, but were not limited to, congestive heart failure, pneumonia, dementia, chronic obstructive pulmonary disease, hypertension, anxiety, dysphagia, and history of pressure ulcer to the right buttock.
A physician order for Resident C, dated September 2024, indicated the resident was to be up in a chair for all meals. The resident was ordered a regular diet and thickened liquids with nectar/mildly thick consistency.
The plan of care for Resident C, dated 8/11/23, indicated the resident was at risk for constipation. The interventions included, but were not limited to, encourage fluids.
The plan of care for Resident C, dated 8/11/23, indicated the resident had alteration in elimination of bowel and bladder. The interventions included, but were not limited to, encourage fluids.
During an interview with the Director of Nursing Services on 9/12/24 at 2:00 p.m., they indicated the nursing staff were responsible to ensure Resident C had fresh water daily.
The hydration policy provided by the Executive Director, on 9/13/24 at 1:00 p.m., indicated the facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.
3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to don personal protective equipment (PPE) prior to entering the room of a resident in contact isolation for 1 of 2 residents reviewed for transmission-based precautions (TBP). (Resident 36)
Findings:
The clinical record for Resident 36 was reviewed on 9/6/24 at 11:35 a.m. The diagnoses included, but were not limited to, hypertension, anxiety, and major depressive disorder.
The physician's orders indicated contact precautions during care every shift for ringworm, starting 7/5/24.
An observation was made on 9/6/24 at 11:40 a.m. There was a sign on Resident 36's door to her room indicating she was in contact precautions and to perform hand hygiene as well as don a gown and gloves prior to entering the room. Certified Nurse Aide (CNA) 11 entered the room at that time with no gown or gloves and shut the door.
An interview was conducted with CNA 11, on 9/6/24 at 11:55 a.m., after she exited Resident 36's room. She indicated she cared for Resident 36 with no gown or gloves, because, to her knowledge, Resident 36 was not in contact isolation. CNA 11 was unsure why the contact isolation sign was on the door and suggested inquiry with management.
On 9/6/24 at 2:17 p.m., an interview was conducted with Licensed Practical Nurse (LPN) 4, the unit manager of the unit where Resident 36 resided. She indicated Resident 36 was indeed in contact isolation. The nurse practitioner wanted her to remain in it until seen by the dermatologist. LPN 4 clarified with CNA 11 earlier that Resident 36 was in contact isolation. LPN 4 educated CNA 11 as well as other nursing staff in regards to contact isolation.
On 9/6/24 at 2:19 p.m., an observation was made. CNA 13 was observed to assist Resident 36 in her wheelchair into her room and position her next to her bed. CNA 13 adjusted Resident 36's feet and pushed her bedside table in front of her. The contact isolation sign remained on Resident 36's door, but CNA 13 was not wearing a gown or gloves.
An interview was conducted with CNA 13, on 9/6/24 at 2:19 p.m., after she exited Resident 36's room. She indicated she did not think Resident 36 was in contact isolation, as she just brought her back from therapy.
An interview was conducted with the Director of Nursing Services (DNS) on 9/9/24 at 12:25 p.m. She indicated they'd tried four different treatments to what they thought was ringworm, but none of them worked. Resident 36 had a dermatology appointment scheduled for December 2024, because that was the soonest appointment they could get. The nurse practitioner discontinued contact isolation for Resident 36 this morning, because the nurse practitioner didn't realize her appointment was three months away.
The 9/9/24 nurse practitioner note read, .acute visit for skin rashes to bilateral elbows. Patient was treated with hydrocortisone cream, terbinafine cream, butenafine cream for ringworm since May of this year with no improvement, so referral made to dermatology but patient agreed at one time and then refused again. Today patient stated that she is using her own cream and area appear [sic] better. Denies itching. Staff relates no other concern .Assessments and Plans .Dermatophytosis, unspecified: Started treating both elbows since May with no efficacy. Area appear [sic] to be not ringworm as it responded OTC [over the counter] cream with no itching. Discontinue Isolation.
The Transmission-Based (Isolation) Precautions policy was provided by the DNS on 9/12/24 at 9:40 a.m. It read, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission .Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment .Contact Precautions- a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment .c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination .
3.1-18(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's infectious disease physician of lab results, as ordered, and obtain a lab, as ordered by the pharmacy, prior to continuing administration of an antibiotic for 1 of 3 residents reviewed for skin conditions. (Resident E)
Findings include:
The clinical record for Resident E was reviewed on 8/1/24 at 12:35 p.m. The diagnoses included, but were not limited to, osteomyelitis, type 1 diabetes mellitus, peripheral vascular disease, and peripheral neuropathy. He was admitted to the facility on [DATE] after a hospitalization involving osteomyelitis of the right foot. He was discharged from the facility on 7/19/24.
The 5/20/24, ED (emergency department) note from the 5/20/24 through 6/1/24 hospital notes indicated, presenting to ED with pain and bleeding from right foot wounds. Also associated with right calf pain similar to pain when he had his peripheral vascular stent placed one year ago He c/o [complains of] foot wound for past couple of weeks, has been trying to manage on his own at home .Assessment/Plan 1. Osteomyelitis of foot .XR [x-ray] right foot showed osteomyelitis involving fifth toe proximal phalanx base as well as head and neck of fifth toe metatarsal.
The 6/1/24, hospital discharge instructions indicated, Instructions From Your Care Team 1. Will need Ceftriaxone and Vancomycin for 6 weeks. Last dose will be on 7/2/24. 2. Will need weekly CBC [complete blood count,] CMP [comprehensive metabolic panel] and Vancomycin trough while on antibiotics. Please fax results to [name of infectious disease physician's] office at [fax number of infectious disease physician.] The Medications section of the discharge instructions indicated to administer 12.5 ml of Vancomycin 100 mg/mL IV (intravenously) every 12 hours with the last dose to be administered on 7/2/24. The Education Materials section of the hospital discharge instructions indicated, You have a condition called osteomyelitis. This is a bone infection caused by bacteria or fungi. It may have spread through the blood from one area of your body to the bone Home Care: Take your medicine exactly as directed.
The 6/1/2024, 5:55 p.m. facility progress note indicated, Patient arrived at facility at/around 1500 [3:00 p.m.] Patient was transported via ambulance from [name of hospital.] Patient arrived via stretcher with no assistance with transfer, patient stood on left foot to pivot from stretcher to bed. Patient is a&ox3 [alert and oriented times 3,] cont [continent] of b/b bowel/bladder,] Patient is non weight bearing on right foot due to 5th toe amputation. Patient currently has a patent picc [peripherally inserted central catheter] line in upper right extremity, he is now taking multiple iv atb [antibiotics] see orders. Patient is nwb [non weight bearing] on right foot, and needs a f/u [follow up] appointment with surgeon made for 6/7/2024 .Patient had 2 ivs infiltrate at hospital in forearm of left arm this arm is painful to touch at this time. Patients right foot has dressing on, patient declined for me to look at it at this time d/t [due to] already being in pain, nurse reported this to following nurse. Nurse noted to call surgeon if patient has increased redness, swelling, drainage at incision site, fever of 100.4 or greater, chills, increased fatigue or tiredness .Patient-oriented to room and call light, patient oriented to bathroom with wheelchair. Patient is now resting comfortably in bed.
The facility's physician orders, effective 6/3/24 through 6/26/24, indicated to obtain a weekly CBC, CMP, and Vancomycin Trough while on antibiotics, and the trough needed to be drawn at 11:30 a.m. Tuesday mornings. The orders, effective 6/26/24, indicated to obtain a weekly CBC, CMP, and Vancomycin Trough while on antibiotics, and the trough needed to be drawn at 11:30 a.m. Wednesday mornings. For both orders, the results were to be faxed to Resident E's infectious disease physician at the same fax number referenced in the hospital discharge instructions. The orders, effective 6/2/24 to 6/12/24, indicated to administer 1.25 gram of Vancomycin IV 1250 mg/250ML (milligrams/milliliters), use 1.25 gram via IV two times a day. The orders, effective 6/12/24 to 7/1/24, indicated to administer 1.25 gram of Vancomycin 1500mg/15ml via IV two times a day. The orders, effective 7/1/24 to 7/8/24 indicated to administer Vancomycin 1500 mg via IV every 8 hours.
The June, 2024 and July, 2024 MARs (medication administration records) indicated the above 7/1/24 Vancomycin order for every 8 hours was administered twice on 7/1/24, 7/3/24, and 7/5/24, and three times on 7/2/24, 7/4/24, 7/6/24 (first administration of the day references progress note regarding administration while away from facility), 7/7/24, and once on 7/8/24.
All CBC, CMP, and Vancomycin Trough lab results for Resident E's entire stay were provided by the DON (Director of Nursing) on 8/2/24 at 10:30 a.m. There were results for the following dates: 6/4/24, 6/12/24, 6/18/24, 6/26/24, and 7/2/24. The 7/2/24 Vancomycin trough result was high at 26.5 ug/mL (microgram per milliliter.) The reference range was 10-20 ug/mL.
A telephone interview was conducted with the Certified Medical Assistant from Resident E's Infectious Disease Physician on 8/2/24 at 1:53 p.m. She indicated they were not notified of Resident E's high Vancomycin trough result from 7/2/24 or any of his other Vancomycin trough, CBC, or CMP results. She stated, I have never received any from them. Reviewing the lab results was important, because that's how we keep an eye on the patient We have nothing in his chart on lab results. As far as the Vancomycin being given until 7/8/24, Resident E's last order from his Infectious Disease Physician was from prior to him leaving the hospital, on 6/1/24, and it was to stop the Vancomycin on 7/2/24 and pull the PICC (peripherally inserted central catheter) after the last dose.
An interview was conducted with the facility's Medical Director on 8/2/24 at 3:05 p.m. He indicated it was possible the 7/2/24 Vancomycin lab result was drawn after a dose of Vancomycin, at the wrong time. They have pharmacy manage Vancomycin dosing, because they should be using a software-based area under the curve calculation to determine dosing. The facility should have administered Resident E's Vancomycin based on the orders transmitted to them by the pharmacy. As far as he was concerned, pharmacy should be managing the Vancomycin and the facility trusted them to do that.
On 8/5/24 at 10:35 a.m., the Director of Nursing (DON) provided documentation she indicated as all the pharmacy documentation regarding Resident E's Vancomycin management. The documentation included a 6/8/24 Vancomycin Recommendation that read, 6/4 trough is slightly low at 9.6 starting Monday 6/10 please increase dose to: Vancomycin 1500 mg every 12 hours. Draw trough 30 minutes prior to dose on 6/12/24. The documentation included a 6/30/24 Recommendation that read, 6/27 trough is on the low end for osteomyelitis at 10.1. Please INCREASE frequency to every 8 hours. New order: Vancomycin 1500 mg q8h [every 8 hours] starting on 7/2/24. Draw trough 30 minutes prior to dose on 7/3/24. The 6/30/24 recommendation was the last pharmacy recommendation included in the documentation. There was no recommendation included regarding the 7/2/24 high Vancomycin lab result.
The June, 2024 MAR indicated the above 6/8/24 pharmacy recommendation to increase the dose to 1500 mg every 12 hours starting 6/10/24 did not start until 6/12/24.
The clinical record did not include, nor did the facility provide, a 7/3/24 Vancomycin trough result, as pharmacy recommended be obtained prior to 7/3/24 administration or any subsequent Vancomycin trough results.
The July, 2024 MAR indicated the last dose of Vancomycin administered to Resident E was on 7/8/24.
The 7/8/24 Grievance Form for Resident E indicated the detail of the complaint/grievance was a medication issue, not ordered correctly, in regards to antibiotic medication.
On 8/2/24 at 2:49 p.m., an interview was conducted with RN (Registered Nurse) 2, who administered Resident E's last dose of Vancomycin on 7/8/24. She indicated she entered the final Vancomycin order into the electronic health record and could not recall if there was an end date but didn't think there was. Prior to administering Vancomycin, she always checked the most recent lab results. She was the one who figured out his Vancomycin trough levels were too high.
An interview was conducted with the DON on 8/5/24 at 10:27 a.m. She indicated the Vancomycin continued until 7/8/24, but there was no Vancomycin trough result from 7/3/24 as recommended by pharmacy. She was on vacation the previous week, and when she returned, on 7/8/24, Resident E had filed a grievance asking about the Vancomycin, so she looked into it and discontinued it.
The Laboratory Services and Reporting policy was provided by the DON on 8/2/24 at 10:30 a.m. It indicated the following, Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services 6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record. 7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.
The Medication Issues of Particular Relevance in Older Adults pharmacy policy was provided by the DON on 8/5/24 at 10:35 a.m. The Parenteral Vancomycin Monitoring section indicated, Use must be accompanied by monitoring of renal function tests (which should be compared with the baseline) and by serum medication concentrations. Serious adverse consequences may occur insidiously if adequate monitoring does not occur Adverse Consequences - May cause or worsen hearing loss and renal failure.
The Medication Administration policy was provided by the DON on 8/5/24 at 10:35 a.m. It indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
This citation relates to Complaint IN00439896.
3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete care plan meetings for residents and their representatives for 2 of 3 residents reviewed for care plan meetings (Resident F and Resident D).
Findings include:
1. Review of the record for Resident F, on 8/1/24 at 1:23 p.m., indicated the diagnoses included, but were not limited to, cerebral palsy, autistic disorder, seizures, anxiety, depression, adult failure to thrive, and intellectual disabilities.
Resident F was admitted on [DATE]. The resident and the resident's representative had two care plan meetings on 1/2/24 and 6/13/24.
2. The clinical record for Resident D was reviewed on 8/2/24 at 12:00 p.m. The diagnoses included, but were not limited to, unspecified intellectual disabilities, essential hypertension, and depression.
The clinical record indicated Resident D had a care plan meeting on 12/12/23. No other care plan meetings were documented after that date.
A care plan meeting document provided by the Director of Nursing Services (DNS), on 8/2/24 at 2:30 p.m., indicated a care plan meeting was held with Resident D and her representative on 12/12/23.
During an interview with the Executive Director (ED), on 8/2/24 at 11:40 a.m., indicated care plan meetings were held as often as needed and quarterly. The ED indicated social services were responsible to ensure care plan meetings were completed quarterly.
A Care Planning-Resident Participation policy provided by the Unit Manager, on 8/2/24 at 12:15 p.m., indicated the following, .8. The facility will honor requests for care plan meetings and acknowledge requests for revisions to the person-centered plan of care. 9. The facility will honor the resident's right to participate in establishing the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. 10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative.
This citation relates to Complaint IN00440019.
3.1-3(n)(3)

Based on interview and record review, the facility failed to ensure a care plan was developed and implemented for seizure-like activities for 1 of 3 residents reviewed for falls. (Resident C)
Findings include:
The clinical record for Resident C was reviewed on 5-3-24 at 2:35 p.m. His diagnoses included, but were not limited to, unspecified tremor and unspecified convulsions. A nursing note, dated 4-12-24, indicated he had a history of seizure activity. At least three seizure-like activities were documented for Resident C on 4-18-24, and least two more seizure-like activities were documented on 4-20-24. At least one seizure-like activity was associated with a fall.
A review of Resident C's clinical record failed to demonstrate any care plan development for care and/or services related to seizure-like activities. This was brought to the attention of the Director of Nursing (DON) on 5-3-24. The DON was informed of the lack of care plans for Resident C related to this resident's seizures or seizure-like activity on 5-3-24 at 4:30 p.m. In an interview with the DON on 5-6-24 at 9:05 a.m., she indicated she had reviewed this resident's clinical record and was unable to locate any care plans for seizures or seizure-like activity.
On 5-6-24 at 1:55 p.m. the DON provided a copy of a policy dated, 2023, and entitled, Comprehensive Care Plans. This policy indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest
practicable physical, mental, and psychosocial well-being .
This Federal tag relates to Complaint IN00433180.
3.1-35(a)
3.1-35(b(1)

Based on interview and record review, the facility failed to ensure a staff member followed policies for the safe use of a mechanical lift, requiring the operation of the mechanical lift to be conducted by 2 staff members, resulting in a fall from the mechanical lift and a fracture for 1 of 3 residents reviewed for falls and the use of mechanical lifts. (Resident B and CNA 3)
The deficient practice was corrected on 4-25-24, prior to the start of the survey, and was therefore past noncompliance. The facility had completed an assessment of the resident who had experienced a fall from a mechanical lift and was sent to an area emergency room, began an immediate investigation into the circumstances of the fall, conducted education and skills checkoffs with staff for safe transfers and use of mechanical lifts, inspected all mechanical lifts in the facility, conducted audits of the clinical records of residents who utilize mechanical lifts and began random care observations for safe mechanical lift operations with staff, and updated her care plans upon return to the facility on 4-24-24.
Findings include:
The clinical record of Resident B was reviewed on 5-3-24 at 10:33 a.m. Her diagnoses included, but were not limited to, cerebral infarction with left non-dominant side affected, diabetes with neuropathy, morbid obesity, cognitive communication disorder, hypertensive with heart disease and chronic kidney disease and general muscle weakness. Her most recent Minimum Data Set (MDS) assessment, dated 2-21-24, indicated she is cognitively intact, is non-ambulatory, uses a wheelchair for mobility and is dependent for all transfers from one surface to another. A review of her care plans indicated she requires a mechanical lift for transfers, with two assist transfers at all times.
The facility sent a report of a fall with fracture to the Indiana Department of Health's Long-Term Care Division on 4-19-24 and a follow-up report on 4-26-24. It indicated Resident B while transferring from her chair to bed, encountered a fall. It indicated she complained of pain and upon notification to the physician, orders were obtained to send her to a local hospital's emergency room for further evaluation. An immediate investigation was begun. The follow-up detailed a new fracture was identified, which was an area of a previous fracture of the left tibial plateau (around the area of the patella/knee cap). It indicated the orthopedic consultant found the fracture to be inoperable and placed a knee immobilizer for resident comfort. It indicated staff education was conducted on safe transfers and mechanical lift procedures immediately. The resident returned to the facility on 4-24-24, with staff monitoring and treating the resident for pain, with no concerns observed. A psychosocial follow-up for 3 days post return for 3 days with no concerns noted. The interdisciplinary team (IDT) met and reviewed the resident for fall interventions and updating of her care plan.
In an interview with the Corporate Executive Director (ED) on 5-3-24 at 10:40 a.m., she shared Resident B is a long-term resident. She explained on the date of the fall, 4-18-24, around 8:00 p.m., Resident B being transferred with a mechanical lift by CNA 3. The aide thought she had the 4 straps secured well and as she went to reach for the resident's cell phone that had fallen, something happened and she (Resident B) fell from the lift. She ended up fracturing her knee and was sent out to the hospital. She did not have surgery for the knee fracture. In a second interview with the Corporate ED on 5-3-24 at 11:45 a.m., she indicated the type of mechanical lift used for this resident requires two (2) persons to operate. She shared CNA 3 was hired in January, 2024, had her normal skills checkoff, as well as participated in the building's annual skills checkoff on 1-10-24, which included mechanical lifts and was successful. The Corporate ED indicated the facility obtained a written statement from CNA 3 and she was placed on suspension, pending investigation and was terminated related to not following the facility's policies regarding mechanical lifts require two (2) persons to operate and this resulted or contributed to a fall with a fracture for Resident B.
A signed statement from CNA 3, dated 4-18-24, indicated Resident B had requested to be put to bed and CNA 3 took her from the dining room to her room to do so, via a Broda chair. CNA 3 indicated the mechanical lift sling was already in place under the resident, hooked resident on the sling on yellow on the top and the bottom was on green .raised her up and removed the chair. Legs were spread on the [brandname of mechanical lift]. When turning the [brandname of mechanical lift] to the bed .realized the bed was too high .walked away from [brandname of mechanical lift] to lower the bed .heard phone fall to the floor that was on the resident's chest. As .turned .saw resident doing roll out of the [brandname of mechanical lift] to the floor .immediately yelled to nurse on the floor for assistance. Resident was laying on back on the floor .sat with resident on the floor to provide comfort while nurse was completing assessment.
A review of CNA 3's employment record was conducted. It indicated she began employment on 12-7-23, has possessed a CNA certification since 10-11-18, completed her general orientation to the facility on 1-3-24, participated in an inservice on Safe Transfer on 1-10-24 and completed her job specific orientation, including Transfer using [brandname of mechanical lift] on 1-23-24. A facility document, dated 4-18-24, indicated her suspension began on 4-18-24, related to Staff person was not using proper techniques when using [brandname of mechanical lift]. Resident fell. It indicated this infraction was deemed, gross misconduct and are subject to immediate suspension, pending investigation for termination if the violation is substantiated.
An IDT [interdisciplinary team] note, dated 4-25-24, reviewed the details of Resident B's fall which occurred on 4-18-24. It indicated the root cause of the fall was, Staff attempting to transfer resident with 1 assist [staff member]. It identified the immediate interventions were to transfer the resident to a local emergency room for further evaluation and treatment. It added other interventions initiated included, Clinical education and evaluation of the function and operation of [brand name of mechanical lift] life [sic]. It indicated Resident B's care plans were reviewed and updated.
On 5-3-24 at 11:55 a.m., the Corporate ED provided a binder, entitled, Ad Hoc QAPI binder related to a fall from a mechanical lift of 4-18-24, dated 4-19-24. This binder included the following information:
-An audit was completed for all residents who use a mechanical lift to ensure plans of care were up to date.
-Education was completed with all staff on safe use of mechanical lifts for transfers with ongoing monitoring to be completed for safe transfers with ongoing monitoring of 3 staff members to be observed weekly for 4 weeks, then monthly for 4 months to complete 6 months. Observations to be completed on alternating shifts and alternating staff. Results will be be brought to QAPI for 6 months to identify trends and to make recommendations. If no trends/issues are identified, then the review will be completed on a prn (as needed basis. This process to be monitored by the ED/designee. A mechanical lift validation checklist for staff was conducted, beginning 4-18-24 and 4-19-24, with ongoing audits 4-25-24 and 5-1-24.
- A Care Plan audit of residents who require the use of mechanical lift was conducted with 4 of 22 residents's care plans requiring updating.
-An education inservice/training entitled, Safe Resident/Handling Transfer related to mechanical lifts was conducted with 35 staff members, dated 4-19-24.
-A mechanical lift inspection was conducted on 4-19-24, and all other mechanical lift with no concerns noted by the maintenance department. Monthly routine mechanical lift inspections are conducted on all mechanical lifts. Records reflect no mechanical lift concerns for over four months.
On 5-3-24 at 12:30 p.m., the Corporate Nurse provided a copy of a policy entitled, Safe Resident Handling/Transfers, dated 2023. This policy indicated It is the policy of this facility to ensure that residents are handled in and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .Two staff members must be utilized when transferring residents with a mechanical lift .
This Federal tag relates to Complaint IN00432977.
3.1-45(a)(1)
3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who admitted to the facility with an identified skin concern received timely treatment and services that was later identified with an unstageable pressure ulcer that had worsened and became infected (Resident E) and failed to ensure a resident received treatment for incontinence associated dermatitis (IAD) who was later identified with a stage 3 pressure ulcer (Resident D) for 2 of 3 residents reviewed for skin integrity.
The deficient practice was corrected on 2/1/24, prior to the start of the survey, and was therefore past noncompliance. The facility had completed full skin assessments on all of the residents, conducted in-service education for wound treatment management, documentation of wound treatments, skin assessments, changes in condition, and pressure injury prevention/management, conducted audits for residents with identified wounds, and conducted audits for new admissions for skin integrity and treatment initiation.
Findings include:
1. The clinical record for Resident E was reviewed on 4/16/24 at 3:30 p.m. The diagnoses included, but were not limited to, bipolar disorder, major depressive disorder, malnutrition, muscle weakness, need for assistance with personal care, and rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle injury). Resident E was admitted to the facility on [DATE].
A Braden Scale (a scale that assesses a patient's risk of developing a pressure ulcers), dated 1/4/24, indicated Resident E was at risk for pressure ulcer development.
A care plan for activities of daily living (ADLs), initiated on 1/9/24, indicated Resident E had interventions listed for 2 staff person assist with bathing, bed mobility, dressing, and morning and bedtime routine.
A care plan for skin, initiated on 1/31/24, indicated Resident E admitted to the facility with a pressure ulcer to the coccyx. The interventions included, but were not limited to, weekly assessment of the skin and treatments as ordered.
A care plan for skin, initiated on 1/31/24, indicated Resident E admitted to the facility with a pressure ulcer to the lower, mid-back. The interventions included, but were not limited to, weekly assessment of the skin and treatments as ordered.
A progress note, type: Clinical admission and dated for 1/3/24 at 10:11 p.m., indicated Resident E had an abrasion to his right knee.
A progress note, type: Skin Only Evaluation and dated for 1/4/24 at 7:35 a.m., indicated Resident E had an abrasion to the right knee. There was documentation of Scabs on his right and left cheeks and chin. Skin tear on his lower back with 0.1 in diameter [sic]. There was no further description of the skin alterations for Resident E.
A progress note, dated 1/7/24, indicated Resident E was admitted to the hospital.
A hospital Discharge summary, dated [DATE], indicated the following, .was admitted on [DATE] due to altered mental status and lethargy .Patient does have multiple Pressure ulcers of mid spine, left spine, left sacrum, right sacrum, and right metatarsal, all present upon admission. Patient will benefit from close outpatient follow-up with Wound Care, as well as frequent position change to avoid worsening of pressure ulcers
A progress note, dated 1/10/24 at 7:45 p.m., indicated Resident E was readmitted to the facility from the hospital. A skin assessment was completed and noted resident still has skin tear on his sacrum, lower back and right foot. Dressing placed on his lower back & sacrum
A Weekly Skin Review, dated 1/11/24, indicated skin tears that were Pre-existing were marked. The document indicated skin tears present to the coccyx, sacrum, and right foot. There were no further assessments that included measurements, condition of the wounds, etiology of the wounds, and/or treatment of such wounds.
The electronic medication administration record (EMAR) and electronic treatment administration record (ETAR) of January of 2024 was reviewed and did not indicate any treatments for Resident E's skin upon admission to the facility on 1/3/24 and upon readmission to the facility on 1/10/24.
A wound assessment report, dated 1/16/24, indicated a stage 3 pressure ulcer to Resident E's coccyx that was Present on Admission. The treatment was listed as cleanse the area with wound cleanser, apply Triad paste, and leave open to air twice daily.
A wound assessment report, dated 1/16/24, indicated a stage 3 pressure ulcer to Resident E's lower back that was Present on Admission. The treatment was listed as cleansing the area with wound cleanser, apply hydrogel, cover with bordered gauze, and change daily.
The EMAR and ETAR of January of 2024 was reviewed and didn't note any treatment orders for Resident E's skin on 1/16/24.
A physician order, dated 1/18/24, was noted to Resident E's mid-lower back to cleanse with normal saline and pat dry, apply collagen to wound bed and cover with bordered foam.
A physician order, dated 1/18/24, was noted to Resident E's sacrum to cleanse with normal saline, pat dry, apply collagen to wound bed and cover with border foam.
These orders were not consistent with the wound assessment report treatment plan from 1/16/24.
A physician order, dated 1/22/24, was noted to Resident E's mid-lower back to cleanse with wound cleanser and pat dry. Apply hydrogel to wound bed and covered with bordered gauze. Change daily and as needed. The order was discontinued on 1/28/24.
A physician order, dated 1/22/24, was noted to Resident E's sacrum to cleanse with wound cleanser and pat dry. Apply Triad paste to wound bed and leave open to air. Complete BID (twice daily) and PRN (as needed). The order was discontinued on 1/28/24.
The ETAR for January of 2024 indicated the Triad paste to Resident E's sacrum to be conducted twice daily but was signed off, as administered, on a daily basis from 1/23/24 to 1/28/24.
A wound assessment report, dated 1/24/24, indicated a stage 3 pressure ulcer to Resident E's coccyx that was stable. The treatment was listed to cleanse the area with wound cleanser, apply Dakins moistened fluffed gauze ((Dakin's solution is a dilute solution of sodium hypochlorite (0.4% to 0.5%) and other stabilizing ingredients, traditionally used as an antiseptic, e.g. to cleanse wounds in order to prevent infection)), cover with bordered foam, and change daily.
A wound assessment report, dated 1/24/24, indicated a stage 3 pressure ulcer to Resident E's lower back that was stable. The treatment was listed to cleanse the area with wound cleanser, apply Dakins moistened fluffed gauze, cover with bordered foam, and change daily.
Physician orders, dated 1/28/24, was noted for Dakins soaked fluffed gauze treatment to Resident E's coccyx and mid-lower back daily. The orders were discontinued on 2/13/24.
A wound assessment report, dated 1/31/24, indicated a stage 3 pressure ulcer to Resident E's coccyx. There was blue and green drainage noted. The treatment remained the same with Dakins moistened fluffed gauze daily.
A wound assessment report, dated 1/31/24, indicated a stage 3 pressure ulcer to Resident E's lower back. There was blue and green drainage noted. The treatment remained the same with Dakins moistened fluffed gauze daily.
A care plan for wounds, dated 1/31/24, indicated Resident E had a wound infection to the coccyx and lower back area. The interventions included, but were not limited to, treatments as ordered and obtain and monitor lab/diagnostic work as ordered.
A progress note, dated 2/1/24, indicated Resident E's pressure ulcers were worsening and will order to get wound culture.
A progress note, dated 2/5/24 at 10:05 p.m., indicated a wound culture was obtained of Resident E's sacrum and taken to the lab.
A progress note, dated 2/7/24 at 12:36 a.m., indicated a wound culture was obtained and sent to the lab within the past 2 days. The lab called and stated that both times the specimen was sent in the wrong collection tubes. The facility did not have the correct specimen tubes. Someone needed to go get the tubes from the lab.
A wound assessment report, dated 2/7/24, indicated an unstageable pressure ulcer to Resident E's coccyx that had worsened and was malodorous (smelling very unpleasant).
A wound assessment report, dated 2/7/24, indicated a stage 3 pressure ulcer to Resident E's lower back. The wound was stable and there were no changes to the treatment.
A skin and wound note, dated 2/7/24 at 4:16 a.m., indicated the following, .lower back pressure ulcer stable noblue [sic] green drainage this week. Coccyx pressure ulcer now classified as unstageable, much worse than last week, new odor and measuring much larger in size. Patient absolutely would not let staff assess wounds properly, let alone debride wounds as they need to be debrided, patient was yelling, cursing and hitting staff .Noted WBC [white blood cell] elevated at almost 30k [30,000]. Wound culture was obtained by staff as previously recommended. Recommend to send patient to ER [emergency room] for further evaluation of coccyx wound due to abrupt worsening status
A hospital document, dated 2/7/24, indicated the following, .Physical Exam .Musculoskeletal .Comments: Approximately 4 cm [centimeters] decubitus ulcer present near the left sacrum with malodorous drainage with tenderness. No significant erythema or warmth .ED [Emergency Department] Course .presenting from ECF [extended care facility] .concerns for infection of decubitus ulcer .Fournier's gangrene with in the right perineum extending from a decubitus ulcer and abscess .recommends transfer to a tertiary center for higher level of care
2. The clinical record for Resident D was reviewed on 4/16/24 at 2:45 p.m. The diagnoses included, but were not limited to, congestive heart failure, muscle weakness, chronic pain syndrome, and edema.
A care plan for skin, revised 1/18/24, indicated Resident D was at risk for pressure ulcer development. The interventions included, but were not limited to, conduct weekly skin inspection and treatments as ordered.
A Braden Scale, dated 12/5/23, indicated Resident D was at risk for pressure ulcer development.
A Skin Only Evaluation, dated 12/16/23, indicated a laceration to the left buttock and excoriation to the perineal area.
There were no physician orders for Resident D's skin for 12/16/23.
A skin and wound note, dated 12/20/23, indicated incontinence associated dermatitis (IAD) was present to the left posterior thigh and left buttock. The plan was to cleanse both areas with water, pat dry, apply triad paste to the wound, leave open to air, and change twice daily.
A skin and wound note, dated 12/27/23, indicated IAD was present to the left posterior thigh and left buttock. The treatment plan remained the same with triad paste to both areas, leave open to air, and change twice daily.
There were no orders for triad paste in Resident D's EMAR and/or ETAR for December of 2023.
A skin and wound note, dated 1/3/24, indicated IAD to the left posterior thigh that was improving. The left buttock was previously classified as MASD [moisture-associated skin damage], progression into PU [pressure ulcer] with full thickness and listed as a stage 3. The treatment plan consisted of triad paste to the left posterior thigh and triad paste with hydrogel to the base of the wound located on the left buttock.
There were no treatment orders to Resident D's buttocks and/or posterior thigh on the EMAR or ETAR for January of 2024.
A progress note, dated 1/4/24, indicated Resident D was not feeling well and sent out to the hospital for a low hemoglobin (a protein containing iron that facilitates the transport of oxygen in red blood cells) level. Resident D didn't return to the facility.
An interview conducted with the Director of Nursing (DON), on 4/17/24 at 12:10 p.m., indicated she had been the DON for a couple of months. When she started working at the facility she started reviewing residents' charts. When she reviewed the charts of the residents with identified skin concerns, she noticed the lack of either having wound assessments, orders for treatment to such wounds, and following the physicians' orders. So, an audit was conducted of the residents with wounds currently at that time and the Nurse Practitioner (NP) from the wound consulting company assisted with doing a full skin sweep of the facility. That was completed on 2/1/24. The facility brought the Assistant Director of Nursing (ADON) on board with being the primary person for the wound management program as the line of focus for them.
A policy titled Pressure Injury Prevention and Management, revised 2/1/24, was provided by the DON on 4/17/24 at 8:35 a.m. The policy indicated the following, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .3. Assessment of Pressure Injury Risk .c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .d. Assessments of pressure injuries will be performed by a licensed nurse, and documented on the N Adv Skin Only Evaluation. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [minimum data set] .4. Interventions for Prevention and to Promote Healing .b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .5. Monitoring .d. The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAPI [Quality Assurance and Performance Improvement] Committee Schedule, and as needed when actual or potential problems are identified
This citation relates to Complaints IN00428308 and IN00429661.
3.1-40(a)(1)
3.1-40(a)(2)

Based on interview and record review the facility failed to treat and assess a resident experiencing emesis and failed to transport a resident with a change in condition to the hospital timely for 1 of 3 residents reviewed for quality of care (Resident C).
Finding include:
During an interview with LPN 23 on 10/19/23 at 2:00 p.m., indicated on 10/6/23, she was not assigned to care for Resident C, but she had went to check on him and got RN 22 to evaluate him also. RN 21 was his assigned nurse on 10/6/23 and told her she knew something was off with the resident during morning medication pass and was waiting to see what the physician on call wanted to do.
During an interview with RN 22 on 10/19/23 at 2:30 p.m., indicated on 10/6/23 she was in morning meeting and someone came down and got her to check on Resident C. RN 2 indicated his oxygen saturation was in the 40's, his eyes were fixed and pinpoint. The resident was having problems breathing and oxygen was placed on the resident and his oxygen saturation came up into the 80's. RN 22 sent the resident to the hospital.
During an interview with RN 21 on 10/19/23 at 4:30 p.m , indicated she was caring for Resident C on 10/6/23 day shift. RN 21 indicated it was reported in shift report to her that the resident had episodes of emesis on 10/5/23 and nothing else was reported about the resident. RN 21 first saw Resident C around 7:30 a.m., during medication pass. RN 21 indicated the resident was not his normal self, the resident was gazing off, his mouth was drooping and his arm was flaccid, normally the resident would give me a fist bump when approached but he did not. RN 21 indicated after breakfast the residents CNA's reported to her that he did not seem like his normal self and she checked his blood sugar and it was within normal limits at 135. RN 21 reported the Director Of Nursing (DON) around 9:00 a.m., Resident C's change in condition and the DON told her not to send him to the hospital that he may have been having Transient Ischemic Attack (TIA) (stroke that last a few minutes). RN 21 indicated she felt like the resident should have been sent to the hospital and she continued to monitor him. RN 21 indicated when she came back from break the nurse covering her was sending Resident C to the hospital.
During an interview with CNA 2 ON 10/19/23 AT 4:07 p.m., indicated she was caring for Resident C on 10/5/23 on evening shift. CNA 2 indicated Resident C threw up continuously between 8:00 p.m. until 10:00 p.m. when she got off work. CNA 2 indicated she reported the resident vomiting continuously to RN 18 and the third shift CNA coming on duty.
During an interview with RN 18 on 10/19/23 at 6:02 p.m., indicated he cared for Resident C on 10/5/23 and the resident had two episodes of emesis. RN 18 called the on call physician and received an order for zofran (antiemetic). RN 18 did not conduct lung assessment on Resident C.
During an interview with the DON on 10/20/23 at 2:25 p.m., indicated she was notified of Resident C's change of condition during morning meeting. The DON indicated nothing had been reported to her about Resident C by RN 21. The DON indicated she did not tell the staff not to send Resident C to the hospital. The DON indicated the expectation was the nurse on duty should have completed an assessment on Resident C on 10/5/23 after he had episodes of emesis to include abdominal and lung assessment.
During an interview with the DON on 10/23/23 at 9:45 a.m., indicated she checked the automated drug unit disposition and there was no zofran signed out for Resident C on 10/5/23.
During an interview with the DON on 10/23/23 at 1:22 p.m., indicated Resident C did not receive zofran or cough syrup on 10/5/23 as ordered.
Review of the record of Resident C on 10/20/23 at 2:04 p.m., indicated the resident's diagnoses included, but were not limited to, Cerebral Vascular Accident (CVA), hemiplegia, hemiparesis, diabetes, right hand contracture, aphasia (difficulty with communication) neuromuscular dysfunction, muscle weakness, hypertension and seizures.
The Annual Minimum Data Set (MDS) assessment for Resident C, dated 10/4/23, indicated the resident was severely cognitively impaired for daily decision making. The resident required total calories through tube feedings.
The State Optional MDS assessment for Resident C, dated 10/4/23, indicated cognitively impaired for daily decision making. The resident required extensive assistance of two people for bed mobility, totally dependent of two people to transfer.
The plan of care for Resident C, dated 9/1/16, indicated the resident had impaired communication and inability to speak due to aphasia/CVA. The intervention included, but were not limited to, fist bump for yes.
The progress note for Resident C, dated 10/5/23, indicated the Nurse Practitioner (NP) was notified that the resident had emesis one time of tube feeding, this may have been triggered by a cough. The NP ordered a Covid test, cough syrup as needed and zofran. There was no documentation that Resident C was provided with zofran, cough syrup or that a Covid test was complete.
The progress note for Resident C, dated 10/6/23 at 10:20 a.m., indicated the resident appeared to be less responsive than normal. The resident was not responding to his name and unable to hold his arm up. Looks and wiggles toes with stimuli. Eyes fixated, and left side of mouth drooping. Vitals were blood pressure- 106/61 , temperature- 98.9, pulse 101, oxygen saturation 90% on room air, blood sugar 135. The physician was notified and an order was received to send to the emergency room. The progress note was electronically signed by RN 21.
The progress note for Resident C, dated 10/6/23 at 10:48 a.m., indicated this nurse was called to Resident C's room. The resident was not responding, tongue protruding, cold/clammy, pupils fixed and pinpoint. Oxygen saturation was 64% on room air, pulse 42. Oxygen placed on resident and Emergency Medical Services (EMS) called and transported to the local hospital. The progress note was electronically signed by RN 22.
The progress note for Resident C, dated 10/9/23 at 6:12 a.m., (late entry for 10/6/23), indicated CNA's concerned about the resident. This nurse went to evaluate the resident, the resident was not responding to his name and request made for RN 22 to come assess the resident. The resident was not holding his arm up off the bed, pupils were not reactive, his face was drooping. The resident had bit his lip and left a hole in his lip. The resident was unable to move eyes to look at staff. Oxygen saturation were 67% and oxygen was applied. The resident was sent to the emergency room (ER) by RN 22 and LPN 23. The resident's last known wellness was before shift start at 6:00 a.m. The resident's nurse stated she knew something was off, but wanted to see what the on call NP wanted to do first.
This citation relates to Complaint IN00419162 and Complaint IN00419396.
3.1-37(a)

Based on interview and record record review the facility failed report allegations of abuse to the Indiana Department of Health and the Administrator, failed to protect residents after an allegation of abuse for 3 of 13 residents reviewed for abuse (Resident K, Resident Q and Resident R).
Findings include:
1.) During an interview with the Administrator on 10/19/23 at 12:40 p.m., indicated on 10/14/23, LPN 19 called and reported that Resident K had a fall. LPN 19 did not report that Resident K reported an allegation of abuse, that CNA 2 had pushed her out of the wheelchair. The Administrator indicated she did not know about the allegation of abuse until 10/16/23 when she came into work and there was a concern form under her door about the allegation.
During an interview with CNA 2 on 10/19/23 at 3:15 p.m., indicated on 10/14/23 during the evening time, Resident K was behind the nursing station picking up papers and taking food out of the refrigerator. CNA 2 indicated she asked the resident if she wanted to go to her room and the resident said yes. The resident appeared anxious and talking gibberish making no sense. Resident K grabbed the CNA by her throat as she was pushing her down to her room, then put her feet down and fell onto the floor. Resident K started screaming and yelling saying the CNA pushed her out of the wheelchair. CNA 2 indicated LPN 19 came and a couple other staff and got the resident off the floor. CNA 2 continued to work until 10:00 p.m and then worked 14 hours on 10/15/23.
During an interview with LPN 19 on 10/20/23 at 1:33 p.m., indicated she was the nurse caring for Resident K on 10/14/23 when the resident fell. LPN 19 indicated she did not witness the fall. CNA 2 indicated she was taking the resident to her room in the wheelchair and the resident became combative and fell. Resident K would not let me assess her and kept yelling CNA 2 pushed her out of her wheelchair. LPN 19 indicated she called the Administrator and the Assistant Director Of Nursing (ADON) and reported the fall, LPN 19 indicated she could not remember if she reported the allegation of abuse.
Review of the record of Resident K on 10/20/23 at 2:55 p.m., indicated the resident's diagnoses included, but were not limited to, congestive heart failure, lack of coordination, weakness, hypertension, weakness, diabetes, depression, osteoarthritis, muscle wasting, cardiomegaly, dementia and mood disturbance.
The Quarterly Minimum Data (MDS) assessment for Resident K, dated 7/25/23, was moderately impaired for daily decision making. The resident required extensive assistance of one. The resident required extensive assistance of one person for locomotion on and off the unit.
The progress note for Resident K, dated 10/14/23 at 8:30 p.m., indicated the resident was found on the floor in the sitting position after a fall from her wheelchair. The resident claimed the CNA pushed her out of the wheelchair. The resident refused an assessment.
The grievance form for Resident K, dated 10/16/23, indicated the resident reported CNA 2 pulled her out of her wheelchair and she landed on the floor. The resident indicated CNA 2 lied about what happened and she no one was around she stuck her tongue out at the resident. The resident did not want CNA 2 to care for her any longer.
2.) During an interview with the Administrator on 10/20/23 at 1:20 p.m., indicated she did not report the allegations of abuse by CNA 20 to the Indiana Department Of Health related to Resident Q and Resident R's allegations filed on grievances because CNA 20 was terminated.
Review of the record of Resident Q on 10/23/23 at 11:28 a.m., cerebral infarction, hemiplegia, chronic obstructive pulmonary disease, cardiomegaly, respiratory failure, osteoarthritis, chronic kidney disease, depression, obesity, muscle weakness, epilepsy, muscle weakness, hypertension, insomnia and anxiety.
The Quarterly MDS assessment for Resident Q, dated 8/7/23, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident required extensive assistance of one person for dressing.
The grievance filed by Resident Q, dated 10/4/23, indicated CNA 20 was very rude, mean and hateful to her. The resident requested to have her pajama bottoms on and CNA 20 put a nightgown on her and said she was not going to change the resident into pajamas. While CNA 20 was assisting the resident to bed she pointed and shook her finger at Resident Q and said you better have everything you want because I am not coming back. CNA 20 told Resident Q that another resident was a nasty B---- because she did not like to be cleaned up.
3.) Review of the record of Resident R on 10/23/23 at 12:00 p.m., indicated the resident's diagnoses included, but were not limited to, atrial fibrillation, diabetes, schizophrenia, hypertension, chronic pain syndrome, cerebral infarction, insomnia, muscle weakness and chronic respiratory failure.
The Quarterly MDS for Resident R, dated 9/3/23, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable.
The grievance filed by Resident R, dated 10/3/23, indicated the resident was attempting to move from the wheelchair to the bed and CNA 20 for help. CNA 20 told the resident Get you A-- out of wheelchair and do it yourself.
The employee memorandum for CNA 20, dated 10/5/23, indicated the staff was terminated from employment.
The abuse policy provided by the Administrator on 10/19/23 at 11:00 a.m., indicated abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. An immediate investigation is warranted when suspicion of abuse, the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. The facility would report all alleged violations to the Administrator, state agency, adult protective services and law enforcement (when applicable) immediately, but not later than 2 hours after the allegation was made.
This citation related to Complaint IN00419396.
3.1-28(a)
3.1-28(c)
3.1-28(d)

Based on interview and record review, the facility failed to ensure oxygen therapy was provided according to physician orders and available for use for 1 of 3 residents reviewed for oxygen therapy. (Resident D)
Findings include:
The clinical record for Resident D was reviewed on 10/23/23 at 1:58 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, congestive heart failure, and muscle weakness.
A grievance form, dated 10/5/23, indicated the Payroll Coordinator was made aware of a concern from Resident D. The grievance form stated Resident was sent to dialysis w/o [without] oxygen on. Staff asked resident where oxygen was at, resident stated that she went to dialysis w/o [without] it & another staff member rolled her down to room & located concentrator & placed her on that & it was @ [at] 61% - staff member placed oxygen on resident .GRIEVANCE OFFICIAL FOLLOW-UP .DNS [Director of Nursing Services] reminded staff to check
A respiratory care plan, revised 10/10/23, indicated Resident D had altered respiratory status and at risk for decreased oxygen saturation related to COPD and sleep apnea. The care plan indicated Resident D wore oxygen and was non-compliant at times. The interventions included, but were not limited to, administer oxygen as needed per the physician orders and monitor oxygen saturation on room air and/or oxygen.
A progress note, dated 10/4/23 at 6:55 a.m., noted the documentation of Resident D's pre dialysis evaluation. It was documented that oxygen was in use per nasal cannula.
A dialysis form, dated 10/4/23, indicated Resident D started dialysis at 7:05 a.m. and 2 liters of oxygen was in place. The notes indicated the following, .Lungs dim/wheezes [diminished/wheezes] .SOB [shortness of breath] exertion, 02 [oxygen] 2L [2 liters] NC [nasal cannula]
An interview conducted with Payroll Coordinator on 10/23/23 at 1:49 p.m., indicated Resident D was at the nurses' station and seemed really out of breath. Resident D indicated that they returned from dialysis without oxygen. The oxygen concentrator was on the back of her wheelchair, but it was empty and did not have any oxygen tubing located on the concentrator or on Resident D. The resident stated they didn't have oxygen on all morning and the girls didn't refill the oxygen tank.
An interview conducted with the Director of Nursing (DON), on 10/23/23 at 1:47 p.m., indicated on 10/4/23, Resident D was sent to dialysis without her oxygen. The DON believed when the staff rounded with Resident D on 10/5/23, they voiced the concern then.
A policy titled Oxygen Administration, undated, was provided by the Payroll Coordinator on 10/23/23 at 2:08 p.m. The policy indicated the following, .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences
This citation relates to Complaint IN00419162.
3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure adequate staffing was available to provide showers, to toilet and/or change residents, transfer residents who utilized a mechanical lift, and conduct dining services in the main dining room. This had the potential to affect 38 of 55 residents that reside in the facility on the Extended Care Unit (ECU).
Findings include:
1. Anonymous interview 1 conducted during the survey from 10/19/23 through 10/23/23, indicated on 10/6/23 there were only 2 Certified Nursing Assistants (CNAs) in the entire facility from 6:00 a.m. until 8:30 a.m. They indicated you cannot expect these aides to take care of 60 people by themselves.
Anonymous interview 2 conducted during the survey from 10/19/23 through 10/23/23, indicated there was typically only 1 CNA working on the Transitional Care Unit (TCU) on day and evening shift. It would be helpful to have 2 CNAs. There are times we have found residents inside the nurses' station and there could have been things she [Resident K] got into due to the lack of supervision one was able to provide on the TCU unit.
Anonymous interview 4 conducted during the survey from 10/19/23 through 10/23/23, indicated on 10/6/23 there were only 2 CNAs for the entire facility until other CNAs showed up around 8:30 a.m. There were usually 3 CNAs that work on ECU. On 10/14/23, there were 2 CNAs on ECU until 11:00 a.m. That was when another staff member was sent home for being ill. That left only 2 CNAs for the entire facility until around 4:00 p.m. To only have 1 CNA on ECU was not feasible. The staff were not able to get everybody up and there were a lot of resident complaints that day. The staff attempted to ensure the residents were dry and turned but no showers could be given. It was not uncommon to have only 2 CNAs on ECU until someone else can show up later, around 8:00 to 10:00 a.m.
Anonymous Interview 5 conducted during the survey from 10/19/23 through 10/23/23, indicated they have noticed more of a struggle with the staff. The lack of care was unbelievable. The ability to bathe residents, provide incontinence care, toileting, everything had declined. The staff will just walk past a resident's room that needed incontinence care and comment I just changed you instead of providing such care. It's the neglect of the residents not being properly cared for.
Anonymous interview 6 conducted during the survey from 10/19/23 to 10/23/23, indicated the quality of care had declined. They are running the units with less staff, and they feel like it's neglect.
Anonymous interview 3 conducted during the survey from 10/19/23 through 10/23/23, indicated there were only 2 CNAs on 10/14/23 for day shift on the ECU until one went home around 11:00 a.m. due to being sick. After 11:00 a.m., that just left one CNA on each unit (TCU and ECU). The ECU unit was usually staffed with 3 CNAs and TCU will staff with 1-2 CNAs. The care would get delayed due to only having 1-2 CNAs on ECU. Sometimes it can be difficult because we have a lot of lifts, and they must find another staff member to assist with such task.
2a. An interview conducted with Resident L, on 10/20/23 at 12:31 p.m., indicated she doesn't get showers and would like to have 3 a week but was lucky to get one a week. The staff tried to run the floor with one person. Last weekend, 10/14/23 to 10/15/23, the facility only had one person on ECU. The staff member was able to provide toileting needs but call lights did not get answered timely. This last Saturday, 10/14/23, the call light was on for over 2 hours. There was an observation of Resident L's room to where a clock was present with the correct time. Resident L indicated her preference was to get up at 11:00 a.m., and on 10/14/23, she did not get up until after 3:00 p.m., due to only having one staff member working on the floor. She had not been changed since 5:00 a.m. Resident L commented on how her bed was soaked with urine. She indicated a grievance was filed regarding what happened on 10/14/23.
A Quarterly MDS (Minimum Data Set) assessment, dated 9/16/23, indicated Resident L was cognitively intact and needed extensive assistance with 2 staff for bed mobility, transfers, dressing, and toilet use.
A grievance form, dated 10/14/23, indicated the following, .Family member called 1:32 p.m. [sic] saying [name of CNA] refused to get her up as she was only aide in building .FOLLOW-UP .Texted [name of CNA] .Both expressed that they are 'short'. I told both to do best as family is bringing in food .Called family back at 1:59 apologizing for [name of CNA] saying that but we do have some call-ins & she should be up shortly
Another grievance form, dated 10/16/23, indicated the following, .Staff worked 6AM-2PM shift on Saturday. Resident [name of Resident L] was in need of assistance getting up. CNA could not lift resident by herself because resident is a two-person lift. Other staff was available at 4pm & CNA & other staff was able to get resident up. CNA had a conversation with the ED [Executive Director] about needing assistance on the floor, and was told, FYI [for your information] sent the mass text about an hour ago. Worry about yourself and finish your schedule, via text
Another grievance form, dated 10/16/23, indicated the following, .Resident needed help getting up and states that there was nobody here to help me. Resident states that there was only [Name of CNA] here to take care of the floor, and that there is never enough help here on the weekends, and that I wasn't the only resident that couldn't get up that day
Another grievance form, dated 10/16/23, indicated the following, .wasn't enough help on the floor- spoke w/ [with] ED @ [at] 2pm & was told that's when mother would be getting up. Resident was not up until 4 p.m. & very saturated with urine
2b. An interview conducted with Resident M, on 10/20/23 at 11:18 a.m., indicated he would like to receive showers twice a week but only received them weekly. His bed doesn't seem to be made. An observation of Resident M's bed unmade was noted during the interview. Resident M commented on how last weekend, 10/14/23 to 10/15/23, the dining room was closed for breakfast and lunch on Saturday and breakfast on Sunday due to not having enough staff. He always eats in the dining room and prefers to eat meals in the dining room. He liked to sit with friends during mealtimes and be there to socialize, instead of eating by himself in his room. Resident M commented on how he had begged and pleaded for the facility to get more staff.
A Quarterly MDS assessment, dated 9/8/23, indicated Resident M was cognitively intact and needed physical help with one staff for bathing.
2c. An interview conducted with Resident O, on 10/20/23 at 11:05 a.m., indicated that care can be delayed regarding putting her to bed and changing her. She would sit wet for extended periods of time. She utilizes a mechanical lift. An observation was conducted of Resident O's room to where there was a clock and phone with the correct time on it. She waited over an hour to be changed when she was wet and burns while sitting in urine. The past weekend, 10/14/23 to 10/15/23, was bad regarding the concerns with staffing.
A Quarterly MDS assessment, dated 8/3/23, indicated Resident O was cognitively intact and needed extensive assistance with 2 staff for bed mobility, transfers, and toileting.
2d. An interview conducted with Resident P, on 10/20/23 at 11:52 a.m., indicated nail care and shaving are not consistent with being provided. Observed Resident P to have long nails with a black substance underneath along with a moderate amount of black facial hair above and below her lips. Her hair was not always washed, and it appeared to be greasy and dirty.
A Quarterly MDS assessment, dated 9/23/23, indicated Resident P was cognitively intact and needed extensive assistance with 2 staff for bed mobility, dressing, toileting, personal hygiene along with total assistance with 2 staff for transfers and bathing.
The time sheets were reviewed for the staff working on 10/14/23. It consisted of the following:
CNA 11 working from 6:00 a.m. to 2:18 p.m. on ECU and clocked back in from 3:57 p.m. to 6:32 p.m.,
CNA 10 working from 6:01 a.m. until 11:03 a.m. on ECU,
CNA 12 working from 10:00 a.m. until 2:20 p.m.,
CNA 14 clocking in at 3:02 p.m.,
CNA 15 clocking in at 3:37 p.m.,
CNA 16 clocking in at 3:49 p.m., &
CNA 17 clocking in at 3:49 p.m.
It appeared that there were no CNAs working on ECU from 2:20 p.m. until 3:02 p.m.
An interview conducted with the Scheduling Coordinator, on 10/19/23 at 3:31 p.m., indicated The Director of Nursing (DON) was on call on 10/6/23. The Executive Director (ED) was on call for 10/14/23. They have a Weekend Supervisor that works from 6:00 a.m. to 6:00 p.m., on Saturday and Sundays. On 10/14/23, it appeared to start out with 3 CNAs on ECU, but she was told that there were only 2 and then one of the CNAs had to leave due to being sick. She was made aware of needing staff at 2:19 p.m., on 10/14/23. There was a mass text sent out for assistance with staffing, but she, the Scheduling Coordinator, was not included on that mass text. So, she contacted a couple of staff and was able to get people to agree with coming into work within minutes. She was able to get 3 staff members to come in at 4:00 p.m. on 10/14/23. The staffing goals consist of the following:
-
2 CNAs on TCU and 3 CNAs on ECU for day shift,
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1.5 CNAs on TCU and 3 CNAs on ECU for evening shift, &
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1 CNA on TCU and 2 CNAs on ECU for night shift.
A Census and Condition report, dated 10/23/23, indicated there was a facility census of 55. Out of the 55 residents there are 13 residents' dependent with transferring, 37 residents' dependent with bathing, 6 residents' dependent for toilet use, and 4 residents' dependent with eating.
A Facility Assessment Tool, dated 6/1/23, was provided by the Executive Director (ED) on 10/23/23 at 1:23 p.m. The document indicated the staffing plan, that consisted of nurse aides, was 11 for the total number needed or an average number. The direct care staff was listed as a ratio of 1:10 on day shift, 1:12 ratio on evening shift, and 1:20 ratio on night shift.
A document provided by the Director of Nursing (DON), on 10/23/23, listed 28 residents that usually come down to the main dining room. There were 3 residents listed as needing to be fed and another 3 residents listed as needing assist.
A document provided by the DON, on 10/23/23 at 11:05 a.m., listed 18 residents who utilized a mechanical lift for transfers.
An interview conducted with the ED, on 10/23/23 at 10:32 a.m., indicated there was no facility policy regarding staffing. The expectations are for the facility to staff with the staff needed for the residents' level of care needs.
3.1-17(a)

Based on interview and record review, the facility failed to ensure a staff member did not work while experiencing signs and symptoms of a gastrointestinal illness before and during their shift. This had the potential to affect 38 out of 55 residents that reside in the facility.
Findings include:
An interview conducted with Certified Nursing Assistant (CNA) 10, on 10/19/23 at 4:00 p.m., indicated she had vomited prior to coming to work on 10/14/23. She had thrown up but since she felt better after throwing up, she felt it was okay to come into work. She worked until 11:00 a.m., on 10/14/23, and proceeded to throw up, again. She also had a fever along with the vomiting.
An interview conducted with CNA 11, ono 10/19/23 at 4:07 p.m., indicated she was working with CNA 10 on 10/14/23. CNA 10 was vomiting and had a fever while working and ended up leaving around 10:30 a.m. on 10/14/23.
The timesheet for CNA 10, dated 10/14/23, indicated they worked day shift (6:00 a.m. to 2:00 p.m.) until 11:03 a.m. on 10/14/23 when they clocked out of work.
An interview conducted with the Executive Director (ED), on 10/20/23 at 2:55 p.m., indicated there was no facility policy for staff working while experiencing illness. The facility follows the Indiana Department of Health standards for this.
A Centers for Disease Control and Prevention (CDC) document, titled Norovirus, reviewed 5/10/23, indicated the following, .Prevention .Do not prepare and handle food or care for others when you are sick .You should not prepare food for others or provide healthcare while you are sick and for at least 2 days (48 hours) after symptoms stop. This also applies to sick workers in restaurants, schools, daycares, long-term care facilities, and other places where they may expose people to norovirus
3.1-18(b)(6)

Based on interview and record review the facility failed to maintain a sanitary environment for a resident when a supper tray was stored in the resident's dresser and acquired maggots for 1 of 5 residents reviewed for sanitary conditions (Resident E).
Finding include:
During an interview with Restorative Aide 5 on 10/20/23 at 11:32 a.m., indicated she found a whole meal tray of maggots in Resident E's dresser drawer, the entire plate was covered in maggots. The tray card was dated for 9/22/23 and she found it on 9/26/23. Restorative Aide 5 reported this to everyone in morning meeting including the Administrator and Director Of Nursing (DON).
During an interview with the DON on 10/23/23 at 12:02 p.m., indicated there were maggots found on a meal tray in Resident E's dresser. The facility did an investigation and the staff member who had delivered the tray had already been terminated for other reasons. There was no documentation of the incident.
Review of the record of Resident E on 10/23/23 at 12:09 p.m., indicated the resident's diagnoses included, but were not limited to, cerebral palsy, hemiplegia, neuromuscular dysfunction of the bladder, dysphagia, diabetes, aphasia, speech disturbance and profound intellectual disabilities.
The Significant Change Minimum Data Set (MDS) assessment, dated 9/22/23, indicated the resident was severely impaired for daily decision making. The resident was rarely/never understood. The resident was totally dependent on staff for eating.
The resident rights policy provided by the DON on 10/23/23 at 12:14 p.m., indicated the residents had the right to a home-like environment.
This citation is related to Complaint IN00419396.
3.1-19(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete documentation of the electronic medication administration records (MAR) and treatment administration records (TAR or ETAR) for 2 of 4 residents reviewed for skin impairment. (Residents B and D)
Findings include:
1. The clinical record of Resident B was reviewed on 10-3-23 at 10:42 a.m. Her diagnoses included but were not limited to, type 2 diabetes with a history of skin ulcers, morbid obesity, a history of skin infections, high blood pressure, general weakness and a history of bilateral lower extremity cellulitits. Her most recent Minimum Data Set (MDS) assessment, dated 9-1-23, indicated she is cognitively intact, is non-ambulatory, requires extensive assistance of or more persons for bed mobility and personal hygiene care, is dependent of 2 or more persons for transfers, toileting and bathing. This MDS assessment identified Resident B as being at risk for pressure ulcer development, but currently was without any pressure ulcers or other skin-related issues.
A review of the MAR and TAR for September 2023, reflected the following undocumented medications and/or treatments, as represented by empty cells or holes on the MAR/TAR grids as follows:
-ammonium lactate 12%, apply 1 application every day shift for day skin topically to bilateral feet and legs. Blank cells on 9-6, 9-7, 9-11, 9-16, 9-17, 9-21 and 9-22.
-Aquaphor External (emollient) Ointment, apply to left elbow every shift for dry skin. Blank cells on 9-6, 9-7, 9-11, 9-17, 9-21 and 9-22.
-Nystop Powder 100,000 units per gram, apply to groin area topically every day and evening shift for rush under breasts and left underarm. Blank cells on 9-6, 9-7, 9-11, 9-17, 9-21 and 9-22 for the day shift and blank cells on 9-3, 9-4, 9-11, 9-17, 9-22 9-23 and 9-30 for the evening shift.
-clotrimazole-betamethasone 1-0.05% cream, apply to groin and abdominal folds topically every shift for excoriation. Blank cells on 9-6, 9-7, 9-11, 9-16, 9-17, 9-19, 9-21 and 9-22 for the day shift; blank cells on 9-3, 9-4, 9-11, 9-17, 9-23, 9-24 and 9-30 for the evening shift and blank cells for 9-2, 9-4, 9-8, 9-15, 9-18, 9-19, 9-20, 9-21, 9-22, 9-23, 9-24 and 9-26 for the night shift.
-Monitor for redness to bilateral lower extremities every and shift and report any abnormal findings to the MD/NP (medical doctor or nurse practitioner) every shift for Nurse measure. Blank cells on 9-6, 9-7, 9-11, 9-17, 9-19, 9-21, 9-22 and 9-30 for the day shift; blank cells on 9-3, 9-4, 9-11, 9-17, 9-23, 9-24 and 9-30 for the evening shift and blank cells for 9-2, 9-4, 9-8, 9-15, 9-18, 9-19, 9-20, 9-21, 9-22, 9-23, 9-24 and 9-26 for the night shift.
A review of the medication administration record (MAR) and the TAR for September, 2023 failed to indicate the 9-28-23 skin assessment was conducted. The TAR reflected vital signs were conducted on 9-7-23, 9-14-23, 9-21-23 and 9-28-23, as a part of the weekly skin review, but did not reflect the skin review had been documented. The documented skin reviews in the progress notes were reflected as completed on 9-14-23 and 9-21-23, but not present for 9-7-23 or 9-28-23.
In an interview with the DON on 10-4-23 at 1:07 p.m., she indicated from her review of the progress notes, it appeared Resident B's open area was healed pretty quickly. She shared around the same time, the Wound Nurse was off work for a few days and she may not have seen the 'stop & observe.' She contained, But the area was looked at. I'm thinking they used the butt cream on the area. But, it should have been charted on [as to size, appearance, etc], as well as when it healed. It looks like the nurse on duty didn't chart the weekly skin assessment that was due around 9-27-23; I think she may have put it on the TAR. That nurse is new to us and an experienced nurse, but she does not have strong computer skills. The September, 2023 MAR nor TAR reflected any specific physician orders for the use of butt cream.
2. The clinical record for Resident D was reviewed on 10/3/23 at 12:30 p.m. The diagnoses included, but were not limited to, end stage renal disease, malnutrition, dependence on renal dialysis, cognitive communication deficit, peripheral vascular disease, and fluid overload. Resident D was admitted to the facility on [DATE].
A skin only evaluation, dated 9/13/23, indicated MASD [moisture associated skin dermatitis] to bilateral buttocks.
A care plan, dated 9/13/23, indicated Resident D had MASD to bilateral buttocks. The interventions were listed to apply treatment per physician order, assessment conducted weekly, and weekly wound documentation.
A physician order, dated 9/12/23, indicated the use of Medihoney gel to bilateral buttocks daily for wound care.
The ETAR for September of 2023 was reviewed and indicated hole(s) for the Medihoney wound treatment on 9/23/23, 9/24/23, and 9/26/23.
An interview conducted with Wound Nurse, on 10/3/23 at 3:00 p.m., indicated Resident D was being followed for MASD to bilateral buttocks. She was not aware of any previous skin concerns for Resident D. Weekly wound and skin assessments were supposed to be conducted weekly.
A policy titled Wound Treatment Management, undated, was provided by Corporate Nurse on 10/4/23 at 12:07 p.m. The policy indicated treatments would be documented on the TAR or in the electronic health record.
This Federal tag relates to Complaints IN00409817, IN00415222 and IN00418208.
3.1-50(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a dependent resident received assistance and supervision with toileting to where they were later found on the floor of the bathroom, for an unknown period, for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident D)
Findings include:
The clinical record for Resident D was reviewed on 10/3/23 at 12:30 p.m. The diagnoses included, but were not limited to, end stage renal disease, malnutrition, dependence on renal dialysis, cognitive communication deficit, peripheral vascular disease, and fluid overload. Resident D was admitted to the facility on [DATE].
An admission minimum data set (MDS) assessment, dated 7/28/23, indicated Resident D was cognitively intact and limited assistance with one staff for toilet use, personal hygiene, dressing, and transfers.
An ADL care plan, initiated on 8/2/23, indicated Resident D had an ADL self-care deficit related to impaired mobility. The interventions included, but not limited to, extensive assistance with bathing, bed mobility, dressing, personal hygiene, and toileting along with incontinence care as needed. Resident D was assistance with walking while with therapy.
A 5-day MDS assessment, dated 8/16/23, indicated Resident D had moderate cognitive impairment and extensive assistance with one staff for transfers, toileting, dressing, and personal hygiene.
Resident D had unwitnessed fall events to where she was attempting to ambulate without assistance on 8/15/23, 9/4/23, 9/6/23 at the dialysis center, and 9/15/23.
Resident D was marked as being confused on 9/4/23 and 9/15/23 after the fall incidents.
A significant change MDS assessment, dated 9/13/23, indicated severe cognitive impairment and extensive assistance with 2 staff for transfers and toileting along with extensive assistance with one staff for dressing and personal hygiene.
A fall incident report, dated 9/15/23, indicated the following, CNA [certified nursing assistant] found res. [resident] on the floor of her bathroom, without her 02 [oxygen], not responsive to CNA. SATS [oxygen saturation] in the 50s when nurse arrived and required sternal rub to respond to nurse .EMS [emergency medical services] called. Resident taken to hospital
A post fall evaluation, dated 9/15/23, indicated the following, .unknown if she was already on the toilet, or going to use the bathroom
A statement, undated, was typed up and signed by Therapy Staff 6 in regards to the incident involving Resident D on 9/15/23. The statement indicated On Friday 9/15/23 I don't remember what time it was I was walking by patient room and she was wheeling wc [wheelchair] into bathroom and asked pt [patient] what she was doing she stated I have to go to the bathroom. I told patient I would help her transfer to toilet. I assisted patient with transfer and her brief was soiled so I removed it and put it in the trash .She stated she needed more time. I took trash to soiled utility and threw it away. I then stopped at nurses station where aide was sitting and I stated I put [name of Resident D] on her toilet and gave her call light and told her to pull it when finished but I wanted you to know I put [name of Resident D] on her toilet. The aide shook her head yes and said ok thank you I will get her
An interview conducted with the Executive Director (ED), on 10/4/23 at 9:40 a.m., indicated Therapy Staff 6 brought this situation to her attention with Resident D. Therapy staff had told CNA 8 about Resident D being on the toilet. CNA 8 doesn't recall being told this. We gave CNA 8 a final written warning due to not responding to care requests. The CNA that found Resident D was CNA 10. The ED was unsure of a timeline to when Resident D was placed on the toilet and when Resident D was found by CNA 10.
An interview conducted with CNA 10, on 10/4/23 at 11:30 a.m., indicated she worked 6:00 a.m. to 6:00 p.m. on 9/15/23. She was assigned to Resident D on 9/15/23. She last checked on Resident D around 12:30 p.m. to 12:40 p.m. Resident D's son was in the room at that time. She found Resident D on the floor in her bathroom around 2:00 p.m. because it was during shift change. Resident D was laying on the bathroom floor and breathing very shallow. This was her first time caring for Resident D. When asked when the last time Resident D was toileted CNA 10 indicated Resident D's son was in her room the whole time and she didn't end up toileting Resident D prior to her being placed on the toilet because she believed that Resident D would press her call light if she needed assistance.
A policy titled Activities of Daily Living, undated, was provided by the Director of Nursing on 10/4/23 at 1:45 p.m. The policy indicated the following, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless is unavoidable .Care and services will be provided for the following activities of daily living .3. Toileting .
.
This Federal tag relates to Complaints IN00418127 and IN00418156.
3.1-38(a)(2)(C)
3.1-38(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure skin impairments were assessed on a weekly basis, ensure appropriate treatments were initiated timely for a skin impairment, and ensure continued treatment for a skin impairment for 3 of 4 residents reviewed for skin integrity. (Residents B, D and E)
Findings include:
1. The clinical record of Resident B was reviewed on 10-3-23 at 10:42 a.m. Her diagnoses included but were not limited to, type 2 diabetes with a history of skin ulcers, morbid obesity, a history of skin infections, high blood pressure, general weakness and a history of bilateral lower extremity cellulitits. Her most recent Minimum Data Set (MDS) assessment, dated 9-1-23, indicated she is cognitively intact, is non-ambulatory, requires extensive assistance of or more persons for bed mobility and personal hygiene care, is dependent of 2 or more persons for transfers, toileting and bathing. This MDS assessment identified Resident B as being at risk for pressure ulcer development, but currently was without any pressure ulcers or other skin-related issues.
A review of Resident B's weekly skin reviews,indicated the reviews were conducted as follows:
-8-17-23: skin intact without any issues identified.
-8-24-23: residents skin dry. nurse will continue to moisturize as needed. No issues were identified.
-8-31-23: skin intact without any issues identified.
-9-7-23: No skin assessment conducted/documented.
9-14-23: skin intact without any issues identified.
-9-20-23 at 9:04 a.m.: Alert Note. Note Text: Open area coccyx area. Nurse notified, barrier cream was applied. Stop and watch given to wound nurse. Wound nurse notified.
-9-21-23: skin intact without any issues identified.
9-28-23: No skin assessment conducted/documented. No other skin notes in the progress notes or in the treatment administration record (TAR) addressed an open area to the coccyx through the chart review on 10-3-23.
A review of the progress notes indicated the above documented open area on 9-20-23. A review of the progress notes reflected Resident B had an unwitnessed fall on 9-21-23. Multiple resident assessments were conducted on 9-21-23 by medical providers and nursing staff for the post-fall assessments, including two medical provider notes on 9-21-23 which did not allude to any new skin issues. A routine weekly skin review was due on/around 9-28-23, but a review of the progress notes and treatment administration record (TAR) did not reflect this was performed or documented.
In an interview on 10-3-23 at 1:35 p.m., with CNA 4, she indicated she was familiar with Resident B and worked with her on a regular basis. CNA 4 recalled Resident B recently had an open area to her coccyx, but it is healed now. She added she could not recall the date, but thought it was within the last month. She recalled it was a very small slit, located at or immediately above her coccyx.
In an interview with LPN 3 on 10-4-23 at 11:56 a.m., she shared she had spoken with the Director of Nursing (DON) recently about Resident B's open area documented on 9-20-23. I did give the 'stop and watch' form to the Wound Nurse on the day I charted it. The DON said there was a skin assessment done a few days later and it was cleared up by then.
In an interview with the Wound Nurse on 10-3-23 at 2:52 p.m., she indicated the last open area she could recall for Resident B was approximately 3 months ago of moisture-associated skin damage (MASD). She indicated she did not recall receiving a stop & watch notification for this resident's skin in the last few weeks.
In an interview with the DON on 10-4-23 at 1:07 p.m., she indicated from her review of the progress notes, it appeared Resident B's open area was healed pretty quickly. She shared around the same time, the Wound Nurse was off work for a few days and she may not have seen the 'stop & observe.' She continued, But the area was looked at. I'm thinking they used the butt cream on the area. But, it should have been charted on [as to size, appearance, etc], as well as when it healed. It looks like the nurse on duty didn't chart the weekly skin assessment that was due around 9-27-23; I think she may have put it on the TAR. That nurse is new to us and an experienced nurse, but she does not have strong computer skills.
A review of the medication administration record (MAR) and the TAR for September, 2023 failed to indicate the 9-28-23 skin assessment was conducted. The TAR reflected vital signs were conducted on 9-7-23, 9-14-23, 9-21-23 and 9-28-23, as a part of the weekly skin review, but did not reflect the outcome of the skin review on the grid. The documented skin reviews in the progress notes were reflected as completed on 9-14-23 and 9-21-23, but not present for 9-7-23 or 9-28-23.
A care plan for Resident B for being at risk for skin integrity was documented as initiated on 9-26-22, and revised on 9-8-23. It indicated she is to have weekly skin inspections conducted.
2. The clinical record for Resident E was reviewed on 10/3/23 at 1:15 p.m. The diagnoses included, but were not limited to, lymphedema, anxiety, chronic pain, absence of left leg below knee, absence of right leg below knee, and disruption of wound. Resident E was admitted to the facility on [DATE].
A Skin Only Evaluation, dated 9/19/23, indicated an amputation to the left and right knee. No other skin concerns were documented.
A physician order, dated 9/18/23, indicated the utilization of house barrier cream three times daily to buttocks.
Another Skin Only Evaluation, dated 9/20/23, indicated resident admitted with unstageable pressure ulcer to sacrum/bilateral buttocks. The evaluation indicated daily treatment with slough tissue present.
A physician order, dated 9/24/23, indicated the utilization of Medihoney gel (wound dressing gel); apply to sacrum/bilateral buttocks daily for wound care.
Another Skin Only Evaluation, dated 9/27/23, indicated sacrum/bilateral buttocks pressure wound remains stable.
An interview conducted with Wound Nurse, on 10/3/23 at 2:55 p.m., indicated I might have been late putting the order in. This was in regards to the Medihoney gel to Resident E's pressure ulcer.
3. The clinical record for Resident D was reviewed on 10/3/23 at 12:30 p.m. The diagnoses included, but were not limited to, end stage renal disease, malnutrition, dependence on renal dialysis, cognitive communication deficit, peripheral vascular disease, and fluid overload. Resident D was admitted to the facility on [DATE].
An admission assessment, dated 7/21/23, did not indicate any open areas.
A skin only evaluation, dated 7/23/23, indicated open lesion to coccyx. There was no further assessment or description of the skin impairment.
A skin only evaluation, dated 8/9/23, indicated redness on coccyx. There was no further assessment or description of the skin impairment.
Weekly skin assessments were documented from 8/11/23 to 9/12/23 with no skin concerns listed.
A skin only evaluation, dated 9/13/23, indicated MASD [moisture associated skin dermatitis] to bilateral buttocks.
A care plan, dated 9/13/23, indicated Resident D had MASD to bilateral buttocks. The interventions were listed to apply treatment per physician order, assessment conducted weekly, and weekly wound documentation.
A document from the wound management company, dated 9/13/23, indicated MASD to bilateral buttocks. The treatment was with Medihoney and bordered foam daily. The date the wound was acquired was listed as 8/9/23.
A physician order, dated 9/12/23, indicated the use of Medihoney gel to bilateral buttocks daily for wound care.
There were no previous orders for treatment of Resident D's buttocks from 9/1/23 until 9/12/23.
A skin assessment, dated 9/20/23, indicated moisture associated skin dermatitis (MASD) to bilateral buttocks.
An interview conducted with Wound Nurse, on 10/3/23 at 3:00 p.m., indicated Resident D was being followed for MASD to bilateral buttocks. She was not aware of any previous skin concerns for Resident D. Weekly wound and skin assessments were supposed to be conducted weekly.
A policy titled Wound Treatment Management, undated, was provided by Corporate Nurse on 10/4/23 at 12:07 p.m. The policy indicated the following, .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .8. The effectiveness of treatments will be monitored through ongoing assessment of the wound
This Federal tag relates to Complaints IN00409817, IN00415222 and IN00418208.
3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with dementia, a history of agitation, anxiety, and combativeness, remained free from physical and verbal abuse, which resulted in a staff member holding the wrists of a resident during care that was later identified with bruising to the bilateral hands and wrists. Using the reasonable person concept, it was likely that this would lead to chronic or recurrent fear and anxiety. (Resident B)
The Immediate Jeopardy began on 4/30/23, when Resident B was held by the wrists during care that was later identified with bruising to the wrist and hands. Area [NAME] President and [NAME] President of Clinical Operations were notified of the Immediate Jeopardy on 5/17/23 at 1:38 p.m. The Past Noncompliance Immediate Jeopardy began on 4/30/2023. The Immediate Jeopardy was removed and corrected on 5/10/23, before entrance into the facility, when the facility completed staff education for abuse, ensure resident-specific behavior care plans were followed, ensure interventions did not include manual method, and ensure allegations of abuse were reported to the appropriate person timely. The correction date was prior to the start of the survey and was therefore Past Noncompliance.
Findings include:
The clinical record for Resident B was reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards others occurred 1-3 days, yes to it interfering with resident's care, yes to significantly intruding on the privacy or activity of others, yes to significant disruption of care or living environment, and rejection of care within 1-3 days. Resident B required the need of extensive assistance with 2 staff person for bed mobility, transfers, dressing, toilet use, and personal hygiene.
An interview conducted with Family Member 8 during the survey indicated Resident B requested his [NAME] device to utilize while he was at the facility. He utilized the device at home and since there was no roommate there wasn't the concern for others privacy. During the last week of being at the facility prior to being hospitalized , Resident B had fallen and acting extra anxious while also picking at his arms. Resident B was having behaviors but Family Member 8 wondered why Resident B was yelling and so upset. The facility staff kept mentioning it was dementia, but it seemed like something else was wrong. Family Member 8 had the ability to review the camera footage that was located on the [NAME] device in Resident B's room. Someone was holding Resident B's wrists and when the other girl applied a shirt on Resident B he commented quit holding my arm and he [male caregiver] didn't. Resident B ended up with bruises to his wrists. The male caregiver commented I'm so high I could burn you up for supper and admitted to being high. He was a new CNA and worked night shift. The male CNA also mentioned I'm going to put my 10.5 up your butt. The staff were being rough and in a hurry while caring for him. Resident B became sensitive and had distrust with others during his stay. It appeared to be a trauma response. Family Member 8 noticed Resident B was sleeping a lot more recently. Family Member 8 reported the incident when she observed it on the camera footage a couple days after it occurred on 4/30/23.
A care plan, dated 2/20/23, indicated Resident B had impaired neurological status related to Alzheimer's disease. The interventions listed were to assist in activities of daily living (ADLs), mobility as needed, and monitor ADLs for assistance and render care as needed.
A care plan, dated 2/24/23, indicated Resident B felt down, depressed, or hopeless, along with difficulty falling or staying asleep, and feeling bad about oneself. The interventions listed were to encourage activity involvement, offer food and beverages to ones liking, and take the time to discuss ones feelings when feeling sad.
A care plan, dated 2/24/23, indicated impaired cognition for Resident B. The interventions listed were to help maintain dignity, help with reminders and cues as needed, allow resident to do what he was capable of doing, at his own pace in his own way, and remember that I (Resident B) am an adult and treat him accordingly.
A behavioral care plan, dated 3/6/23, indicated the following, .I [Resident B] sometimes have incidents of being uncooperative with care AEB [as evidenced by]; anxiousness, pinching, grabbing at staff, lifting my feet off ground during transfers, being verbally aggressive with staff (cursing, yelling), swinging at staff/attempting to hit .Interventions .Approach me one caregiver at a time. Multiple people talking in the room may agitate me .Attempt one task at a time with short simple instructions. Don't rush me .Explain to resident in simple terms what you are trying to do and how it will benefit him/her .Offer fluids or snack .Offer toileting/incontinent care when needed .Play some jazz music if I am combative or restless .Please explaining [sic] what you are doing and allow me time to comprehend before attempting .Provide a quiet calm area for me to unwind when agitated. Loud noises can cause me agitation .Provide care in pair when agitated .Provide me with drumsticks and an object to drum on when agitated. Place me away from others I may inadvertently injure [sic]
A trauma care plan, dated 3/6/23, indicated the following, .I have a hx [history] of trauma r/t [related to] Physical/Verbal abuse, physical/emotional neglect, sudden unexpected loss of family member, witness to violence. If experiencing a trigger from history of Trauma, I may display signs and symptoms of Anxiety, fear, irritability, being easily startled, outburst of anger or rage, emotional swings/detachment, self-blame, and shame The interventions listed were to arrange for mental health services as indicated, encourage to express thoughts and feelings in a safe place, identify the items that lessen the effects of trauma and provide comfort, observe for signs and symptoms of depression, anxiety, eating disorders, sleep disturbances, and substance use disorder, and provide a quiet, non threatening environment with decreased stimulation.
A care plan, dated 4/10/23, indicated Resident B refused care at times. An intervention was listed to re-approach resident when he refused care.
A psychiatry progress note, dated 4/11/23, indicated Resident B was anxious, had agitation, general weakness, easily fatigued, and negative for aggression. There was severe impairment for judgement, insight, and disengaged for Resident B's attitude/rapport.
A Quarterly MDS assessment, dated 4/13/23, noted Resident B with severe cognitive impairment, yes to feeling down, depressed or hopeless for 12 to 14 days, and yes to trouble concentrating on things for 12 to 14 days.
A wound assessment report, dated 4/26/23, indicated a cluster of small skin tears from self inflicted scratching noted measuring 9 x 2.5 centimeters.
A progress note, dated 4/30/23 at 1:43 p.m., indicated the following, .CNA brought camera from resident room that was positioned to point at his bed. Camera was hidden near TV. Camera removed from resident room, brought to nurses station and battery removed
An encounter note, dated 5/3/23, indicated the following, .Spoke to daughter in lengthy period overall patient?s [sic] condition .Daughter also would like to talk to Psych/mental health provider
A progress note, dated 5/4/23, indicated the following, .ALZHEIMER'S DISEASE .worsening, verbally and physically combative with staff .if continues patient needs to be send out to inpatient psych .Restlessness and agitation .buspar discontinued, as daughter worries makes her dad lethargic
An incident reported to the Indiana State Department of Health survey report system, reported on 5/5/23, indicated Resident B's daughter presented to the facility to pick up a camera located in Resident B's room on 4/30/23 while staff were providing care. The daughter of Resident B allowed the Executive Director (ED) to view a small clip of two Certified Nursing Assistants (CNAs) providing care to Resident B on 4/30/23. One male CNA (CNA 2) entered the room and stated to Resident B They brought me in here to set you straight, I am going to put my foot up your butt. While female CNA (CNA 4) provided care to Resident B, CNA 2 was observed on video holding Resident B's forearms. CNA 2, before leaving Resident B's room, told Resident B that he would keep him straight if he continued to hit, kick, and spit, that he would stick his 10.5 up his butt. The follow up, dated 5/10/23, indicated skin assessments were conducted on Resident B with no concerns noted. Employee education completed on Abuse and Neglect, and reporting policy. CNA 2 was terminated for violation of abuse and CNA 4 was terminated for violation of reporting abuse.
A typed statement of an interview with CNA 2, dated 5/5/23, indicated the following, .I [CNA 2] held his [Resident B's] hands for [Name of CNA 4] because he is combative. I had my hand around his wrists but didn't use any force or anything. I am bigger than him. He was hitting, kicking, and smacking. I don't remember saying They brought me in here to set you straight, I am going to put my foot up your butt., or I am going to keep you straight if you continue to hit, kick and spit, I will stick my 10.5 up your butt. I wasn't harming him and I know it is illegal for that camera to be in there.
A typed follow-up statement of an interview with CNA 2, dated 5/8/23, indicated the following, .In response to the question regarding holding [Name of Resident B's] wrist, [Name of CNA 2] stated he did that to keep the female caregiver from being hit. [Name of CNA 2] stated he did not use any force and that he would do it again to keep the facility staff safe. [Name of CNA 2] stated he did not recall stating he would put his foot up [Name of Resident B's] butt but acknowledged it was on the video and he shouldn't have said that.
A document titled 3 Step Employee Memorandum, dated 5/5/23, indicated CNA 2 was terminated from employment for Resident abuse or neglect (physical, sexual, verbal or mental).
A typed statement of an interview with CNA 4, dated 5/5/23, indicated the following, .[Name of CNA 4] reported to the building for her shift and was taken to the conference room .ED spoke to [Name of CNA 4] about the events that had taken place on Sunday 4.30.23 [4/30/2023]. She [CNA 4] stated they had found a camera in [Name of Resident B's] room while providing care .explained to [Name of CNA 4] that she was on video providing care with a male caregiver. In the videov is [sic] was observed that the male care giver stated They brought me in here to set you straight, I am going to put my foot up your butt. While she provided care to the resident the male caregiver [CNA 2] was observed in the video holding [Resident B's] forearms. The male caregiver before leaving the room stated to the resident I am going to keep you straight if you continue to hit, kick, and spit, I will stick my 10.5 up your butt. When I asked [Name of CNA 4] why she hadn't reported the event, she stated, I had an ear bud in my ear listening to a podcast and I didn't hear it. When questioned about her reaction to the camera when finding it, she stated oh no, were going to be in trouble, she didn't recall it.
A typed follow-up statement of an interview with CNA 4, dated 5/8/23, indicated the following, .[Name of CNA 4] stated that when she went to ask for help with [Name of Resident B] because he was combative earlier in the morning. She asked [Name of CNA 6], but he was busy assisting another caregiver. [Name of CNA 4] stated she went to ask [Name of CNA 2] for assistance but was hesitant because he makes out of pocket remarks towards female co-workers. [Name of CNA 4] stated she didn't hear [Name of CNA 2] make any statements regarding putting his foot up [Name of Resident B's] butt. Female caregiver stated she thought it was okay that the male caregiver held [Name of Resident B's] arms because he was protecting her [CNA 4] from getting hit. [Name of CNA 4] stated she said oh no, we're going to be in trouble at the end of the video because she was concerned about [Name of CNA 2] holding [Name of Resident B's] arms.
A document titled, 3 Step Employee Memorandum, dated 5/9/23, indicated CNA 4 was terminated from employment for failure to report observed resident abuse or neglect, or a physical injury of a resident.
A skin evaluation, dated 5/4/23 at 4:00 p.m., indicated the following skin issues:
- Skin Issue #1 of bruising to left hand between index finger and middle finger measuring 1 x 1 centimeter,
- Skin Issue #2 of bruising to left first knuckle measuring 1 x 1 centimeter,
- Skin Issue #3 of bruising to left wrist measuring 2 x 2 centimeters,
- Skin Issue #4 of bruising to left hand between thumb and index finger measuring 2 x 1 centimeters,
- Skin Issue #5 of bruising to left arm measuring 6 x 5.5 centimeters,
- Skin Issue #6 of bruising to right wrist measuring 2 x 3.5 centimeters,
- Skin Issue #7 of bruising to right hand measuring 7 x 4.7 centimeters,
- Skin Issue #8 of bruising to right fifth knuckle measuring 0.5 x 1 centimeter, &
- Skin Issue #9 of bruising under the right eye measuring 0.5 x 0.5 centimeters.
A typed statement for CNA 5, dated 5/5/23, indicated the following, .We block his arms [Resident B] while we are providing care and I haven't seen anything alarming while providing his care. When you approach and tell him what you're doing he doesn't strike as much
A typed statement for LPN (Licensed Practical Nurse) 3, dated 5/5/23, indicated the following, .staff would just block him [Resident B] when he became combative .He usually calms down as you talk to him
A typed statement for CNA 6, dated 5/5/23, indicated the following, .I do hold his [Resident B's] wrists, but I do that to protect other staff members while they are providing care .He was concerned about the camera because he was worried, he may be on there holding the resident's wrist .Employee [CNA 6] educated on how to handle resident's that are combative and to be restraint free immediately before returning to the floor
A Social Services note, dated 5/8/23 at 9:54 a.m., indicated psychosocial follow up with Resident B was conducted. No distress noted at that time.
There were no previous Social Services notes in regards to the follow up of the incident reported on 5/5/23.
An interview conducted with CNA 6, on 5/17/23 at 1:05 p.m., indicated on a few occasions he attempted to hold Resident B's wrists during personal care. He was not aware that it was considered a restraint or abuse. The facility had CNA 6 retake a class on abuse and now he knows what to do the next time this were to happen. The CNA class he participated in did not go over behaviors or how to deal with residents with dementia. He has worked at the facility for approximately 3 years and there was a lot of agency staff and they would discuss their history of working at the State hospital in regards to restraining residents. The staff would try to hold Resident B's hands but he continued to focus on the CNA providing care but sometimes we would hold his wrists in attempt to calm him.
An interview conducted with Director of Nursing (DON), on 5/17/23 at 1:30 p.m., indicated she reviewed video footage of CNA 2 grabbing Resident B's wrists during care as well as making comments that were inappropriate and not acceptable at the facility.
An interview conducted with CNA 2, on 5/17/23 at 3:00 p.m., indicated Resident B was physical during care with hitting and kicking at the staff members. He cared for Resident B on 2 occasions. At the beginning of Resident B's care he would attempt to bribe him with ice cream. As soon as the other female CNA (CNA 4) started to care for Resident B, he starting flailing his arms. CNA 2 stated he previously worked at a behavioral unit in the long-term care facility and they conducted procedures like manual methods. The other staff members at the facility are the ones that told CNA 2 they usually handle Resident B with manual methods like holding his hands and wrists. He had only worked at the facility for a couple of weeks and only received 1 day of orientation and then he was working by himself.
A policy titled Abuse, Neglect and Exploitation, revised October 2022, was provided by the Area [NAME] President on 5/16/23 at 9:52 a.m. The policy indicated the following, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Policy Explanation and Compliance Guidelines .1. The facility will develop and implement written policies and procedures that .a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property .b. Establish policies and procedures to investigate such allegations .c. Include training for new and existing staff on activities that constitute abuse .reporting procedures, and dementia management and resident abuse prevention
This Federal deficiency relates to Complaint IN00408060.
3.1-27(a)(1)
3.1-27(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure influenza and pneumococcal immunizations were offered and/or administered for 3 of 5 residents reviewed for immunizations. (Residents H, 29, and 49)
Findings include:
1. The clinical record for Resident H was reviewed on 5/19/23 at 9:10 a.m. Resident H was admitted to the facility in December of 2022. No influenza vaccine was documented since admission. The immunizations documentation indicated Resident H received a previous pneumococcal vaccine in 2012. There were no further pneumococcal vaccinations documented since the previous vaccine was administered prior to Resident H turning [AGE] years of age.
2. The clinical record for Resident 29 was reviewed on 5/19/23 at 9:25 a.m. There was no influenza or pneumococcal vaccine documented in Resident 29's clinical record.
3 The clinical record for Resident 49 was reviewed on 5/19/23 at 9:11 a.m. Resident 49 was admitted to the facility on [DATE] with documentation of a pneumococcal vaccine given on 10/1/2013 but no influenza vaccine documented since admission. There were no further pneumococcal vaccinations documented since the previous vaccine was administered prior to Resident 49 turning [AGE] years of age.
An interview conducted with Area [NAME] President on 5/19/23 at 12:11 p.m., indicated the facility staff were unable to find indication of the influenza vaccine and/or pneumococcal vaccines being administered to Resident's H, 29, and 49.
A policy titled Pneumococcal Vaccine (Series), undated, was provided by the Area [NAME] President (AVP) on 5/22/23 at 9:37 a.m. The policy indicated the following, .1. Each resident will be assessed for pneumococcal immunization upon admission .Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized .5. The type of pneumococcal vaccine .offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations
A policy titled Influenza Vaccination, undated, was provided by the AVP on 5/22/23 at 9:37 a.m. The policy indicated the following, .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza
3.1-13(a)(1)

Based on interview and record review, the facility failed to ensure an infection control program that consisted of mapping and tracking infections for 11 of 12 months reviewed.
Findings include:
The infection control binder was provided by the Area [NAME] President on 5/22/23 at 2:50 p.m. She indicated the facility found the binder in the Clinical Education Coordinator's office. The binder included the following:
June of 2022- blank,
July of 2022- blank,
August of 2022- blank,
September of 2022- blank,
October of 2022 - blank,
November of 2022- blank,
December of 2022- blank,
January of 2023- blank,
February of 2023- Facility mapping with a list of cultures obtained in November and December of 2022,
March of 2023- facility mapping with a list of cultures obtained but none referring to lung as marked on the facility map, &
April of 2023- facility mapping with a list of cultures obtained.
The binder did not reflect the number of infections, where they were acquired, and/or the rate of infection.
A document titled Infection Surveillance Monthly Report, dated May of 2023, was provided by the Area [NAME] President on 5/19/23 at 12:11 p.m. The document noted the total number of infections, if they were community acquired, if they were acquired in the facility, the infection category, and the rate of facility acquired infections.
An interview conducted with the Area [NAME] President, on 5/19/23 at 12:11 p.m., indicated the only infection surveillance log she could locate was for May of 2023. She was unsure if it was being conducted prior to the Assistance Director of Nursing (ADON's) arrival to the facility.
A policy titled Infection Prevention and Control Program, undated, was provided by the Area [NAME] President on 5/22/23 at 9:37 a.m. The policy indicated the following, .1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .3. Surveillance .a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment, and accepted national standards .b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee
3.1-18(b)(1)(A)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a system was in place to review pharmacy reviews and potential recommendations for 4 of 5 residents reviewed for unnecessary medications. (Resident 18, Resident E, Resident 25, and Resident 50)
Findings include:
1. The clinical record for Resident 18 was reviewed on 5/18/23 at 1:10 p.m. The diagnoses included, but were not limited to, muscle weakness, diabetes mellitus, malnutrition, vascular dementia, and visual hallucinations.
A quarterly minimum data set (MDS) assessment, dated 4/13/23, indicated the use of a antipsychotic and antidepressant for the previous 7 day look behind period of the MDS assessment.
A physician order, dated 12/14/22, noted the use of Seroquel (antipsychotic medication) 50 milligrams in the morning and 100 milligrams at bedtime for visual hallucinations.
A pharmacy review, dated 9/29/22, indicated the clarification for the appropriate use for the medication Seroquel. There was no documentation to show that the recommendation was followed up with.
A monthly pharmacy review was documented as conducted on the following date(s):
9/1/22,
9/21/22,
10/23/22,
11/18/22,
12/23/22,
1/17/23,
2/20/23,
3/28/23, &
4/22/23.
2. The clinical record for Resident E was reviewed on 5/22/23 at 10:50 a.m. The diagnoses included, but were not limited to, diabetes mellitus, bipolar disorder, anxiety disorder, and depressive episodes. Resident E was admitted to the facility on [DATE].
A physician order, dated 12/2/22, was noted for aripiprazole 30 milligrams (antipsychotic); give 1 tablet daily for bipolar disorder.
A physician order, dated 4/5/23, was noted for citalopram 20 milligrams (antidepressant); give 1.5 tablets by mouth daily for depressive episodes.
A monthly pharmacy review was documented as conducted on the following date(s):
4/22/23,
3/28/23,
2/20/23,
1/17/23,
12/23/22, &
12/2/22.
There was no documentation in the clinical record about any possible recommendations for the following pharmacy reviews.
3. The clinical record for Resident 50 was reviewed on 5/16/23 at 4:06 p.m. The diagnoses included, but were not limited to, congestive heart failure, diabetes mellitus, schizophrenia, and depression.
A physician order, dated 4/5/23, was noted for escitalopram 5 milligrams (antidepressant) daily for depression.
A physician order, dated 2/3/23, was noted for risperidone 4 milligrams (antipsychotic) daily at bedtime for moods.
A monthly pharmacy review was conducted on the following date(s):
2/7/23,
2/20/23,
3/28/23,
4/22/23,
4/29/23,
5/4/23,
5/13/23, &
5/18/23.
There was no documentation in the clinical record about any possible recommendations for the following pharmacy reviews.
4. The clinical record for Resident 25 was reviewed on 5/16/23 at 3:51 p.m. The diagnoses included, but were not limited to, chronic pain syndrome, diabetes mellitus, anxiety disorder, depression, and encephalopathy.
A physician order, dated 5/22/23, was noted for escitalopram 20 milligrams, half tablet, daily for depression.
A physician order, dated 4/25/23, was noted for aripiprazole 5 milligrams daily for depression.
A monthly pharmacy review was conducted on the following date(s):
1/3/23,
1/14/23,
2/20/23,
3/28/23,
4/3/23,
4/10/23,
4/14/23,
4/22/23, &
5/20/23.
There was no documentation in the clinical record about any possible recommendations for the following pharmacy reviews.
An interview conducted with Area [NAME] President, on 5/19/23 at 10:50 a.m., indicated she could not locate pharmacy reviews or recommendations for Resident 18.
A policy titled Pharmacy Services, undated, was provided by the Area [NAME] President on 5/22/23 at 9:37 a.m. The policy indicated the following, .Compliance Guidelines .4. The licensed pharmacist will collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify, evaluate, and resolve pharmaceutical concerns which affect resident care, medical care, or quality of life such as the .a. Provision of consultative services by a licensed pharmacist as necessary .8. The pharmacist, in collaboration with the facility and medical director, should include within its services to .a. Develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmaceutical services, including procedures to support resident quality of life such as those that support safe, individualized medication administration programs .9. The pharmacist, in collaboration with the facility and medical director, may include other aspects of pharmaceutical services such as .a. Development of procedures and guidance in relation to medication issues and/or adverse effects
3.1-25(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate approach of care and implement interventions for a resident with dementia with a history of agitation, anxiety, and combativeness, for 1 of 2 residents reviewed for dementia care. (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards others occurred 1-3 days, yes to it interfering with resident's care, yes to significantly intruding on the privacy or activity of others, yes to significant disruption of care or living environment, and rejection of care within 1-3 days. Resident B required the need of extensive assistance with 2 staff person for bed mobility, transfers, dressing, toilet use, and personal hygiene.
A care plan, dated 2/20/23, indicated Resident B had impaired neurological status related to Alzheimer's disease. The interventions listed were to assist in activities of daily living (ADLs), mobility as needed, and monitor ADLs for assistance and render care as needed.
A care plan, dated 2/24/23, indicated Resident B felt down, depressed, or hopeless, along with difficulty falling or staying asleep, and feeling bad about oneself. The interventions listed were to encourage activity involvement, offer food and beverages to ones liking, and take the time to discuss ones feelings when feeling sad.
A care plan, dated 2/24/23, indicated impaired cognition for Resident B. The interventions listed were to help maintain dignity, help with reminders and cues as needed, allow resident to do what he was capable of doing, at his own pace in his own way, and remember that I (Resident B) am an adult and treat him accordingly.
A behavioral care plan, dated 3/6/23, indicated the following, .I [Resident B] sometimes have incidents of being uncooperative with care AEB [as evidenced by]; anxiousness, pinching, grabbing at staff, lifting my feet off ground during transfers, being verbally aggressive with staff (cursing, yelling), swinging at staff/attempting to hit .Interventions .Approach me one caregiver at a time. Multiple people talking in the room may agitate me .Attempt one task at a time with short simple instructions. Don't rush me .Explain to resident in simple terms what you are trying to do and how it will benefit him/her .Offer fluids or snack .Offer toileting/incontinent care when needed .Play some jazz music if I am combative or restless .Please explaining [sic] what you are doing and allow me time to comprehend before attempting .Provide a quiet calm area for me to unwind when agitated. Loud noises can cause me agitation .Provide care in pair when agitated .Provide me with drumsticks and an object to drum on when agitated. Place me away from others I may inadvertently injure [sic]
A trauma care plan, dated 3/6/23, indicated the following, .I have a hx [history] of trauma r/t [related to] Physical/Verbal abuse, physical/emotional neglect, sudden unexpected loss of family member, witness to violence. If experiencing a trigger from history of Trauma, I may display signs and symptoms of Anxiety, fear, irritability, being easily startled, outburst of anger or rage, emotional swings/detachment, self-blame, and shame The interventions listed were to arrange for mental health services as indicated, encourage to express thoughts and feelings in a safe place, identify the items that lessen the effects of trauma and provide comfort, observe for signs and symptoms of depression, anxiety, eating disorders, sleep disturbances, and substance use disorder, and provide a quiet, non threatening environment with decreased stimulation.
A care plan, dated 4/10/23, indicated Resident B refused care at times. An intervention was listed to re-approach resident when he refused care.
A behavior note, dated 4/11/23 at 5:51 a.m., indicated Resident B was being verbally and physically aggressive. Resident B was hitting, scratching, kneeing the CNAs [Certified Nursing Assistants], and cursing at them during care. The intervention attempted was the staff asking Resident B not to hit and curse along with talking through care with the CNAs. The interventions were listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A behavior note, dated 4/12/23 at 5:46 a.m., indicated Resident B was yelling and cursing at CNA. Resident B attempted to knee the CNA and hit her. The intervention attempted was attempted redirection and talk Resident B through being changed. The interventions were listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A behavior note, dated 4/13/23 at 5:57 a.m., indicated Resident B was hitting and cursing at CNAs, as well as attempting to bite them while they were trying to change his incontinent product and sheets that were soiled. The interventions attempted were Resident asked very nicely not to do that and to be nice. The intervention was listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A behavior note, dated 4/26/23 at 5:44 a.m., indicated Resident B was hitting, biting, kicking, and cursing at staff during care. Staff attempted to talk to the resident and let him know everything they were doing. Resident B was asked if he was in pain, and if there was anything the facility staff could do to help. The interventions were listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A wound assessment report, dated 4/26/23, indicated a cluster of small skin tears from self inflicted scratching noted measuring 9 x 2.5 centimeters.
A progress note, dated 4/30/23 at 1:43 p.m., indicated the following, .CNA brought camera from resident room that was positioned to point at his bed. Camera was hidden near TV. Camera removed from resident room, brought to nurses station and battery removed
An interview conducted with Family Member 8 during the survey indicated Resident B requested his [NAME] device to utilize while he was at the facility. He utilized the device at home and since there was no roommate there wasn't the concern for others privacy. During the last week of being at the facility prior to being hospitalized , Resident B had fallen and acting extra anxious while also picking at his arms. Resident B was having behaviors but Family Member 8 wondered why Resident B was yelling and so upset. The facility staff kept mentioning it was dementia, but it seemed like something else was wrong. Family Member 8 had the ability to review the camera footage that was located on the [NAME] device in Resident B's room. Someone was holding Resident B's wrists and when the other girl applied a shirt on Resident B he commented quit holding my arm and he [male caregiver] didn't. Resident B ended up with bruises to his wrists. The male caregiver commented I'm so high I could burn you up for supper and admitted to being high. He was a new CNA and worked night shift. The male CNA also mentioned I'm going to put my 10.5 up your butt. The staff were being rough and in a hurry while caring for him. Resident B became sensitive and had distrust with others during his stay. It appeared to be a trauma response. Family Member 8 noticed Resident B was sleeping a lot more recently. Family Member 8 reported the incident when she observed it on the camera footage a couple days after it occurred on 4/30/23.
An encounter note, dated 5/3/23, indicated the following, .Spoke to daughter in lengthy period overall patient?s [sic] condition .Daughter also would like to talk to Psych/mental health provider
A progress note, dated 5/4/23, indicated the following, .ALZHEIMER'S DISEASE .worsening, verbally and physically combative with staff .if continues patient needs to be send out to inpatient psych .Restlessness and agitation .buspar discontinued, as daughter worries makes her dad lethargic
There were no other psychiatry progress notes since the previous one on 4/11/23.
A behavior note, dated 5/4/23 at 12:51 a.m., indicated Resident B was hitting, spitting on staff, cursing and threatening staff. They attempted to redirect resident and that was not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A progress note, dated 5/4/23 at 6:28 a.m., indicated Resident B was swinging and trying to hit and bite staff during obtaining vital signs. No interventions were documented as attempted when behaviors were present.
A behavior note, dated 5/5/23, indicated the following, .Screaming shut up, get in line were in line to get to tomorrow, pointing to resident talking saying he is going to make them shut up, telling them to go out in the yard with him and see what he will do to the resident.Interventions attempted: asked resident if he would like to be moved to a quieter area, where there is less noise. Resident says 'don't you move me im [sic] where I am supposed to be. Asked resident if he would like to get cleaned up ready for bed and have some snacks and warm coffee in bed he agrees, resident states that will be nice .effective, resident resting in bed quietly at this time
A progress note, dated 5/6/23 at 5:14 a.m., indicated while attempting to obtain vital signs Resident B was swinging arms and cursing at staff. No interventions were documented as attempted when behaviors were present.
A progress note, dated 5/7/23 at 4:59 p.m., indicated Resident B was yelling out for daughter. They explained to resident she wasn't there currently. Resident B said okay but as soon at the staff left the room, Resident B began yelling again. No interventions were documented as attempted when Resident B continued to yell out.
A progress note, dated 5/10/23 at 5:32 a.m., indicated Resident B was being combative with care that shift. Resident B was hitting, cursing, and screaming. Resident not easily redirected. No other interventions were documented as attempted when redirection did not appear to be successful.
A progress note, dated 5/11/23 at 9:04 p.m., indicated Resident B was admitted to the hospital with weakness, altered mental status, and acute encephalopathy related to hypotension.
An interview conducted with CNA 6, on 5/17/23 at 1:05 p.m., indicated on a few occasions he attempted to hold Resident B's wrists during personal care. He was not aware that it was considered a restraint or abuse. The facility had CNA 6 retake a class on abuse and now he knows what to do the next time this were to happen. The CNA class he participated in did not go over behaviors or how to deal with residents with dementia. He has worked at the facility for approximately 3 years and there was a lot of agency staff and they would discuss their history of working at the State hospital in regards to restraining residents. The staff would try to hold Resident B's hands but he continued to focus on the CNA providing care but sometimes we would hold his wrists in attempt to calm him.
An interview conducted with Director of Nursing (DON), on 5/17/23 at 1:30 p.m., indicated she reviewed video footage of CNA 2 grabbing Resident B's wrists during care as well as making comments that were inappropriate and not acceptable at the facility.
An interview conducted with CNA 2, on 5/17/23 at 3:00 p.m., indicated Resident B was physical during care with hitting and kicking at the staff members. He cared for Resident B on 2 occasions. At the beginning of Resident B's care he would attempt to bribe him with ice cream. As soon as the other female CNA (CNA 4) started to care for Resident B, he starting flailing his arms. CNA 2 stated he previously worked at a behavioral unit in the long-term care facility and they conducted procedures like manual methods. The other staff members at the facility are the ones that told CNA 2 they usually handle Resident B with manual methods like holding his hands and wrists. He had only worked at the facility for a couple of weeks and only received 1 day of orientation and then he was working by himself.
A policy titled Dementia Care, revised 2/2023, was provided by the Regional [NAME] President on 5/17/23 at 3:20 p.m. The policy indicated the following, .It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being .Policy Explanation and Compliance Guidelines .1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible .3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illnesses .4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary .8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e., physician, mental health provider, licensed counselor, pharmacist, social worker) .9. All staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help resident's attain or maintain the highest practicable physical, mental, and psychosocial well-being
3.1-37(a)

Based on interview and record review, the facility failed to ensure complete documentation of pre and/or post dialysis evaluations for 1 of 1 resident reviewed for dialysis. (Resident 28)
Findings include:
Resident 28's record was reviewed, on 5/17/23 at 3:12 p.m., and indicated Resident 28 had diagnoses that included, but were not limited to, end stage kidney disease, type 2 diabetes mellitus, high blood pressure, and depression.
An admission Minimum Data Set Assessment, dated 7/5/22, indicated Resident 28 was cognitively intact, and received hemodialysis.
Physician's orders for dialysis care included, but were not limited to:
1. Post Dialysis Assessment. Assess site for s/s (signs and symptoms) of bleeding, infection, post dialysis complications. Notify MD of any abnormal changes. Every Mon, Wed, Fri, started 1/23/23
2. Pre dialysis assessment. Assess site for any s/s of bleeding and infection. Notify MD of any abnormal changes. One time a day every Mon, Wed, Fri for dialysis. Dated: 1/23/2023
3. Dialysis Treatment on (M/W/F) at [Name of Dialysis Center] one time a day every Mon, Wed, Fri for Dialysis.
Started 11/21/2022
4. Send Dialysis Communication Binder with Resident to Dialysis on Monday, Wednesday, and Friday
every day shift every Mon, Wed, Fri for monitoring. Started 11/7/2022
Review of dialysis communication forms, in the clinical record, indicated there were no communication forms from the facility to the dialysis center on these dates: 4/3/23, 4/10/23, 4/24/23, 4/26/23, and 5/15/23.
There were no communication forms from the dialysis center to the facility on these dates: 5/1/23, and 5/5/23.
On 5/19/23, at 2:55 p.m., the Area [NAME] President indicated they could not find the dialysis communication forms for the dates requested.
A policy for Hemodialysis was provided by the Area [NAME] President on 5/22/23 at 11:30 a.m. The policy included, but was not limited to: Policy: This facility will provide the necessary car and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis .5. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as dialysis communication form or other form, that will include, but limit itself to .e. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site
3.1-37(a)

Based on interview and record review the facility failed to provide pain management for a resident who had a fall with a fracture and failed to follow up PRN (as needed) pain medicine for a resident who had ineffective pain relief for 2 of 3 resident's reviewed for pain (Resident 36 and Resident E).
Finding include:
1. Review of the resident 36 on 5/18/23 at 4:20 p.m., indicated the resident's diagnoses included, but were not limited to, pulmonary fibrosis, protein calorie malnutrition, schizoaffective disorder, profound intellectual disabilities, dysphagia, osteoporosis and polyneuropathy.
The progress note for Resident 36, dated 4/5/23 at 3:54 p.m., indicated the resident slipped and complained of right knee pain. A new order was obtained for an x-ray.
The progress note for Resident 36, dated 4/5/23 at 6:06 p.m., Resident complained of right knee pain and an x-ray was ordered. The x-ray results indicated a fractured patella (knee).
The Nurse Practitioner (NP) progress note for Resident 36, dated 4/6/23 at 12:00 a.m., indicated the resident was seen today for a fall occurring on 4/5/23. The resident had right knee swelling and pain.
The progress note for Resident 36, dated 4/6/23 at 12:45 p.m., indicated the resident was complaining of pain to the right knee. The resident was rubbing the area of pain and repeatedly stating my knee hurts with facial grimacing noticed. The right knee had swelling and bruising.
During an interview with the Administrator on 5/19/23 at 1:40 p.m., indicated the facility did not treat Resident 36 pain after his fall with fracture on 4/5/23 until 4/9/23.
2. The clinical record for Resident E was reviewed on 5/17/2023 at 2:33 p.m. The medical diagnosis included weakness.
A quarterly minimum data set assessment, dated 4/20/2023, indicated Resident E was cognitively intact.
A physician order for Resident E, dated 2/22/2023, indicated the use of an opioid pain medications every 12 hours as needed for pain.
A pain care plan for Resident E, dated 10/4/2021, indicated to utilize pain monitoring tool to evaluate effective of interventions.
Review of the April and May medication administration record for Resident E indicated the effectiveness of pain medication as unknown on 4/4/2023, 4/23/2023, 4/24/2023, 4/29/2023, 5/3/2023, 5/4/2023, 5/15/2023, and as ineffective on 4/18/2023.
An interview with Resident E on 5/15/2023 at 1:53 p.m. indicated she had 10/10 pain in her knee, hip, and groin area. She had requested as needed pain medication and was waiting for it. She indicated that the pain medication does not really help that much but is better than nothing. She has been having pain on and off for a couple months, but believed it was time for her follow up to get shots in her knee.
An interview with the Area [NAME] President on 5/22/2023 at 1:45 p.m. indicated that the staff had not follow up or notified the physician on the aforementioned unknown/ineffective pain medication follow up.
A policy entitled, PRN Medications, was provided by the Area [NAME] President on 5/15/2023 at 2:30 p.m. the policy indicated, .Evaluate the effectiveness of the medication and document the findings .
A policy entitled, Pain Management, was provided by the Area [NAME] President on 5/18/2023 at 10:10 a.m. The policy indicated, .In order to help a resident attain and maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will .Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated .Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .
3.1-37(a)

Based on observation, interview, and record review, the facility failed to monitor intake totals for a dependent resident who utilized a gastrostomy tube (a tube that is inserted into the stomach through the abdominal wall for nutrition) and failed to follow up when a resident's residual was less than 100 milliliters per MD orders. This affected 2 of 2 residents reviewed for gastrostomy tubes. (Residents 4 and 14)
Findings include:
1. On 5/16/23 at 3:32 p.m., Resident 4 was observed in bed, his eyes were closed and his gastrostomy tube was infusing water at 65 milliliters/hour via a mechanical pump.
Resident 4's record was reviewed on 5/17/23 at 2:04 p.m. The record indicated Resident 4 had diagnoses that included, but were not limited to, stroke with paralysis on one side, difficulty speaking, type 2 diabetes mellitus, seizures, and gastrostomy tube.
A Quarterly Minimum Data Set assessment, dated 3/15/23, indicated Resident 4 was severely cognitively impaired, required extensive assistance of one for all activities of daily living, was totally dependant on staff for eating, and utilized a feeding tube.
A care plan, last updated on 3/20/23, indicated a focus for: Nutrition: I am dependent on tube feeding/at risk for inadequate fluid intake due to: Dx of CVA with aphasia (unable to speak) and dysphagia (difficulty swallowing) .I have an elevated BMI (body mass index) indicating overweight status. Goal: Maintain nutritional status and body weight. Interventions: Head elevated at least 30 degrees every shift. 24 hour total of G-tube feeding intake every night shift .Enteral feed total every shift. Enteral formula and feedings as ordered. Enteral Feed Order two times a day Glucerna continuous with flushes as ordered. flush G-tube with 30ml water before and after medication adm. 15ml between each med every shift .NPO (nothing given by mouth): G-tube for Hydration/Nutrition .TF (tube feeding) as ordered.
Physician's orders for Tube feeding included, but were not limited to:
1. Increased H20 (water) flush to additional 90 ml (milliliters) from 0900-1200 while tube feeding is off to equal 2160 ml in a 24 hour period, four times a day for extra hydration related to gastrostomy status. Started on 5/4/2023
2. Flush with 30ML of water: Before and after any tube feeding Before and after any medications (all medication should not be visible in the tube or extension after flushing) .At least once every 24 hours, every shift for G-tube care. Started 3/15/2023
3. Enteral Feed every shift Glucerna 1.5 Cal or equivalent to Diabetisource via G-tube at 65 ml/hr, with H2O flush 90 ml/hr x 20 hrs/day. Started 2/17/23
4. NPO diet, NPO texture. Started 12/19/2022
A Nutritional Assessment, dated 3/7/23, indicated Resident 4's estimated fluid needs are 1700 - 2000 milliliters per day.
Review of the Medication Administration Records indicated the Enteral feeding and water flushes were checked that they were administered, but there were no totals in milliliters that indicated how much had been given each shift or in a 24 hour period.
During an interview, on 5/22/23 at 10:34 a.m., the Area [NAME] President indicated the nurses have not been clearing the pump, and she does not know how many milliliters he gets every 24 hours.
2. The clinical record for Resident 14 was reviewed on 5/22/2023 at 10:35 a.m. The medical diagnosis included dysphagia.
A Significant Change in Condition Minimum Data Set Assessment, dated for 3/31/2023, indicated that Resident 14 was cognitively impaired, utilized a feeding tube, and had an unexpected significant weight loss.
A nutrition care plan, dated 1/5/2018, indicated that Resident 14 required a g-tube for nutrition.
A physician order for Resident 14 indicated to obtain residual tube feeding measurements every shift and to hold the tube feeding for one hour if the residual was more than 100 ml then re-check. Then if the residual remained greater than 100 ml to call the physician.
Review of the administration record for Resident 12 indicated that his residual tube feeding on 5/12/2023 was 240 ml.
There was no documentation on the medical record to indicate that the tube feeding was held, rechecked, or the physician notified.
An interview with the Area [NAME] President on 5/22/2023 at 1:30 p.m. indicated there was no documentation to infer the tube feeding was held, rechecked, or the physician notified. The nurse caring for the resident would be responsible for conducting orders as written.
A policy entitled, Care and Treatment of Feeding Tubes, was provided by the Area [NAME] President on 5/22/2023 at 11:30 a.m. The policy indicated, .It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .Feedings tubes will be utilized according to physician orders .Direction for staff regarding how to manage and monitor .Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders .The facility will notify and involve the physician or designated practitioner of any complications .
3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure recommendations were initiated timely for residents with identified weight loss, failed to obtain weights as ordered, and failed to implement weekly weights for a resident identified with significant weight loss for 5 of 8 residents reviewed for nutrition. (Resident 18, 45, F, 22, and 8)
Findings include:
1. The clinical record for Resident 18 was reviewed on 5/18/23 at 1:10 p.m. The diagnoses included, but were not limited to, muscle weakness, diabetes mellitus, malnutrition, vascular dementia, and visual hallucinations.
A quarterly minimum data set (MDS) assessment, dated 4/13/23, indicated Resident 18 had weight loss and not on a weight loss regimen.
A care plan for nutrition, revised 4/18/23, indicated Resident 18 was at risk for malnutrition and swallowing difficulty with a history of weight changes. The interventions included, but were not limited to, house shake daily added on 4/18/23, and weekly weights added on 10/7/22.
Another nutrition care plan, revised 4/18/23, indicated Resident 18 had an elevated body mass index and the interventions listed were to provide diet as ordered and obtain weights per physician orders.
The following weights were noted in Resident 18's clinical record:
1/24/23 at 190.2 pounds,
2/1/23 at 191.8 pounds,
3/17/23 at 198.0 pounds,
4/6/23 at 188.4 pounds,
5/1/23 at 185.2 pounds,
5/2/23 at 168.8 pounds and 186.8 pounds,
5/6/23 of 168.2 and 180.4 pounds,
5/7/23 of 182.6 pounds,
5/10/23 of 170.1 pounds,
5/13/23 of 182.1 pounds, &
5/14/23 of 184.4 pounds.
A nutrition at risk (NAR) progress note, dated 4/7/23, indicated a 5.1% weight loss over the past 30 days. A recommendation was noted for a house shake at breakfast to prevent further weight loss.
A NAR progress note, dated 4/14/23, indicated an updated weight was requested due to the most recent weight being dated for 4/6/23. The recommendation was noted for a house shake at breakfast to prevent further weight loss.
A physician order, dated 4/18/23, indicated a house shake in the morning for a supplement. There were no previous orders for a house shake for Resident 18.
2. The clinical record for Resident 45 was reviewed on 5/18/23 at 10:21 a.m. The diagnoses included, but were not limited to, breast cancer, anemia, muscle weakness, schizophrenia, and psychotic disorder with delusions.
A quarterly MDS assessment, dated 3/29/23, indicated no weight loss for Resident 45.
A nutrition care plan, revised 10/1/22, indicated being at risk for chewing difficulty due to being edentulous (without teeth). The interventions listed included, but were not limited to, weights as ordered and diet as ordered.
The following weights were noted for Resident 45:
12/6/22 at 222 pounds,
1/3/23 at 219 pounds,
3/8/23 at 189.4 pounds,
3/14/23 at 219.9 pounds,
4/6/23 at 167.2 pounds,
4/18/23 at 169.8 pounds,
5/6/23 at 183.6 pounds, &
5/16/23 at 184 pounds.
A NAR progress note, dated 3/9/23, indicated to weigh Resident 45 per physician orders.
A NAR progress note, dated 3/23/23, indicated the recommendation for double protein portions at breakfast to provide additional protein for wound healing.
A NAR progress note, dated 3/31/23, indicated the same recommendation for double protein portions at breakfast to provide additional protein for wound healing.
A NAR progress note, dated 4/7/23, indicated the same recommendation for double protein portions at breakfast to provide additional protein for wound healing.
A physician order, revised on 4/14/23, was noted for double protein portions at breakfast for Resident 45's diet.
A NAR progress note, dated 5/3/23, indicated the recommendation for a house shake at lunch to promote adequate oral intake.
A physician order, dated 5/17/23, was noted for a house shake one time a day, at 1:00 p.m., to promote adequate oral intake.
There were no previous physician orders for a house shake for Resident 45.
A physician order, dated 4/17/23, indicated weekly weights for Resident 45.
The electronic treatment administration record for May of 2023, noted the weekly weights were not obtained on 5/2/23 and 5/9/23.
A policy titled Nutritional Management, undated, was provided by the Area [NAME] President on 5/19/23 at 9:15 a.m. The policy indicated the following, .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition .2. Identification/assessment .a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .4. Care plan implementation .a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care .b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to .iii. Weight-related interventions .c. Real food will be offered first before adding supplements
3. The clinical record for Resident F was reviewed on 5/17/2023 at 10:55 a.m. The medical diagnosis stroke and lack of coordination.
A minimum data set assessment, dated 3/10/2023, indicated Resident F was cognitively intact and at risk for pressure areas.
A physician order, dated 4/18/2023, indicated for Resident F to have weekly weights every Tuesday. No weekly weights were obtained 5/2/2023, 5/9/2023, or 5/16/2023.
4. The clinical record for Resident 22 was reviewed on 5/22/2023 at 10:30 a.m. The medical diagnoses included diabetes and asthma.
A Quarterly Minimum Data Set Assessment, dated 4/10/2023, indicated that Resident 22 was cognitively impaired and had weight loss that was not physician prescribed.
A nutrition care plan, dated 1/20/2023, indicated for Resident 22 to have weights obtained as ordered.
A physician order, dated 4/17/2023, for Resident 22 indicated to have weekly weights obtained every Tuesday related to weight loss.
The administration record for Resident 22 indicated weights were not obtained on 5/2/2023 and 5/16/2023 and was left blank on 5/9/2023.
5. The clinical record for Resident 8 was reviewed on 5/22/2023 at 11:08 a.m. the medical diagnoses included depression and cachexia.
A Quarterly Minimum Data Set Assessment, dated 4/25/2023, indicated that Resident 8 was cognitively intact.
An observation and interview with Resident 8 on 5/15/2023 at 1:43 p.m. indicated he was laying in bed at this time. His clothing was noticeably loose. He indicated he is losing weight, but he is unsure why. He stated he was only weighed every now and again and when asked to clarify he said every 6 weeks or so.
A physician order for Resident 8, dated 12/19/2022, indicated to obtain weight every month.
A nutritional care plan, dated 5/6/2021, indicated Resident 8 was at risk for weight loss and to obtain weights as ordered.
Weights for Resident 8 were as follows:
4/3/2023 - 121 pounds
5/1/2023 - 101.8 pounds
5/7/2023 - 118.1 pounds, this was struck out on 5/11/2023.
5/11/2023 - 94 pounds
A nutrition progress note, dated 5/3/2023, questioned the accuracy of the 5/1/2023 weight and recommended a re-weight.
An interview with the Area [NAME] President on 5/22/2023 at 11:30 a.m. indicated that Resident 8's weights were in question due to fluctuations, so his weight loss was not isolated until 5/11/2023. The nurse practitioner was in to see him on 5/17/2023 for his poor appetite and he picked up to be reviewed on Nutritional at Risk Committee on 5/19/2023.
No order for weekly weight was entered or obtained per Resident 8's chart after identified significant weight change on 5/11/2023.
An interview with the Area [NAME] President on 5/22/2023 at 11:30 a.m. indicated that the scale was down when she stated in the building on 3/27/2023 and was repaired by the new maintenance director on 5/5/2023. She was unsure why the weights had not been obtained on 5/9/2023 or 5/16/2023.
A policy entitled, Weight Monitoring, was provided by the Area [NAME] President on 5/22/2023 at 11:30 a.m. The policy indicated, .A weight monitoring schedule will be developed upon admission for all residents .Weights should be recorded at the time obtained .Residents with weight loss - monitor weight weekly .
3.1-46(a)(1)

Based on observation, interview and record review the facility failed to supervise a resident during meals as instructed by the Speech Therapist, failed to implement fall interventions, and failed to ensure adequate supervision and known whereabouts of a resident for 4 of 7 residents reviewed for accidents (Resident 3, Resident 49, Resident 36 and Resident 23).
Findings include:
1. During an observation on 5/18/23 at 12:31 p.m., Resident 3 was laying in bed eating lunch. There was no staff present during this meal observation.
Review of the record of Resident 3 on 5/18/23 at 2:00 p.m., indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease, age related osteoporosis, dysphagia, hypertension, dementia, muscle weakness and age related debility.
The Speech Therapy discharge summary for Resident 3, dated 10/18/22, indicated the discharge instructions were supervision/full feed during all meals, upright positioning in bed, small bites/sips, extended time between with slow rate.
2a. During an interview with Resident 49's family member on 5/15/23 at 2:24 p.m., indicated the resident had several falls at the facility since admission.
During an observation on 5/16/23 at 3:23 p.m., Resident 49 was laying in bed. The resident did not have a low bed or fall mat beside her bed.
During an observation on 5/17/23 at 3:43 p.m., Resident 49 was laying in bed, she indicated she wished someone would come change her because she was wet. When queried where her call light was she indicated she did not know. Resident 49's call light was activated. The Unit Manager came into the room and indicated the resident's call light was on the floor between her bed and the wall. The Unit Manager indicated the first shift CNA's that assisted her to bed should have ensured she had her call light. The resident did not have a low bed or fall mat beside her bed. The resident's remote to her bed was hanging on the grab bar beside the resident's head.
During an observation on 5/18/23 at 10:24 a.m., Resident 49 was laying in bed. The resident did not have a low bed or fall mat beside her bed.
During an observation on 5/18/23 at 12:30 p.m., Resident 49 was laying in bed. The resident did not have a low bed or fall mat beside her bed. The resident's remote to her bed was within reach.
During an observation and interview on 5/18/23 at 1:12 p.m., the Unit Manager indicated the facility had put the fall mat down for Resident 49 approximately 10 minutes ago. The Unit Manager verified Resident 20 did not have a low bed and the resident was holding the remote to her bed.
2b. Review of the record of Resident 49 on 5/17/23 at 1:55 p.m., indicated the resident's diagnoses included, but were not limited to, displaced intertrochanteric fracture of the left femur, difficulty walking, lack of coordination, muscle weakness, repeated falls, intellectual disabilities, age related osteoporosis and depression.
The Minimum Data Set (MDS) for Resident 49, dated 5/3/23, indicated the resident was severely impaired for daily decision making. The resident required extensive assistance of two people to transfer and did not ambulate.
The plan of care for Resident 49, dated 2/9/23, indicated the resident was at risk for falls related to a history of falls. The interventions included, but were not limited to, call light available, do not give the resident the bed remote due to resident raises the bed to the high position, keep bed remote on the floor near the foot of the bed for safety, low bed with mat.
During an interview with the Administrator on 5/18/23 at 1:37 p.m., indicated it was the responsibility of the nurses and CNA's to ensure Resident 49's fall interventions were in place.
3. Review of the resident 36 on 5/18/23 at 4:20 p.m., indicated the resident's diagnoses included, but were not limited to, pulmonary fibrosis, protein calorie malnutrition, schizoaffective disorder, profound intellectual disabilities, dysphagia, osteoporosis and polyneuropathy.
The post fall evaluation for Resident 36, dated 12/21/22 at 4 a.m., indicated the resident had unwitnessed fall states he fall out of bed. The resident had bump present above left temple that was sore to touch.
During an interview with the Administrator on 5/19/23 at 1:50 p.m., indicated the facility did not implement any fall interventions to prevent further falls after Resident 36 fell and hit his head on 12/21/23.
The fall prevention policy provided by the Administrator on 5/18/23 at 2:20 p.m., indicated each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.
4. The clinical record for Resident 23 was reviewed on 5/19/23 at 9:30 a.m. The diagnoses included, but were not limited to, cerebral palsy, autistic disorder, anxiety disorder, depression, and adult failure to thrive.
An admission minimum data set (MDS) assessment, dated 3/21/23, indicated a brief interview for mental status assessment was not conducted due to resident is rarely/never understood, physical behavior symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavior symptoms not directed towards others occurred 1-3 days, behaviors put Resident 23 at risk for physical illness or injury, behaviors significantly interfere with resident's care, and significantly intrude on the privacy of others.
An activities of daily living (ADL) care plan, revised 3/21/23, indicated Resident 23 had an ADL self care deficit related to cerebral palsy, autism, and failure to thrive. The interventions included, but were not limited to, Resident is not to go to TCU [Transitional Care Unit/Rehabilitation Unit] at all. Know residents where abouts at all times. Keep resident on ECU [extended care unit].
An observation conducted of Resident 23, on 5/15/23 at 11:30 a.m., to where she was propelling herself in her wheelchair in the main dining room. She was headed outside of the dining room while headed in the direction of the center hallway. She did not have a shirt on and her breasts were exposed. Another resident, Resident 45, was coming up the hallway from TCU and commented she's naked, referring to Resident 45. There was no staff members in the dining room at the time of observation.
An observation conducted of Resident 23, on 5/16/23 at 11:45 a.m., to where she was propelling herself in her wheelchair coming down the hallway on TCU from the dining room and continued down the TCU hallway towards the front entrance of the building. There was nursing staff present and no one attempted to redirect Resident 23 while she was observed on TCU.
An interview conducted with Nursing Assistant (NA) 15, on 5/18/23 at 10:52 a.m., indicated she was familiar with the care of Resident 23. She would always try to know of Resident 23's whereabouts and ensure she didn't go anywhere besides ECU.
An interview conducted with Certified Nursing Assistant (CNA) 16, on 5/18/23 at 10:58 a.m., indicated she was familiar with Resident 23's care. Resident 23 would go in and out of other resident's rooms when she first was admitted to the facility. Some residents were okay with Resident 23 going into their rooms and others would prefer for Resident 23 not to be in their rooms. CNA 16 indicated how Resident 23 was a busy person and would propel herself in her wheelchair everywhere. The building has a circular floorplan and Resident 23 would go all around the facility, including the TCU unit. If staff were unable to locate Resident 23, they would call over to TCU and the TCU staff would mention how Resident 23 was over there and she was okay. It wasn't an uncommon circumstance for Resident 23 to make her way all around the facility. CNA 16 wasn't aware of any limitations to where Resident 23 wasn't allowed on the TCU unit.
An interview conducted with CNA 17, on 5/18/23 at 2:08 p.m., indicated her main unit that she worked on was TCU. While she was working on TCU it was common to see Resident 23 propel herself in her wheelchair onto the TCU unit. Resident 23 would roam up and down the hallway, but she didn't see Resident 23 attempt to go in any resident rooms on TCU.
A policy titled Behavioral Health Services, undated, was provided by the Area [NAME] President on 5/19/23 at 9:15 a.m. The policy indicated the following, .2. The facility will consider the acuity of the resident population. This includes residents with mental disorders .3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .10. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents .Behavioral health training as determined by the facility assessment will include, but is not limited to, the competencies and skills necessary to provide the following .a. Person-centered care and services that reflect the resident's goals for care .f. Care specific to the individual needs of residents that are diagnosed with a mental, psychosocial, or substance use disorder, or other behavioral health conditions
3.1-45(a)(2)

Based on interview, observation, and record review, the facility failed to ensure Resident 23's foot pedals were in place while she was in her wheelchair for 1 of 2 residents reviewed for assistive devices.
Findings include:
The medical record for Resident 23 was reviewed on 5/15/2023 at 1:20 p.m. The medical diagnoses included autistic disorder and cerebral palsy.
An admission Minimum Data Set Assessment, dated 3/21/2023, indicated that Resident 23 was cognitively impaired, utilized a wheelchair, and needed assistance with transferring.
An activities of daily living care plan, dated 3/21/2023, indicated that Resident 23 utilized footrests to her wheelchair.
An observation on 5/15/2023 at 11:43 a.m. indicated Resident 23 was able to propel herself in her wheelchair with the use of her arms. Her feet hung down and did not contact the floor. She did not have footrests on her wheelchair at this time.
An observation on 5/15/2023 at 12:22 p.m. indicated Resident 23 remained in her wheelchair and did not have her footrests in place.
An observations on 5/15/2023 at 1:15 p.m. indicated Resident 23 remained in her wheelchair and did not have her footrests in place.
An interview with the Restorative Aide 10 on 5/16/2023 at 11:30 a.m. indicated that Resident 23 could not use her legs to propel herself.
A policy entitled, Use of Assistive Devices, was provided by the Area [NAME] President. The policy indicated, .Facility staff will provide appropriate assistance to ensure that the resident can use the assistive device .
3.1-42(a)(2)

2. During an observation on 5/15/23 at 1:20 p.m., Resident 20 was laying in bed with both heels on the bed, the right foot had a bandage on it. There were no pressure relieving boots observed in the resident's room.
During an observation on 5/16/23 at 12:46 p.m., Resident 20 was laying in bed with both heels on the bed, the right foot had a bandage on it. There were no pressure relieving boots observed in the resident's room.
During an observation and interview on 5/17/23 at 3:47 p.m., Resident 20 was laying in bed with both heels on the bed, the right foot had a bandage on it. There were no pressure relieving boots observed in the resident's room. The resident indicated sometimes staff put pressure relieving boots on her and sometimes they would use pillows to keep her heels off of her bed. The resident's call light was activated. QMA 12 came into the resident's room and per request floated Resident 20's heels. Resident 20 indicated that felt much better with her heels not laying on the bed.
Review of the record of Resident 20 on 5/17/23 at 3:00 p.m., indicated the resident's diagnoses included, but were not limited to, diabetes, anxiety, insomnia, major depression, muscle weakness and delusional disorder.
The Significant Change Minimum Data Set (MDS) assessment for Resident 20, dated 4/17/23, indicated the resident was cognitively intact for daily decision making. The resident had no behaviors of rejection of care. The resident required extensive assistance of two people for bed mobility, did not ambulate and was at risk for developing pressure ulcers. The resident had an unstageable pressure ulcer.
The physician recapitulation for Resident 20, dated May 2023, indicated the resident was ordered to float heels every shift to relieve pressure and pressure relieving boots to bilateral feet while in bed as tolerated (4/23/23).
The pressure wound assessment for Resident 20, dated 5/17/23, indicated the resident had a 2.0 centimeter (cm) by 2.0 cm unstageable pressure ulcer on the right heel. The wound was covered with eschar.
During an interview with the Administrator on 5/18/23 at 3:58 p.m., indicated it was the nurses and CNA's to ensure Resident 20's heels were floated and ensure pressure relieving boots were in place.
The pressure injury prevention and management policy provided by the Administrator on 5/19/23 at 9:15 a.m., indicated the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Evidence based interventions for prevention would be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions included, but were not limited to, redistribute pressure such as offloading heels.
3.1-40(a)(2)
Based on interview, observation, and record review, the facility failed to timely follow up on recommendation for the management of Resident F's stage three pressure area and failed to provide pressure relieving boots or float heels for Resident 20's unstageable pressure ulcer to the right heel for 2 of 6 residents reviewed for pressure ulcers.
Findings included:
1. The clinical record for Resident F was reviewed on 5/17/2023 at 10:55 a.m. The medical diagnosis stroke and lack of coordination.
A minimum data set assessment, dated 3/10/2023, indicated Resident F was cognitively intact, at risk for pressure areas, and had a stage three pressure area.
A wound nurse practitioner note, dated 3/23/2023, included the recommendation for imaging, laboratory testing, and a wound culture for Resident F's stage three pressure area to his coccyx. This pressure area measures 1.34 x 0.87 cm (centimeters) x an unmeasurable depth.
A wound nurse practitioner note, dated 3/30/2023, included the recommendation for imaging, laboratory testing, and a wound culture for Resident F's stage three pressure area. This pressure area measured 2.15 x 1.60 cm x an unmeasurable depth.
An interview with the Area [NAME] President on 5/22/2023 at 1:45 p.m. indicated that the recommendations from Resident F's pressure area was not conveyed to the primary care providers until 3/29/2023. She stated that the previous director of nursing was responsible for reviewing the wound care notes and then informing the primary care providers of the recommendation, but these recommendations were identified and relayed on 3/29/2023 when the current acting director of nursing was completing an audit of all wounds.
Physician orders for Resident F's imagining and laboratory test were entered into the medical record on 3/30/2023.

4. On 5/16/23, at 11:06 a.m., Resident J was observed in bed, his right hand was contracted and his splint was lying on the over bed table. There was no rolled towel between his chest and his right arm.
On 5/16/23 at 3:35 p.m., Resident J was observed in bed, watching TV and he had no splints on his hands. He did not have a rolled towel under his right arm.
On 5/17/23 at 12:50 p.m., Resident J was observed in bed, eating lunch. He did not have his splint on. When asked if he has had his splint on today, he shook his head No. He did not have a rolled towel between his right arm and chest.
Resident J's record was reviewed on 5/17/23 at 11:23 a.m. The record indicated Resident J had diagnoses that included, but were not limited to, right dominant side paralysis after a stroke, unable to speak, type 2 diabetes mellitus with diabetic neuropathy, hypertensive heart disease, and a right hand contracture.
A Significant Change Minimum Data Set assessment, dated 4/7/23, indicated he required extensive assist of 2 for personal hygiene, was completely dependent on 2 staff for bathing, he had impairment on one side of upper extremities - shoulder, elbow, wrist and hand - in functional limitations of range of motion, and did not receive restorative nursing including splints.
A care plan, with a revision date of 1/20/23, indicated a focus for: I am at risk for skin impairment r/t (related to muscle weakness, needing assistance with skin care and positioning, increase moisture (incont), episodes of dry skin,
refusing adl care at times .Goal: My skin integrity will remain intact through next review period .Splinting instructions for contracture management: Pt will wear right palm protector and be positioned with rolled towel between pt's chest and right arm up to 24 hrs as tolerated. Remove twice daily for hygiene and ROM as tolerated. Check skin prior to
placement daily at 0800. Date Initiated: 04/03/2023
Physician's orders included:
Splinting instructions for contracture management: Pt (patient) will wear right palm protector and be positioned with rolled towel between pt's chest and right arm up to 24 hrs as tolerated. Remove twice daily for hygiene and ROM (range of motion) as tolerated. Check skin prior to placement daily at 0800 every day and evening shift. Start date: 4/8/2023
Wash inside right hand once daily with soap and water and dry completely between each finger due to contractures. Dry, Clean, rolled wash cloth to be placed in hand to help maintain skin integrity every day shift. Start date: 4/6/2023
Review of behaviors and refusals, that were documented in the Kardex, indicated Resident J had not refused any care in the last 30 days.
During an interview, on 5/19/23, at 10:20 a.m., LPN 21 indicated they wash his right hand with soap and water and place a rolled up wash cloth in his hand. She didn't see if he uses a splint, then checked his physician's orders and said that he did wear a splint, and said he uses a soft splint, it is off twice a day, and placed on at 8 a.m.
During an interview, on 5/19/23, at 10:30 a.m., CNA 22 indicated 3rd shift took off the hand splint on their last round this morning, but he can remove it himself. She puts the splint on after his morning care, and he refused it this morning.
On 5/19/23, at 10:52 a.m., the Area [NAME] President indicated it would be on the point of care Kardex if they refuse care like fingernails trimmed or a palm protector.
On 5/19/23, at 10:58 a.m., the AM the Unit Manager said it should be in the Kardex or resident's chart if he refused his hand splint.
On 5/22/23, at 2:19 p.m., the Area [NAME] President indicated splints are under the physician's orders, for their policy.
A policy for Consulting Physician/Practitioner Orders was provided by the Area [NAME] President on 5/22/23 at 11:30 a.m. The policy included, but was not limited to, The attending physician shall authenticate orders for the care and treatment of assigned residents
3.1-37(a)
Based on interview and record review the facility failed to follow up and ensure a resident had proper preparation prior to a procedure resulting in the procedure not being able to be completed, failed to complete neurological assessments after a resident fell and hit his head, failed to apply a palm protector as ordered by the physician, apply a rolled towel as ordered by the physician, and failed to obtain weekly weights for congestive heart failure (CHF) for 1 of 7 residents reviewed for accidents, 1 of 4 residents reviewed for quality of care, 1 of 2 residents reviewed for positioning/mobility, and 1 of 8 residents reviewed for nutrition. (Resident 20, Resident 36, Resident J and Resident 35)
Findings include:
1. During an interview with Resident 20 on 5/15/23 at 1:16 p.m., indicated she was suppose to have a scope last week and the facility did not follow the appropriate prep work prior to the scope. The resident indicated she went to the hospital to have the procedure done and they sent her back to the facility because she had received medication she was not suppose to of had prior to the procedure.
During an interview with the Director Of Nursing (DON) on 5/17/23 at 1:52 p.m., indicated Resident 20 had reported to her that the nurse gave her medicine she was suppose to have on hold and that she had to reschedule her procedure. The DON indicated she had not had a chance to look into the situation.
Review of the record of Resident 20 on 5/17/23 at 3:00 p.m., indicated the resident's diagnoses included, but were not limited to, diabetes, anxiety, insomnia, major depression, muscle weakness and delusional disorder.
The Significant Change Minimum Data Set (MDS) assessment for Resident 20, dated 4/17/23, indicated the resident was cognitively intact for daily decision making.
The local hospital after visit summary for Resident 20, dated 4/13/23, indicated the resident was to have a gastrointestinal procedure on 5/11/23.
The progress note for Resident 20, dated 5/9/23 at 10:02 a.m., indicated the local hospital called to give pre-procedure instructions. The resident was to have an endoscopy on 5/11/23 and to arrive at the hospital at 8:30 a.m. The surgeon wanted the resident to have no solid food after 12 noon on 5/10/23, the resident could have clear liquid until midnight the night before. The physician also did not want the resident to take any over the counter medications, vitamins or diabetic medications the day of the procedure.
The Medication Administration Record (MAR) for Resident 20, dated May 2023, indicated the resident received potassium, multivitamin, clonazepam (antianxiety medication), eliquis (blood thinner), buspar (antianxiety) and protonix at 8:00 a.m., on 5/11/23.
The food consumption for Resident 20, dated 5/10/23, indicated resident ate 76-100 % of lunch and supper.
During an interview with the Unit Manager on 5/19/23 at 11:00 a.m., indicated Resident 20 was not able to get her procedure on 5/11/23 because she was suppose to have her eliquis (blood thinner) held for two days. The facility was unable to find the pre op orders for the procedure. Nursing would be responsible to follow up with the hospital to ensure the orders were in place for what was to be held or not done. The order should have been clarified. Dietary should have been notified and an order put in for the clear liquid diet.
2. Review of the resident 36 on 5/18/23 at 4:20 p.m., indicated the resident's diagnoses included, but were not limited to, pulmonary fibrosis, protein calorie malnutrition, schizoaffective disorder, profound intellectual disabilities, dysphagia, osteoporosis and polyneuropathy.
The post fall evaluation for Resident 36, dated 12/21/22 at 4 a.m., indicated the resident had unwitnessed fall states he fell out of bed. The resident had bump present above left temple that was sore to touch.
During an interview with the Administrator on 5/19/23 at 1:50 p.m., indicated Resident 36 did not have any neurological assessments after his fall on 12/21/22 when he hit his head.
The facility neurological assessment protocol provided by the Administrator on 5/19/23 at 2:00 p.m., indicated neurological checks would be preformed every 15 minutes four times, then every thirty minutes four and times, then hourly four times, then every eight hours for 72 hours.
The incidents and accidents policy provided by the Administrator on 5/19/23 at 2:10 p.m., indicated in the event of an unwitnessed fall or a blow to the head, the nurse would initiate neurological checks per protocol and document on the neurological flow sheet. Abnormal findings would be reported to the practitioner.
3. The clinical record for Resident 35 was reviewed on 5/16/2023 at 3:45 p.m. The medical diagnosis included congestive heart failure.
A Quarterly Minimum Data Set Assessment, dated 3/2/2023, indicated Resident 35 was cognitively intact.
A cardiovascular care plan, dated 8/28/2021, indicated to monitor Resident 35's weights.
A physician order, dated 4/14/2023, indicated to obtain Resident 35's weight weekly on Tuesday.
The administration record for Resident 35 indicated that her weight was not obtained on 5/2/2023, 5/9/2023, and 5/16/2023.
An interview with the Area [NAME] President on 5/22/2023 at 11:30 a.m. indicated that the scale was down when she started in the building on 3/27/2023 and was repaired by the new maintenance director on 5/5/2023. She was unsure why the weights had not been obtained on 5/9/2023 or 5/16/2023.

Based on observation, interview and record review the facility failed to provide an ongoing activity program for 2 of 2 residents reviewed for activities (Resident 11 and Resident 3).
Findings include:
1.) During an observation on 5/15/23 at 11:41 a.m., Resident 11 was laying in bed awake, with no TV or radio playing.
During an observation on 5/16/23 at 3:28 p.m., Resident 11 was sitting in the common area, not engaging in any type of activity.
During an observation on 5/17/23 at 3:41 p.m., Resident 11 was laying in bed awake, there was no TV or radio playing.
During an observation on 5/18/23 at 10:22 a.m., Resident 11 was sitting in the common area, not engaging in any type of activity.
Review of the record of Resident 11 on 5/18/23 at 3:35 p.m., indicated the resident's diagnoses included, but were not limited to, cerebral palsy, spastic hemiplegia, diabetes, aphasia, profound intellectual disabilities, hypertension and pain.
The Annual Minimum Data Set assessment (MDS) for Resident 11, dated 2/19/23, indicated it was very important for the resident to listen to music, be around animals, keep up with the news, do things with groups of people, participate in his favorite activity, go outside for fresh air and participate in religious services.
During an interview with the Administrator on 5/18/23 at 12:45 p.m., indicated Resident 11 had no documented activities for the past three months.
2.) During an interview with Resident 3's family member on 5/15/23 at 11:48 a.m., indicated Resident 3's TV had not been on for three weeks. The family member indicated she had reported to multiple staff that the TV was not working. The family member indicated the resident was elderly and the only thing she really enjoyed doing for activities was watch TV. Observation the resident's TV was turned on with no signal available.
During an observation on 5/16/23 at 3:25 p.m., Resident 3 was laying in bed awake, the TV was not on.
During an observation and interview on 5/17/23 at 12:46 p.m., Resident 3 was laying in bed awake with no TV on, interview with the Administrator indicated she was unaware of the resident's TV not working and would report it to Maintenance.
During an interview with the Maintenance Director on 5/17/23 at 12:50 p.m., indicated Resident 3's TV was not broke, but had not been on the correct input and that is why is had not worked.
During an interview with the Administrator on 5/18/23 at 12:50 p.m., indicated there were no documented activities for Resident 3 for the past three months.
During an interview with the Administrator on 5/18/23 at 1:35 p.m., indicated activity staff were responsible to ensure residents TV or music was playing in their rooms.
Review of the record of Resident 3 on 5/17/23 at 1:55 p.m., indicated the resident's diagnoses included, but were not limited to, displaced intertrochanteric fracture of the left femur, difficulty walking, lack of coordination, muscle weakness, repeated falls, intellectual disabilities, age related osteoporosis and depression.
The plan of care for Resident 3, dated 2/7/23, indicated the resident preferred independent activities or spending time with my family rather than doing things in groups. The resident liked looking out the window in her room, listening to music and having the TV on.
The Activity policy provided by the Administrator on 5/18/23 at 2:20 p.m., indicated the facility would provide an ongoing program to support residents in their choice of activities. The activities would be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being.
3.1-33(a)

4. During an interview, on 5/15/23 at 2:29 p.m., Resident H indicated his fingernails need trimmed. His fingernails were observed to long and had a brown substance under the nails.
On 5/16/23 at 3:30 p.m., Resident H was in bed watching TV, his fingernails were long with a brown substance under the nail.
Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection.
A Significant Change Minimum Data Set assessment, dated 4/27/23, indicated Resident H was cognitively intact, required extensive to total assist of two for activities of daily living, including bathing and personal hygiene.
A care plan, dated 1/5/23, indicated: DIAGNOSIS: Resident has personal history of Stroke/TIA with dominant right sided hemiplegia. Goal: Will maintain current level of function through next review. Revised on 1/2023 Interventions: Assist in ADL's and mobility as needed .Monitor ADL's for assistance and render care as needed. (1/05/2023)
He has a care plan that he prefers bed baths to showers.
There was no documentation in the Kardex or point of care that resident had refused care.
On 5/19/23, at 10:52 a.m. the Area [NAME] President indicated it should be on point of care/Kardex if they refuse care like having their fingernails trimmed.
5. On 5/16/23 at 11:07 a.m., Resident J's fingernails on both hands were observed to be long and had a light brown substance under most of the nails. Resident J shook his head no when asked if the nails are the length he liked, and shook his head yes when asked if he liked them shorter.
On 5/16/23 at 3:35 p.m., Resident J was observed in bed, watching TV, his fingernails were long with a brown substance under the nails.
Resident J's record was reviewed on 5/17/23 at 11:23 a.m. and indicated diagnoses that included, but were not limited to, weakness on one side, following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, difficulty speaking and swallowing, right hand contracture, and heart disease.
On 5/17/23 at 12:50 p.m., Resident J was in bed, eating lunch, His fingernails were observed to have a soiled brown substance under them.
A Significant Change Minimum Data Set assessment, dated 4/7/23, indicated Resident J required extensive assistance of 2 for personal hygiene and was totally dependent on staff for bathing.
A care plan for activities of daily living, last revised on 1/14/2022, indicated a problem for a physical functioning deficit related to muscle weakness due to right sided weakness from a stroke, type 2 diabetes with neuropathy, peripheral vascular disease, left below the knee amputation, and neurogenic bladder. Interventions included, but were not limited to: DIABETIC: Nurse to do nail care PRN.
On 5/19/23 at 10:13 a.m. resident shook his head Yes, when asked if he likes his fingernails shorter. His nails were observed to be long with a brown substance under the nails.
On 5/19/23 at 10:30 a.m., CNA 10 indicated he refuses nail care when she tries to trim them.
On 5/19/23 at 10:52 a.m. the Area [NAME] President indicated it should be on point of care Kardex if a resident refuse care, for example, his fingernails trimmed.
Review of behaviors documented in the Kardex indicated he had not refused any care in the last 30 days.
Res refused showers on 5/18/23, 5/17/23, 5/16/23, 5/11/23, and several other days, a bed bath was given, he prefers bed baths.
A Policy for Activities of Daily Living (ADLs), was provided by the Area [NAME] President on 5/19/23 at 9:15 a.m. The policy included, but was not limited to, The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition,, grooming, and personal and oral hygiene .:
This Federal deficiency relates to Complaint IN00407646 and IN00406095.
3.1-38(a)(2)(A)
3.1-38(a)(3)(A)
3.1-38(a)(3)(E)
Based on interview, observation, and record review, the facility failed to ensure Resident D, F, and G had their facial hair shaved per their preference and failed to provide nail care for dependent residents (Resident J and H) for 5 of 9 residents reviewed for activities of daily living (ADL) care.
Findings include:
1. The clinical record for Resident D was reviewed on 5/17/2023 at 1:34 p.m. The medical diagnoses included a history of a stroke affecting the left non-dominant side and weakness.
A quarterly minimum data set assessment, dated 3/8/2023, indicated that Resident D was cognitively intact and needed extensive assistance from staff with personal hygiene activities of daily living.
An observation and interview on 5/16/2023 at 10:43 a.m. with Resident D indicated she was sitting in her wheelchair in the common area with white facial hair on her chin. She indicated she did not like to have facial hair and the staff would shave her, but only on shower days if she asked.
An observation of Resident D on 5/17/2023 at 1:30 p.m. indicated she was still in her wheelchair at this time and still had white facial hair on her chin.
2. The clinical record for Resident F was reviewed on 5/17/2023 at 10:55 a.m. The medical diagnosis stroke and lack of coordination. A minimum data set assessment, dated 3/10/2023, indicated Resident F was cognitively intact and needed assistance with his personal hygiene activity of daily living.
An interview and observation of Resident F on 5/16/2023 at 11:06 a.m. indicated he had long facial hair. He indicated he did not like to have a beard but preferred to be clean shaven. He indicated the staff do not assist him regularly with shaving and it had been sometime since someone last shaved him.
An observation of Resident F on 5/16/2023 at 3:04 p.m. indicated he continued to have long facial hair at this time.
3. The clinical record for Resident G was reviewed on 5/17/2023 at 11:45 a.m. The medical diagnoses included chronic pain and muscle weakness.
A quarterly minimum data set assessment, dated 2/20/2023, indicated that Resident G was cognitively intact and needed assistance with her personal hygiene activity of daily living.
An observation and interview on 5/15/2023 at 1:32 p.m. indicated that Resident G was in her room at this time. She had long white hair to her chin and upper lip. She indicated that staff would usually assist her with shaving on her shower days but had not today. She stated the facial hair does bother her and when she was at home, she would shave the areas daily in the morning.
An observation on 5/16/2023 at 2:20 p.m. indicated Resident G in her room at this time with continued white facial hair.

Based on interview, observation, and record review, the facility failed to ensure Resident D's corrective lenses were in place for 1 of 2 residents reviewed for corrective lenses.
Findings included:
The clinical record for Resident D was reviewed on 5/17/2023 at 1:34 p.m. The medical diagnoses included a history of a stroke affecting the left non-dominant side and weakness.
A quarterly minimum data set assessment, dated 3/8/2023, indicated that Resident D was cognitively intact and needed extensive assistance from staff for dressing and transferring activities of daily living.
A vision care plan, dated 6/23/2021, indicated for Resident D to receive assistance with placement and cleaning of her glasses as needed.
An observation and interview on 5/16/2023 at 10:43 a.m. with Resident D indicated she was sitting in her wheelchair in the common area and did not have her eyeglasses in place. She indicated the staff had forgotten them in her room that morning and she was unable to propel herself back to get them.
An observation of Resident D on 5/16/2023 at 12:03 p.m. indicated she was still in her wheelchair at this time and still did not have her glasses placed.
A policy entitled, Hearing and Vision Services, was provided by the Area [NAME] President on 5/22/2023 at 11:30 a.m. The policy indicated, .Employees will assist the resident with the use of any device or adaptive equipment needed to maintain vision and hearing .
3.1-38(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the discharge summary was completed in full for 1 of 3 closed records reviewed. (Resident 54)
Findings include:
The clinical record for Resident 54 was reviewed on 5/22/23 at 11:22 a.m. The diagnoses included, but were not limited to, neoplasm of prostate, muscle weakness, hypertension, anxiety disorder, and secondary malignant neoplasm of bone.
A Discharge summary, dated [DATE], was not completed in regard to summary of stay, functional mobility, continence, nutrition, activities, skin condition(s), medication information, treatments, community resource guide for any follow-up in regards to Resident 54's care.
An interview conducted with Area [NAME] President, on 5/22/23 at 1:46 p.m., indicated Resident 54's discharge was prior to them arriving at the facility. She was not sure why the discharge summary wasn't completed in full.
3.1-36(a)(1)
3.1-36(a)(2)
3.1-36(b)

Based on interview and record review, the facility failed to develop a care plan for Resident E's use of medication to treat her hypothyroidism and failed to develop a care plan for constipation for a resident with a diagnosis of constipation for 2 of 5 residents reviewed for unnecessary medications. (Resident E and Resident H)
Findings include:
1. During an interview, on 5/15/23 at 2:55 p.m., Resident H indicated he has always had problems with constipation and said he has gone 10 days sometimes without a bowel movement.
Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection.
A Significant Change Minimum Data Set assessment, dated 4/27/23, indicated Resident H was cognitively intact, did not walk, is always incontinent of bowels, had no constipation, and is on a scheduled pain medication regimen.
Resident H had a physician's order for Morphine, which has a high risk for constipation, 1.250 mg via bolus up to 6 times daily with a dose restriction of 1 bolus every 4 hours. Start date: 4/27/23.
On 5/22/23, at 1:52 p.m., the Area [NAME] President provided a copy of a care plan for Potential for drug related complications associated with use of psychotropic medications and indicated that is the only care plan they have that addresses constipation. The care plan did not address goals or interventions for constipation.
2. The clinical record for Resident E was reviewed on 5/17/2023 at 2:33 p.m. The medical diagnosis included hypothyroidism.
A quarterly minimum data set assessment, dated 4/20/2023, indicated Resident E was cognitively intact.
A physician order for Resident E, dated 12/15/2022, indicated the use of medication for hypothyroidism to be given daily.
No care plan was located for the use of this medication or management of Resident E's hypothyroidism.
An interview with the Area [NAME] President on 5/22/2023 at 11:45 a.m. indicated that there was no care plan for Resident E's medication or management of her hypothyroidism.
A policy entitled, Comprehensive Care Plans, was provided by the Area [NAME] President on 5/22/2023 at 11:30 a.m. The policy indicated, .The comprehensive care plan will describe, at a minimum, the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .
3.1-35(a)

Based on observation, interview and record review the facility failed to provide a speciality cup as ordered by the physician, failed to provide a straw to drink with, failed to keep fluids within reach, and failed to provide a whirlpool bath as preferred for 1 of 2 residents reviewed for hydration and 1 of 5 residents reviewed for shower preferences. (Resident 3 and Resident E).
Finding include:
1. During an interview with Resident 3's family member on 5/15/23 at 11:57 a.m., indicated when the family visits the resident does not always have fresh water and the resident would not have a straw to drink out of (no speciality cup observed). The family member indicated the resident could not drink without a straw. Resident 49 was observed to have a styrofoam cup with water and a lid, with no straw to drink from.
During an observation on 5/16/23 at 3:25 p.m., Resident 3 was laying in bed with a styrofoam cup with a lid on it and no straw (no speciality cup observed).
During an observation on 5/18/23 at 10:24 a.m., Resident 3 was laying in bed, the resident's water was out of her reach on her bedside table (no speciality cup observed). The resident's call light was activated, QMA 11 came in the room. QMA 11 placed the resident's bedside table where the resident could reach her water.
During an observation on 5/18/23 at 12:31 p.m., Resident 3 was laying in bed eating lunch. The resident had a styrofoam cup with a lid and no straw (no speciality cup observed).
Review of the record of Resident 3 on 5/18/23 at 2:00 p.m., indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease, age related osteoporosis, dysphagia, hypertension, dementia, muscle weakness and age related debility.
The Quarterly Minimum Data Set (MDS) for Resident 3, dated 5/3/23, indicated the resident was severely impaired for daily decision making. The resident required limited assistance of one person for drinking.
The plan of care for Resident 3, dated 2/7/23, indicated the resident had the potential for alteration in hydration related to episodes of edema, needing assistance with fluids and poor fluid intake.
The physician order for Resident 3, dated 4/14/23, indicated the resident was ordered an adaptive cup with cover/lids.
During an interview with the Regional [NAME] President on 5/18/23 at 1:35 p.m., indicated dietary was responsible to provide Resident 3's speciality cup. The Dietary Manager reported there were new staff in the kitchen and Resident 3's speciality cup got missed.
2. The clinical record for Resident E was reviewed on 5/17/2023 at 2:33 p.m. The medical diagnoses included local infection of the skin tissue and weakness.
A quarterly minimum data set assessment, dated 4/20/2023, indicated Resident E was cognitively intact and was totally dependent on staff for assistance with bathing.
A profile task for Resident E, dated 12/7/2022, indicated for Resident E to have whirlpool baths Tuesday evening and Saturday morning. No whirlpool baths were given in the last 30 days upon review.
An interview with Resident E on 5/15/2023 at 1:56 p.m. indicated that Resident E preferred to have whirlpool baths due having skin conditions. She felt like this helped with her skin, but she had not had a whirlpool bath in the last 6 weeks per her recall.
A policy entitled, Accommodation of Needs, was provided by the Area [NAME] President on 5/22/2023 at 4:25 p.m. The policy indicated, .Facility staff shall make efforts to reasonably accommodate the needs and preferences of the residents .
3.1-3(v)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection.
A Significant Change Minimum Data Set (MDS) assessment, dated 4/27/23, indicated Resident H was cognitively intact, is on a scheduled pain med regimen, received as needed pain medications, did not receive non-medication interventions for pain, and a pain assessment interview should be conducted but there were no answers in the pain assessment interview.
Care plan: Last revised 1/20/23:
Focus: PAIN: Needs Pain management and monitoring related to: Chronic pain syndrome, pressure ulcer, spondylosis. Resident does have pain pump. Goals: Patient will achieve acceptable pain level goal through the next review. Interventions: Administer Pain medication as ordered. Evaluate need to provide medications prior to treatment or therapy.
Observe for potential medication side effects. Utilize pain monitoring tool to evaluate effectiveness of interventions. warm compress to affected area.
Physician's orders for pain management:
Resident can receive Morphine 1.250 milligrams via bolus up to 6 times daily with a dose restriction of 1 bolus every 4 hours. Start date 4/28/2023
Acetaminophen Oral Tablet 325 MG (Acetaminophen)
Give 2 tablets by mouth every 4 hours as needed for pain or discomfort, maximum dose of acetaminophen is 3,000 mg from all sources in 24 hours AND Give 2 tablet by mouth every 4 hours as needed for Temp Greater than 100.4 Dated 4/24/2023
Biofreeze External Gel 4 %, Apply to bilateral legs topically every 6 hours as needed for pain and discomfort. Start date 4/19/2023
Lidocaine External Patch 4 %, Apply to back topically two times a day for pain and discomfort Don't use patch more than 8 hours and remove per schedule. 4/20/2023
During an interview, on 5/22/23, at 10:35 a.m., the Area [NAME] President indicated the nurses didn't complete the pain assessment for Resident H on the MDS for 4/27/23.
On 5/22/23, at 11:30 a.m., the Area [NAME] President indicated they go by the Resident Assessment Instrument Manual for their policy on completing the MDS.
Based on interview and record review, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessment regarding to mood and behavior for 1 of 2 residents reviewed for dementia care (Resident B), the use of corrective lenses for 1 of 2 residents reviewed for vision (Resident 26), and complete the pain assessment portion for 1 of 3 residents reviewed for pain (Resident H).
Findings include:
1. The clinical record for Resident B was reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards others occurred 1-3 days, yes to it interfering with resident's care, yes to significantly intruding on the privacy or activity of others, yes to significant disruption of care or living environment, and rejection of care within 1-3 days. Resident B required the need of extensive assistance with 2 staff persons for bed mobility, transfers, dressing, toilet use, and personal hygiene.
A quarterly MDS assessment, dated 4/13/23, indicated Resident B did not exhibit any physical, verbal, or other behaviors during the lookback period of the MDS assessment.
A behavior note, dated 4/11/23 at 5:51 a.m., indicated Resident B was being verbally and physically aggressive. Resident B was hitting, scratching, kneeing the CNAs, and cursing at them during care. The intervention attempted was the staff asking Resident B not to hit and curse along with talking through care with the CNAs. The interventions were listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A behavior note, dated 4/12/23 at 5:46 a.m., indicated Resident B was yelling and cursing at CNA. Resident B attempted to knee the CNA and hit her. The intervention attempted was attempted redirection and talk Resident B through being changed. The interventions were listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A behavior note, dated 4/13/23 at 5:57 a.m., indicated Resident B was hitting and cursing at CNAs, as well as attempting to bite them while they were trying to change his incontinent product and sheets that were soiled. The interventions attempted were Resident asked very nicely not to do that and to be nice. The intervention was listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
A behavior note, dated 4/26/23 at 5:44 a.m., indicated Resident B was hitting, biting, kicking, and cursing at staff during care. Staff attempted to talk to the resident and let him know everything they were doing. Resident B was asked if he was in pain, and if there was anything the facility staff could do to help. The interventions were listed as not effective. No other interventions were documented as attempted when redirection did not appear to be successful.
2. The clinical record for Resident 26 was reviewed on 5/17/23 at 4:00 p.m. The diagnoses included, but were not limited to, anxiety disorder, muscle weakness, depressive episodes, and anemia.
A care plan for vision, initiated on 6/13/2020, indicated Resident 26 was at risk for vision impairment and wears glasses on occasion.
A progress note, dated 12/9/22 at 12:31 p.m., indicated Optometry came to the facility and delivered glasses to Resident 26. They were adjusted to fit.
A quarterly MDS assessment, dated 4/26/23, indicated Resident 26 was cognitively intact, her vision was adequate, and marked no for corrective lenses.
An interview conducted with Resident 26, on 5/16/23 at 3:29 p.m., indicated she was able to see through her glasses without any issue.
An interview conducted with MDS Coordinator, on 5/22/23 at 12:04 p.m., indicated the MDS assessments for Resident 26 and Resident B were marked incorrectly in regards to vision and behavior. She did corrections for both residents. The expectations are to follow the Resident Assessment Instrument (RAI) manual.

Based on interview and record review, the facility failed to provide written bed hold information when a resident was sent to the hospital. This affected 2 of 5 residents reviewed for hospitalization. (Residents H and 50)
Findings include:
1. Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection.
Progress notes indicated Resident H was sent to the local hospital on the following dates:
- 5/17/2023 at 1:40 p.m.:
Resident has been complaining of increased pain. New area on right side of lower butt cheek. Resident has had a bolus of morphine. Is still complaining of pain. Called wound center, wound center has advised that best interest of patient is to send to ER to evaluate.'
- 4/14/23 at 8:30 a.m.:
Resident has c/o (complained of) abdominal pain and scrotum pain, urine leakage noted around catheter in brief, clear frothy emesis noted in basin .resident requested to be sent to ER, verbal order received to transport to ER, wife notified and informed, 911 called for transport, report called to (local hospital ER), DON and admin notified.
- 4/4/2023 at 8:25 p.m.:
writer and another nurse walked by residents' room and noticed resident was not wearing his 02 @ the time, 2L of 02 via N.C. (nasal cannula) was applied and residents 02 was taken and was 87% at this time. NP (Nurse Practitioner) was called to the bedside and ordered for resident to be sent to ER to be evaluated and treated, and 02 to be increased to 4L. Residents' vitals obtained at this time and are as follows; BP- 120/82, P-80 regular, 02-92% on 4L of 02 via N.C., RR- 20, Temp.- 98.6, resident has a cough and is expiring mucous at this time. Resident is A&O (alert and oriented) x1 @ this time and roommate stated that resident had choked on fluids while trying to drink. Resident's wife was contacted and stated that she will go out to the hospital to be with him, 911 called for transportation, (local) Emergency Department called to give report to nurse, (local) Fire Department arrived at 8:39AM to transport resident to hospital.
- 3/25/2023 at 8:49 p.m.:
Res[ident] adm[itted] to (local) Hosp. Dx. (diagnoses) UTI, (urinary tract infection) Encephalopathy (brain disease) and Hyponatremia (low blood sodium).
Notification of bed hold information. in writing to the resident's representative, could not be located in the resident's clinical record.
On 5/19/23 at 10:50 a.m., the Area [NAME] President indicated Resident H did not have the bed hold information in his clinical record for the dates he was sent to the hospital.
2. Resident 50's record was reviewed on 5/16/23 at 4:06 p.m. and indicated Resident 50 had diagnoses that included, but were not limited to, congestive heart failure, type 2 diabetes mellitus, schizophrenia, difficulty swallowing, difficulty walking, heart disease, chronic pain syndrome and chronic respiratory failure with low blood oxygen.
Progress notes indicated Resident 50 was sent to the hospital on the following days:
- 5/10/2023 at 4:47 a.m.: Resident states he fell in his bathroom and helped himself up off the floor then told the nurse he fell, vitals immediately after the fall was 117/54 94 64 97.6 18 and 15 mins later vitals were 119/45 97 66 97.7 18, on call placed to [Nurse Practitioner] to state the events in which she stated she would be rounding on him this morning but resident then fell to the ground again in the common area complaining of pain to chest, abdomen and head at 10/10, call placed to 911 and [Nurse Practitioner] to send to ER for further Evaluation. DON and family aware.
- A progress note, dated 5/13/2023 at 11:25 p.m., indicated: Emergency services were in the facility to transport resident to the hospital to be evaluated and treated for chest pain, coughing, and wheezing. He was assisted to the cart and report was called to the emergency room.
Resident 50 was also sent to the hospital on 5/10/23, 5/2/23 and 4/27/23.
Notification in writing of the bed hold information could not be located in his clinical record.
On 5/19/23 at 10:50 a.m., the Area [NAME] President indicated Resident 50 did not have documentation of the bed hold information when he was sent to the hospital.
A policy for Bed Hold Prior to Transfer was provided by the Area [NAME] President on 5/22/23 at 11:30 a.m. The policy included, but was not limited to, It is the policy of this facility to provide written information to the resident and /or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave .The facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed -hold and reserve bed payment policy well in advance of being transferred to the hospital or when taking therapeutic leave of absence from the facility .The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences
3.1-12(a)(25)[A]
3.1-12(a)[25)(B)

Based on interview and record review, the facility failed to ensure the appropriate transfer and discharge paperwork provided to a resident upon transfer to an area hospital was included in the resident's clinical record for 2 of 5 residents reviewed for hospitalization. (Resident H and 50)
Findings include:
1. Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection.
Progress notes indicated Resident H was sent to the local hospital on the following dates:
- 5/17/2023 at 1:40 p.m.:
Resident has been complaining of increased pain. New area on right side of lower butt cheek. Resident has had a bolus of morphine. Is still complaining of pain. Called wound center, wound center has advised that best interest of patient is to send to ER to evaluate.'
- 4/14/23 at 8:30 a.m.:
Resident has c/o (complained of) abdominal pain and scrotum pain, urine leakage noted around catheter in brief, clear frothy emesis noted in basin .resident requested to be sent to ER, verbal order received to transport to ER, wife notified and informed, 911 called for transport, report called to (local hospital ER), DON and admin notified.
- 4/4/2023 at 8:25 p.m.:
writer and another nurse walked by residents' room and noticed resident was not wearing his 02 @ the time, 2L of 02 via N.C. (nasal cannula) was applied and residents 02 was taken and was 87% at this time. NP (Nurse Practitioner) was called to the bedside and ordered for resident to be sent to ER to be evaluated and treated, and 02 to be increased to 4L. Residents' vitals obtained at this time and are as follows; BP- 120/82, P-80 regular, 02-92% on 4L of 02 via N.C., RR- 20, Temp.- 98.6, resident has a cough and is expiring mucous at this time. Resident is A&O (alert and oriented) x1 @ this time and roommate stated that resident had choked on fluids while trying to drink. Resident's wife was contacted and stated that she will go out to the hospital to be with him, 911 called for transportation, (local) Emergency Department called to give report to nurse, (local) Fire Department arrived at 8:39 AM to transport resident to hospital.
- 3/25/2023 at 8:49 p.m.:
Res[ident] adm[itted] to (local) Hosp. Dx. (diagnoses) UTI, (urinary tract infection) Encephalopathy (brain disease) and Hyponatremia (low blood sodium).
Notification in writing to the resident's representative could not be located in the resident's clinical record.
On 5/19/23 at 10:50 a.m., the Area [NAME] President indicated Resident H did not have a transfer and discharge notification in his record for the times he was sent to the hospital.
2. Resident 50's record was reviewed on 5/16/23 at 4:06 p.m. and indicated Resident 50 had diagnoses that included, but were not limited to, congestive heart failure, type 2 diabetes mellitus, schizophrenia, difficulty swallowing, difficulty walking, heart disease, chronic pain syndrome and chronic respiratory failure with low blood oxygen.
Progress notes indicated Resident 50 was sent to the hospital on the following days:
- 5/10/2023 at 4:47 a.m.: Resident states he fell in his bathroom and helped himself up off the floor then told the nurse he fell, vitals immediately after the fall was 117/54 94 64 97.6 18 and 15 mins later vitals were 119/45 97 66 97.7 18, on call placed to [Nurse Pratitioner] to state the events in which she stated she would be rounding on him this morning but resident then fell to the ground again in the common area complaining of pain to chest, abdomen and head at 10/10, call placed to 911 and [Nurse Pratitioner] to send to ER for further Evaluation. DON and family aware.
- A progress note, dated 5/13/2023 at 11:25 p.m., indicated: Emergency services were in the facility to transport resident to the hospital to be evaluated and treated for chest pain, coughing, and wheezing. He was assisted to the cart and report was called to the emergency room.
Resident 50 was also sent to the hospital on 4/27/23, 5/2/23, and 5/13/23.
Notification in writing, of the reason for transfer to the hospital that was provided to the resident's representative could not be located in his clinical record.
On 5/19/23 at 10:50 a.m., the Area [NAME] President indicated Resident 50 did not have a notification in his record for the reason he was sent to the hospital each time.
A policy for Bed Hold Prior to Transfer was provided, by the Area [NAME] President, on 5/22/23 at 11:30 a.m. The policy included, but was not limited to, It is the policy of this facility to provide written information to the resident and /or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave.
3.1-12(a)(6)(A)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physical and verbal abuse event was reported to the Administrator and state agency timely for 1 of 4 residents reviewed for abuse. (Resident B)
Findings include:
The clinical record for Resident B [NAME] reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE].
An admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards others occurred 1-3 days, yes to it interfering with resident's care, yes to significantly intruding on the privacy or activity of others, yes to significant disruption of care or living environment, and rejection of care within 1-3 days. Resident B required the need of extensive assistance with 2 staff person for bed mobility, transfers, dressing, toilet use, and personal hygiene.
A progress note, dated 4/30/23 at 1:43 p.m., indicated the following, .CNA brought camera from resident room that was positioned to point at his bed. Camera was hidden near TV. Camera removed from resident room, brought to nurses station and battery removed
An interview conducted with Family Member 8 during the survey indicated Resident B requested his [NAME] device to utilize while he was at the facility. He utilized the device at home and since there was no roommate there wasn't the concern for others privacy. During the last week of being at the facility prior to being hospitalized , Resident B had fallen and acting extra anxious while also picking at his arms. Resident B was having behaviors but Family Member 8 wondered why Resident B was yelling and so upset. The facility staff kept mentioning it was dementia, but it seemed like something else was wrong. Family Member 8 had the ability to review the camera footage that was located on the [NAME] device in Resident B's room. Someone was holding Resident B's wrists and when the other girl applied a shirt on Resident B he commented quit holding my arm and he [male caregiver] didn't. Resident B ended up with bruises to his wrists. The male caregiver commented I'm so high I could burn you up for supper and admitted to being high. He was a new CNA and worked night shift. The male CNA also mentioned I'm going to put my 10.5 up your butt. The staff were being rough and in a hurry while caring for him. Resident B became sensitive and had distrust with others during his stay. It appeared to be a trauma response. Family Member 8 noticed Resident B was sleeping a lot more recently. Family Member 8 reported the incident when she observed it on the camera footage a couple days after it occurred on 4/30/23.
An incident reported to the Indiana State Department of Health survey report system, reported on 5/5/23, indicated Resident B's daughter presented to the facility to pick up a camera located in Resident B's room on 4/30/23 while staff were providing care. The daughter of Resident B allowed the Executive Director (ED) to view a small clip of two Certified Nursing Assistants (CNAs) providing care to Resident B on 4/30/23. One male CNA (CNA 2) entered the room and stated to Resident B They brought me in here to set you straight, I am going to put my foot up your butt. While female CNA (CNA 4) provided care to Resident B, CNA 2 was observed on video holding Resident B's forearms. CNA 2, before leaving Resident B's room, told Resident B that he would keep him straight if he continued to hit, kick, and spit, that he would stick his 10.5 up his butt. The follow up, dated 5/10/23, indicated skin assessments were conducted on Resident B with no concerns noted. Employee education completed on Abuse and Neglect, and reporting policy. CNA 2 was terminated for violation of abuse and CNA 4 was terminated for violation of reporting abuse.
An interview conducted with Director of Nursing (DON), on 5/17/23 at 1:30 p.m., indicated she reviewed video footage of CNA 2 grabbing Resident B's wrists during care and she reported such immediately to the Area [NAME] President.
A policy titled Abuse, Neglect and Exploitation, revised October of 2022, was provided by the Area [NAME] President on 5/16/23 at 9:52 a.m. The policy indicated the reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes. The timeframe listed was immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or no later than 24 hours.
3.1-28(a)