Every finding on record at Adams Woodcrest

Based on observation, interview, and record review the facility failed to ensure sanitation of an ice machine; labeling, dating and removal of expired food items in the kitchen and unit pantries. 110 of 110 residents received food prepared in the facility kitchen. Findings include: During a kitchen observation beginning [DATE] at 9:11 AM, a bottle of lemon juice was observed in a reach in cooler with an open date of [DATE]. No printed manufacturers expiration date was found on the bottle. Ziploc baggies filled with light brown material were observed in a container directly beneath the evaporator and fan unit in the walk-in freezer. The bags were frozen together and covered in an irregular pyramid shaped clump of ice about 4 inches above the container and spread across the width of the container, covering about ,d+[DATE] of the contents of the container. An additional container of Ziploc bagged bananas contained bananas dated [DATE] and [DATE] with visible white frosty debris on top of the bananas. A bag of tater tots tied closed with a twist-tie was observed on a shelf. No open date was recorded on the bag of tater tots. During an interview, on [DATE] at 9:14 AM, the Nutrition Services Manager (NSM) indicated lemon juice was fine for a long time and did not need discarded. The NSM did not provide a date on which the juice should be discarded. During an interview, on [DATE] at 9:15 AM, the Dietary Manager (DM) indicated the lemon juice should be discarded within 7 days. The DM indicated the bags covered in ice contained bananas and should be discarded. She indicated frozen bananas were good for one year. The DM indicated the tater tots should have been dated upon opening. During an observation, on [DATE] at 10:13 AM, two cups of yogurt were observed in the refrigerator in the A-wing pantry. The expiration date on each container was [DATE]. Two containers of lime sherbet were observed in the freezer with no expiration date. During an interview, on [DATE] at 10:14 AM, Qualified Medicine Aide (QMA) 5 indicated the yogurt cups should have been discarded upon expiration and should not have been in the refrigerator. QMA 5 indicated she was not able to determine when the lime sherbet should be discarded because the container did not have an expiration date. During an observation, on [DATE] at 10:38 AM, a round container of ice cream with a loosely applied lid was observed in the freezer in the dementia unit. No open date or manufacturer's expiration date was observed on the container. A rectangular container of black raspberry ice cream was observed in the same compartment of the freezer with no open date on the container. The expiration date on the container contained an ink smear, obscuring the date. Certified Nurse Aide (CNA) 7 opened each lid, revealing a ,d+[DATE] inch coating of frost covering the top of each product. During an interview, on [DATE] at 10:39 AM, CNA 7 indicated the ice cream containers should have been dated when opened and should be discarded. During an observation, on [DATE] at 11:20 AM, black debris was observed in the upper interior portion of the ice machine in the A- wing pantry. In the refrigerator, a foil wrapped container was observed with no date visible. Containers of lime sherbet with no expiration date, and a container of chocolate ice cream with an expiration date on ,d+[DATE] were observed in the freezer. During an interview, on [DATE] at 11:21 AM, Licensed Practical Nurse 6 indicated the black debris should not be present in the ice machine and the machine should be taken out of service and cleaned prior to any further use. She indicated items in the refrigerator and freezer should be dated when opened and discarded upon the expiration date. She indicated any undated items should be discarded. A current policy, titled Resident Pantry, dated ,d+[DATE], provided by the Administrator on [DATE] at 5:12 PM indicated the nursing staff was responsible for cleaning and maintaining the residents' pantries. The policy indicated all food and drink items should be marked with the date opened at the time of opening and discarded 7 days after opening. The policy indicated the nursing department was responsible for checking for and discarding expired items daily. A current policy, titled Labeling, Dating, and Discarding Foods, provided by the Administrator on [DATE] at 5:12 PM indicated all foods, once opened or manufactured, should be labeled, dated, and discarded to food code regulations. The policy indicated frozen items should be discarded within 180 days. A current policy, titled Ice Machines and Portable Ice Carts, provided by the Administrator on [DATE] at 5:12 PM indicated ice machines should be cleaned quarterly and as needed when contaminated or visibly soiled. 3XXX,d+[DATE](i)(3)

Based on interview and record review the facility failed to enusre non pharmacologic interventions were utilized prior to giving anti-anxiety medication to 1 of 6 residents reviewed. (Resident 4) Findings include: In an interview, on 11/21/24 at 10:02AM, the Registered Nurse (RN 3) indicated Resident 4 frequently had behaviors related to anxiety. RN 3 indicated Resident 4 was difficult to redirect but if caught early or at the right time you could attempt playing music or walk with her. RN 3 indicated giving her the prn (as needed) Ativan ( anti anxiety medication) was the easiest and best way to deal with the behaviors. Resident 4's record review began on 11/22/24 at 12:22PM. Resident 4's diagnoses included Alzheimer's disease, chronic pain, and anxiety. Resident 4's physician orders included Buspar 20mg three times a day. Ativan tablet 0.5mg give 1 tablet by mouth every 4 hours as needed for distress start date 10/29/24 end date 11/12/24. Ativan 1mg tablet give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days start date 11/13/24 and end date 11/21/24. Ativan tablet 1mg, give 1 tablet by mouth every 4 hours as needed for anxiety for 3 Months dated 11/21/24. Resident 4's current comprehensive Minimum Data Set (MDS), dated [DATE], Section D, for mood indicated no issues. Section E for Behaviors indicated no issues. Resident 4's Medication Administration Record (MAR), dated November 2024 was reviewed. On 11/1/24, Ativan 0.5 mg was administered at 3:02 PM. On 11/7/24, Ativan 0.5mg was administered at 12:34PM On 11/8/24, Ativan 0.5mg was administered at 8:57PM. On 11/9/24, Ativan 0.5mg was administered at 9:00AM. On 11/9/24, Ativan 0.5mg was administered at 4:40PM. On 11/12/24, Ativan 0.5mg was administered at 2:05PM. On 11/13/24, Ativan 0.5mg was administered at 2:00PM. On 11/15/24, Ativan 0.5mg was administered at 7:04PM. On 11/21/24, Ativan 0.5mg was administered at 7:20PM A progress note, dated 11/1/24 at 3:16 PM, indicated the resident refused medications all day. She had a garbage bag packed of random things, and said she was going home. She had been paranoid, hallucinating, and interfereing with other residents. RN3 was finally able to convince the resident to take prn Ativan at around 3PM. The note indicated the staff would continue to monitor behaviors. No deescalating techniques were documented in the note. A progress note, dated 11/7/24 at 6:14PM, indicated Resident 4 was VERY anxious throughout the shift. Very argumentative with staff and refused to come back from hair salon. Resident 4 refused to take her medications after several attempts, until RN 3 indicated they were from her daughter. PRN Ativan was given at this time. Resident 4 was tearing apart an entire box of tissues and pulling apart the layers and trying to sew them back together. Resident 4 refused to use her walker. Resident 4 attempted to enter the restroom with other residents. PRN Ativan was given. The note did not indicate any deescalating techniques were attempted. A progress note, dated 11/8/24 at 10:39PM, indicated Resident 4 was anxious, was getting dressed for the day after bedtime shower. The resident stated she had to go pick up her kids several times asking where her car was and when the family was coming. PRN Ativan given and effective. No deescalating techniques were documented as attempted. There were no progress notes, dated 11/9/24, regarding Resident 4's behaviors, anxiety, or any interventions attempted prior to antianxiety medication administration . A progress note, on 11/12/24 at 3:55PM, indicated Resident 4 very anxious. PRN Ativan given. Resident 4 asked the same questions repeatedly, the residents packed the entire closet onto her walker and took them to nursing station to inform them she was moving out. Resident 4 was attempting to rouse other residents into leaving with her. PRN Ativan was given but was ineffective. The staff would continue to monitor. No deescalating techniques were documented. A progress note, dated 11/13/24 at 5:52PM, indicated Resident 4 was very anxious after lunch and packing clothes again. Received new orders from the physician to increase Ativan from 0.5mg to 1mg every 4 hours as needed (PRN). It was given. Resident 4 calmed down and was able to enjoy visiting with daughter and friend. There was no documentation deescalating techniques had been attempted. No progress notes were available, dated 11/15/24, to address the use of PRN Ativan. A progress note, dated 11/21/24 at 6:07 PM, indicated Resident 4 refused medications, refused to get dressed and stayed in a house coat throughout the day. Resident 4 was hitting the utility room door. Resident 4 was very difficult to redirect and became very argumentative with staff. Resident 4 was packing belongings. Resident 4's daughter was at supper and indicated she could not convince her mother to get dressed either. There was no documentation of PRN Ativan administration or the medications effectiveness. Behavior monitoring, dated November 2024, indicated the facility was monitoring frequent crying, repeated movements, yelling, kicking/hitting, pushing, grabbing, pinching, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care, none of the above, and not applicable. The only behavior symptom marked was on 11/1/24 at 11:23 PM for refusal of care. There was no other documentation regarding Resident 4's behaviors. Resident 4 was care planned for resistive to care related to dementia, behavioral problems increased anxiety and repetitive questioning, the resident has anxiety, and resident used psychotropic medications. The increased anxiety, refusing medications, attempting to get peers to elope, and repetitive questioning were not on CNA behavior monitoring tasks. Resident 4's Behavior Summary, dated November 2024, indicated Resident 4 had an increase in anxiety 11/20, 11/17, 11/16, and 11/13. The interventions were listed as one-on-one and calls to family. Behavior committee recommendations were; Resident 4 had an increase in anxiety, Ativan 1mg was effective, continue to observe. In an interview, on 11/26/24 at 9:32 AM, the Administrator indicated all staff should be using deescalating techniques and documented behaviors. The Administrator indicated they recently switched their computerized charting, yet the staff were required to document deescalating techniques used and their effectiveness. A policy titled, Behavioral Health Services [NAME] Heritage/[NAME] Woodcrest dated 2/2017, provided by the Administrator on 11/26/24 at 9:24AM indicated .11.Facility will implement person-centered care approached designed to meet the goals and needs of each resident, which includes non-pharmacological interventions. Examples of individualized non pharmacological interventions to help meet behavioral health needs of all ages may include but are not limited to .focusing the resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities, offering verbal reassurance, n. utilizing techniques such as music, art, massage, reminiscing, Providing support with skills related to verbal reescalation, coping skills, and stress management. A policy titled, Psychotropic Medication Policy and Procedure dated 2/1/1994 provided by the Administrator on 11/26/24 at 9:24AM, focused on the duration of the order and each member of the team responsibility to ensure monitoring was in place. There were no noted specified nonpharmacological interventions noted throughout the policy. 3.1-48(b)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was observed during food delivery. 16 of 23 residents were present in the dining room. On 2/1/23 beginning at 11:21 AM, meal service in the A-wing dining room was observed. Server 2 was observed removing her pen from her shirt pocket, then going from table to table taking orders for residents seated at the tables. Server 2 went back and forth to the kitchen window, passing order slips to the kitchen staff through the window. She was observed reaching into the service window placing dishes of food on trays for delivery. Server 2 was observed touching dishes, glassware, tables, silverware, occupied wheelchairs, and residents. She used hand sanitizer one time during meal service to 16 residents. In an interview on 2/1/23 at 11:53 AM, Server 2 indicated she did not know how frequently hand hygiene should be performed. She indicated she normally uses hand sanitizer between every few trays and after touching a resident or their belongings, but she did not during the lunch meal that day. During an interview on 2/2/23 at 11:10 AM, the Dietary Manager indicated hand hygiene should be performed between tasks and after touching residents. A current facility policy titled Hand Hygiene dated 4/27/1987 was reviewed. The policy indicated antiseptic hand rub should not be used during the assembly of meal trays. The policy also indicated servers should ensure their hands were always clean when holding plates or cutlery and hand hygiene should be performed after contact with residents' skin and medical equipment. 3.1-21(a)(3)

Based on observation, interview and record review, the facility failed to ensure physician orders were followed for 2 of 8 Residents reviewed. (Resident 20, and Resident 31) Findings include: 1) During an observation, on 2/1/23 at 8:47AM, QMA 3 (Qualified Medication Aide) took Resident 20's blood pressure prior to medication administration. Resident 20's blood pressure was 122/63. QMA 3 indicated to Resident 20, the medication propranolol would be held due to the blood pressure result. Resident 20 received all other medications due at 8AM. QMA 3 documented medication as held. Resident 20's record was reviewed, on 2/1/23 at 02:08 PM, indicated an order for propranolol 80mg daily related to hypertension to be held if SBP (Systolic Blood Pressure) was below 110. Resident 20's blood pressure medication was documented as follows: On [DATE], propranolol was given, blood pressure result was documented as 105/71 On [DATE], propranolol was held, blood pressure result was documented as 125/81 On [DATE], propranolol was held, blood pressure result was documented as 118/76 On [DATE], propranolol was given; blood pressure result was documented as 104/76 On [DATE], propranolol was held, blood pressure result was documented as 113/71 On [DATE], propranolol was given; blood pressure result was documented as 104/62 Resident 20's diagnosis included weakness, history of fractures, heart disease, and personal history of pulmonary embolism. 2) Resident 31's record was reviewed on 01/31/23 2:24 PM. The record indicated she had a pharmacy recommendation dated 8/8/22 for Metoprolol tartrate 50mg twice a day to be reduced to 25mg twce per day. The Physician/Prescriber response indicated they agreed with a note to take daily blood pressure for a week and call reults to the presciber. The review was signed by nurse practioner (prescribing provider) on 8/11/22. Resident 31's diagnosis included dementia, heart disease, and edema. Resident 31's medication orders indicated metoprolol was prescribed in May 2022, 50mg twice a day for hypertension and to hold if pulse was below 60. The medication was not changed according to the pharmacy recommendation. In the month of August 2022, Metoprolol was documented as held on: 8/3 am dose 8/4 am dose 8/5 am dose 8/6 am dose 8/7 am dose 8/8 pm dose 8/9 am dose 8/10 am and pm dose 8/11 pm dose 8/12 pm dose 8/13 am dose given with pulse of 49, pm dose held 8/17 am dose 8/18 am dose 8/19 am and pm dose 8/22 am dose 8/23 pm dose 8/26 am dose 8/28 am dose 8/29 am dose The month of September 2022, Metoprolol was documented as held on: 9/2 pm dose 9/7 am dose 9/10 am dose 9/11 am dose 9/14 am and pm dose 9/16 am dose 9/17 am dose 9/19 am dose 9/21 am dose 9/22 am dose 9/24 pm dose 9/26 pm dose 9/27 am dose 9/29 am dose 9/30 am dose The month of October 2022, Metoprolol was documented as held on: 10/3 am dose 10/4 am dose 10/5 am dose 10/6 am dose 10/8 pm dose 10/25 pm dose 10/30 am dose 10/31 am dose documented as given with pulse of 56 In the month of November 2022, Metoprolol was documented as held on the following: 11/2 am dose 11/3 am dose 11/6 am dose 11/8 am dose 11/9 am dose 11/10 am dose 11/11 am dose 11/12 am dose 11/13 am dose was documented as given with pulse of 52 11/14 pm dose 11/16 am and pm doses 11/18 am dose 11/19 am dose 11/20 am dose 11/21 am dose 11/23 am dose 11/25 am dose 11/26 am dose 11/27 am dose 11/28 pm dose 11/29 pm dose 11/30 pm dose In the month of December 2022, Metoprolol was documented as held on the following: 12/1 both am and pm doses 12/5 pm dose 12/6 am dose held; pm dose given with pulse of 52 12/7 pm dose 12/8 pm dose 12/9 am dose 12/13 am dose 12/15 am dose 12/16 am dose 12/17 am dose 12/18 pm dose 12/20 am dose 12/21 am dose held; pm dose documented as given with pulse 51 12/22 am dose 12/23 am dose 12/27 pm dose 12/29 am dose 12/30 am dose 12/31 am and pm doses In the month of January 2023, Metoprolol was documented as held on the following: 1/4/23 am dose 1/5 am dose 1/7 pm dose 1/8 pm dose 1/9 am dose 1/10 am dose documented as given with pulse 58 1/11 am dose 1/12 am dose documented as given with pulse 53 1/13 am dose 1/16 am dose 1/19 am and pm doses 1/20 am dose 1/24 pm dose 1/25 am and pm doses 1/29 pm dose 1/30 am dose 1/31 am dose In an interview on 2/1/23 at 10:04 AM, the ED (Executive Director] indicated the nurse putting the order in did not properly read the pharmacist recommendations and only put in an alert to send the prescriber blood pressures for one week. The ED indicated the prescriber generally writes out the order in the note section of pharmacy reviews and the directions were unclear. The ED indicated she asked the provider who agreed with the pharmacy recommendations to clarify her order from August of 2022. The provider indicated she agreed with the pharmacy recommendations and the medication was reduced as intended. No current policy was provided by time of exit conference. 3.1-37

Based on observation, record review, and interview the facility failed to provide treatment to a scabbed area as ordered for 1 of 18 residents. (Resident 7) Finding include: In an interview on 3/21/22 at 11:53 AM, Resident 7, indicated there was a small circular scabbed area located on the left side of their face, near the resident's jaw line. The area was open to air. There was some redness noted surrounding the area. Resident 7 indicated there was some irritation, and sometimes staff would put something on it, but the treatments were not consistent. She indicated it was irritating and she knew that it was there. In an observation and interview, on 03/21/22 at 11:53PM, the scabbed area was about 0.5 cm round and had redness around it There was no bandage noted to the area. On 3/23/22 at 3:00PM, a record review was begun. Resident 7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 7's most recent MDS indicated her BIMS score was an 8, indicating some memory and cognition difficulties. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An order was placed on 3/22/22 to begin skin protocol, monitor the scabbed area on the left jaw once daily until healed, every day shifts. Resident 7's most current care plan dated 3/24/22, indicated, areas of concern regarding skin as being at risk for pressure ulcer with goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date (target date 3/2022). The interventions included but not limited to; Administer treatments as ordered and monitor for effectiveness. Educate the resident /family /caregivers as to causes of skin breakdown. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Document alternative methods. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor skin during daily care and assess weekly. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth). The care plan did not include concerns or focus on the behavior of bothering the scabbed area. A progress notes dated 03/23/22 at 12:18 PM indicated the resident was noted to have a pencil eraser size scabbed area on her left jaw. The area is slightly red, but the resident denied any discomfort. An order was put in to monitor the area. The resident had history of picking on her skin. A review of the progress notes dated February and March 2022 indicated the following: On 3/23/22, a skin wound was noted, and Resident 7 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] A note was entered after skin assessments on 3/10/22 and 3/3/22. The skin assessments were completed and no issues were found A progress note dated 2/21/22 indicated Resident 7 went to a dermatologist appointment and had left cheek scraped. Orders were to clean area with and water daily, apply Vaseline and to apply a band aid. The MAR and TAR dated February and March 2022 did not include any orders for treatment to Resident 7's left cheek. The following orders on the March 2022 TAR indicated a start date of 3/31/22: Family updated on skin issues weekly on day shift every Thursday for Traumatic left jaw wound. Left jaw traumatic wound to be measured weekly. Complete wound assessment every day shift on Thursday Physician is to be updated weekly on skin issues on Thursday for left jaw wound; A review of the TAR dated March with start date of 3/24/22 indicated: Monitor scabbed area on the left jaw (pencil eraser size) once daily until healed. Cleanse wound with wound cleaner and pat dry; apply [MEDICATION(S)], cover with band aid. If resident removes band aid leave open to room air. A review of skin assessments dated 2/3/22; 2/10/22; 2/17/22; 3/3/22; 3/10/22; and 3/17/22 did not indicate any area on Resident 7's left cheek. On 03/23/22 at 10:15 A.M. in an interview, QMA 3 indicated she did not notice the scabbed area while giving Resident 7 thier medications. QMA 3 indicated she was not given any information regarding Resident 7's skin during report at the beginning of her shift. QMA 3 indicated the next step was for her to start a skin sheet on the area. In an observation on 3/23/22 at 10:17 AM, Resident 7's nails were above her fingertips. Resident 7 indicated she could pick the scab off easily but then it would bleed a lot. The resident was encouraged to not pick at it per QMA 3. Resident 7 denied pain. An interview with Administrator on 3/23/22 at 4:15PM, indicated Resident 7 was a picker and therefore sores or scabs were not unusual for her.The Administrator indicated a skin assessment should be done for new areas of concern. In an interview, on 03/24/22 04:02 PM, LPN 2 indicated to put in orders, do new, then after the order was in, go back into MAR or TAR (medication administration record or treatment administration record) depending on the type of order medication versus treatment to ensure the order was there and correct. The importance of ensuring the order was on the MAR or TAR was not charted meant you didn't do it and if it was not on the MAR or TAR it would not be done. A current facility policy, Titled, date, was provided by the Assistant Director of Nursing on 3/25/22 at (time). The policy indicated .indicated the purpose of policy was to ensure accurate complete medication orders all changes in clinical record will be automatically transmitted to pharmacy through the MAR 3.1-37

Based on interviews and record review, the facility failed to monitor side effects of anticoagulant medication for 1 of 5 residents reviewed. (Resident 63) Findings include: The record review for Resident 63 began on 3/24/22 at 9:58 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) Assessment, dated 3/2/22, indicated Resident 63 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate impairment). The MDS indicated Resident 63 received anticoagulant medication of [MEDICATION(S)] two times a day and Aspirin daily. A record of a physician's order, dated 10/21/2021, indicated to give [MEDICATION(S)] (anticoagulant) tablet 5mg (milligram) give 1 tablet by mouth two times a day related to unspecified [CONDITION(S)]. Aspirin (anticoagulant) tablet chewable give 81mg by mouth one time a day related to unspecified [CONDITION(S)] was ordered on 10/11/2021 and discontinued on 3/7/2022. There were no physician orders to monitor for side effects of anticoagulants between 10/21/21 and 3/21/22. An order, dated of 3/21/2022 indicated the following: Anticoagulant Therapy: Monitor/document/report prn (as necessary) adverse reactions of anticoagulant therapy such as blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden change in v/s (vital signs) every shift. A review of Resident 63's care plans, provided by the Director of Nursing (DON) on 3/25/22 at 1:12 P.M., indicated a care plan focus of dated 3/25/2022: The resident is on anticoagulant therapy. The goal was, the resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions were to administer anticoagulant medications as ordered by physician, monitor for side effects and effectiveness of medication [MEDICATION(S)], perform a daily skin inspection, report abnormalities to the nurse, labs as ordered, and report abnormal lab results to the MD (medical doctor). An intervention of Monitor/document/ report prn (as necessary) adverse reactions of anticoagulant therapy such as blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden change in v/s (vital signs) was initiated on 3/25/2022. an intervention of resident/family/caregiver teaching was to include the following: Take/give medication at the same time each day, use soft toothbrush, use electric razor, avoid activities that could result in injury, take precautions to avoid falls, signs/symptoms of bleeding was initiated 3/25/2022, review medication list for adverse interactions, avoid us of aspirin or NSAIDS (non-steroidal anti-[CONDITION(S)] drugs). A review of the Medication Administration Record (MAR), schedule dated February 2022 and March 2022, provided by the DON on 3/25/2022 at 1:12 P.M., indicated the following: Aspirin tablet chewable give 81mg by mouth one time a day related to unspecified [CONDITION(S)], start date 10/11/2021 was administered as ordered on February 1, 2022 through the discontinued date of March 7, 2022. [MEDICATION(S)] tablet 5mg give 1 tablet by mouth two times a day related to unspecified [CONDITION(S)], start date 10/11/2021 was administered as ordered on February 1, 2022 through present. There was no documentation of monitoring for side effects of anticoagulants in the month of February and March 1 through 21, 2022. A review of the MAR dated March 2022 indicated anticoagulant therapy monitoring began on 3/22/2022. The staff were to document, and report prn (as necessary) adverse reactions of anticoagulant therapy such as blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden change in v/s (vital signs) every shift During an interview, the DON on 3/25/2022 at 9:15 A.M., indicated when an order was entered, the information went to the MAR and/or TAR (treatment administration record). General orders would not go on the MAR or TAR, but when an order with a specific task was put on the MAR and/or TAR, the staff were aware to do that task. If a task was not on the MAR or TAR, the staff were not aware to do that task. During an interview, the Administrator on 3/25/2022 at 10:48 A.M., indicated when a nurse received a new order, she placed the new order on a sticky note and attached it to the 24-hour report so the new order would be communicated to the staff in the report. During an interview LPN (Licensed Practical Nurse) 2 on 3/25/2022 at 12:57 P.M., indicated she looked at the TAR to find out what treatments to do for the resident, and looked at the MAR to find out what medication the resident was to receive. LPN 2 indicated when an anticoagulant was ordered for a resident, she would look for bruising or bleeding, and when a medication required monitoring, it would be indicated on the MAR. She indicated when she found a medication that required monitoring, but did not have the monitoring ordered, she would add the monitoring to the TAR. She indicated new orders were entered by the nurse and the order written on a report sheet, then the third shift nurse checked the new orders on the report sheet and made sure the orders were in the computer under orders. Medication orders entered in the computer went to pharmacy and placed on the MAR, treatments were filtered to the TAR. Monitoring for side effects of medication would be entered as a separate order. If an order was not on the MAR or TAR, she was not be aware to do it. A review of a current policy, Monitoring Anticoagulant Therapy, issued to Senior Living, date issued 1/14/20, provided by the Administrator on 3/25/2022 at 9:10 A.M indicated the following policy statement, Anticoagulants include medications such as [MEDICATION(S)] that delay or prevent blood from coagulating or clotting. This medication and other anticoagulants are marked with a Black Box Warning. It is the policy of the facility to provide anticoagulant therapy ([MEDICATION(S)]) in a safe and therapeutic manner while providing adequate monitoring. Background information indicated, . Both thromboembolic and bleeding risks increase with age, and the number of older adults treated with anticoagulants is increasing The procedure, assessment and recognition indicated, . 1. As part of the initial assessment, the physician will help identify individuals who are currently anticoagulated . a. Monitor for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications The monitoring and follow up indicated, .4. The staff and physician will monitor for possible complications individuals who are being anticoagulated and will manage related problems A current facility policy, Monitoring Anticoagulant Therapy, dated 1/14/20, was provided by the Administrator on 3/25/22 at 9:10 AM. The policy indicated .Anticoagulants include medications such as [MEDICATION(S)] that delay or prevent blood from coagulating or clotting. This medication and other anticoagulants are marked with a Black Box Warning. It is the policy of the facility to provide anticoagulant therapy ([MEDICATION(S)]) in a safe and therapeutic manner while providing adequate monitoring. Background information indicated, . Both thromboembolic and bleeding risks increase with age, and the number of older adults treated with anticoagulants is increasing The procedure, assessment and recognition indicated, . 1. As part of the initial assessment, the physician will help identify individuals who are currently anticoagulated . a. Monitor for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications The monitoring and follow up indicated, .4. The staff and physician will monitor for possible complications individuals who are being anticoagulated and will manage related problems 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure an unattended medication cart was secured and locked for 1 of 3 medication carts observed in 1 of 2 units in the facility, which had the potential to affect 40 of 66 residents who resided in B and C wings. Findings include: During an observation of the medication cart on C Wing Peach Street on 12-2-2020 at 11:36 a.m., the locked mechanism was observed to not be pushed in to secure the medications stored inside. The medication cart was observed to be unattended by the nurse and the drawers of the medication cart could be accessed by any person in the near vicinity, except for one drawer with a keyed lock. At 11:39 a.m., Nurse 1 was observed at the nurse station. The medication cart was out of view from where she was sitting. An interview at this time with Nurse 1 indicated she forgot to lock the medication cart. The nurse indicated she normally locked the medication cart when she left the cart unattended. An observation on C Wing Peach Hall on 12-2-2020 at 4:25 p.m., indicated the medication cart was observed outside room [ROOM NUMBER], was unlocked (as the locking mechanism was not pushed in) and unattended. Nurse 1 was observed to be in the resident's room with her back to the medication cart. As Nurse 1 came out of room [ROOM NUMBER], she was observed to take the keys out of her pocket, used the key in the lock and opened a medication drawer to obtain medication. An observation on C Wing Spring Street on 12-2-2020 at 4:30 p.m., indicated Nurse 1 had moved the medication cart to the wall outside room [ROOM NUMBER]. The nurse was observed to gather supplies from the cart. The nurse was then observed to leave the medication cart unlocked and unattended as she entered room [ROOM NUMBER]. A current policy, Storing Medications last revised 10/2011 was provided by the DON (Director of Nursing) on 12-2-2020 at 6:02 p.m. The Policy indicated, .Purpose: To ensure that drugs are stored safely .Policy Statement: Medications will be stored in locked carts When not attended by a person permitted access, all drug storage areas and devices must be kept locked 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure infection control practices related to resident equipment disifection, PPE (Personal Protective Equipment) usage and hand hygiene, during the Covid -19 pandemic were followed. These deficiences had the potential to affect 66 of 71 residents on 2 of 3 units observed in the facility. (Units B and C) Findings include: 1. An observation of the area just outside the healthcare entrance, but inside the building, on 12-2-2020 at 10:47 a.m., indicated a large board was observed to be leaning up against the wall with clips holding paper bags. The paper bags were observed to have names on them. No dates were observed on the bags except for one bag for Staff 2. The date on the bag was 10-27. An interview with CNA 3 (Certified Nurse Aide) by the board holding the paper bags, on 12-2-2020 at 10:50 a.m., indicated this was where staff stored their KN95 masks after their shift. She indicated she worked full time and will wear the KN95 mask she had on five times a week. The CNA indicated if her KN95 mask broke or was soiled, she could ask for a new one. She indicated she did not date the paper bag when she received a new one. CNA 4 was interviewed at this time. CNA 4 indicated she worked PRN (as needed), and she did not date the bag when she received a new KN95. Both CNAs indicated they received a new mask on the first of each month. Both indicated they had received a new KN95 the day before. They indicated the new KN95 mask was to be worn for the full month of December on their shifts. An interview with Housekeeper 5 on 12-2-2020 at 11:47 a.m., indicated she kept her mask in a paper bag in her locker after she completed each shift. She indicated she was working this week on Monday, Tuesday, Wednesday, Thursday, Saturday and Sunday and will wear the same mask each day she worked. She indicated she was given one new mask each month. She indicated she had received a new one on 12-1-2020. An interview with CNA 6 on 12-2-2020 at 11:50 a.m., indicated the facility provided one KN95 mask for him to wear during his shifts every month. He indicated if his mask broke, he would go to his nurse to obtain another one. The CNA indicated he was a full time worker and this week he worked Tuesday, Wednesday, Thursday and Friday. He indicated after his shift he will store his mask in the paper bag provided by the facility. He indicated he was provided a new mask and paper bag on 12-1-2020. He also indicated he could get a new mask if he wanted a fresh one. An interview with Nurse 7 on 12-2-2020 at 12:07 p.m., indicated she worked 9 days in a 14 day pay period at the facility and was provided a new KN95 mask on the first of each month. The nurse indicated at the end of her shift, she placed her KN95 mask in a paper bag inside her locker. She indicated a new paper bag was also provided at the first of the month and she was able to obtain a new KN95 mask if her mask broke or became soiled. An interview with the DON on 12-2-2020 at 12:19 p.m., indicated the staff wore KN95 masks throughout the facility. She indicated they did not use the N95 masks. On 12-2-2020 at 1:27 p.m., the Administrator provided a Department Specific PPE (Personal Protective Equipment) Plan for Senior Living. The Plan indicated, under mask the letter R and a checkmark was in the row for the tasks Patient Contact (within 6 feet of patient) and Universal Masking - all areas, at all times. The R was defined as Reuse. An interview with Nurse 8 on 12-2-2020 at 2:10 p.m., indicated she worked in the Covid unit. She indicated she had a KN95 mask in a paper bag she kept in the clean room on the table when she was not working and she was provided a new KN95 mask each month. The nurse indicated she was scheduled to work Monday thru Friday each week for 12 hour shifts and used the same KN95 mask. She indicated if the mask was soiled or broke, she could get a clean KN95 mask. On 12-2-2020 several staff KN95 masks were observed. Some of the KN95 masks only had KN95 on them and some had the KN95 with the number GB2626-2006. Information from the named Company for the KN95 numbered GB2626-2006 was on the approved KN95 list from the FDA website. The instructions from the company's website did not indicate usage instructions, only donning instructions and how it was made. On 12-2-2020 at 2:42 p.m., the Administrator provided a manufacturer sheet for a Surgical Respirator. the Manufacturer's sheet did not have usage instructions included. On 12-2-2020 at 2:53 p.m., the Administrator was asked for the instructions from the manufacturer of their KN95. He indicated he could not find any manufacturer instructions. At this time the Administrator provided a copy of the KN95 box with information printed on the side of the box: matters needing attention .1. Please keep the mask in a sanitary, dry and ventilated environment .3. When using mask ensure the nose bridge is properly positioned on nose to prevent air leakage .4. This product is disposable and is for one time use only .5. Please use these steps to ensure masks are being used correctly, otherwise there is risk of bacterial contaminants entering An interview with the Administrator on 12-2-2020 at 6:03 p.m., indicated the facility staff were provided a new KN95 mask every month and staff were able to get a replacement if their mask breaks or became soiled. He indicated there were guidelines out earlier he thought that indicated monthly changes on masks. There was no additional policy or guidance from the facility regarding the number of times a KN95 mask should be reused. 2. During an observation of the lunch meal tray pass on 12-2-2020 at 11:24 a.m., CNA 6 was observed to carry a room tray to room [ROOM NUMBER]. At 11:26 a.m., CNA 6 was observed to come out of room [ROOM NUMBER] with the dome lid from the plate in his hands. He carried the dome lid down hall to the dining area and placed it on top of the tray cart. CNA 6 was then observed to pick up another meal tray and delivered it to a resident seated in the C wing dining area. This dining area was for residents who needed assistance or supervision. The CNA was not observed to use hand sanitizer after coming out of room [ROOM NUMBER] and prior to handling another residents meal tray. On 12-2-2020 at 11:26 a.m., CNA 9 was observed to serve a meal tray to a resident in the C wing dining room, then return the dome cover and place the dome cover on top of the meal tray cart. Without using hand sanitizer, CNA 9 took another tray and delivered it to a resident in the C wing dining room. She set up the tray for the resident. There were 5 residents observed in the C wing dining room at this time. On 12-2-2020 at 11:50 a.m., CNA 6 was interviewed. The CNA was asked how often and when he used hand sanitizer. CNA 6 indicated he used hand sanitizer after leaving a resident's room and after every encounter with residents. In an observation on Peach Hall on 12-2-2020 at 4:25 p.m., Nurse 1 was observed in resident's room. As Nurse 1 came out of the resident's room, she was not observed to use hand sanitizer. Nurse 1 then obtained a medication from the medication cart, returned to the resident's room, administered the medication, and returned to the medication cart. Nurse 1 was not observed to use hand sanitizer after the medication pass. Nurse 1 indicated she had to obtain a blood sugar on Spring Street, donned gloves and then moved the medication cart to the room on Spring Street. The nurse gathered the rest of the supplies with the same gloves on, and entered the resident's room to obtain the blood sugar. After she obtained the blood sugar, she left the room, discarded her supplies, and cleaned the glucometer Nurse 1 was not observed to use hand sanitizer prior to donning the gloves nor after doffing her gloves. 3. In an observation on 12-2-2020 at 4:25 p.m., CNA 10 was observed in a room on Peach Street with a resident who asked to use the bathroom. CNA 10 was observed to obtain a lift, push it into the resident's room, then waited on another staff to assist. On 12-2-2020 at 4:35 p.m. CNA 11 was observed push a hoyer lift out of a resident's room on Spring Street. The CNA was observed to place the hoyer lift in the hall next to the wall. CNA 11 was interviewed at this time and asked what she would use to clean the lift. CNA 11 indicated she did not know and would have to check. The CNA was also asked if she was going to clean the mechanical lift after it was used. She indicated she was not sure they were cleaning the lift after each use. The DON was asked about cleaning the lifts after each use and what type of chemical was used to clean the lifts. The DON indicated she would have to check with housekeeping. A facility policy was requested on cleaning the lifts. On 12-2-2020 at 4:37 p.m., CNA 10 was observed to come around the corner from Peach Street and was asked if she cleaned the lift after using it for the resident on Peach Street. She indicated she did not remove the lift from the room, and was unsure if the lift was cleaned or not. On 12-2-2020 at 4:38 p.m., an interview with Nurse 12 indicated she had assisted CNA 10 with using the lift to transfer the resident on Peach Street. Nurse 12 indicated she placed the lift in the hall and indicated she did not clean the lift as she thought the aides cleaned the lifts after each resident use. On 12-2-2020 at 4:40 p.m., the DON indicated the facility did not have a policy on cleaning the lifts after each resident use. The DON indicated the pads were changed each resident. An interview with the DON and Administrator on 12-2-2020 at 6:03 p.m., indicated one resident who had tested positive for Covid-19 on 11-26-2020 with the results returned on 11-27-2020 required the use of a lift for transfers. A current policy Masking requirements for Senior Living dated 11-18-2020, was provided by the Administrator on 12-2-2020 at 6:03 p.m. The policy indicated .Purpose: To prevent the spread of Covid-19 by following appropriate guidelines .Policy Statement: The facility will utilize face masks as directed by the CDC (Center for Disease Control) and Indiana Department of Health .1. All Staff will wear an approved N95 or KN95 mask and eye protection for delivery of care .8. Masks and shields may be worn the entire shift if not visibly wet or soiled. The Center for Disease Control and Prevention Pandemic Planning published recommended guidance for extended use and limited reuse of N95 respirators on March 27, 2020. The website address for the information can be located at https://www.cdc.gov/niosh/topics/HCWcontrols/recommendedguidanceextuse.html The recommendations indicated .to reduce the chances of decreased protection caused by a loss of respirator functionality, consult with the respirator manufacturer regarding the maximum number of donnings or uses they recommend for the N95 respirator model .if no guidance is available, preliminary data suggests limiting the number of reuses to no more than five uses per device to ensure an adequate safety margin .some devices have not been FDA (Federal Drug Administration) cleared for reuse .some manufacturers product user instructions recommend to discard after each use . A current policy, Coronavirus Disease 2019 Guidelines dated 3-3-2020 was provided by the Administrator on 12-2-2020 at 10:35 a.m. The policy indicated .perform hand hygiene using ABHS (Alcohol Based Hand Sanitizer) before and after all patient contact .before putting on and upon removal of PPE, including gloves .Implement Environment Infection Control .2. All non-dedicated, non disposable medical equipment used for patient care should be cleaned and disinfected using hospital approved disinfectants Guidance from the CDC, Preparing for COVID-19 in Nursing Homes updated 11-20-2020 indicated .Environmental Cleaning and Disinfection: Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas .Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment .Use an EPA-registered disinfectant from List N on the EPA website to disinfect surfaces that might be contaminated with [DIAGNOSES REDACTED]-CoV-2 .Ensure HCP (Healthcare Personnel) are appropriately trained on its use Website address, https://cdc.gov/coronavirus/2019-ncov/hcp.long-term-care.html 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure 7 of 7 residents (Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, and Resident 36) reviewed were screened consistently for Covid 19 signs and symptoms. The facility also failed to ensure employee screenings were conducted and verified by a staff member. This had the potential to affect 88 of 88 residents residing in the facility. Findings include: 1. A review of Resident 30's record on 10/30/2020 at 4:25 p.m., indicated [DIAGNOSES REDACTED]. A review of the Covid-19 signs and symptoms monitoring form, indicated no screening had been completed for Resident 30 on 10/16, and 10/22/2020. 2. A review of Resident 31's record on 10/30/2020 at 4:30 p.m., indicated [DIAGNOSES REDACTED]. A review of the signs and symptoms monitoring form, indicated no screening had been completed for Resident 31 on 10/16, and 10/22/2020. 3. A review of Resident 32's record on 10/30/2020 at 4:35 p.m., indicated [DIAGNOSES REDACTED]. A review of the signs and symptoms monitoring form, indicated no screening had been completed for Resident 32 on 10/16, and 10/22/2020. 4. A review of Resident 33's record on 10/30/2020 at 4:40 p.m., indicated [DIAGNOSES REDACTED]. A review of the signs and symptoms monitoring form, indicated no screening had been completed for Resident 33 on 10/16, and 10/22/2020. 5. A review of Resident 34's record on 10/30/2020 at 4:45 p.m., indicated [DIAGNOSES REDACTED]. A review of the signs and symptoms monitoring form, indicated no screening had been completed for Resident 34 on 10/16, and 10/22/2020. 6. A review of Resident 35's record on 10/30/2020 at 4:50 p.m., indicated [DIAGNOSES REDACTED]. A review of the signs and symptoms monitoring form, indicated no screening had been completed for Resident 35 on 10/18, and 10/24/2020. 7. A review of Resident 36's record on 10/30/2020 at 4:55 p.m., indicated [DIAGNOSES REDACTED]. A review of the signs and symptoms monitoring form, indicated no screening had been completed for Resident 36 on 10/18, and 10/24/2020. 8. A review of the Employee Pre-Shift Medical Screening for 10/29, and 10/30/2020, indicated the employees were signing and completing their own screen. Verification by another employee had not been documented. During an interview on 10/29/2020 at 3:45 p.m., the RN (Registered Nurse) Clinical Director indicated the employees screened themselves for Covid-19 and take their own temperatures. During an interview on 10/30/2020 at 1:30 p.m., the Director of Clinical Services indicated the undated Employee Pre-Shift Medical Screening form was the form the networks hospital used, and the employees screened themselves. A current facility policy, Coronavirus Pandemic, dated 3/15/2020, provided by the RN Clinical Director on 10/30/2020 at 1 p.m., indicated the following: .All staff is screened on arrival to shift and verified .All resident's will be screened daily . 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure proper technique was used during subcutaneous injections for 2 of 2 residents observed. (Resident 39 and Resident 69) Findings include: 1. A review of Resident 39's record on 11/18/2019 at 12 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 15 out of 15, meaning cognitively intact. The score was obtained from the MDS (Minimum Data Set) Quarterly Assessment, dated 9/14/2019. [DIAGNOSES REDACTED]. On 11/12/2019 at 10:59 a.m., LPN (Licensed Practical Nurse) 1 was observed administering 5 units of insulin by subcutaneous (fatty layer of skin tissue) injection with one hand to Resident 39's abdomen. LPN 1 did not use her free hand to pinch up and hold the fatty tissue prior to injecting the needle into the skin. 2. A review of Resident 69's record on 11/18/2019 at 12:15 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 4 out of 15, meaning severe cognitive impairment. The score was obtained from the MDS Quarterly Assessment, dated 10/9/2019. [DIAGNOSES REDACTED]. On 11/14/19 at 11:52 a.m., LPN 4 was observed administering 4 units of insulin by subcutaneous injection with one hand to Resident 69's abdomen . LPN 4 did not use her free hand to pinch up and hold the fatty tissue prior to injecting the needle into the skin. During an interview on 11/12/2019 at 11:19 a.m., LPN 2, indicated the nurse would pinch the skin up prior to and during the injection of insulin. During an interview on 11/12/2019 at 11:45 a.m., RN (Registered Nurse) 3 on the B wing, indicated she pinched the fatty tissue of the skin prior to the insulin being administered. During an interview on 11/18/2019 at 9:05 a.m., the Interim DON (Director of Nursing) indicated the nurses may have thought they did not have to pinch the skin if the residents abdomen was distended (bloated). Neither Resident 39, or Resident 69 had a distended abdomen. During an interview on 11/18/2019 at 11:19 a.m., LPN 5, on the C wing, indicated she pinched an inch of skin prior to the insulin being injected. During an interview on 11/18/2019 at 11:37 a.m., LPN 1, on the C wing, indicated she pinched the skin prior to injecting the needle. During an interview on 11/18/2019 at 11:46 a.m., LPN 6, on B wing, indicated the nurse would pinch the skin prior to and during the administration of insulin. A Checklist, Job Specific Orientation, for staff nurses, provided by the DON on 11/18/2019 at 11:03 a.m., indicated a section of IM (intramuscular) and SQ (subcutaneous) medications, with a section for the trainee to initial and the trainer to initial. LPN 1's was initialed by both on 6/12/2014, provided by the Human Resource Coordinator on 11/18/2019 at 1:31 p.m., on their computer. A Nursing Journal article reference, How to administer a subcutaneous injection, dated (MONTH) 2004, and provided by the Interim DON on 11/18/2019 at 11:35 a.m., indicated the following: .gently grasp a skin fold, insert the needle at the appropriate angle . the article also had a diagram picture of skin being pinched with needle insertion indicating a two handed skilled technique. A policy, Medication Administration: Injection Insulin Prepared and Administration, dated 10/2011, and provided by the DON on 11/18/2019 at 9:16 p.m., indicated the following: .gently raise fold of skin with your thumb and index finger . 3.1-14(i)

Based on observation, interview, and record review the facility failed to ensure side rails were maintained to prevent gaps affecting 2 out of 95 residents reviewed for safe side rails. (Resident 103 and Resident 66) Findings include: 1. A review of Resident 103's clinical record on 11/09/2017 at 4:37 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 14 out of 15, meaning the resident was cognitively intact. [DIAGNOSES REDACTED]. On 11/09/2017 at 9:24 a.m., an observation showed Resident 103's left hand side rail was not secured to the bed frame. A screw was exposed and the rail swung out away from the bed frame, creating a gap larger than 6 inches. During an interview with CNA 1 on 11/9/2017 at 11:50 a.m., they indicated the side rail were to be attached to a black box and locked into place. CNA 1 indicated the screw should not be exposed and it should attach to a black box, that was missing, on the bed frame. CNA 1 indicated Resident 103 did not sleep in her bed, she sleeps in her chair. A review of Resident 103's Care Plans indicated a Care Plan dated 11/8/2017 for 1/4 side rails to bed as ordered for bed mobility and transfers. Resident 103's physician's orders [REDACTED].upper 1/2 side rails x2 (meaning each side of the bed) for bed mobility . Resident 103's 14 day MDS (Minimal Data Set) assessment dated [DATE] indicated an extensive assistance in bed mobility with one assist from the staff. A form titled User-Service Manual Joerns Deluxe Assist Handle Model F028 dated 2015, provided by the DON on 11/15/2017 at 11:54 a.m., indicated .Warning: Risk of Serious Injury or Death. Do not use this assist device until you have verified that it is locked in place. Injury to resident or caregiver may result if this procedure is not followed . .Warning: In the event worn or broken part(s) are identified, remove the device from service until repairs are made . Figure 1 on page 4 of the manual indicated a nut retainer, the piece that was missing from Resident 103's bed and rail. On 9/16/2017 an Evaluation for use of Siderails was completed and indicated that siderails were not indicated at that time. 2. A review of Resident 66's clinical record on 11/09/2017 at 4:48 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 4 out of 15, meaning severe cognitive impairment. [DIAGNOSES REDACTED]. On 11/09/2017 at 9:44 a.m., an observation showed Resident 66's right hand side rail was loose. The rail moved back and forth away from the mattress. The rail was not secured tightly to the bed frame, creating a measured gap of 5.5 inches between the rail and mattress. An observed sticker on the bed frame indicated the following: .creating too small or too large of gap between the siderail or assist device can create an entrapment hazard. Death and serious injury may result. prior to use read all instructional and warnings in the user service manual . Resident 66's Physician order [REDACTED]. upper 1/4 siderails x1 (meaning one rail) on bed, right side for transfers in and out of bed . Resident 66's Care Plans for ADL's (Activities of Daily Living) indicated under the section for Bed mobility . Able to use quarter rails to help with positioning in bed and getting in/out of bed with physical assist from staff . On 10/19/2017 an Evaluation for use of Siderails was completed and indicated the use of quarter bilateral rails for Resident 66 to support self and exit the bed safely. During an interview with CNA 1 on 11/9/2017 at 11:52 a.m., they indicated they did not know if the side rail on Resident 66's bed was supposed to be that way and was going to ask the nurse. During an interview with CNA 3 on 11/09/2017 at 1:49 p.m., they indicated the CNA's will let the nurse know when something was broken or needed fixed. The nurse would submit a work order in the computer system when something needed fixed. A review of the maintenance prevention report on 11/9/2017 at 1:30 p.m., found on the conference table, titled Fire Safety/Life Safety/Utilities Management/Clinical Equipment Monthly Report, dated 10/10/2017 indicated the following: .Clinical Equipment: Bed Safety Inspection. All beds side rails checked. Mattress gaps all OK. Side rails latch all OK The report indicated the follow up date was ongoing. During an interview with LPN 2 on 11/09/2017 at 1:53 p.m., they indicated a work order was submitted for the side rails after the CNA reported concerns. During an interview with the Administrator on 11/09/2017 at 1:59 p.m., indicated the maintenance staff, from the facility network, checked the rails monthly as part of the Quality Assurance program. During an interview with the Clinical Engineering Tech on 11/09/2017 at 2:55 p.m., indicate they inspect the beds yearly, and included what was on the Fire Safety/Life Safety/Utilities Management/Clinical Equipment Monthly Report. A policy titled Bed Frame/Mattress assessment dated ,[DATE] and provided by the Director of Nursing on 11/15/2017 at 10:22 a.m., indicated . the facility must conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bedrolls and mattress are compatible . Under the section of Procedure, the policy indicated the following: .Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.) and identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) The User-Service Manual Jokers Deluxe Assist Handle Model 028 indicated in Figure 2 on page 4, the mounting bracket that attaches to the bed frame and the same that attached to Resident 66's bed frame. .Insert the bushing completely into the mounting bracket until the flange is resting upon the bracket. Failure to ensure proper installation may lead to damage to the bushing, a reduced product life, and/or poor function of the assembly. Lock the assist handle by engaging the latch pin into the latch(item 6) (Figure 5) Maintenance/inspection information: Visually inspect the assist handle and mounting bracket, and check for loose hardware on a monthly basis. Tighten loose hardware as stated in the installation instructions. When mounting to an 80 inch head section, line up holes A&E and holes B&G and when mounting to a 76 inch head section line up holes A&E and holes B&F . 3.1-19(c)

Based on observation, interview and record review, the facility failed to ensure personal privacy for 2 of 3 residents reviewed for privacy. (Resident D and Resident E). Findings include: 1. Resident D's record was reviewed 10-23-2017 at 12:31 P.M. Resident D's [DIAGNOSES REDACTED]. A review of Resident D's quarterly MDS (Minimum Date Set) assessment dated [DATE] indicated Resident D had a Brief Interview for Mental Status (BIMS) score of 4. This indicated Resident D was not interviewable, and cognition was severely impaired. On 10-23-2017 at 11:48 A.M., Resident D was observed up in her wheelchair at an activity. She was well groomed, and smiling. A review of progress notes dated 10-5 through 10-12-2017 did not indicated Resident D had a change in mental status or behavior. In an interview on 10-23-2017 at 11:59 AM, CNA 1 indicated she had witnessed a picture of Resident D posted on Snap Chat. The resident was watching television. She indicated she knew the resident was not able to give her consent to the picture. CNA 1 indicated the posting had been reported to the Supervisor and the picture removed. CNA 1 indicated staff were not allowed to take pictures of residents, let alone put them on social media. 2. Resident E's record was reviewed 10-23-2017 at 1:31 P.M. Resident E's [DIAGNOSES REDACTED]. A review of Resident E's quarterly MDS dated [DATE] indicated Resident E had a BIMS score of 8. This indicated Resident E was not interviewable, and cognition was moderately impaired. On 10-23-2017 at 11:17 A.M., Resident E was observed up in her wheelchair in her room. She was well groomed, and calm. A review of progress notes dated 10-5 through 10-17-2017 did not indicated Resident E had a change in mental status or behavior. In an interview on 10-23-2017 at 11:59 AM, CNA 1 indicated she had witnessed a video of Resident E posted on Snap Chat. The resident was watching television. She indicated she knew the resident was not able to give her consent to the video. CNA 1 indicated the posting had been reported to the Supervisor and the video removed. CNA 1 indicated staff were not allowed to take pictures of residents, let alone put them on social media. A review of CNA 2's employee file indicated she had read and agreed to abiding by Resident Rights and preventing abuse. In an interview on 10-23-2017 at 11:22 AM, the Director of Nursing indicated the staff member should not have taken pictures or videos of the residents. This Federal tag is related to Complaint IN 721. 3.1-3(q)

Based on observation, interview, and record review, the facility failed to ensure medication refrigerators were maintained at the proper temperature to store medications in 2 of 3 refrigerators observed for medication storage. This had the potential to affect the 65 residents who resided on the 2 of 3 units. (C Wing and AECC). Findings include: 1. The C wing medication room was toured with LPN (Licensed Practical Nurse) #1 on 8/28/15 at 10:10 a.m. LPN #1 opened the medication refrigerator door and the dial thermometer was observed to be hanging from the shelf at the front of the refrigerator. LPN #1 read the temperature from the thermometer as 30 degrees F (Fahrenheit). The contents of the medication refrigerator included, but were not limited to, the following medications: [REDACTED]. The C wing medication refrigerator was observed with LPN #2 on 8/31/15 at 3:40 p.m. LPN #2 opened the medication refrigerator door and read the thermometer temperature as 33 degrees F. A vial of insulin was shaken and it was observed not to be frozen and still in liquid form. The Refrigerator Temperature logs were observed on the counter in the medication room. On 8/31/15 at 3:45 p.m., copies of the Refrigerator Temperature logs were received from LPN #3, Unit Manager of the C wing. The Unit Manager was interviewed at this time. LPN #3 indicated on Friday, August 28, 2015, she got a new thermometer for the medication refrigerator on the unit because she noticed the temperatures weren't good and the glass on the front of the thermometer wasn't secure. She indicated the desired temperature for the medication refrigerator should have been 32-44 degrees F. On 8/31/15 at 3:50 p.m., the Refrigerator Temperature Logs were reviewed. The temperatures were logged three times a day at 6:30 a.m., 2:30 p.m. and 10:30 p.m. The August 2015 temperatures ranged from 28 degrees F. to 36 degrees F. and had 80 entries of temperatures 36 degrees F. or below. The July 2015 Refrigerator temperatures recorded ranged from 28 degrees F. to 42 degrees F. and had 65 entries of temperatures 36 degrees F. or below. On 9/1/15 at 9:52 a.m., the DON (Director of Nursing) was interviewed. She indicated the completed temperature logs were sent to the Unit Managers upon completion. 2. During an observation of the AECC medication room with RN #4 on 8/28/15 at 10:30 a.m., the medication refrigerator's thermometer was in the center of the top shelf. The thermometer measured 32 degrees F. (Fahrenheit). During an interview with RN #4 on 8/28/15 at 10:32 a.m., he indicated the refrigerator's temperature was read and recorded at shift change, which was currently every 12 hours. RN #4 indicated the refrigerator temperature was 32 degrees F. but did not indicate the temperature was too cold. RN #4 reviewed the refrigerator temperature log and indicated the temperatures recorded ranged from 30 to 33 degrees F. During an interview with RN #4 on 8/31/15 at 3:52 p.m., he indicated the thermometer in the AECC medication refrigerator measured 30 degrees F. RN #4 indicated he was not aware of what the temperature parameters should have been. RN #4 checked for documentation of what the temperatures should have been and indicated he could not find any guidance for the refrigerator temperature parameters in the unit's medication room. RN #4 placed a new thermometer in the refrigerator and turned the refrigerator's thermostat to a warmer temperature. During the observation on 8/31/15 at 3:55 p.m., the AECC refrigerator contained the following medications: [REDACTED] Two, unopened Novolog Flex pens (Insulin), both flex pens were filled by Pharmacy on 8/17/15. The Novolog Flex pens were opaque and it could not be determined if the insulin was frozen. Two IV (intravenous) doses of Famotidine (for stomach) 20 mg (milligram)/50 ml (milliliter) in IV Balls (elastomeric pump), which were filled by the Pharmacy on 8/28/15. The medication was liquid inside the balls and did not appear to be frozen. Two vials of Tubersol (to test for [DIAGNOSES REDACTED]) Inj (Injection) 5/0.1 ml. The medication was liquid in the vials and did not appear to be frozen. Seven syringes of Influenza Vaccine 2014-2015 Formula with an expiration date of May 2015. The Refrigerator EDK (Emergency Drug Kit) filled by the Pharmacy on 8/24/15 was in the refrigerator and contained the following medications: [REDACTED] One 10 ml vial of Novolog (Insulin); One 10 ml vial of Novolin (Insulin) 70/30; One 10 ml vial Humalog Mix (Insulin) 75/25; One 10 ml vial Novolin R (Insulin); One 10 ml vial Novolin N (Insulin); One 10 ml vial Lantus (Insulin)10; Four suppositories of Promethazine (anti-histamine) 12.5 mg Supp; Four,1 ml vials of Lorazepam (for anxiety) 2 mg/ml. The medications were in a zip-locked plastic box and did not appear to be frozen. An interview with RN #4 at 4:05 p.m., indicated the Influenza Vaccine was expired and the RN was observed to remove the Influenza Vaccine syringes from the refrigerator for disposal. During an interview with the DON (Director of Nursing) on 8/31/15 at 4:15 p.m., she indicated the refrigerator temperatures were not to be below freezing and indicated the nursing staff should have adjusted the thermostat to keep the temperature above freezing. She also indicated the expired medications should have been removed from the refrigerator. She further indicated the facility did not administer the Influenza vaccine after March 31, 2015 per the facility policy. The DON indicated the Pharmacy Tech checked the facility's medication carts, treatment carts and medication rooms monthly for expired medications and further indicated the expired Influenza Vaccines were missed. An interview with the DON on 8/31/15 at 5:05 p.m., indicated the Pharmacy Tech did not check the medication storage on the AECC unit, because the residents were short term stays at the facility. She further indicated the nurses should have removed the expired Influenza Vaccine from the refrigerator. Review of the AECC Refrigerator Temperature documentation provided by the DON on 9/1/15 at 2:05 p.m., indicated the following: The July 2015 refrigerator temperatures were measured and documented 2 to 3 times a day. The documented temperatures ranged from 28 degrees F. to 34 degrees F and included 90 entries of temperatures below 36 degrees F. The August 2015 refrigerator temperature were measured and documented 2 to 3 times a day from 8/1/15 to 8/16/15 at shift change. The documented temperatures ranged from 30 degrees F. to 32 degrees F. The refrigerator temperatures were measured and documented 2 times a day at shift change from 8/17/15 to 8/31/15. The documented temperatures ranged from 30 degree F. to 33 degrees F and included 76 entries of temperatures below 36 degrees F. 3. On 8/31/15 at 4:30 p.m., a review of the current facility policy, provided by the DON, titled, Medication Storage in the Facility, dated January 2007, indicated, .Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier.Medications requiring refrigeration or temperatures between .36 degrees F. and 46 degrees F. are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.Outdated, contaminated or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal. On 9/1/15 at 1:00 p.m., a review of the manufacturer's recommendations, provided by the DON, for the storage of the medications stored in the facility's medication refrigerators indicated the following: .Lorazepam liquid.Store at Cold Temperature-Refrigerate.36 degrees - 45 degrees F.; .Aplisol.Storage.DO NOT FREEZE.This product should be stored at.36 degrees - 46 degrees F.; .Tubersol.Store at 35 degrees to 46 degrees. DO NOT FREEZE.; .vancomycin.Store at room temperature for less than or equal to 2 wk (weeks) after reconstitution.; .Avonex.store reconstituted solution in refrigerator; DO NOT FREEZE.; .Risperdal.Stability after reconstitution.the product my remain at room temperature, but must be used within 6 hr (hours).; .famotidine.store in cool environment.IV sol (solution) stable for 48 hr at room temperature.; .Insulins: Humalog.Novolin R.Novolin N.Lantus.Novolog 70/30.Store at room temperature for less than 1 mo (month); keep away from heat and sunlight; refrigerate all other supply.do not freeze. 3.1-25(m)

Based on observation, interview and record review, the facility failed to implement an action plan for the identified concerns regarding the handwashing and sanitizing of hands during meal service, ensuring food was protected from potential contamination in the dining rooms; monitoring and providing a meal or snack within the recommended amount of time after administering a fast acting insulin, monitoring a safe environment for residents for fall prevention and for loose pills and alcohol prep pads being accessible in the side compartments of the medication carts, monitoring for expired supplements and for meal tray delivery to a resident on isolation without using the appropriate personal protective equipment or performing handwashing prior to and after delivery of the tray, monitoring foley catheter care with tubing that was on the floor and maintaining the posting of the ISDH (Indiana State Department of Health) complaint number at a height level that could be read and posting of the complaint number in the intermediate care wings of the facility. This had the potential to affect 120 of 120 residents who resided at the facility. Findings include: The QAPI (Quality Assurance/Performance Improvement) committee, consisted of the Administrator, the DON (Director of Nursing), the Medical Director and the Managers of each of the Facility's Departments. The committee met monthly and they failed to identify and to implement an action plan to correct and monitor the handwashing and sanitizing of hands during meal service, ensuring food was protected from potential contamination in the dining rooms; monitoring and providing a meal or snack within the recommended amount of time after administering a fast acting insulin, monitoring a safe environment for residents for fall prevention and for loose pills and alcohol prep pads being accessible in the side compartments of the medication carts, monitoring for expired supplements and for meal tray delivery to a resident on isolation without using the appropriate personal protective equipment or performing handwashing prior to and after delivery of the tray, monitoring foley catheter care with tubing that was on the floor and maintaining the posting of the ISDH (Indiana State Department of Health) complaint number at a height level that could be read and posting of the complaint number in the intermediate care wings of the facility. An interview with the DON (Director of Nursing) on [DATE] at 11:57 a.m., indicated the QAPI Committee met monthly and indicated the Committee was not aware of these concerns. On [DATE] at 2:28 a.m., the DON provided the facility's policy, Performance Improvement dated ,[DATE], which indicated "...The Quality Assurance Committee is responsible for identifying and monitoring areas that require preventive and corrective action, particularly issues which negatively affect quality of care and services provided to residents. The Committee also develops and initiates plans of action to correct any identified quality of care problems and evaluates results of corrective actions for implementation of problem resolutions...." 3XXX,[DATE](a)(2)

Based on interview and record review the facility failed to ensure a bed alarm was in place and adequate staff were in place for 2 residents (Resident #105 and Resident #117) to prevent falls. This deficient practice resulted in a skin tear for Resident #117 and a fall with a fracture and resultant surgery for [REDACTED]. The facility also failed to ensure loose pills and alcohol prep pads were not accessible to the 15 of 120 residents in the facility identified as being confused and independently mobile. Findings include: 1. Review of the clinical record for Resident #105 on 8/11/14 at 11:21 a.m., indicated the following: [DIAGNOSES REDACTED]. Resident#105 was admitted to the facility on [DATE]. A Physician's order for Resident #105, dated 9/4/13, indicated Physical Therapy 1-2 weeks for therapeutic exercises, therapeutic activities, gait, neuro re-education, and safety education. A Physician's order for Resident #105, dated 9/11/13, indicated to discontinue physical therapy services after treatment on this date. The order recommended for the resident to continue with restorative programs. A Fall Risk Assessment for Resident #105, dated 10/16/13, indicated the following: he experienced 1-2 falls during the last 90 days, he displayed any of the behaviors (such as easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the cause of the day, wanders, abusive, resists care); his balance was unsteady, but he was able to re-balance without physical support; and he currently took or had taken 3 or more medications within the last 7 days (such as anesthetic, antianxiety, anticonvulsant, antidepressant, antihistamine, antihypertensive, antipsychotic, benzodiazepine, cardiovascular, cathartic, hypoglycemic, hypnotic/sedative, muscle relaxant, narcotic). The assessment also indicated a score of 10 which placed him at high risk for falls. A Fall Investigation for Resident #105, dated 10/17/13, indicated he was observed on the floor of his room by staff performing bed check. The investigation also indicated he was wearing only socks and slipped and fell when trying to take himself to the bathroom. The investigation further indicated his care plan was updated with the intervention to reinforce the resident to use his call light for assistance. No injuries were noted from the fall. A physician's order for Resident #105, dated 11/13/13, indicated may have low bed for safety (bed in low position when in bed). A Fall Risk Assessment for Resident #105, dated 11/13/14, indicated the following: he experienced 1-2 falls during the last 90 days; he displayed any of the behaviors; he had moderately impaired vision; he ambulated with problems and with devices; he was not able to attempt the balance test without physical help; he had 1-2 health conditions present (such as cardiovascular, neuromuscular, orthopaedic, electrolyte imbalance, unstable blood sugar, perceptual, psychiatric or cognitive, nutritional factors); and he had currently took or had taken within the last 7 days 3 or more medications. The assessment also indicated a score of 24 which placed him at high risk for falls. A Fall Investigation for Resident #105, dated 11/14/13, indicated he had taken himself to the bathroom, removed his brief, walked back to bed, urinated on the floor, slipped in the urine and fell . The investigation also indicated his care plan was updated with the intervention for bed to be in low position when resident was in the bed. No injuries were noted from the fall. A Minimum Data Set (MDS) assessment for Resident #105, dated 11/25/13, indicated a score of 11 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The MDS also indicated he required extensive assistance with the physical assistance of 1 person for transfers and walking in room. The MDS further indicated he was not steady, only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. The MDS also indicated a walker and wheelchair were normally used by Resident #105. A Fall Investigation for Resident #105, dated 12/4/13, indicated a housekeeper was walking in the hallway and observed the resident on the floor in his room close to the bed of his roommate. The investigation also indicated his care plan was updated with the interventions for a Posey alarm to be used when in bed or up in a chair. No injuries were noted from the fall. A Physician's order for Resident #105, dated 12/4/13, indicated a Posey alarm on when in bed and chair to alert staff of independent transfers (frequent falls). A Fall Risk Assessment for Resident #105, dated 12/7/13, indicated the following: he experienced 3 or more falls during the last 90 days; his cognitive status had changed in the last 90 days; he displayed any of the behaviors; he required assistance with elimination; he displayed an unsteady balance, but was able to rebalance without physical support; he had 1-2 health conditions present; and he had currently took or had taken within the last 7 days 3 or more medications. The Fall Risk Assessment indicated a total score of 17 which placed Resident #105 at high risk for falls. A Nursing Progress Note for Resident #105, dated 12/8/13 at 7:02 a.m., indicated he sustained a fall at 4:45 a.m. The note also indicated he was found lying on his left side with a walker clenched at both sides. Resident #105 appeared to be alert and oriented times three. The note further indicated the left foot was rotated to the side with pain on movement of the left leg and severe pain on standing up. The note also indicated the physician was called and an order was received to send him to the hospital for evaluation, possible admit, and treatment. A Nursing Note for Resident #105, dated 12/8/13 at 7:33 a.m., indicated his roommate went outside of his room and told staff members "we got a man down in here." The note also indicated the resident was found lying on his left side with his walker turned over at his doorframe of the bathroom. The note further indicated upon assessment his left foot was slightly rotated to the left side. The note also indicated the hip felt in place but the resident had severe pain on little movement of the left leg with a rotated foot, and severe pain as he was briefly placed in a standing position. His physician was notified and an order was received to send the resident to the ER (emergency room ). The note also indicated "It was then reported to writer that (resident's name's) posey alarm was hooked up to his recliner but not his actual bed from which he was transferring self to restroom from." A physician's order for Resident #105, dated 12/8/13, indicated to send to ER for evaluation, treatment, and possible admission (fall, possible broken hip). A Nursing Progress Note for Resident #105, dated 12/8/13 at 7:52 a.m., indicated the hospital ER was called and the facility was informed the resident did indeed suffer a broken left hip. The note also indicated he would be admitted to the hospital. An emergency room Report for Resident #105, dated 12/8/13, indicated he was brought to the ER with the chief complaint of left hip pain from a fall. The report also indicated the radiographs of the left hip showed a complete displaced angulated left femoral neck fracture. The report further indicated Resident #105 was admitted to the hospital for surgery. A Fall Investigation for Resident #105, dated 12/10/13, indicated his roommate was asking for assistance when the Certified Nursing Assistant (CNA) entered the room and observed the resident on the floor. The investigation also indicated the nurse entered the room and observed the resident lying on his left side on the floor in the bathroom. The investigation further indicated the resident complained of pain in his left hip and leg region. Orders were given to send the resident to the hospital ER for evaluation. The investigation also indicated the nurse was interviewed and stated "I checked the alarm once the resident was transferred to the hospital and observed the posey box alarmed to the chair pad and not the pad in his bed." The investigation did not indicate if his bed was in the low position. The DON was interviewed on 8/12/14 at 2:42 p.m. During the interview she indicated the Posey alarm should have been on his bed. A Restorative Program for Resident #105, dated 12/26/13, indicated he required 2 assist with all mobility, one following with a wheelchair and one with a contact guard assist. Review of the Fall Investigations for Resident #105 ,dated 12/20/13 and 12/31/13, indicated he experienced two falls. Following the fall on 12/31/14, he complained of pain to his right hip and an order was received to send him to the ER for evaluation. Upon his return to the facility a bruise, measuring 14 cm x 6.8 cm was noted to the top of his right foot. A physician's order for Resident #105, dated 12/31/13, indicated strict fall precautions. The order also indicated the resident has fallen within the last month with a hip fracture. The further indicated he was clearly unsafe on his own and required assistance at all times. Review of the Fall Investigations for Resident #105 dated 1/2/14, 1/10/14, 1/15/14, and 1/20/14, indicated he experienced 5 falls with 2 falls occurring on 1/2/14. A Nursing Progress Note for Resident #105, dated 1/2/14 at 1:22 p.m. as a late entry for 1/2/14 at 9:30 a.m., indicated he was ambulating with assist for restorative program and his knee buckled and he fell to the floor, hitting his temple area on the handrails in the hall. The note also indicated a 4.0 cm x 0.4 cm abrasion was noted to his left temple area and an abrasion was noted to his left knee, measuring 1.0 cm x 1.0 cm. The note did not indicate the number of staff assisting him with ambulation or a gait belt or walker were in use. This was the second fall for Resident #105 on 1/2/14. A staff statement concerning the fall for Resident #105 on 1/2/14 at 1:22 p.m., provided by the DON on 8/14/14 at 9:52 a.m., indicated 2 staff were with him when he was ambulating in the hallway and a gait belt was used. The statement did not indicate whether 1 staff was following behind him with a wheelchair. A Fall Investigation for Resident #105, dated 1/3/14, indicated the resident was ambulating in the hallway with 2 staff members when his knees buckled causing him to fall to the floor. The resident fell left, falling into the wall and handrail, hitting the left temporal area of his head on the handrail as he fell to the floor. The CNA's attempted to slow and cushion the fall. An abrasion was noted to his left temple area and his left knee. Therapy was notified due to second fall of the day. Therapy completed an evaluation to use a saddle cushion with a lap tray. The care plan was updated with the interventions. The investigation did not indicate if a gait belt or walker were in use. The MDS assessment for Resident #105, dated 1/17/14, indicated he required extensive assistance with the physical assistance of 2 persons for transfers and walking in room. The MDS also indicated he was not steady, only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. A physician's order for Resident #105, dated 1/29/14, indicated 2 assist with all transfers. Occupational Therapist #20 was interviewed on 8/12/14 at 2:40 p.m. During the interview she indicated the restorative program for Resident #105 was written at the time of his discharge from therapy. She also indicated the restorative program was provided to nursing for staff to follow and a hard copy was in his clinical record. A physician's order for Resident #105, dated 4/15/14, indicated Posey alarm on when in bed or Broda chair to alert staff of attempt to self transfer. A physician's order for Resident #105, dated 6/13/14, indicated to discontinue the Posey alarm in bed and to discontinue the floor mat at bedside. The order also indicated Posey alarm on when in chair/Broda to alert staff of attempts at self transfer. A physician's order for Resident #105, dated 6/20/14, indicated to discontinue Posey alarm in bed. A Nursing Progress Note for Resident #105, dated 7/22/14, indicated he was observed on the right side of his bed on the floor. The note also indicated he had rolled off the bed and onto the floor. The note further indicated his bed was in the low position at the time. A small skin tear was noted to his right outer calf. A Fall Risk Assessment for Resident #105, dated 7/22/14, indicated he experienced 1-2 falls during the last 90 days; displayed behaviors such as easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive, resists care; elimination with assistance; confined to chair; not able to attempt balance test without physical help; 3 or more health conditions present; and medications. The assessment also indicated he was at high risk for falls and the intervention of a sensory pad to his bed was initiated. Review of the Fall Investigation for Resident #105, dated 7/23/14, indicated he was observed laying on the floor in his room beside his bed on his back. The investigation also indicated the Posey alarm which had been used in his Broda chair and bed were discontinued on 6/26/14 due to resident's decreased responsiveness A facility care plan for Resident #105, with a start date of 8/24/13 and the most current review date of 7/23/14, indicated the problem area of potential for falls related to confusion, often doesn't use call light, weakness, and history of falls. Approaches to the problem included, but were not limited to, anticipate and meet needs as resident often does not use call light to request assist, be sure call light is in reach and encourage resident to use it for assistance as needed, respond promptly to requests for assistance, encourage use of assistive device of walker, encourage to wear non-skid footwear when transferring or up in wheelchair, floors free from spills or clutter, provide adequate glare free lighting, personal items within reach, reinforce resident to use call light to call for assistance periodically, and monitor for changes in balance, gait, or ability transfer/ambulate safely. The intervention of place bed in low position when in bed was added on 11/15/13. The intervention of Posey alarm to be in place when in bed and/or chair was added on 12/4/13. 2. Review of the clinical record for Resident #117 on 8/12/14 at 1:54 p.m., indicated the following: [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment for Resident #117, dated 6/30/14, indicated he required extensive assistance with the physical assistance of 2 staff for transfers. The MDS also indicated he was not steady, only able to stabilize with staff assistance. A Fall Risk Assessment for Resident #117, dated 6/27/14, indicated: he displayed any of the behaviors of easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varies over the course of the day, wanders, abusive, resists care; he required assistance with elimination; he was confined to a chair; he was not able to attempt balance test without physical help; he had 3 or more health conditions present (such as cardiovascular, neuromuscular, orthopaedic, electrolyte, perceptual, psychiatric or cognitive, nutritional factors); and he had currently taken or taken within the last 7 days 3 or more medications (such as anesthetic, antianxiety, anticonvulsant, antidepressant, antihistamine, antihypertensive, antipsychotic, benzodiazepine, cardiovascular, cathartic, hypoglycemic, hypnotic/sedative, muscle relaxant, narcotic). The assessment also indicated a total score of 20, which placed him at high risk for falls. Nursing Progress Notes for Resident #117, dated 8/7/14 at 7:32 a.m., indicated a CNA was transferring him from his bed to his wheelchair when his foot slid from under him and he was lowered to the floor. The note also indicated he received a skin tear to his right calf. The note further indicated his physician was notified and the order received for Bacitracin (antibiotic ointment) and Band-Aid to skin tear daily. A Skin Assessment Form for Resident #117, dated 8/7/14, indicated a skin tear measuring 1 cm (centimeter) x 5 cm on his right calf. The assessment also indicated the treatment of [REDACTED]. A Resident Care Guide for all shifts, provided by the Director of Nursing on 8/12/14 at 10:30 a.m., indicated Resident #117 required a gait belt and 1-2 assist for transfers. A facility care plan for Resident #117, with a start date of 4/18/14, indicated the problem area of potential for falls related to hemiparesis, impaired mobility, osteoarthritis, and incontinence. Approaches to the problem included, but were not limited to, anticipate and meet needs, encourage to wear non-skid footwear when transferring or up in wheelchair, floors free from spills or clutter, provide adequate glare free lighting, personal items within reach, and monitor for changes in balance, gait, or ability to transfer safely. The care plan did not indicate the need for a gait belt during transfers or the number of staff required to transfer him safely. RN #18 was interviewed on 8/13/14 at 10:15 a.m. During the interview she indicated the resident care guides were developed by the director of restorative services. RN #19 was interviewed on 8/13/14 at 10:30 a.m. During the interview she indicated she based the resident care guide for 1-2 assist for transfers for Resident #117 on the physician order for [REDACTED]. She also indicated there were no guidelines for staff to follow on when to use 1 person assist and when to use 2 person assist and the physician order for [REDACTED]. She further indicated Resident #117 was to be seen by his physician to address and determine the exact order for his requirements for transfer. The physician's order for one assist for transfers had not been updated since 1/14/13. A current facility policy "Resident Alarms for Safety", revised on May, 2013 and provided by the Staff Development Coordinator on 8/13/14 at 10:15 a.m., indicated "...Resident alarms may be used for residents as a non-restraining device that alerts staff to a resident rising from a bed or chair without assistance...Identify residents at risk for falls using fall risk assessment on admission. High risk for falls include but are not limited to frequent falls, confused residents, noncompliant residents, unsteady or weak in ambulating and/or bed rail climber...Notify physician and obtain order for alarm use...." A current facility policy "Fall Prevention", dated 2/1/94 and provided by the Director of Nursing on 8/13/14 at 8:30 a.m., indicated "...It is the policy...to identify residents at risk for falls and to implement a fall prevention program to reduce the risk of falls and possible injury...Within three (3) days of admission...complete the initial risk assessment...The charge nurse or the unit manager will reassess each resident...Based on the outcome of the assessments, a fall risk prevention plan will be incorporated into the resident's comprehensive plan of care...All staff involved with the resident's care will be notified on the resident's fall risk status...The interdisciplinary team will review the resident's fall risk prevention plan at a minimum of quarterly, during care conference, and modify the plan as needed, based upon the resident's functional status during the review period. Referrals will be made to other health professionals as needed...High fall risk controls: a) Make frequent checks...d) Provide safety devices...f) Provide assistive devices...If a resident experiences a fall, further investigation and assessment is imperative to reduce the risk of more falls...." A current facility policy "Restorative Program", revised on May, 2013 and provided by the Staff Development Coordinator on 8/13/14 at 19:15 a.m., indicated "...Restorative Nursing Programs will be set up under the supervision/recommendations of the therapy department for those residents that require ongoing treatment to maintain or improve their level of independence and range of motion...Documentation of number of aides to assist...." 3. An observation of the Peach Tree medication cart on 8-12-2014 at 10:38 a.m., indicated 2 pills (a white capsule and a white tablet) were in the bottom of the side compartment of the medication cart where the straws were located. The side compartment was located just below eye level of a resident in a wheelchair. An interview with Nurse #1 and Nurse #2 on 8-12-2014 at 10:38 a.m., indicated they were not aware of the loose pills in the side compartment. On 8-13-2014 at 8:30 a.m., the Director of Nursing (DON) indicated there were 15 residents in the facility who were confused and independently mobile. A policy "Medication Storage in the Facility" dated January 2007 and provided by the DON on 8-13-2014 at 11:30 a.m., indicated "...the medication supply is accessible only to licensed nursing personnel..." and "...the provider pharmacy dispenses medications in containers...medications are kept in these containers...." 4. An observation of the Maple Street medication cart on 8-12-2014 at 2:11 p.m., indicated an opened box of alcohol prep pads was in the side compartment of the medication cart. The side compartment was located just below eye level of a resident in a wheelchair. An interview with Nurse #4 on 8-12-2014 at 3:20 p.m., indicated the alcohol pads that were stored in the outside compartment of the Maple Street medication cart were not usually there as the box usually contained tape. Nurse #4 counted 19 alcohol pads inside the open box stored in the open side compartment of the medication cart. An interview with the DON on 8-14-2014 at 9:55 a.m., indicated the alcohol prep pads were to be stored inside the locked medication cart and the DON indicated it was not expected for the alcohol prep pads to be stored in the open compartment on the side of the medication cart. The DON indicated the alcohol prep pads should have been stored in the locked medication cart. A copy of the Material Safety Data Sheet for the 70% Isopropyl Alcohol in water dated 10-17-1996 and provided by Nurse #23 indicated for "...emergency and first aid procedures...ingestion-give 1 pint warm water...in all cases seek emergency medical attention immediately...." A review of a copy of the alcohol medium prep pad package identified as "...saturated with 70% alcohol....", used in the facility and provided by the DON on 8-14-2014 at 9:55 a.m., indicated "...Warnings...keep out of reach of children...if swallowed, get medical help or contact a Poison Control Center right away...." 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate greater than 5%, with the facility having 5 medication errors out of 28 opportunities for error, resulting in a 17.8% error rate. This affected 5 of 13 residents observed for medication pass (Residents #126, #145, #12, #70 and #50), and 3 of 6 nurses observed to pass medications. (Nurse #1, #3 and #4) Findings include: 1. During the medication pass observation, Nurse #4 was observed to administer Resident #126's potassium chloride on 8-11-2014 at 4:26 p.m. without food. A review of the signed Physician's recapitulation (recap) for July 2014 indicated [DIAGNOSES REDACTED]. A review of the July 2014 recap indicated an order for [REDACTED]. A review of the Meal Time Schedule provided by the Certified Dietary Manager on 8-7-2014 at 12:30 p.m., indicated the evening meal was served in the Forest Cafe between 5:00 p.m. and 6:30 p.m. A review of the Mosby's 2014 Nursing Drug Reference book, identified by the Director of Nursing (DON) as the facility reference material for medication information, on 8-13-2014 at 12:05 p.m., indicated for potassium "...administer: po (by mouth) route...with or after meals...." 2. During the medication pass observation, Nurse #3 was observed to administer Resident #145's insulin ([MEDICATION NAME] 5 units subcutaneously) on 8-11-2014 at 4:51 p.m. in her room. Resident #145 indicated she would have her evening meal in the dining room (Forest Cafe). An observation on 8-11-2014 at 5:22 p.m., indicated Resident #145 was served her evening meal. A review of the signed Physician's recapitulation (recap) for July 2014 indicated Resident #145's [DIAGNOSES REDACTED]. A review of the July 2014 recap indicated an order [MEDICATION NAME] 5 units sub q (subcutaneously) before meals for diabetes. 3. During the medication pass observation, Nurse #1 was observed to administer Resident #12's insulin ([MEDICATION NAME] 5 units sub q) for a blood sugar of 154 on 8-12-2014 at 10:55 a.m. in her room. An observation on 8-12-2014 at 11:20 a.m., indicated Resident #12 arrived at the Forest Cafe and was served her lunch at 11:47 a.m. Water and coffee were provided while the resident was waiting for her meal to be served. A review of the signed Resident's [DIAGNOSES REDACTED].#12's [DIAGNOSES REDACTED]. A review of the signed Physician's admission orders [REDACTED]. 4. During the medication pass observation, Nurse #1 was observed to administer Resident #70's insulin ([MEDICATION NAME] 4 units sub q) for a blood sugar of 242 on 8-12-2014 at 11:04 a.m. in her room. An observation on 8-12-2014 at 11:20 a.m., indicated Resident #70 was in the Forest Cafe dining room and her lunch was served at 11:35 a.m. A review of the signed Physician's recapitulation (recap) for July 2014 indicated Resident #70's [DIAGNOSES REDACTED]. A review of the July 2014 recap indicated the order for [MEDICATION NAME] was to inject sub q per sliding scale. The sliding scale was based on a glucose check before meals and at bedtime with a blood sugar of 181 - 250 = 4 units of [MEDICATION NAME] would be given; a blood sugar of 251 - 300 = 6 units of [MEDICATION NAME] would be given and a blood sugar of 301 - 350 = 8 units of [MEDICATION NAME] given. 5. During the medication pass observation, Nurse #1 was observed to administer Resident #50's insulin ([MEDICATION NAME] 4 units sub q) for a blood sugar of 190 on 8-12-2014 at 11:11 a.m. An observation on 8-12-2014 at 11:34 a.m., indicated Resident #50 arrived in the Forest Cafe and the resident's lunch was not served by 11:50 a.m. A review of the signed Resident's [DIAGNOSES REDACTED].#50's [DIAGNOSES REDACTED]. A review of the signed Physician's admission orders [REDACTED]. The sliding scale was based on a glucose check before meals and at bedtime with a blood sugar of 181 - 250 = 4 units of [MEDICATION NAME] would be given; a blood sugar of 251 - 300 = 6 units of [MEDICATION NAME] would be given and a blood sugar of 301 - 350 = 8 units of [MEDICATION NAME] given. A review of the meal time schedule provided by the Dietary Manager on 8-7-2014 at 12:30 p.m., indicated the lunch meal began in the Forest Cafe (main dining room for A and C wings) and was scheduled from 11:00 a.m. to 1:00 p.m. An interview with Nurse #2 on 8-13-2014 at 9:17 a.m., indicated for residents with [MEDICATION NAME]injections, meals should be served within 15 minutes after the insulin injections were given. An interview with the Pharmacist #8 on 8-13-2014 at 9:21 a.m., indicated residents who were given [MEDICATION NAME]injections should have a meal or snack within 15 minutes of the injection. An interview with the DON (Director of Nursing) on 8-13-2014 at 10:05 a.m., indicated for residents with [MEDICATION NAME]injections, a meal should be served within 30 minutes of the injection. A review of the Mosby's 2014 Nursing Drug Reference book on 8-13-2014 at 12:05 p.m., indicated the [MEDICATION NAME] (Insulin [MEDICATION NAME]) was a "high alert..." medication, "...is given...just before the beginning of a meal..." and the onset was "...10-20 minutes...." 3.1-25(b)(9)

Based on observation, interview and record review the facility failed to ensure staff washed and/or sanitized their hands at the appropriate time during meal service and failed to protect resident meal trays and food from potential contamination during meal service potentially affecting 28 residents out of 119 residents who ate their meals in the Tea Dining Room and the Java Dining Room. Findings include: 1. During an observation of the breakfast meal in the Tea Dining Room on 8/8/14 the following was observed: - At 7:42 a.m., Certified Nursing Assistant (CNA) #10 was observed to remove a meal tray from an open cart containing meal trays and place it on the half-wall separating the dining room and the common hallway. She was not observed to wash or sanitize her hands before removing the meal tray from the cart. She removed all the lids from the glasses and mugs and removed the protective dome cover from the plate to prepare the plate for the resident. She then carried the un-protected meal tray from the half-wall through the common hallway and around the open cart before delivering the meal tray to the resident. - At 7:44 a.m., CNA #10 was observed to remove another meal tray from the open cart and place it on the half-wall separating the dining room and the common hallway. She was not observed to wash or sanitize her hands before removing the meal tray from the cart. She removed all the lids from the glasses and was observed to handle a glass by the drinking rim when pouring out the ice water and pouring juice into the glass. She was observed to also remove the protective dome cover from the plate to prepare the plate for the resident. She then carried the un-protected meal tray from the half-wall through the common hallway and around the open cart before delivering the meal tray to the resident. - At 7:47 a.m., CNA #10 was observed to push a resident up closer to the table by moving her geri-chair. She then was observed to remove another meal tray from the open cart and place it on the half-wall separating the dining room and the common hallway. She was not observed to wash or sanitize her hands after assisting a resident in their geri-chair and before handling the meal tray from the open cart. She was observed to handle 3 disposable glasses by the drinking rims while pouring beverages into the glasses. She then handled the glasses by the drinking rims when placing the full glasses of beverages on the meal tray. She was observed to also remove the protective dome cover from the plate to prepare the plate for the resident. She then carried the un-protected meal tray from the half-wall through the common hallway and around the open cart before delivering the meal tray to the resident. - At 7:51 a.m., CNA #11 was observed to push a resident in a wheelchair down the hallway into the dining room. She immediately removed a meal tray from the open cart and passed it to a resident without washing or sanitizing her hands. 2. During an observation of the breakfast meal in the Java Dining Room on 8/8/14 the following was observed: - At 8:14 a.m., CNA #12 was observed to push an open cart containing meal trays down the hallway and placed it by the entrance into the dining room. She then removed a meal tray from the open cart and delivered it to a resident's room. She was not observed to wash or sanitize her hands before delivering the meal tray. - At 8:17 a.m., CNA #12 removed a second meal tray from the open cart and delivered it to a resident's room. She was not observed to wash or sanitize her hands before handling the meal tray. - At 8:19 a.m., CNA #13 was observed to place a pen in the pocket of her uniform and immediately removed a meal tray from the open cart and delivered the meal tray to a resident in the dining room. She was not observed to wash or sanitize her hands before handling the meal tray. 3. During an observation of the lunch meal in the Tea Dining Room on 8/8/14 the following was observed: - At 11:34 a.m., LPN #14 was observed to remove a meal tray from the open cart and deliver it to a resident's room. She was not observed to wash or sanitize her hands before delivering the meal tray. - At 11:36 a.m., CNA #15 was observed to remove meals trays and deliver them to 2 residents in the dining room. She was not observed to wash or sanitize her hands before handling the meals trays. - At 11:39 a.m., CNA #15 was observed to move a resident in a wheelchair up closer to the dining table. She then used the resident's eating utensils to cut up her food. She also was observed to remove a slice of bread from the wrapper with her bare fingers, place the slice of bread on the meal tray, and use her bare fingers to stabilize the bread while she applied butter. She was not observed to wash or sanitize her hands after touching the wheelchair. - At 11:40 a.m., CNA #10 was observed to reposition a resident in her geri-chair. She then removed a meal tray from the open cart and delivered it to the resident. She was not observed to wash or sanitize her hands before handling the meal tray. - At 11:45 a.m., CNA #16 was observed to move a resident in the dining room. She then picked up the resident's eating utensils and placed the eating utensils into the hand of the resident. She was not observed to wash or sanitize her hands before picking up the eating utensils. 4. During an observation of the lunch meal in the Tea Dining Room on 8/12/14 the following was observed: - At 11:31 a.m., CNA #16 was observed to touch her uniform and the gait belt fastened around her waist. She then removed a meal tray from the open cart and delivered it to a resident in the dining room. She was not observed to wash or sanitize her hands before handling a meal tray. - At 11:34 a.m., CNA #16 was observed to remove another meal tray from the open cart and delivered it to a resident in the dining room. She was not observed to wash or sanitize her hands. 5. During an observation of the lunch meal in the Java Dining Room on 8/12/14 the following was observed: - At 11:45 a.m., CNA #17 was observed was observed to take a meal tray from the open cart containing meal trays and place it on the half-wall separating the dining room and the common hallway. She was not observed to wash or sanitize her hands before removing the meal tray from the cart. She removed all the lids from the glasses and mugs and removed the protective dome cover from the plate to prepare the plate for the resident. She then carried the un-protected meal tray from the half-wall through the common hallway and around the open cart before delivering the meal tray to the resident. The Dietary Manager and the Clinical Manager were interviewed on 8/12/14 at 2:16 p.m. During the interview they indicated they would expect staff to wash their hands before meal service started and to use hand sanitizer in-between the passing of meal trays. They also indicated staff should wash their hands after touching anything soiled. They further indicated staff should never touch food with their bare hands and should take meal trays to residents completely covered. A current facility policy "Meal Service", revised on June, 2013, and provided by the Clinical Manager on 8/12/14 at 3:56 p.m., indicated "...To insure resident meals are prepared and served in an organized manner and are sanitary and safe to consume...Nursing is responsible for distributing the trays to and from the residents...a. Nursing will perform hand hygiene between each resident when passing meals tray to those eating in their room or in the feeding lounges on each wing or when contaminated....b. Nursing staff will not handle prepared food without proper hand protection or hand hygiene...c. Nursing staff will not uncover food prior to serving tray to the resident...." 6. During an observation of lunch meal service to Resident's room on A-Wing on 8/8/14 from 11:28 a.m. to 12:20 p.m. the following was observed: - At 11:50 a.m., Certified Nursing Assistant (CNA) #10 was observed to touch her face and was not observed to wash or sanitize her hands before removing a lunch meal tray from the cart. CNA #10 delivered the tray to an unidentified Resident in their room. The CNA removed the protective dome cover from the plate and the plastic lids from the food and beverages on the tray without performing hand hygiene. 3.1-21(i)(1)

Based on observation, interview and record review, the facility failed to ensure individual unidentified medication tabs/capsules were secured in the medication container in 4 of 4 medication carts in 2 of 3 wings (Wing A and C). The facility also failed to ensure expired Nepro supplements were removed from 1 of 2 pantries. Findings include: An observation of the Elm Street medication cart with Nurse #5 on 8-12-2014 at 2:55 p.m., indicated 5 1/2 pills were loose in the bottom of the second drawer of the medication cart and 2 pills were loose in the bottom of the 3rd drawer. An observation of the A wing supply room with Nurse #5 on 8-12-2014 at 3:05 p.m., indicated nineteen 8 ounce cans of Nepro had an expiration date of 7-1-2014 and one 8 ounce can of Nepro had an expiration date of 5-1-2014. An observation of the Maple Street medication cart with Nurse #4 on 8-12-2014 at 3:10 p.m., indicated 1 loose pill was found in the bottom of the 2nd drawer. An interview with Nurse #4 on 8-12-2014 at 3:20 p.m., indicated she was not sure how often the medication carts were cleaned. An observation of the Peach Tree medication cart with Nurse #6 on 8-12-2014 at 3:25 p.m., indicated there was 1 capsule and a half of a pill found in the bottom of the 3rd drawer. An interview with Nurse #6 on 8-12-2014 at 3:30 p.m., indicated the medication carts were cleaned weekly on the night shift. An observation of the Spring Street medication cart with Nurse #7 on 8-12-2014 at 3:40 p.m., indicated there were a total of 6 pills found in the bottom of the medication cart - 2 pills in the 2nd drawer, 3 pills in the 3rd drawer and 1 pill in the bottom drawer. An interview with the Director of Nursing (DON) on 8-13-2014 at 10:00 a.m., indicated the medication carts were checked every night for expired medications and the staff was also to check the bottom of the drawer for loose pills. An interview with the DON on 8-14-2014 at 8:57 a.m., indicated the unit managers usually check the expiration dates of the supplements during the daily rounds. An interview with Nurse Unit Manager #24 on 8-14-2014 at 9:00 a.m., indicated the Scheduler was responsible for ensuring the expired supplements were removed. An interview with the Scheduler #25 on 8-14-2014 at 9:20 a.m., indicated she did the ordering and stocking of the supplements and also would remove any expired supplements and products. A policy "Medication Storage in the Facility" dated January 2007 and provided by the DON on 8-13-2014 at 11:30 a.m., indicated "the provider pharmacy dispenses medications in containers...medications are kept in these containers...." A policy for the removal of expired supplements was requested on 8-14-2014 at 12:15 p.m. but was not provided. 3.1-25(j) 3.1-25(k) 3.1-25(l) 3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure the foley catheter tubing was kept from laying on the floor for 1 of 14 residents identified with a foley catheter. (Resident #130) Findings include: Observations of the foley catheter tubing for Resident #130 were as follows: -On 8-12-2014 at 10:50 a.m., the foley catheter tubing was on the floor under the wheelchair as Resident #130 propelled down the C wing hall. -On 8-12-2014 from 11:15 a.m. to 11:50 a.m., during lunch in the Forest Cafe, the foley catheter tubing was laying on the floor under Resident #130's wheelchair. -On 8-13-2014 at 8:16 a.m., during breakfast in the Forest Cafe, the foley catheter tubing for Resident #130 was laying on the floor under the wheelchair. On 8-13-2014 at 9:38 a.m., during an activity in the Forest Care, the foley catheter tubing for Resident #130 remained on the floor under the wheelchair. On 8-13-2014 at 9:55 a.m., an observation of Resident #130 in an activity in the Forest Cafe with the Director of Nursing (DON) indicated the foley catheter tubing was laying on the floor. An interview with the DON on 8-13-2014 at 9:58 a.m., indicated the resident preferred the foley catheter tubing to come out of the pant leg and it was difficult to keep the tubing off the floor. The DON indicated the tubing needed to be up off the floor. An interview with CNA #9 on 8-13-2014 at 11:50 a.m., indicated a resident with a foley catheter would have the drain bag placed in a bag and secured under the wheelchair, the tubing would be placed so it comes out the bottom of the pant leg and the tubing should not be on the floor. The record review for Resident #130 began on 8-13-2014 at 3:08 p.m. The physician's recapitulation for June 2014 was signed by the physician on 6-26-2014. [DIAGNOSES REDACTED]. The physician orders [REDACTED]. A review of the infection report dated 8-29-2013 and provided by the DON on 8-13-2014 at 11:50 a.m., indicated the resident had a urinary tract infection due to [MEDICATION NAME] faecalis (a bacteria). Resident #130 was transferred to the emergency room for increased pain and confusion and returned to the facility for intravenous antibiotic. A review of the urinary catheter care plan initiated on 7-5-2013 indicated "...do not let drainage bag or tubing touch the ground at any time...." A "Foley Catheter - Care of Indwelling Catheter" policy dated 7-13-2001 and provided by the DON on 8-13-2014 at 10:50 a.m., indicated "...catheter tubing... should not be touching the floor when resident is sitting in a chair...." 3.1-41(a)(1)

Based on interview and record review, the facility failed to follow a physician order [REDACTED]. Findings include: Review of the clinical record for Resident #105 on 8/11/14 at 11:21 a.m., indicated the following: [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment for Resident #105, dated 11/25/13, indicated a score of 11 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The MDS also indicated he required extensive assistance with the physical assistance of 1 person for transfers and walking in room. The MDS further indicated he was not steady, only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. The MDS also indicated a walker and wheelchair were normally used by Resident #105. A physician's orders [REDACTED]. A Fall Risk Assessment for Resident #105, dated 12/7/13, indicated he was at high risk for falls. A Nursing Progress Note for Resident #105, dated 12/8/13 at 7:02 a.m., indicated he sustained a fall at 4:45 a.m. The note also indicated he was found lying on his left side with a walker clenched at both sides. Resident #105 appeared to be alert and oriented times three. The note further indicated the left foot was rotated to the side with pain on movement of the left leg and severe pain on standing up. The note also indicated the physician was called and an order was received to send him to the hospital for evaluation, possible admit, and treatment. A Nursing Note for Resident #105, dated 12/8/13 at 7:33 a.m., indicated his roommate went outside of his room and told staff members "we got a man down in here." The note also indicated the resident was found lying on his left side with his walker turned over at his doorframe of the bathroom. The note further indicated upon assessment his left foot was slightly rotated to the left side. The note also indicated the hip felt in place but the resident had severe pain on little movement of the left leg with a rotated foot, and severe pain as he was briefly placed in a standing position. His physician was notified and an order was received to send the resident to the ER (emergency room ). The note also indicated "It was then reported to writer that (resident's name's) posey alarm was hooked up to his recliner but not his actual bed from which he was transferring self to restroom from." A physician's orders [REDACTED]. A Nursing Progress Note for Resident #105, dated 12/8/13 at 7:52 a.m., indicated the hospital ER was called and the facility was informed the resident did indeed suffer a broken left hip. The note also indicated he would be admitted to the hospital. An emergency room Report for Resident #105, dated 12/8/13, indicated he was brought to the ER with the chief complaint of left hip pain from a fall. The report also indicated the radiographs of the left hip showed a complete displaced angulated left femoral neck fracture. The report further indicated Resident #105 was admitted to the hospital for surgery. A Fall Investigation for Resident #105, dated 12/10/13, indicated his roommate was asking for assistance when the Certified Nursing Assistant entered the room and observed the resident on the floor. The investigation also indicated the nurse entered the room and observed the resident lying on his left side on the floor in the bathroom. The investigation further indicated the resident complained of pain in his left hip and leg region. Orders were given to send the resident to the hospital ER for evaluation. The investigation also indicated the nurse was interviewed and stated "I checked the alarm once the resident was transferred to the hospital and observed the posey box alarmed to the chair pad and not the pad in his bed." The DON was interviewed on 8/12/14 at 2:42 p.m. During the interview she indicated the Posey alarm should have been on his bed. A current facility policy "Resident Alarms for Safety", revised on May, 2013 and provided by the Staff Development Coordinator on 8/13/14 at 10:15 a.m., indicated "...Resident alarms may be used for residents as a non-restraining device that alerts staff to a resident rising from a bed or chair without assistance...Identify residents at risk for falls using fall risk assessment on admission. High risk for falls include but are not limited to frequent falls, confused residents, noncompliant residents, unsteady or weak in ambulating and/or bed rail climber...Notify physician and obtain order for alarm use...." 3.1-35(g)(2)