Hickory Creek At Sunset

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the code status of a resident was clear and concise and was the desire of the resident for 1 of 24 resident code status reviewed (Resident 17). Findings include:Resident 17's record was reviewed on [DATE] at 10:46 a.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia with anxiety (a common complication where a person experiences a loss of cognitive function alongside feelings of excessive worry, restlessness, and being on edge) and major depressive disorder (a mood disorder characterized by persistent feelings of sadness and loss of interest that interfere with daily life). A POST form (Physician Orders for Life Sustaining Treatment-a medical order form that documents a patient's treatment preferences in the event of an emergency), dated [DATE], indicated the resident desired to have CPR (Cardiopulmonary Resuscitation) attempted if she had no pulse and was not breathing. At the same time, the POST form indicated the resident desired to allow natural death if the resident had a pulse and was not breathing. An admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had moderate cognitive deficit, had mild depression, and no documented behaviors. A care plan, dated [DATE], indicated the resident had experienced emotional abuse trauma related to being abandoned by her husband and was at risk for experiencing traumatization, feeling unsafe/untrusting, and/or distressed. During an interview, on [DATE] at 11:24 a.m., the resident indicated she did not wish to have CPR performed. She did not feel as if the facility had explained the situation well enough for her at the time of her admission. She was so rattled at that time that she would have likely just signed anything that they placed in front of her. During an interview, on [DATE] at 11:39 a.m., Certified Nursing Assistant, (CNA) 8 indicated she was not aware of what the code status of the resident was, but it would be on her assignment sheet, or she could have the nurse look it up. During an interview, on [DATE] at 11:43 a.m., Licensed Practical Nurse (LPN) 9 indicated the code status would be in the resident's electronic record and a copy of the POST form would be in the code status manual. The resident's POST form indicated both CPR to be done and allow natural death. The LPN indicated the status contradicted each other. On [DATE] at 11:47 a.m., observation of the code status manual indicated the manual lacked documentation of the resident's POST form. During an interview, on [DATE] at 11:50 a.m., the Unit Manager indicated she had noticed the resident's POST form had conflicting information on it. She believed that someone had gone back to the resident to get clarification as to the resident's code status wishes. At the same time, the Unit Manager was unable to locate a copy of the residents' POST form in the code status manual. During an interview, on [DATE] at 1:26 p.m., the Director of Nursing Services (DNS) indicated the resident's admission was a very unusual circumstance. They worked very hard and quickly to get the resident into the facility. She was unsure who would have reviewed the POST information with the resident. It could have been the admitting nurse, the admissions person, or the unit manager. She understood that the POST form was confusing to understand. On [DATE] at 11:50 a.m., the DNS provided a document, with a revision date of 5/19, titled, Physician's Order for Scope of Treatment (POST), and indicated it was the policy currently being used by the facility. The policy indicated, .The POST should reflect the resident's current treatment preferences.Initiating a POST form: .3. The physician, advanced practice nurse.should discuss the benefits, burdens, efficacy, and appropriateness of treatment and medical interventions with the resident/legally recognized health care decision maker. A health care provider such as a nurse or social worker can explain the POST form to the resident/legally recognized health care decision maker; however, the physician, advanced practice nurse.is responsible for discussing treatment options with the resident/legally recognized health care decision maker. 3.1-4(a)3.1-4(A)(ii)3.1-53.1-7

Based on record review and interview, the facility failed to inform a resident and/or their representative of the benefits, risks, and alternatives for a medication prior to initiating a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (Resident 3). Findings include:Resident 3's record was reviewed on 11/18/25 at 1:45 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 10/22/25, indicated the resident was cognitively intact and received an antidepressant during the look back period. A physician's order, dated 9/11/25, indicated to administer 1 tablet of mirtazapine (antidepressant) 15 milligrams (mg) by mouth at bedtime for weight loss. The medical record lacked documentation of an Interdisciplinary (IDT) Psychotropic New/Increase Order Observation, or other documentation the resident was notified of the benefits, risks, alternatives, and the black box warning associated with the medication, was completed prior to the initiation of the mirtazapine. An event report, dated 9/10/25, indicated the resident's representative was notified of the order for mirtazapine for depression and decreased appetite. The event lacked documentation the resident and/or the resident's representative were notified of the benefits, risks, alternatives, and the black box warning associated with mirtazapine, prior to the initiation of the medication. On 11/20/25 at 10:59 a.m., the Director of Nursing (DON) provided a nutrition at risk (NAR) IDT note, dated 9/11/25, and indicated it was documentation consent was obtained from the resident for the mirtazapine. The note indicated, .Summary of Root Cause for Weight Change/Nutrition Concern: Resident often has poor meal intake, reports she is just eating how she was at home. New recommendations/interventions: Appetite stimulant as ordered. Friend and resident happy with the initiation of Remeron [mirtazapine] as it also helps with depression and thing [sic] this medication would be beneficial to resident. The note lacked documentation the resident and her friend were notified of the benefits, risks, alternatives, and the black box warning associated with mirtazapine, prior to the initiation of the medication. An article titled, Atypical antidepressants, dated 10/4/19, was accessed at https://www.mayoclinic.org/diseases-conditions/depression/in-depth/atypical-antidepressants/art-20048208, on 11/24/25. The article indicated, .Suicide risk and antidepressants. Most antidepressants are generally safe, but the FDA requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help. Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood. A second record review was completed on 11/20/25 at 9:49 a.m. An IDT Psychotropic Medication New/Change Order Review was opened and completed on 11/19/25. The observation was backdated to 9/12/25. During an interview, on 11/20/25 at 10:23 a.m., the Executive Director (ED) indicated they normally reviewed informed consent and medications during the residents' care plan meetings. They were not aware consent had to be obtained prior to initiating or increasing a psychotropic medication. The ED was not able to find documentation the resident or her representative was notified of the benefits, risks, alternatives, and black box warning associated with mirtazapine prior to the initiation of the medication. On 11/20/25 at 11:09 a.m., the DON provided a document titled, Psychotropic Management, last revised in July 2025. The policy indicated, .Definition: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories.Anti-depressant.Procedure.2.The IDT Psychotropic New/Increase Order observation in Matrix should be used for increases or initiation of psychotropic medications. 3.1-3(n)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's medical record was accurate when the resident's physician's orders were not updated to reflect their selections on the Physician's Orders for Scope of Treatment (POST) form (documentation of the resident's wishes at the end of life) for 1 of 24 residents' code statuses reviewed (Resident 1). Findings include: Resident 1's record was reviewed on 11/19/25 at 10:20 a.m. Census information indicated the resident was hospitalized from [DATE] to 10/2/25. Diagnoses on the resident's profile included, but were not limited to, nontraumatic intracranial hemorrhage (bleeding within the skull) and Parkinson's disease (a progressive movement disorder of the nervous system). An admission Minimum Data Set (MDS) assessment, dated 10/9/25, indicated the resident had a severe cognitive impairment and a feeding tube (inserted into the abdomen for artificial nutrition). The resident's current physician's orders included the following orders related to code status. -A physician's order, dated 2/5/24, indicated, POST For Orders: Section A: CARDIOPULMONARY RESUSCITATION (CPR) [emergency lifesaving procedure performed when the heart stops beating]: Patient has no pulse AND is not breathing. Special Instructions: Attempt Resuscitation/CPR. When not in cardiopulmonary arrest, follow orders B, C, and D. -A physician's order, dated 2/5/24, indicated, POST Form Orders: Section B: MEDICAL INTERVENTIONS: If patient has pulse AND is breathing OR has pulse and is NOT breathing. Special Instructions: Full intervention: Treatment goal: Full interventions including life support measures in the intensive care unit. -A physician's order, dated 2/5/24, indicated, POST Form Orders: Section C: ANTIBIOTICS: Special Instructions: Use antibiotics consistent with treatment goals. -A physician's order, dated 2/5/24, indicated, POST Form Orders: Section D: ARTIFICIALLY ADMINISTERED NUTRITION: Always offer food and fluids by mouth if feasible. Special Instructions: No artificial nutrition. An updated POST form was signed on 10/10/25, after the resident returned from the hospital stay. The form indicated Section A: do not attempt CPR, Section B: Comfort measures, allow natural death, Section C: Use antibiotics consistent with treatment goals, Section D: long-term artificial nutrition. The record lacked documentation the physician's orders were updated with the new POST form. During an interview, on 11/19/25 at 11:50 a.m., the Director of Nursing (DON) indicated she was not sure why the physician's orders were not updated in October when the resident's POST form preferences were changed. On 11/19/25 at 11:50 a.m., the DON provided a document titled, Physician's Order for Scope of Treatment (POST), last revised in May 2019. The policy indicated, .Policy: It is the policy of the facility that Physician's Orders for Scope of Treatment (POST) forms will be honored and executed per the following guidelines as residents and/or legally recognized health care decision maker's desire.5. Ensure that physician's orders indicating the decisions made on the POST for are added to the resident's orders (i.e. CPR Medical Interventions, Antibiotics, Artificially Administered Nutrition). 3.1-50(a)(2)

Based on observation and interview, the facility failed to provide the open date of medication stored in 1 of 2 medication administration carts. Findings include: On 11/20/25 at 9:55 a.m., during the observation of the North Hall medication administration cart, an opened un-dated Aspart 100 unit insulin pen (an injection device that you can use to deliver preloaded insulin into your subcutaneous tissue, the innermost layer of skin in your body) prescribed for Resident 5 was observed. On 11/20/25 at 10:00 a.m., during an interview Licensed Practical Nurse (LPN) 11 indicated the insulin pen had been opened on 11/19/25 in the evening. She acknowledged the pens should be dated when opened. On11/20/25 at 11:30 a.m., the Director of Nursing (DON) provided a document titled, Storage and Expiration Dating of Medications and Biologicals, dated 06/30/25, and indicated it was the policy currently being used by the facility. The policy indicated, .11. Once any medications or biologicals package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler)when the medication has a shortened expiration date once opened.11. 3 If a multidose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 3.1-25(j)3.1-25(m)3.1-25(n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was safely transported in the wheelchair resulting in a fall for 1 of 2 residents reviewed for accidents (Resident 1). Findings include:Resident 1's record was reviewed on 11/19/25 at 10:20 a.m. Census information indicated the resident was hospitalized from [DATE] to 10/2/25. Diagnoses on the resident's profile included, but were not limited to, Parkinson's disease (a progressive movement disorder of the nervous system), neurocognitive disorder with Lewy bodies (a decline in thinking ability, especially in the areas of attention, visual perception, and planning and organization), and repeated falls. A physician's order, dated 2/14/24, indicated anti-roll backs (device to keep the wheelchair from rolling backwards if a resident stood up without locking the wheels) to the resident's wheelchair. A physician's order, dated 1/3/25, indicated the resident may use cushion with pommel-type (designed to promote proper positioning by preventing patients from sliding forward in their wheelchair seats) wedge in wheelchair. An annual Minimum Data Set (MDS) assessment, dated 9/8/25, indicated the resident had a severe cognitive impairment and required supervision/touching assistance with eating, substantial/maximal assistance with oral hygiene, and was dependent with toileting hygiene, showering/bathing, chair/bed transfers, toilet transfers, and tub/shower transfers. An Occupational Therapy (OT) evaluation was dated 9/22/25. The evaluation indicated the resident had repeated falls and generalized muscle weakness. The resident fell on 9/14/25 and 9/16/25 and was referred to OT. The resident used a manual wheelchair with a pommel cushion, anti-rollbacks, and a foot board under the wheelchair (board to keep the resident's feet from getting caught under the chair). The resident required supervision with eating and maximal assistance with personal hygiene, lower body dressing, putting on/taking off footwear, showering/bathing, and toileting hygiene, and minimal assistance with upper body dressing. The resident exhibited difficulty propelling himself in the wheelchair. The resident required skilled OT to address deficits including safety awareness, repeated falls, muscle weakness, and decreased activity tolerance. A charting event, dated 9/28/25, indicated the resident had a decline in condition. A progress note, dated 9/28/25, indicated the resident was not acting normally at dinner. The resident was reaching out ahead of himself, had a blank stare, and was not wheeling himself in his wheelchair. When the staff attempted to communicate with the resident, he was minimally responsive. The resident's oxygen saturation (oxygen level in the blood, normally between 96 and 100 percent) was 80 percent. Oxygen was provided at three liters (l), and the resident's oxygen saturation rose to 90 percent. The resident remained minimally responsive. The physician ordered the resident to be sent to the hospital for further evaluation. The hospital Discharge summary, dated [DATE], indicated a final diagnosis included acute metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body) and despite hydration and treatment of infection his encephalopathy at baseline must be really bad with severe underlying dementia and Parkinson's disease, he is barely able to open eyes spontaneously, nonverbal. A final diagnosis of Parkinson's disease indicated, despite medications, the resident exhibited a lot of rigidity. A progress note, dated 10/2/25, indicated the resident returned to the facility. The resident was a nothing by mouth (NPO) status, and a gastrostomy tube (g-tube) (tube inserted into the abdomen for artificial nutrition) had been placed. All medications were to be administered through the g-tube. A progress note, dated 10/3/25, indicated the resident was readmitted to the facility yesterday. The resident was lethargic with very swollen lower arms and hands. The continuous tube feedings continued. The physician was notified of the resident's current condition. A progress note, dated 10/5/25, indicated the resident was responsive but was not behaving at baseline. The resident was still lethargic. The resident had signs and symptoms of pain with hygiene and toileting. The resident was checked on routinely. An OT therapy evaluation was dated 10/6/25. The evaluation indicated the resident's primary diagnosis was metabolic encephalopathy, and he exhibited generalized muscle weakness, abnormal posture, and pain in the joints of both hands. The resident was referred due to a recent hospitalization and was having pain, especially in the hands. The goal was to keep the resident comfortable. The resident's prior level of functioning was up daily in manual wheelchair, self-propelled at a slow pace, required assist of one staff with toileting and dressing. The evaluation indicated the resident was totally dependent with ADLs. The resident required skilled OT to address impairments and deficits including abnormal posture, pain, decline in self-care, edema (swelling), and positioning. The resident's prior level of functioning was a manual wheelchair, but the resident was currently bed bound and would be placed in a Broda (equipped with advanced tilt and recline features) chair. The resident's therapy goal was to decrease pain. A progress note, dated 10/7/25, indicated the resident attempted to climb out of bed, was assisted up into the wheelchair, and was one on one supervision with staff. An OT note, dated 10/9/25, indicated the resident was up in the Broda chair with the leg/foot rest extended for comfort. The CNA and nurse reported the resident was able to stand and transfer to the Broda chair. The resident was active, moving in the Broda chair, and OT would follow-up with positioning. An admission MDS assessment was completed upon the resident's hospital return and was dated 10/9/25. The assessment indicated the resident had a severe cognitive impairment. Activities of daily living (ADLs) indicated eating, chair/bed transfers, and toilet transfers were not attempted, and the resident was dependent for oral hygiene, toileting hygiene, showering/bathing, putting on and taking off footwear, and personal hygiene. A fall event, dated 10/11/25, indicated the resident fell out of the wheelchair while being pushed, hit his head, and abrasions were noted. The Certified Nurse Aide (CNA) was pushing the resident in the wheelchair, the resident put his feet down, and he fell out of the wheelchair on his face. The intervention was to place foot pedals on the wheelchair and ensure the resident's feet were on the foot pedals before pushing him in the wheelchair. A progress note, dated 10/11/25, indicated the CNA was pushing the resident in the wheelchair, the resident put his feet down, fell out of the wheelchair, and hit the front of his forehead. There was a scraped area on the resident's forehead. The resident was more alert that day and talked at times. The note lacked documentation if the resident's ability to be safely pushed in a wheelchair had changed related to his decline in condition. An IDT note, dated 10/11/25, indicated the resident was being propelled in the wheelchair and put his feet down, which caused him to fall. There was an abrasion to the center of his forehead. The determined root cause of the fall was weakness to bilateral lower extremities. The intervention put in place to address the root cause was foot pedals when up in wheelchair related to being able to propel the wheelchair with his hands successfully. The record lacked documentation of OT or nursing notes, between 10/10/25 and 10/11/25, which indicated the resident was safe to be placed back in the manual wheelchair, instead of the Broda chair or the resident was safe to be pushed in the wheelchair without foot pedals considering his increased muscle weakness and change in condition. A current care plan indicated the resident was at risk for falls due to a history of falls, advanced age, incontinence, high-risk medication use, Parkinson's disease, neurocognitive disorder with Lewy bodies, requires assistance with transfers and ADLs, altered awareness of surroundings, impulsiveness, lack of understanding of physical limitations, and experiencing decline in ability to mobilize his wheelchair. An intervention, dated 10/13/25, indicated foot pedals when up in wheelchair. During an interview, on 11/19/25 at 2:16 p.m., the Executive Director (ED) indicated when the resident planted his feet while being pushed in the wheelchair and fell. The foot pedals were placed as an intervention for the fall. The resident had a decline in condition when he returned to the hospital, but he did return to his baseline. During an interview, on 11/19/25 at 2:41 p.m., CNA 5 indicated when the resident returned from the hospital, they tried to put him in a Broda chair, but it had not worked out. The resident had a decline in condition when he returned from the hospital and was not able to do as much. Therapy decided which residents required foot pedals and placed them in the resident's rooms if they needed them. The staff was not able to obtain foot pedals for wheelchairs on their own or in response to a change in the resident's ability to hold their feet up while being pushed in the wheelchair. During an interview, on 11/20/25 at 8:55 a.m., Certified Occupational Therapy Assistant (COTA) 16 requested the DON be present during interview regarding the resident's wheelchair. During the interview the DON answered the questions, and COTA 16 did not answer. The DON indicated the resident was in a Broda chair when he returned from the hospital. The resident had a lot of swelling and not much energy upon his return. The resident started to climb out of the Broda, so they put him in the wheelchair to see what happened. There were no foot pedals put on because he was able to propel himself. She thought the resident tried to stand up while being pushed in the wheelchair, and that was why he fell. Foot pedals were in the shed, and she thought staff could access them if needed. CNAs should have pushed residents at normal speed and watched to ensure their feet were raised. On 11/20/25 at 9:06 a.m., the DON provided a document titled, Fall Management Policy, last revised in June 2025. The policy indicated, .Policy: It is the policy.to ensure residents residing within the community have adequate assistance to prevent injury related to falls.Procedure: Fall Risk.5. The resident specific care requirements will be communicated to the assigned caregiver utilizing the resident profile or CNA assignment sheet. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to complete accurate skin assessments and obtain treatments for 2 of 2 residents reviewed for quality of care (Residents 28 and 49). Findings include: 1. On 11/17/2025 at 12:10 p.m., during an observation and interview of Resident 28, observed a bandage on the lower right abdominal fold of the resident. The bandage was dated 11/12/25. The resident indicated the bandage was applied when she was recently in the hospital for an open wound that would not heal. A large purple bruise was observed on the top of the right upper thigh. The resident indicated it had occurred while in the hospital.
On 11/18/25 at 10:00 a.m., during an interview the resident indicated the abdominal dressing had not been changed but the wound nurse told her she would come in and change it.
On 11/18/25 at 2:30 p.m., the medical record of Resident 28 was reviewed. The resident was re-admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems) and type 2.
A care plan, dated 9/11/23, indicated the resident was at risk for skin breakdown. Interventions included, but were not limited to, assess and document skin condition weekly and as needed, notify MD of abnormal findings, and apply preventative treatment as ordered.
A care plan, dated 2/2/24, indicated the resident was at risk for bleeding/bruising related to use of antiplatelet medication. Interventions included, but was not limited to, document abnormal findings and notify MD (medical doctor).
A Minimum Data Set (MDS) admission assessment, dated 9/11/25, indicated the resident had mild cognition deficit and required moderate assistance with daily care needs.
An admission skin assessment, dated 11/15/25, indicated an abrasion to the lower right abdomen with measurements of the wound indicating 1.0 centimeters (cm) by (x) 1.4 cm.
On 11/20/25 at 9:42 a.m., during an interview Licensed Practical Nurse (LPN) 10 indicated she had assessed the area on the abdomen of Resident 28 with the Nurse Practitioner (NP) on 11/19/25 and had obtained treatment orders at that time. She did not recall the dressing being dated 11/12/25. LPN 10 indicated upon admission and re-admission to the facility the nurse would complete a head to toe assessment of the resident and would notify the physician of any wounds and request treatment orders.
On 11/20/25 at 9:48 a.m., during an interview Certified Nurse Aide (CNA) 8 indicated she would notify the nurse of dressings dated several days after admission and she would check the resident's skin for abnormalities and notify the nurse.
On 11/20/25 at 10:55 a.m., during an interview the Director of Nursing (DON) indicated the nurse on the unit probably lifted the dressing, dated 11/12/25, observed the wound, measured the wound and then re-applied the soiled dressing, dated 11/12/25, because the nurses know the wound nurse liked to do her own dressings. She indicated she would have to look at the assessment to determine why the bruise on the upper right leg was not identified upon admission. She did not know why the physician had not been notified upon re-admission regarding the abdominal wound.
A Physician order, dated 11/19/25, indicated to apply a pea size amount of Mupirocin ointment 2% topically once a day. Special instructions were to cleanse the abrasion located on the right lower quadrant with normal saline water, pat dry, apply mupirocin ointment, and cover with dry dressing.
On 11/20/25 at 2:30 p.m., review of wound documentation indicated the abdominal wound measurements obtained on 11/19/25 indicated abdominal wound was 1 cm x 1 cm.
The medical record indicated the abdominal wound was measured on 11/17/25. The wound measurements were 12 cm x 12 cm. On 11/20/25 at 2:35 p.m., during an interview the DON indicated the measurements for 11/17/25 were incorrect.
On 11/20/25 at 11:30 a.m., the DON provided a document, titled, Skin Management Program, dated 5/22, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure for alterations in skin integrity pressure and non-pressure 1. Alterations in skin integrity will be reported to the MD/NP, the resident and or resident representative as well as to the direct care staff.2. Treatment order will be obtained from MD/NP.3. All alterations in skin integrity will be documented on the admission observation in the medical record in the admission observation (new admitted and re-admitted residents).
On 11/20/25 at 11:30 a.m., the DON provided a document, titled, Resident change in condition policy, dated 11/2018, and indicated it was the policy currently being used by the facility. The policy indicated, .3. Non urgent medical change.a. All symptoms and unusual signs will be documented it the medical record and communicated to the attending physician promptly.
2. Resident 49's record was reviewed on 11/19/25 at 9:23 a.m. The profile indicated the resident diagnoses included, but were not limited to, rhabdomyolysis (a serious medical condition where damaged skeletal muscles breaks down, releasing harmful substances like myoglobin [an iron and oxygen binding protein in muscle tissue] into the bloodstream that can cause kidney damage and failure), chronic obstructive pulmonary disease (COPD – a progressive lung disease that causes restricted airflow and breathing problems), and hypertension (elevated blood pressure).
The facility census indicated Resident 49 admitted to the facility on [DATE].
A care plan, dated 9/4/24, indicated Resident 49 was at risk for skin breakdown due to history of pressure wound, very limited mobility, and limited sensory perception. Interventions included, but were not limited to, assess and document skin condition weekly and as needed, turn and reposition at least every 2 hours, and encourage the resident to eat at least 75% of meals.
A care plan, dated 9/5/24, indicated Resident 49 required assistance with toileting due to repeated falls. Interventions included, but were not limited to, assess and document skin condition weekly and as needed, and document any abnormal findings to doctor.
A quarterly Minimum Data Set (MDS) assessment, dated 10/24/25, indicated Resident 49 had no cognitive impairment and required substantial assistance with toileting, bathing, and dressing.
During an interview, on 11/17/25 at 11:38 a.m., Resident 49 indicated he had a fall at the facility in the last couple of weeks, but he wasn't sure of the exact day. He pulled up the pant leg that was to his right lower extremity, a healing bruise was noted to cover his entire knee cap. The bruise was yellow, green, and purple in color and there was a scab noted on the top side of his knee cap. The resident indicated it was tender to the touch, but he didn't think he had broken anything when he fell.
Review of fall event documentation, dated 11/5/25 at 10:10 a.m., indicated Resident 49 had a fall that was witnessed walking briskly to the dining room. The documentation indicated he fell on his bottom and had no injuries.
Review of IDT (interdisciplinary team) note, dated 11/5/25 at 10:12 a.m., indicated Resident 49 had a fall at the facility on 11/4/25 at 1:10 p.m. The note indicated the resident fell onto his buttocks when he was walking briskly with his walker to the dining room. No injuries were noted, no x rays were obtained, and the resident wasn't sent to the emergency room.
Review of weekly skin assessment note, dated 10/31/25 at 2:04 p.m., indicated Resident 49 had no areas of concern related to skin integrity alteration. The skin assessment didn't identify a bruise to his right knee.
Review of a weekly skin assessment note, observation date of 11/6/25 at 4:10 p.m. with a completion date of 11/12/25 at 4:11 p.m., indicated Resident 49 had no areas of concern related to skin integrity alteration. The skin assessment didn't identify a bruise to his right knee.
Review of weekly skin assessment note, dated 11/15/25 at 12:07 p.m., indicated Resident 49 had no areas of concern related to skin integrity alteration. The skin assessment didn't identify a bruise to his right knee.
Review of wound management documentation, dated 11/19/25 at 10:13 a.m., indicated Resident 49 had no wounds.
During an interview, on 11/19/25 at 9:40 a.m., Licensed Practical Nurse (LPN) 4 indicated the nurses had a schedule they went by for the weekly skin assessments. The skin assessments should be head to toe and any or all skin imperfections were documented under observations in the computer system.
During an interview, on 11/19/25 at 10:10 a.m., Director of Nursing Services (DNS) indicated she was not aware that Resident 49 had a bruise to his right knee, she was not sure if it occurred when he had his last fall.
During an interview, on 11/19/25 at 10:39 a.m., Certified Nurse's Aide (CNA) 6 indicated she would report any skin imperfections that a resident may have to the nurse. She indicated that during showers, she would sometimes see a new skin area, and she would document it on the shower sheet, and the nurse would be made aware of it as well.
During an interview, on 11/19/25 at 10:42 a.m., Registered Nurse (RN) 7 indicated weekly skin assessments were completed Tuesday through Sunday by a schedule. The skin assessments were documented under the observation tab in the computer, and the nurses should be completing a head-to-toe assessment of the resident's skin. If the nurse noted a new skin imperfection, then a skin event should be opened in the computer system, and the wound nurse would be notified.
During an interview, on 11/19/25 at 10:45 a.m., CNA 5 indicated if she noted a new skin area to a resident, she would place it on the shower sheet and notify the nurse. She had not noticed a bruise on Resident 49's knee recently. She indicated Resident 49 did require assistance with his showers from staff.
During an interview, on 11/19/25 at 11:35 a.m., the DNS indicated she was not sure whether the bruise to Resident 49's right knee was from his fall or not, but the nursing staff should have noted the bruise on the weekly skin assessments and a skin event should have been documented as well.
The article, What do the Colors of a Bruise Mean, dated 1/18/24, was retrieved on 11/24/25 from the Medical News Today website at https://www.medicalnewstoday.com. The guidance included: Bruises typically change color as they heal, at first appearing red, purple, or darker surrounding skin. They may progress to blue, black, or green before fading.After 10-14 days the bruise may turn yellowish-brown to light brown.
On 11/19/25 at 11:20 a.m., the DNS provided a document with a revised date of 8/25, titled, Documentation Guidelines for Nursing, and indicated it was the policy currently being used by the facility. The policy indicated, .Weekly skin and vital sign assessment observation (All new skin areas must be reported to the wound nurse with new skin event completed) .8. New Skin Event, initiate for any newly identified skin conditions (except for new admissions or readmissions) .IDT initial wound review: after any new facility acquired wound/skin injury is found.
3.1-37

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was coded accurately for 1 of 19 residents' MDS assessments reviewed (Resident 3). Findings include:Resident 3's record was reviewed on 11/18/25 at 1:45 p.m. An admission MDS assessment, dated 7/21/25, indicated the resident had an intellectual disability (ID) or developmental disability (DD), with no organic (physical) condition. The resident's diagnosis list lacked documentation the resident had a diagnosis of an ID or DD. During an interview, on 11/20/25 at 1:20 p.m., the MDS Coordinator indicated the resident's assessment was coded in error, and the resident did not have an ID or DD. The facility used the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual as their policy for MDS coding. The CMS RAI manual version 3.0, dated October 2025, indicated, .A1550: Conditions Related to Intellectual Disability/Developmental Disability (ID/DD) Status.Item Rationale: To document conditions associated with intellectual or developmental disabilities.Coding Instructions: Check all conditions related to ID/DD status that were present before age [AGE].Code Z: if ID/DD condition is not present. 3.1-31(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure a resident was safely transported in her wheelchair resulting in a fall and nasal fracture for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 1/22/25, prior to the start of the survey, and was therefore past noncompliance.
Findings include:
During an interview, on 2/4/25 at 10:23 a.m., Resident B indicated she was admitted to the facility in December 2024 with a right shoulder and right hip fracture following a fall at home. On the morning of 1/10/25, the facility's bus driver was going to take her out to an appointment in Indianapolis to have her sutures removed from her previous fracture repair. The bus driver pushed her in her wheelchair, from her room towards the exit door, and she was moving pretty fast. There was a dip in the floor near the dining room, and when the bus driver pushed the wheelchair over the dip the resident's foot got caught on the floor. She was wearing sneakers, and the bottom of them caught on the floor. The resident went face first out of the wheelchair and sprained her right foot, fractured her nose, and sustained a black eye. The resident did not remember if she had foot pedals for her wheelchair available, but they were not in place at the time the incident occurred. The resident indicated after the fall, the staff assisted her back to the wheelchair, and they proceeded to her appointment in Indianapolis. The physician's office, in Indianapolis, sent her to the emergency room (ER) from her appointment. At the ER, they diagnosed the resident with a nasal fracture. The facility's bus driver took the resident back to the facility, the same day, after the ER visit. The resident indicated she had pain related to the fall. At the same time, the resident was observed with a small purple bruise under her right eye, surrounded by yellowish/greenish bruising.
On 2/4/25 at 11:58 a.m., a change in the floor grade was observed when walking to the dining room from the 100 hall. The floor went up slightly when walking in that direction.
Resident B's record was reviewed on 2/5/25 at 9:40 a.m. Diagnoses on the continuity of care document (CCD) included, but were not limited to, fracture of unspecified part of the neck of the right femur (large bone in thigh) and unspecified fracture of the lower end of the right humerus (bone in the upper arm).
An admission Minimum Data Set (MDS) assessment, dated 12/29/24, indicated the resident was cognitively intact and had not refused care. The resident had an impairment in mobility of one side of the upper and lower extremities. The resident used a manual wheelchair, was dependent for wheeling 50 feet and making 2 turns, and was dependent for wheeling 150 feet. The resident was dependent with lower body dressing and for putting on and taking off footwear.
A fall event, dated 1/10/25, indicated the resident had a witnessed fall, hit her head, and experienced pain. There was bruising and swelling noted. The resident was being pushed in the dining room by staff, and went down a slope, while going to the facility's bus. The resident was lying on her stomach and had shoes on. Environmental factors observed in the area of the fall indicated, foot pedals off. The intervention put in place to prevent another fall was to ensure foot pedals were in place when the resident used the wheelchair.
An Interdisciplinary Team (IDT) note, dated 1/10/25, indicated the resident fell when a staff member propelled the resident and her feet caught on the floor when exiting the dining room. The resident fell forward out of the wheelchair. There was bruising to the resident's ankle and face and bleeding from her nose. The immediate, short term intervention indicated the resident was assisted into the wheelchair and went to the appointment. Foot pedals were applied to the wheelchair. The intervention put in place to address the root cause of the fall was to put foot pedals on the resident's wheelchair when the staff propelled her.
A care plan, initiated on 12/24/24, indicated the resident was at risk for falls and had a history of falls prior to admission. An intervention, dated 1/10/25, indicated, foot pedals on wheelchair when staff propelling her.
ER discharge instructions, dated [DATE], indicated diagnoses from the ER visit included fall, periorbital (around the eye) hematoma (localized collection of blood caused by an injury) of the right eye, and nasal bone fracture. The discharge instructions indicated the resident needed to maintain sinus precautions (measures taken to prevent further irritation or injury to the sinuses).
During an interview, on 2/4/25 at 12:05 p.m., Certified Nurse Aide (CNA) 4 indicated when the resident fell her shoe caught just right on the dip in the floor, and she fell forward out of the wheelchair. It was an easy area to trip over. He was not sure if the resident should have had foot pedals in place at the time of the fall, but she did have foot pedals afterwards.
During an interview, on 2/4/25 at 2:56 p.m., Licensed Practical Nurse (LPN) 3 indicated he was not sure which residents were required to have foot pedals for their wheelchair. He did not remember if the resident should have had foot pedals at the time of her fall.
During an interview, on 2/4/25 at 3:04 p.m., CNA 5 indicated she was the bus driver the day the resident's fall occurred. She told the resident to keep her feet up, but when they hit the dip in the floor, near the dining room, the resident's sneakers hit the ground and got stuck. CNA 5 indicated she stopped, grabbed the resident's shoulders, and tried to pull her back, but the resident fell. She did not think the fall would have occurred if the resident had not been wearing the sneakers with a bottom that was easy to get stuck to the floor. CNA 5 did not indicate, however, any extra precautions taken when propelling the resident while she was wearing the sneakers. Staff assisted the resident back into the wheelchair, and she took the resident to her appointment. Foot pedals were not on the resident's wheelchair when the incident occurred, and she was not able to remember if they were put on after the fall or not. Since the incident, it was made a requirement to put foot pedals on wheelchairs when the residents used the facility's bus for transportation. They received training on using foot pedals when residents went to appointments. When residents were propelled down ramps they were trained to put their hands on the resident's shoulder.
During an interview, on 2/5/25 at 8:45 a.m., the Executive Director (ED) indicated they did not have a facility policy regarding wheelchairs or a requirement for foot pedals. After the incident, they made it their policy to use foot pedals for all residents going out for appointments unless they refused.
On 2/5/25 at 9:45 a.m., the ED provided a document titled, Fall Management Policy, last revised in August 2022 and indicated it was the policy currently being used by the facility. The policy indicated, .Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls
The deficient practice was corrected by 1/22/25 after the facility implemented a systemic plan that included the following actions: immediate assessment by the charge nurse of the effected resident and the provision of first aide and follow-up care, staff members who provided assistance to residents with wheelchair transport received education on proper wheelchair transport activities, staff members educated that residents who required assistance with wheelchair mobilization for appointments outside of the facility should use foot pedals while being transported to and from the appointment, and a Quality Assurance and Performance Improvement (QAPI) plan implemented with the completion of an audit tool for scaled ongoing monitoring. The first audit tool was completed on 1/22/25.
This citation relates to Complaint IN00451216.
3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the dignity of a resident during meal service for 1 of 2 dining observations (Resident B).
Findings include:
During observation of the lunch meal in the main dining room, on 9/5/24 at 12:22 p.m., Resident B was sitting at a table along with Resident C. Both residents required physical assistance with eating their meals. Both residents had been provided drinks and were being assisted with their drinks by an unidentified staff member.
On 9/5/24 at 12:42 p.m., Resident C received her meal tray and was assisted to eat by the unidentified staff. No tray was served to Resident B. Nursing Assistant in Training (NAIT) 5 sat at the table to assist Resident B with her drink.
On 9/5/24 at 12:58 p.m., Resident B requested that she get at least something to eat. At the same time, the resident indicated that she had requested a hamburger as a substitute for the scheduled meal way before she had been brought into the dining room, so the kitchen should have had plenty of time to prepare it for her. NAIT 5 went to the kitchen station to check on the resident's meal tray.
On 9/5/24 at 1:02 p.m., NAIT 5 brought Resident B's meal tray to the table and began to assist her with her meal.
Resident B's record was reviewed on 9/11/24 at 9:42 a.m. The profile indicated the resident's diagnoses included, but were not limited to, quadriplegia (a type of paralysis that affects all four limbs and the torso) and dysphasia (difficulty swallowing).
A quarterly Minimum Data Set (MDS) assessment, dated 7/23/24, indicated the resident had no cognitive deficit and was dependent with substantial/maximum assistance with eating.
A care plan, dated 4/11/23, indicated the resident required assistance with activities of daily living (ADL-the basic tasks people do to care for themselves and live independently) which included, but were not limited to eating. Interventions included, but were not limited to, assist with eating and drinking.
During an interview, on 9/5/24 at 2:31 p.m., Resident B indicated having to wait for her meal at lunch had upset her. The kitchen knew she wanted a hamburger instead of what was being served way before she was brought into the dining room. The kitchen staff told her they had to go out to buy hamburger and prepare it for her. She felt that was odd because she understood they had just had a delivery earlier in the morning.
During an interview, on 9/10/24 at 11:10 a.m., the Certified Food Manager (CFM) indicated, on 9/5/24, the resident had requested hamburger for a lunch meal alternative. They had a delivery come that morning, but hamburger was not on the delivery. She had to run out to get the hamburger, to fix it for the resident. The resident was offered something else but had declined.
During an interview, on 9/10/24 at 12:32 p.m., the Executive Director (ED) indicated her understanding was that the staff had offered the resident her cottage cheese while she was waiting for her hamburger on the lunch meal on 9/5/24.
During an interview, on 9/10/24 at 1:41 p.m., Resident B indicated she did not remember anyone offering her anything to eat. If staff would have offered her cottage cheese she would have taken it, because she always ate her cottage cheese.
On 9/10/24 at 2:25 p.m., the ED provided an undated document, titled, Your Rights and Protections as a Nursing Home Resident, and indicated it was the policy currently being used by the facility. The policy indicated, .You have the right to be treated with dignity .You have the right to decide .your meals
This citation relates to Complaint IN00442280.
3.1-3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based to observation, interview, and record review, the facility failed to ensure medications and biologicals were dated when opened, and failed to properly dispose discontinued medication, for 1 of 2 medication carts and 1 of 1 medication rooms observed for medication storage (Residents 256, 51, and 33).
Findings included:
1. On [DATE] at 9:50 a.m., the West/North medication cart contained an opened and undated bottle of Brimonidine eyedrops (used to lower pressure in the eyes). The bottle contained a label that indicated it was for Resident 256.
During an interview with Registered Nurse (RN) 4, she indicated that it was their policy not to use eyedrops after 30 days of opening.
Resident 256's record was reviewed on [DATE] at 10:18 a.m., her diagnoses included, but were not limited to, type two diabetes (a chronic condition that occurs when the body doesn't produce enough insulin or doesn't use insulin properly).
A physician's order, dated [DATE], indicated to administer Brimonidine drops 0.2%, 1 drop in each eye, twice daily.
During an interview on [DATE] at 2:29 p.m., the DON indicated that the expiration date for eyedrops, after opening, depended on what the medication was.
2. On [DATE] at 9:50 a.m., Registered Nurse (RN) 4 pulled a medication bottle from the West/North medication cart drawer. The medication, observed it to be an opened bottle of Latanoprost eyedrops (used to lower pressure in the eyes) with an opened date of [DATE]. The bottle contained a label that indicated it was for Resident 51.
During an interview with RN 4, she indicated the eyedrops were not good anymore. She was not sure if the medication had been administered after the use by date.
Resident 51's record was reviewed on [DATE] at 10:19 a.m., her diagnoses included, but were not limited to, glaucoma (eye condition where the optic nerve, which connects the eye to the brain, becomes damaged).
A physician's order, dated [DATE], indicated to administer Latanoprost drops, 0.005%, one drop in each eye at bedtime.
3. On [DATE] at 9:50 a.m., the West/North medication cart contained and opened and undated bottle of Refresh Relieva eyedrops (used to relieve eye discomfort and prevent irritation). The label indicated it was for Resident 51.
Resident 51's record was reviewed on [DATE] at 10:19 a.m., her diagnoses included, but were not limited to, glaucoma (eye condition where the optic nerve, which connects the eye to the brain, becomes damaged).
The record lacked documentation of a current physician's order for Refresh Relieva eyedrops.
A historical physician's order, with a beginning date of [DATE] and a discontinuation date of [DATE], indicated to administer Refresh Relieva drops 0.5-0.9%, one drop into both eyes at bedtime.
On [DATE] at 10:35 a.m., Registered Nurse (RN) 4 indicated she could not find a current order for Resident 51's Refresh Relieva eyedrops, and they should have been discarded after [DATE].
4. On [DATE] at 9:50 a.m., the West/North medication cart contained and opened and undated multidose vial of Lidocaine HCL 1% solution. The bottle contained a label that indicated it was for Resident 33.
During an interview with Registered Nurse (RN) 4, she indicated that the Lidocaine was used to reconstitute Resident 33's Ceftriaxone (antibiotic) injection and should have been dated when opened.
Resident 33's record was reviewed on [DATE] at 1:40 p.m., her diagnoses included, but were not limited to, urinary tract infection.
A nursing progress note, dated [DATE], indicated urinalysis with culture and sensitivity was reported to the on call and a new order was received, to administer Ceftriaxone, one gram daily, intramuscularly (injected by needle into the muscle), for five days.
A physician's order, with a beginning date of [DATE] and a discontinuation date of [DATE], indicated to administer Ceftriaxone, reconstituted solution, one gram injection, once daily.
5. On [DATE] at 9:10:05 a.m., the back hall medication room had a container with five vials of Tuberculin solution (a medication used to test for tuberculosis [serious bacterial infection]), one of the five vials had been opened and not dated.
During an interview with Registered Nurse (RN) 4, she indicated that the vial of tuberculin solution should have been dated when opened and was only good for 30 days after opening.
On [DATE] at 3:30 p.m., the Director of Nursing (DON) provided the policy titled, Storage and Expiration Dating of Medications and Biologicals, with a revision date of [DATE], and indicated the policy was the one currently used by the facility. The policy indicated, .11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened .11.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container .11.3. If a multi-dose vial of an injectable medication has been opened or accessed (i.e. needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 11.4. When an ophthalmic solution or suspension has a manufacturer shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container .21. Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider. 21. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law
On [DATE] at 3:30 p.m., the DON provided the policy titled, Disposal/Destruction of Expired or Discontinued Medication, with a revision date of [DATE], and indicated the policy was the one currently used by the facility. The policy indicated, .2. Once an order to discontinue a medication is received, facility staff should remove this medication from the resident's medication supply
On [DATE] at 3:30 p.m., the DON provided an undated document titled, Omnicare, Medication Storage Guidance, and indicated the policy was the one currently used by the facility. The policy indicated, .Multiple-Dose Vials for Injection, Date when opened and discard unused portion after 28 days .Tuberculin Tests: Aplisol Injection; Tubersol Injection .Date when opened and discard unused portion after 30 days .Xalatan Opthalmic Solution (latanoprost) .Date when opened and discard after 6 weeks
On [DATE] at 3:30 p.m., the DON provided an undated document titled, Brimonidine Tartrate 0.2% w/v Eye Drops, and indicated it was the manufacturers guidelines currently used by the facility. The policy indicated, .6.3 Shelf Life .After first opening: 28 days
On [DATE] at 3:30 p.m., the DON provided an undated document titled, Refresh Tears - carboxymethylcellulose sodium solution/drops Allergan, inc., and indicated it was the manufacturers guidelines currently used by the facility. The policy indicated, .Refresh Tears .discard 90 days after opening
3.1-25(j)
3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure proper handwashing procedure during meal service for 1 of 2 dining observations.
Findings include:
During an observation of the lunch meal service, on 9/5/24 at 12:27 p.m., Nursing Assistant in Training (NAIT) 5 was observed to wash hands for less than 20 seconds and to turn off the water faucet without using a paper towel as a barrier. She then proceeded to serve trays to multiple residents in the dining room.
During an interview, on 9/10/24 at 3:08 p.m., the Director of Nursing (DON) indicated all staff should all be aware of proper handwashing technique. The NAIT had been trained on handwashing and should have known better.
On 9/10/24 at 2:25 p.m., the Executive Director (ED) provided a skills competency document, with a revision date of 7/2022, titled, Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Steps: .6. Vigorously rub hands for at least 20 seconds .10. Use paper towel to turn off faucet
3.1-21(i)(3)

Based on observation, interview, and medical record review, the facility failed to honor a resident's dietary dislikes and food preferences 1 of 3 residents reviewed for food preferences (Resident G).
Findings include:
On 6/27/24 at 12:27 p.m., during observation and interview Resident G indicated he can't have gassy foods, spicy foods, or greasy food due to an issue with his digestion related to his paralysis. He indicated he had met with the dietitian when he was admitted , and he had told the staff several times of his food preferences. He understood he had a regular diet ordered but the staff did not provide his preferences as requested. The resident indicated he continued to receive foods he can't tolerate. He indicated at times he must eat it because there was only grilled cheese or cold cuts sandwich offered as an alternate. He was given sausage and eggs every day though he had told them he can't eat greasy food.
On 6/27/24 at 1:05 p.m., observed the resident being served the noon meal. The diet slip indicated a regular diet. He was served sausage pizza for lunch. His preferences and dislikes were not listed on the diet slip. The resident indicated he has told the staff many times of his dislikes. He had only met once with a dietitian but had voiced complaints to the Administrator and the Director of Nursing. He indicated he had continued to be served foods that he did not like or tolerate.
On 6/28/24 at 2:00 p.m., during an interview with the Administrator, she indicated she had offered numerous alternates to the resident. She indicated the diet ticket would not indicate the resident's dietary dislikes because the resident changed his mind all the time. She indicated he would not be served foods that were on a dislike list if a list had been provided. A food preference list had not been created for Resident G. She indicated she had been aware of different preferences the resident had communicated to her. She indicated she had not tried alternate ways of communication for the resident to express his dislikes and preferences.
On 6/28/24 at 9:00 a.m., the medical record of resident G was reviewed. Resident was admitted to the facility with diagnoses which included, but not limited to, paraplegia (paralysis that occurs in the lower half of the body), gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), generalized anxiety disorder (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat), and major depressive disorder (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks).
The medical record lacked documentation of care plan addressing dietary food preferences.
On 6/27/2024 at 2:00 p.m., the Administrator provided a document, titled, Residents Rights, dated 3/15/17, and indicated it was the policy currently being used by the facility. The policy indicated, .Residents Rights .Respect and Dignity .The right to reside and receive services in the facility with reasonable accommodation of your needs and preferences .Self Determination .You have the right to make choices about aspects of your life in the facility
that are significant to you
This citation relates to Complaint IN00435710.
3.1-21(d)(4)
3.1-21(d)(5)

Based on observation, interview, and record review, the facility failed to ensure a resident with a history of post-traumatic stress disorder and anxiety, received appropriate services to attain the highest practicable mental and psychosocial well-being resulting in psychosocial distress for 1 of 2 residents reviewed for psychosocial wellbeing (Resident G).
Findings include:
On 6/27/24 at 12:27 p.m., during a routine observation and interview with the resident, he was sitting up in his wheelchair in his room. The resident was alert and meticulous in his note taking and record keeping. He indicated he had notes, recordings of conversations, and text messages when he had voiced and written his concerns to the Administrator, facility staff, and the Director of Nursing. He was pleasant but emotional during the interview.
The resident indicated he has severe abandonment anxiety. He had suffered from this since his accident when his wife tried to kill him resulting in trauma. The resident indicated he had been seeing psychiatric (psych) services since his accident but did not use the services through the facility. The resident indicated the facility staff were aware of this.
When he was admitted he was in a room on the East side of the building and used the shower room on that side. The resident indicated he was placed in the shower room and the call light cord would not reach him where he was sitting. The staff tied a string to the cord to enable him to call for assistance. The resident indicated the facility staff told him they could not tie a string to the cord due to it being a choking hazard. The resident indicated the string was removed and he was provided a bell to ring for assistance. He was unsure of the exact date of the occurrence. The resident indicated he was placed in the shower room on a bedside commode to use the restroom. He rang the bell, and no one answered or came to assist him. The resident indicated he became increasingly upset and fearful. He indicated he started yelling and throwing things that were within his reach. The Administrator came to the door and obtained assistance for him. The resident indicated he told the Administrator he had been left for around 1.5 hours.
He was moved to another room in the west hall and was advised the shower room had a call system which would reach him. The resident indicated he had been left several times in the shower room since being moved. On 5/28/24 the resident indicated he had an appointment to have an MRI at the hospital and he needed to complete his bowel regiment prior to leaving for his appointment. The resident indicated he had asked several staff members to take him to the bathroom. One of the Certified Nurse Aides (CNA) took him to the shower room and left him there. He indicated he was left in the shower room for about 30 minutes. He pulled the light cord, and no one came, and he started yelling for help. He indicated after some time the staff came in to assist him, he was unsure of how long he had been left without assistance.
The resident indicated he had been forgotten 4 or 5 different times in the shower room.
The resident indicated another occasion when he had been forgotten in the shower room, he was unsure of the date of occurrence. The resident indicated he had to yell for assistance because no one answered the bell. The resident indicated a nurse opened the door and told him he had heard him yelling and would get an aide to assist him.
During the interview the resident provided copies of dated text messages that had been sent to the Director of Nursing regarding being forgotten in the shower room, asking for help and indicated he had mental health issues related to problems in his past. The resident became emotional when retelling of the incidents and had to stop several times. He indicated this had caused him a great deal of anxiety and he had felt abandoned by the staff.
The resident indicated on 5/28/24 he was sent to the hospital for an MRI and was told by the nurse his transportation was taken care of. The resident indicated he was not given any information about who was taking him or picking him up. The resident indicated he was left outside the hospital to wait to be picked up. The transportation van did not show up. The resident indicated he attempted to call the facility for about 30 minutes. No one answered the phone. An off duty employee from the facility saw him at the hospital and took him back to the facility. He indicated he was very fearful and anxious at the time and felt abandoned by the staff.
On 6/27/24 at 12:46 p.m., during an interview, CNA 4 indicated on 5/31/24 she had placed the resident in the shower room because he was needing to go to the bathroom before leaving to have an MRI done at the hospital. She acknowledged she did not tell anyone she had placed the resident in the shower room. She gave him a call light to call for assistance and left to do other things. The CNA indicated she was working on appointments and she and another CNA heard someone yelling for help. The other CNA asked who was in the shower room. She told the CNA she put the resident in the shower room to use the bathroom. The CNA then removed the resident from the shower room.
On 6/28/24 at 9:00 a.m., the medical record of Resident G was reviewed. The resident was admitted to the facility with diagnosis which included, but not limited to, burn of unspecified degree of right foot, paraplegia (paralysis that occurs in the lower half of the body), generalized anxiety disorder (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat), and major depressive disorder (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks).
Most recent MRI assessment indicated the resident was minimal assist of one for activities of daily living (ADL).
A care plan, dated 4/11/2024, indicated the resident was at risk for signs and symptoms of anxiety (worried facial expressions, repetitive movements, shortness of breath, nausea, sweating, tremors, irritability, insomnia, reports of anxiety). Resident had a diagnosis of anxiety. Interventions included, but were not limited to, encourage resident to verbalize fears and anxiety; offer validation and reassurance, maintain a calm environment, observe for increase in signs and symptoms of anxiety; and obtain psych services as appropriate.
A care plan, dated 2/29/2024, indicated the resident was a new admission to the facility and requires implementation of services to promote physical, emotional, and psychosocial well-being. Interventions included, but were not limited to, assist with transfers, ambulation, bed mobility, toileting and/or incontinent care, and honor resident wishes.
A care plan, dated 3/11/2024, indicated resident was at risk for signs and symptoms of depression, expresses feeling depressed, feeling tired, trouble concentrating, feeling nervous, and/or fidgety. Resident had a diagnosis of depression. Resident reported feeling down, trouble concentrating, feeling tired and moving slowly on recent PHQ-9. Interventions included, but were not limited to, allow resident to express feelings and frustrations; offer validation and support; and emphasize and promote independence and feelings of control and choice.
The medical record lacked evidence of a trauma assessment being completed after the resident informed the Director of Nursing and Administrator, he had a diagnosis of PTSD. The record lacked documentation for offering of additional behavior health services. The record lacked evidence of a care plan for trauma-based care.
On 6/28/2024 at 2:00 p.m., the Administrator provided a document, titled, Trauma Informed Cre, dated 2/20, and indicated it was the policy currently being used by the facility. The policy indicated, .It is the policy of this facility to ensure that residents who are trauma survivors receive culturally competent trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident .Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma .Procedure .2. Residents who screen positive for a history of trauma will be referred to behavioral health services for further screening. 3. Behavioral health services will assist the resident and interdisciplinary team in developing a plan of care which will be added to the medical record. This plan of care will incorporate individual experiences .4. The plan of care will routinely be evaluated whether the interventions have been able to mitigate(or reduce) the impact of identified triggers on the resident that may cause re-traumatization
On 6/27/2024 at 2:00 p.m., the Administrator provided a document, titled, Resident Rights, dated 3/15/17, and indicated it was the policy currently being used by the facility. The policy indicated, .Resident Rights .Safe Environment .You have the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety
This citation relates to Complaint IN00435710.
3.1-43(a)(1)

Based on observation and interview, the facility failed to assist the resident in obtaining transportation from a hospital appointment for 1 of 1 residents reviewed for transportation (Resident G).
Findings include:
On 6/27/24 at 12:27 p.m., during a routine observation and interview with Resident G, he was sitting up in his wheelchair in his room. Resident G was very alert and meticulous in his note taking and record keeping. He indicated he had notes and recordings of conversations and text messages when he had voiced and written his concerns to the Administrator, facility staff and the Director of Nursing about being left at the hospital without transportation back to the facility.
The resident indicated on 5/28/24 he was sent to the hospital for an MRI. He was told by the nurse his transportation was taken care of, but he was not given any information about who was taking him. When he completed the MRI approximately an hour and a half later, he was left outside. His transportation van did not show up. The resident indicated he had attempted to call the facility for about 30 minutes. No one answered the phone. When the transportation van did not come to the hospital an off duty employee of the facility brought him back to the facility after randomly seeing him outside the hospital.
On 6/28/24 at 9:57a.m., during a confidential interview Employee 3 indicated on 5/28/24 they were leaving the hospital where Resident G had been. The resident was sitting outside in the front of the hospital and indicated he was waiting for the van. He had been there for an MRI and was told by the driver he was not on his list to pick up. While the employee observed the resident call the facility at least six times with no answer. The employee called the facility and talked to the supervisor. The employee explained the situation and asked who was picking up the resident. The supervisor indicated no one knew what was going on. The employee agreed to bring him back to the facility. The employee indicated the same day just prior to the resident going to the hospital he had been left in the shower room and he was very upset and feeling abandoned.
On 6/28/24 at 10:05a.m., during a confidential interview Employee 5 indicated Employee 3 called on 5/28/24 about Resident G being left at the hospital. The employee spoke to several staff members regarding who was picking him up and asked for the transportation phone number. The staff indicated they did not have a number. No one knew who to call.
On 6/28/24 at 9:00 a.m., the medical record of Resident G was reviewed. Resident G was admitted to the facility with diagnoses which included, but not limited to, burn of unspecified degree of right foot, paraplegia (paralysis that occurs in the lower half of the body), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), generalized anxiety disorder (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat), and major depressive disorder (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks).
On 6/28/2024 at 2:33 p.m., the Administrator provided an undated document, titled, ASC Facility Bus/Van Transportation Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Transportation will be provided by the facility bus/van for residents participating in activities outside of the facility .Outside transport should be the chosen option prior to utilizing facility van for physician and or other medical related appointments .
On 6/27/2024 at 2:00 p.m., the Administrator provided a document, titled, Resident Rights, dated 3/15/17, and indicated it was the policy currently being used by the facility. The policy indicated, .Resident Rights .Safe Environment .You have the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety
This citation relates to Complaint IN00435710.
3.1-49(j)(3)

Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided for dependent residents for 1 of 16 residents reviewed for Activities of Daily Living (ADL) (daily self-care activities) care (Residents 17).
Findings include:
On 7/27/23 at 10:30 a.m., during the Resident Council meeting, Resident 17 indicated he had been double briefed at night, several times a month over past several months. He did not know why. He was blind and unable to identify the staff members. He was double briefed again the previous night and was left without being changed and was a mess, soaked in urine, in the morning.
The Resident Council Members indicated the staff came in and woke them up during the night and ask if they needed to be changed. The residents indicated there were not enough supplies. The facility staff told them they were often out of briefs and the supplies would not come in for several days.
On 7/28/23 at 9:35 a.m., Certified Nurse Aide (CNA) 16 indicated the facility had not had enough briefs at times for the residents. When the resident was wet, they gave them a shower or bed bath. They used pink pads when they did not have briefs available. She indicated she had provided care to several residents who were found to be double briefed and saturated in urine, staff gave lots of showers and bed baths because of this.
On 7/28/23 at 9:45 a.m., Resident 17's record was reviewed. Diagnoses included but were not limited to, hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength), following cerebral infarction (when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel), affecting right dominant side, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes).
A quarterly Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 6/27/23, indicated the resident required extensive assistance of two persons for dressing and toileting.
Care plans, dated 4/11/23, indicated the resident was experiencing complications/residual effects which impact daily function related to diagnosis Cerebral Vascular Accident (CVA) (when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel) with right dominate hemiplegia. An approach, dated 4/11/23, indicated to assist with Activities of Daily Living (ADLs) (activities related to personal care), as needed.
Urinary Incontinence care plan, dated 4/11/23, indicated the resident required assistance with toileting due to impaired and decreased mobility ., approaches dated 4/11/23, assist with elimination assist with incontinent care.
On 7/28/23 at 2:52 p.m., Registered Nurse (RN) 8 indicated, all residents should be provided incontinence care when wet or soiled.
On 7/28/23 at 2:52 p.m., RN 8 indicated the facility did not have a policy for ADL care, and provided document, titled INCONTINENT BRIEF APPLICATION, dated 02/2010 and review dated 4/2012. RN 8 indicated it was the current policy for the facility. The policy indicated, .Procedure steps .1. Verify resident and explain procedure . 2. Provide policy . 3. Wash hands . 4. Put on gloves . 5. Unfasten and remove brief resident is currently wearing . 6. Provide perineal care . 7. Place back of brief between resident's . 8. Bring front of brief between resident's legs and up to waist . 9. Fasten each side of brief and adjust to fit . 10. Redress or position resident as needed . 11. Remove gloves . 12. Wash hands . 13. Soiled or used brief should be secured in plastic bag and disposed of in soiled utility room .14. Do not leave in residents' room
3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's dignity was maintained when the resident was not changed after an incontinence episode and instead asked to eat alone in her room while seated in a soiled brief and wheelchair instead of eating her meal in the main dining room per her usual preference for 1 of 16 residents reviewed for dignity (Resident 5).
Findings include:
During an observation, on 7/24/23 at 12:20 p.m., Resident 5 was observed seated in her wheelchair in her room staring out the window and appeared upset. Resident 5 indicated her husband used to visit daily, but for the last few months he had been unable to visit her. She enjoyed eating breakfast and lunch in the main dining room to socialize with everyone. However, today, she was in the therapy room with Physical Therapist (PT) 5 and had wet herself and the urine ran onto the therapy floor. PT 5 told Resident 5 that she would take her down to her room to be changed from the wet brief before lunch. PT 5 wheeled the resident out of the therapy room, to the resident's room, and told the staff that the resident needed to be changed. Certified Nursing Assistant (CNA) 17 had come into the resident's room and told the resident that the resident was going to be assisted to eat in her room, then the resident would be laid down in bed and the brief changed after eating lunch.
On 7/24/23 at 12:26 p.m., CNA 17 brought Resident 5's lunch tray into her room and indicated she was told by staff, CNA 10, to assist Resident 5 with her meal in her room, because Resident 5 had soiled in her brief. CNA 17 was to lay her down after feeding the resident lunch. CNA 17 indicated she did not have the time to change Resident 5's brief now. Resident 5 told CNA 17 she wanted to eat the ice cream first, because the ice cream was already melting. CNA 17 opened the partially melted ice cream container and fed Resident 5 the soft ice cream, while Resident 5 sat in her wheelchair in the urine saturated brief.
On 7/24/23 at 12:39 p.m., PT 5 indicated at about noon Resident 5 was in the therapy room receiving therapy. The resident was repositioned in the wheelchair, the resident was saturated in urine, and the urine was running onto the therapy floor. PT told Resident 5 that she would take her down to her room to be changed from the wet brief before lunch. PT 5 indicated she had told CNA 10 that Resident 5 was wet and needed to be changed. CNA 10 told CNA 17, Resident 5 needed to be changed from the wet brief.
On 7/24/23 at 12:59 p.m., the Administrator indicated she had spoken to Resident 5 and the resident had indicated she would eat her meal in her room, before being changed from the wet brief. The Administrator then had spoken to CNA 10. CNA 10 told the Administrator that she had told CNA 17 to feed Resident 5 in her room, then change her wet brief. Staff had not asked Resident 5 if the resident wanted to be changed from the wet brief, prior to eating lunch. The Administrator indicated she had sent CNA 10 and CNA 17 home for not providing incontinence care to the resident before the resident was assisted to eat her lunch.
On 7/24/23 at 1:20 p.m., the Administrator indicated she had spoken to the PT 5. PT 5 indicated she had told CNA 10 and CNA 17 that Resident 5 needed to be changed from the wet brief. The Administrator indicated she was going to have staff complete a skin sweep of all residents in the building.
On 7/24/23 at 3:03 p.m., the Regional [NAME] President (VP) indicated, CNA 17 was sent home today for not providing incontinence care to Resident 5. The facility was completing a facility wide skin check review of all the residents.
On 7/25/23 at 10:05 a.m., Resident 5 indicated yesterday at lunch time, my ice cream was already melting, and my sandwich was warm. So I wanted to eat my meal, while the ice cream was still partially frozen, and the sandwich was still warm.
On 7/26/23 at 10:48 a.m., the [NAME] President (VP) indicated Resident 5 had soiled her brief in the therapy room. PT 5 took the resident back to her room and notified CNA 10 the resident needed incontinence care due to a wet brief. CNA 10 had communicated that information of Resident 5's wet brief to CNA 17. CNA 17 had asked CNA 10 for guidance because it was mealtime. So, CNA 17 had asked Resident 5 what the resident preferred, being fed lunch or being changed now. Resident 5 indicated she would eat first. The CNA left the room to get the resident's lunch tray and then fed her lunch. Resident 5 was cognitive and was able to make her needs known. The facility had suspended from work CNA 17 and CNA 10 for not providing incontinence care, prior to feeding Resident 5 her lunch.
On 7/27/23 at 8:45 a.m., the Regional Director of Clinical Operations (RDCO) 14 indicated she had spoken to Resident 5 and Resident 5 had indicated, staff had asked her if she wanted to be transferred into the bed and changed or did the resident want to eat her lunch first. Resident 5 had told staff that she would eat her lunch first and then be changed from the wet brief.
Resident 5's record was reviewed, on 7/26/23 at 9:15 a.m. Diagnoses included, but were not limited to, major depressive disorder (mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), unspecified anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), quadriplegia (a symptom of paralysis [loss of the ability to move and sometimes to feel anything in part or most of the body] that affects all a person's limbs and body from the neck down), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand, right wrist, left wrist, dysphagia-oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat) and complete traumatic amputation at level between the right knee and ankle.
A significant change in status Minimum Data Set (MDS) assessment, dated 4/25/23, indicated Resident 5 was cognitively intact; required total dependence of two staff members for bed mobility, transfer, bathing, and toilet use; total dependence of one staff member for eating and personal hygiene; had functional limitation in range of motion in the upper and lower extremities on both sides of the body; was always incontinent of bladder and bowel; and had a stage 3 pressure ulcer injury (full-thickness skin loss potentially extending into the subcutaneous tissue layer), and was at risk for pressure ulcers.
An ADL's functional status/rehabilitation potential care plan, dated 4/11/23, indicated the resident required assistance with ADL's including bed mobility, transfers, eating, and toileting with interventions included, but were not limited to, assist with transfers as needed per mechanical lift and two staff assistance, assist with eating and drinking as needed, and assist with dressing/grooming/hygiene as needed, with the goal of the resident had a desire to improve current functional status.
A progress note, dated 4/3/23 at 6:39 p.m., indicated, Resident 5 had acquired a new wound/skin injury, stage 3 pressure ulcer, to the right gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) with pain of tenderness to touch or pain when pressure was on the area. The root cause of the pressure ulcer determination was of high friction area, incontinence, and staying in a wheelchair. A new intervention was initiated of staff to assist resident to bed between meals.
A pressure ulcer/injury care plan, dated 4/7/23, indicated Resident 5 had a pressure ulcer to the right gluteal fold, with interventions included, but were not limited to, staff to assist resident to bed between meals, if the resident preferred to stay up, offer to lay down and change resident prior to getting back up, keep off affected area as much as possible, and keep area clean and dry.
A urinary incontinence care plan, dated 4/11/23, indicated Resident 5 required assistance with toileting/incontinence due to diagnoses and medication use, with interventions included, but were not limited to, assist with elimination and incontinence care as needed, with the goal of the resident will be free from adverse effects from incontinence.
A Physical Therapy treatment encounter note, dated 7/24/23 at 1:31 p.m., indicated Resident 5 had received physical therapy on that day and the session had ended early due to the resident requiring assistance for clean up from soiling her brief and during the therapy session had experienced 4 out of 10 intermittent pain scale in the right thigh region and both knees.
A note, handwritten and signed by PT 5, dated 7/24/23 at 3:22 p.m., indicated, PT 5 had Resident 5 in the therapy gym, repositioned the resident in her wheelchair, and noticed a puddle of urine on the floor. CNA 12 walked by the gym and Resident 5 told CNA 12 that she needed to be changed. CNA 12 told Resident 5 and PT 5 the name of the CNA in charge of the resident's care (CNA 17) and to let her know. PT 5 took the resident back to her room. On the way back, CNA 12 and CNA 17 passed each other in the hallway and CNA 12 told CNA 17 that Resident 5 needed to be changed and she glanced in our direction. PT 5 took Resident 5 to her room, gave the resident her call light, and went to find towels. As PT 5 exited the linen closet, CNA 17 was observed walking into Resident 5's room. Resident 5 indicated to CNA 17 that she needed to be change. PT 5 returned to the therapy gym.
A handwritten note, dated 7/24/23, signed by CNA 17, indicated therapist had pushed Resident 5 down and the hall, 12:10 p.m., lunch time, and told CNA 17 Resident 5 was wet and left a puddle on the floor in therapy. CNA 17 had felt under the resident's wheelchair, and it was not wet, and CNA 17 did not observe any wetness. CNA 17 had asked another CNA what to do. The CNA told CNA 17 to ask Resident 5 if it was okay to feed her in her room today for lunch and then change her brief . Resident 5 had indicated she wanted to eat first, and that was what CNA 17 did, fed her then laid Resident 5 down and changed her.
A handwritten note, dated 7/24/23, signed by CNA 10, indicated, a CNA came to her and asked what she would do. CNA 10 indicated, she would ask Resident 5 what she wanted to do, get changed or eat first. Resident 5 told the other CNA she wanted to eat first. So, the CNA fed the resident in her room for her dignity.
A Social Services Director (SSD) handwritten note, dated 7/24/23, indicated Resident 5 had told the SSD, the therapy lady had told Resident 5 that she had a little puddle underneath her, when she was in therapy and the therapist brought the resident back to her room and told staff the resident was wet and needed to be changed. Staff told the therapist to leave the resident in her room, staff would feed the resident in her room, then put the resident in her bed to change her wet brief, and that was fine with the resident. The resident would like to be changed, but it was feeding time now. The food came and the ice cream was already melting, and she ate that first.
A handwritten note, dated 7/26/23, signed by the RDCO, the Administrator, and the Registered Nurse/Unit Manager (RN) 8 indicated, during an interview, Resident 5 had indicated, on Monday 7/24/23, the aide came into her room without her lunch tray and asked Resident 5 if she wanted to be changed first and then eat. The resident had told the aide that she wanted to eat first. The aide returned to the resident's room with the lunch tray.
A psychologist note, dated 7/28/23 at 1:26 p.m., indicated a session with Resident 5 had been conducted, on this date, via telehealth of a staff request for a wellness check for Resident 5, related to the event, on Monday 7/28/23. Resident 5 described the event in question. She indicated she experienced an incontinence episode around the time lunch was being served. Resident 5 shared how she was hungry and her lunch, notably included ice cream, so she elected to be changed after she finished her ice cream and meal. Resident 5 reported it was her decision to eat first before initiating the care/hygiene process. Resident 5 denied having been denied access to care, any emotional distress or mental anguish related to this event. She denied it as having been traumatic and further denied any associated related trauma or distress symptom response.
The resident's record and incident investigation lacked documentation that the resident was educated that her food would be kept warm and her ice cream cold if she elected to get changed first and taken to the dining room. The record lacked documentation that the resident was educated on the effects on her pressure ulcers of sitting in urine. The record lacked documentation the resident was assessed for pain when sitting in her urine.
Prevention and Care for Incontinence-Associated Dermatitis Among Older Adults: A Systematic Review - PMC (nih.gov) (2010) was retrieved on 7/25/23 from the National Library of Medicine website. The guidance included, .Damage to the skin can occur within 10-15 minutes following contact with moisture from stool or urine, causing overhydration and a slight swelling. In addition, the presence of friction and shear mechanical forces can decrease skin functioning and cause skin injury. Thus, the potential for skin breakdown among incontinent older adults requires careful assessment and care .
On 7/24/23, the ADM provided and identified a document as the facility's admission agreement, including the Resident Rights policy, for all residents and was the current facility policy, dated 12/2022. The policy indicated, .Nursing Home Resident Rights .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident .Respect and Dignity .The resident has the right to be treated with respect and dignity, including the right to: .Reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents
3.1-9(a)

Based on record review and interview, the facility failed to accurately report weekend staffing hours in the PBJ (payroll-based journal) reporting system for the 1 of 3 staffing quarters in 2023.
Findings include:
During review of the CASPER (Community Assessment for Public Health Emergency Response) report, on 7/21/23 at 9:00 a.m., the CASPER report indicated, the facility had reported low weekend staffing and a 1-star staffing rate for the second quarter of 2023.
During an interview, on 7/28/23 at 9:28 a.m., the Regional [NAME] President of Clinical Operations (VP) indicated, the PBJ information was inputted by the corporate office and the data was not correct. The salary staff and the agency staff were not included on the schedule for the PBJ data.
During an interview, on 7/28/23, the Administrator (ADM) indicated the facility did not have a policy regarding the PBJ reporting and the facility followed the state regulation regarding this.
The deficient practice was corrected by 4/1/23, prior to the start of the survey and was therefore Past Noncompliance. The facility had implemented a systemic plan that included hiring more licensed and unlicensed staff for the weekends, moving staff to work the weekends, and accurately reporting staffing hours. Current staffing was reviewed during the survey without concerns.
3.1-17(a)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, when 3 errors were observed during 35 opportunities resulting in an error rate of 8.57% related to not administering medication in accordance with physician's orders and manufactures instructions for 3 of 3 residents observed for insulin administration (Residents 20, 17, and 9).
Findings include:
During a random continuous observation, on 7/26/23 from 11:25 a.m. to 12:44 p.m., Registered Nurse (RN) 11 indicated there were 4 residents with orders for blood glucose monitoring using a glucose meter and insulin coverage before lunch. Resident 24 was observed to refuse to have her blood sugar checked per glucose meter, RN 11 indicated the refusal was normal for this resident.
1. On 7/20/23 at 12:41 p.m., RN 11 was observed preparing a glucose meter and Novolog flex pen (a rapid-acting insulin available in a disposable insulin pen with a push-button extension) for Resident 20. RN 11 indicated the resident had always done his own blood sugar check and given his own insulin as he did not like the staff poking him. RN 11 gave Resident 20 the glucose meter, and observed as he checked his glucose, the reading was 259 (normal range for an adult per the American Diabetic Association 70-99).
RN 11 was observed to prepare a Novolog flex pen, indicated the resident was to receive 11 units (U) per the routine dose, and due to his high blood sugar reading would get an additional 6 U. RN prepared the flex pen by putting a needle on the opened pen, dialed up the dosage, and handed the flex pen and alcohol prep pad to the resident. RN 11 observed the resident as he cleaned the skin on the back of his right upper arm out of his sight, place the flex pen against his skin, pushed the button, and immediately pulled the needle back out. During this process, RN 11 was not observed to clean the end of the flex pen before putting a needle on the pen, did not prime the pen (perform an air shot by dialing up 2 U of insulin, press the button, and make sure insulin came out of the needle to assure no air bubbles and pen functional), and did not prompt the resident to hold the needle in his arm long enough to allow the insulin medication time to administer (slowly counting to 10 after pressing the dose button). Additionally, the sliding scale insulin was administered late.
Resident 20's record was reviewed on 7/27/23 at 9:54 a.m. Diagnoses on Resident 20's profile included, but were not limited to, schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis), and type 2 diabetes mellitus (the body either doesn't produce enough insulin, or it resists insulin) with skin ulcer, diabetic kidney disease, and diabetic retinopathy (damage to the retina).
A physician's order, dated 5/5/23, indicated Novolog Flex Pen U-100 Insulin, administer insulin subcutaneous per sliding scale according to blood glucose results three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m.
If Blood Sugar is less than 60, call MD (physician).
If Blood Sugar is 0 to 119, give 0 Units.
If Blood Sugar is 120 to 160, give 2 Units.
If Blood Sugar is 161 to 200, give 5 Units.
If Blood Sugar is 201 to 240, give 8 Units.
If Blood Sugar is greater than 240, give 11 Units.
If Blood Sugar is greater than 400, call MD.
A physician's orders, dated 5/22/23, indicated Novolog Flex Pen U-100 Insulin give 6 U subcutaneous three times a day at 7:30 a.m., 12:00 p.m., and 5:00 p.m., administer with sliding scale dosage.
A physician's order, dated 7/11/23, indicated Lantus Solostar U-100 Insulin give 13 U twice daily 6:00 a.m. - 11:00 a.m., and 6:00 p.m. - 11:00 p.m. RN 11 indicated, this insulin was administered around 5:00 a.m. by the night nurse.
Blood sugar monitoring for Resident 20, dated July 2023, indicated his blood glucose levels were documented 3 to 5 times daily, and ranged from 79 to 346. There were only 2 readings within the normal range.
Resident 20's record, dated 1/16/23 to 7/27/23, lacked documentation a medication self-administration assessment was completed. The record lacked a physician's order for self-administration of insulin, a care plan for self-administration of medication, and documentation the resident was educated on proper procedure for administering insulin with a Novolog flex pen.
A quarterly Minimum Data Set (MDS) assessment, dated 6/27/23, indicated the resident had the ability to make himself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicated the resident had moderately impaired cognition. Documentation of 7 insulin injections were received during the last 7 days.
A care plan for Resident 20, indicated the resident was at risk for effects of hyperglycemia (blood glucose levels too high) or hypoglycemia (blood glucose levels too low) related to use of glucose lowering medication and/or diagnosis of diabetes mellitus. The goal was for the resident to not experience symptoms of hyperglycemia or hypoglycemia. Interventions included diet as ordered, document abnormal findings and notify the MD, medications as ordered, and monitor blood sugars as ordered.
During an interview, on 7/27/23 at 9:48 a.m., RN 11 indicated she was not sure if Resident 20 had a physician's order to self-administer his medications. But he would not let the staff poke him, he had done it before being admitted , and it was his choice to do his own.
During an interview on 7/27/23 at 10:20 a.m., Resident 20 was observed lying on the bed. He indicated he had been back into the facility for about 7 months. During his stay staff had allowed him to check his own blood sugars and administer his own insulin. When giving his insulin he held the needle in the skin about 2 seconds. Staff had not educated him on the use of the glucose monitor or giving his own insulin.
2. During a random insulin administration observation for Resident 17 on 7/26/23 at 11:39 a.m., RN 11 was observed to check the blood glucose level with a result on 212. She then prepared a Novolog flex pen but putting a needed onto an opened pen, dialed up 6 U of Novolog insulin, put the insulin needle into the abdomen, pushed in the plunger, and immediately pulled the needle back out. RN 11 did not clean the pen before putting on a needle, did not prime the flex pen, and when the insulin was administered she put the needle into the skin and pulled it back out in one fluid movement, not giving time for the insulin to administer.
Resident 17's record was reviewed on 7/27/23 at 10:39 a.m. Diagnoses on Resident 17's profile included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy (nerve damage that occurs with diabetes that most often affects the legs and feet).
A physician's order, dated 8/20/23, indicated to administer Novolog Flex Pen U-100 Insulin per sliding scale according to blood glucose results three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m.
If Blood Sugar is less than 60, call MD.
If Blood Sugar is 0 to 129, give 0 Units.
If Blood Sugar is 130 to 175, give 3 Units.
If Blood Sugar is 176 to 225, give 6 Units.
If Blood Sugar is 226 to 275, give 9 Units.
If Blood Sugar is 276 to 325, give 12 Units.
If Blood Sugar is 326 to 400, give 20 Units.
If Blood Sugar is greater than 400, call MD.
Blood sugar monitoring for Resident 17, dated July 2023, indicated his blood glucose levels were documented 3 times daily, ranged from 75 to 398, and had only 5 readings within the normal range.
A quarterly MDS assessment, completed on 6/27/23, indicated the resident had the ability to make himself understood and to understand others. BIMS score 12/15 indicated moderately impaired cognition. Documentation of 7 insulin injections were received during the last 7 days.
A care plan for Resident 17, indicated the resident was at risk for effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus. The goal was for the resident to not experience symptoms of hyperglycemia or hypoglycemia. Interventions included, diet as ordered, document abnormal findings and notify the MD, medications as ordered, and monitor blood sugars as ordered.
3. During a random insulin administration observation for Resident 9 on 7/26/23 at 12:14 p.m., RN 11 was observed to check the blood glucose level with a result of 354. She then dialed up 18 U of Novolog insulin (Novolog 8 U routine and 10 U sliding scale), put the insulin needle into the abdomen, push in the plunger, and immediately pull the needle back out. She was observed to take the insulin pen out of the refrigerator and administer. It should have been used at room temperature by taking the flex pen out of the refrigerator 1 to 2 hours before use. When the insulin was administered, she put the needle into skin and pulled it out in one fluid movement, not giving time for the insulin to administer. Additionally, the medication was administered late after removing the resident from the dining room after she had already started eating.
Resident 9's record was reviewed on 7/27/23 at 11:42 a.m. Diagnoses on Resident 9's profile included, but were not limited to, Alzheimer's disease, and type 2 diabetes with kidney disease and diabetic neuropathy.
A physician's order for Resident 9, dated 7/11/23, indicated Novolog Flex Pen U-100 Insulin, administer 8 U subcutaneous three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m. Hold if blood sugar under 120.
A physician's order for Resident 9, dated 7/18/23, indicated Novolog Flex Pen insulin, administer insulin subcutaneous per sliding scale according to blood sugar results three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m.
If Blood Sugar is less than 60, call MD.
If Blood Sugar is 0 to 119, give 0 Units.
If Blood Sugar is 120 to 200, give 4 Units.
If Blood Sugar is 201 to 250, give 7 Units.
If Blood Sugar is greater than 250, give 10 Units.
If Blood Sugar is greater than 400, call MD.
Blood sugar monitoring for Resident 9, dated July 2023, indicated her blood glucose levels were documented 3 times daily, always documented as above normal, ranged from 102 - 544, with 3 readings over 400 on 7/7 at 544, 7/10 at 496, and 7/16 at 436.
A quarterly MDS assessment, completed on 6/21/23, indicated resident usually had the ability to make herself understood and usually to understand others. BIMS score 12/15 indicated moderately impaired cognition. Documentation of 7 insulin injections were received during the last 7 days.
A care plan for Resident 9, indicated the resident was at risk for effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus. The goal was for the resident to not experience symptoms of hyperglycemia or hypoglycemia. Interventions included, diet as ordered, document abnormal findings and notify the MD, medications as ordered, and monitor blood sugars as ordered.
During an interview on 7/27/23 at 9:40 a.m., Registered Nurse (RN) 11 indicated, at lunch time there were 6 residents that had orders for blood sugar monitoring with insulin coverage, and if she was the only nurse or working with a Qualified Medication Aide (QMA), she checked the blood sugar levels and administered the insulin for all of them. There were 3 glucose monitors that were shared between residents for blood sugar monitoring, and the residents all had flex pens with insulin. The insulin pens were kept in the medication room refrigerator before being opened. After a flex pen was opened it was stored at room temperature on the medication cart for up to 28 days. Her process for administering insulin included, put a needle on the insulin pen, dial up the amount of insulin to be administered, ask the resident where they wanted their shot, put the needle in the skin, push the dial button, hold a couple to 3 seconds, and take out the needle.
During an interview on 7/27/23 at 2:15 p.m., RN 11 indicated she had received education on use of the Novolog flex pen in the past but had not had education at this facility. She was not aware of needing to bring the flex pen up to temperature when removing from the refrigerator by waiting 1 to 2 hours before using or holding the flex pen in the skin by counting to 10, per manufacturer instructions. She thought she only needed to hold the pen in the skin for administration for 3 seconds.
During an interview on 7/27/23 at 3:45 p.m., the Executive Director (ED) indicated blood glucose monitoring and insulin administration education had been provided to staff in preparation for their annual survey, she was unable to locate documentation of the education.
On 7/27/23 at 3:45 p.m., the Regional Director of Clinical Operations (RDCO) provided a Nursing Skills Competency list, titled, Insulin Pen Administration, dated 10/2019, and indicated the competency was the one currently being used by the facility. The competency indicated, 8. Attach pen needle by twisting the needle onto end of insulin. 9. Pull off and remove outer pen needle protective cap and cover. 10. Prime the pen by dialing 2 units. 11. Push the end of the pen to push out the 2 units. [A small drop of insulin should be visible. If insulin does not appear, repeat]. 12. Dial desired insulin dosage to be administered to resident. 13. Choose an injection site. 14. Cleanse injection site with alcohol swab and allow to dry. 15. Grasp about one inch of skin between thumb and finger of non-dominant hand. 16. Insert pen needle at a 45 - 90 - degree angle into skin. 17. Push injection button down at end of pen completely to give insulin. 18. Wait 5 - 10 seconds while keeping insulin pen and pen needle in place, to ensure all insulin is given. 19. Pull the insulin pen and needle out from the injection site .
3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure proper handling of linens used in the kitchen and to ensure paper towels were available for proper handwashing, during 1 of 2 kitchen observations. This deficient practice had the potential to effect 36 of 36 residents who received food from the kitchen.
Findings include:
1. On 7/24/23 at 9:46 a.m., Housekeeper 6 was observed carrying clean linen into the kitchen area. The linens were being held up against the housekeeper's uniform.
2. The initial kitchen observation was completed with [NAME] 7, on 7/24/23 at 10:04 a.m. While washing their hands at the handwashing sink, the visitor observed there were no paper towels available to dry their hands and to turn off the water at the sink. At the same time, [NAME] 7 indicated since there were no paper towels available, there were clean towels in the bin under the sink, which would be used to dry their hands and turn off the water at the sink. She had not yet seen a housekeeper to request more paper towels be placed next to the handwashing sink. A towel from the bin was used, by the visitor, to dry their hands. When retrieving a second towel to turn off the water at the sink, the visitor pulled what appeared to be a dry mop head from the bin.
On 7/24/23 at 10:07 a.m., [NAME] 7 retrieved the used towels from the visitor and then touched a lid of the receptacle, she identified as the receptacle to place the dirty towels into after use, with her bare hands. After touching the lid of the receptacle, she indicated had completed a safe food handing course and understood she needed to wash her hands after touching the lid. The [NAME] was not observed to wash her hands during the remainder of the kitchen observation.
During an interview, on 7/24/23 at 11:18 a.m., the Housekeeping Supervisor indicated there should always be paper towels in the kitchen and staff should not be using the towels in the bin below the handwashing sink to dry their hands. The kitchen staff should have notified one of the housekeeping staff and got the paper towels refilled. The towels in the bin under the handwashing sink were for use in the sanitation of the kitchen. The housekeeping staff would always ensure there were paper towels in the kitchen storage room available for the kitchen staff. At the same time, she indicated no staff should ever carry clean linens up against their bodies.
During an interview, on 7/25/23 at 10:59 a.m., the Culinary Manager indicated paper towels were not routinely kept in the kitchen storage room. Housekeeping provided the paper towels to the kitchen. When paper towels were needed, the kitchen staff were to notify the housekeeper to replace their stock. The cloth towels in the bin were used for cleaning purposes only.
On 7/25/23 at 11:36 a.m., the Regional Director of Clinical Operations (RDCO) provided a document, with a revision date of 7/2022, titled, Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .Hand Hygiene with soap and water [hand washing]. 1. Check that the sink area are supplied with soap and paper towels .8. Use clean paper towel; dry hands and wrists thoroughly. 9. Discard paper towels in wastebasket. 10. Use paper towels to turn off faucet
On 7/25/23 at 12:00 p.m., the RDCO provided a document, with a revision date of 12/2021, titled, Laundry/Linen, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .2 .i. Clean linen should be carried away from body to prevent contamination
3.1-19(g)
3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure proper storage of a respiratory bilevel positive airway pressure (BiPAP) equipment (machine used to supply pressure to push air into the lungs) (Resident 15) and failed to ensure a physician's order for oxygen therapy was followed (Resident 13) for 2 of 2 residents reviewed for respiratory care.
Findings include:
1. On 7/25/23 at 11:15 a.m., Resident 15's BiPAP mask was observed unbagged, on the resident's bed.
On 7/26/23 at 12:57 p.m., Resident 15's BiPAP mask was observed unbagged, on the resident's bed. Resident 15 indicated, he used the BiPAP every night to help with his breathing and sleep.
On 7/27/23 at 11:54 a.m., Resident 15's BiPAP mask was observed on the resident's bed, not bagged.
On 7/27/23 at 2:56 p.m., the Regional Director of Clinical Operations (RDCO) observed Resident 15's unbagged BiPAP mask on the resident's bed and indicated, the BiPAP face mask should be bagged, when not in use.
Resident 15's record was reviewed, on 7/27/23 at 2:04 p.m. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia (deficiency in the amount of oxygen reaching the tissues in the body) and chronic obstructive pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A quarterly Minimum Data Set (MDS) assessment, dated 6/29/23, indicated the resident was cognitively intact, experienced shortness of breath when lying flat, and received oxygen therapy.
A care plan, dated 11/22/22, indicated the resident was at risk for impaired gas exchange related to chronic respiratory failure with hypoxia and COPD. Interventions included, but were not limited to, BiPAP treatments as ordered.
A physician's order, dated 11/22/22, indicated, BiPAP Settings: 12-16cm H2O (water) with 3 liters (L) of oxygen at bedtime and off upon waking.
On 7/28/23 at 8:50 a.m., the RDCO provided and identified an undated document as a current facility policy, titled Bi-Level Therapy, and she indicated, the facility policy did not specify the storage of a BiPAP mask, but the BiPAP face mask should be bagged, when not in use.
2. On 7/24/23 at 10:00 a.m., during an observation, Resident 13 was sleeping in bed. The head of the bed was slightly elevated. The call light was under the left hand. A water pitcher was on a table against the far wall out of the reach of the resident. Oxygen was being administered via an oxygen concentrator, (concentrators pull in room air, separates the other gases from the oxygen, exhausts the other gasses, and delivers the oxygen to the patient), at 4 liters (L) via nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels).
On 7/25/23 at 11:15 a.m., observed the resident lying in bed with call light under her left hand. The head of the bed was in a slightly elevated position. Oxygen was being administered at 4 L via NC per an oxygen concentrator. Resident appeared to be anxious and tearful and indicated she was in pain. Licensed Practical Nurse (LPN) 5 administered pain medication. Resident was groaning and made gurgling sounds. Registered Nurse (RN) 8 observed resident. The resident vomited a large amount of yellow liquid. The head of the bed was elevated, and personal care was provided to the resident.
On 7/26/23 at 2:16 p.m., observed the resident lying in bed. The head of the bed was elevated, and oxygen was being administered at 4 L via NC per an oxygen concentrator. The resident denied pain, the call light was within reach. The resident indicated she did not feel well but gave no specific complaints and indicated she had no recurrence of nausea or vomiting from the day before.
On 7/27/23 at 9:15 a.m., observed the resident lying in bed. The water pitcher was on the overbed table within reach. The call light was on the left side of the bed within reach. Oxygen was being administered at 4 L via NC per an oxygen concentrator.
On 7/27/23 at 11:45 a.m., interview with RN 8, RN observed the oxygen delivery was set at 4 L and being administered via a nasal cannula (NC). The RN indicated the oxygen order was for oxygen administration 2 L at bedtime. The RN lowered the oxygen to 2 L.
On 7/27/23 at 11:50 a.m., RN 8 reviewed the medical record, current orders, and the current hospice orders, and identified a physician order dated 5/10/23 for oxygen administration 2 to 5 L as needed for diagnosis of, Chronic Obstructive Pulmonary Disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems). The current medical record indicated, an order dated 4/14/23, oxygen administration 2 liters per nasal cannula at night. RN 8 acknowledged the oxygen was administered continuously and orders were different.
On 7/27/23 at 2:00 p.m., phone interview with hospice nurse, the nurse indicated an order was written and dated, 5/10/2023 for oxygen to be administered at 2 to 5 L as needed. The hospice nurse indicated the order had been initiated during hospice admission and the hospice nurse would write an order and would notify the facility nurse of any new orders that were written during the admission process. During follow-up visits the hospice nurse would review and verify all orders, any orders that were written during that visit were given to the nurse assigned to the resident.
On 7/25/23 at 12:12 p.m., the medical record for Resident 13 was reviewed. The medical record indicated an order for hospice care services for diagnosis of COPD. Hospice physician order, dated 5/10/23, indicated oxygen administration 2 to 5 L as needed for diagnosis of COPD. The current medical record indicated an order, dated 4/14/23, oxygen administration, 2 liters per nasal cannula at night. The oxygen order for both medical records lacked documentation of oxygen administration device and lacked documentation for an indication to administer oxygen as needed and at night.
Diagnoses included, but were not limited to, hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength), following other cerebrovascular disease affecting right dominant side, COPD, Hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), with anxiety (a feeling of fear, dread, and uneasiness) It can be a normal reaction to stress), Unspecified sequelae (residual effects or conditions produced after the acute phase of an illness or injury has ended) of cerebral infarction (the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel).
The Quarterly Minimum Data Set, (MDS-a standardized assessment tool that measures health status in nursing home residents), dated 7/6/23, indicated a diagnosis of COPD, Hospice services, and oxygen administration.
A Care Plan dated 4/11/2023, indicated the Resident has potential for impaired gas exchange related to diagnosis of COPD and shortness of breath when lying flat. Goal date 8/27/2023, the resident will have adequate respiratory functions as evidenced by decreased or absence of dyspnea, improved breath sounds, decreased or absence of shortness of breath and improved oximetry results. An intervention, dated 4/11/23, included but were not limited to, administer medications as ordered, and administer oxygen as ordered 2 L at night.
Documentation lacked evidence of communication between the facility and the hospice nurse identifying correct oxygen orders for oxygen delivery device, liter flow or administration times.
On 7/28/23 at 10:14 a.m., the Regional Director of Clinical Operations (RDCO) provided a document titled, Hospice Policy dated 1/2016, revision dates 11/17, 10/18, 8/19 and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility that when a resident elects the hospice benefit that the contracted hospice company and facility will coordinate to establish both a person-centered plan of care reflecting the physical, spiritual, mental, and psychosocial needs of the resident as well as a pattern of communication between the hospice company, healthcare professionals, facility staff and resident/representative. Procedure: .2. c. Care and services (including medications and supplies) that the facility and hospice will provide in order to be responsive to the residents needs and desire for hospice care
On 7/28/23 at 10:45 a.m., the Regional Director of Clinical Operations (RDCO) provided an undated document titled, Oxygen Therapy and Devices and indicated it was the policy currently being used by the facility. The policy indicated, . Indications for oxygen use . 1. Obstructive pulmonary disease . Definition of Oxygen . 1) Oxygen is a drug which must be ordered by a physician . c. Concentrated . i. Units plugs into the wall . ii. Concentrators pull in room air, separates the other gases from the oxygen, exhausts the other gasses, and delivers the oxygen to the patient .Initiation of oxygen .1) Verify physician order .7) Apply device to the patient with appropriate liter flow .Oxygen Devices .1) Nasal cannula .a. Low flow device by which nasal prongs are placed in the nares to deliver up to 44% oxygen using 1-6 LPN
3.1-47(a)(4)
3.1-47(a)(5)
3.1-47(a)(6)