Every finding on record at Allisonville Meadows

Based on observation, interview and review, the facility failed to timely have the interdisciplinary team (IDT) determine and document self-administration of medications and treatments were clinically appropriate for 1 of 1 randomly observed resident. (Resident F) Findings include:A physician order, dated 6/14/26, indicated Resident F was to receive 2 puffs of a 90 micrograms albuterol inhaler. The resident's clinical did not include a physician order or a self-medication assessment was conducted to determine if Resident F was able to self-medicate her inhaler safely.An observation was made of Resident F in her room on 8/3/26 at 10:51 a.m. Resident F was observed sitting in her wheelchair next to her bedside table. The bedside table contained an albuterol inhaler sitting on it. An interview was conducted with License Practical Nurse (LPN) 1 on 8/3/27 at 10:53 a.m. She indicated Resident F did not have a physician order or a self-medication assessment in her medical record that had been conducted to indicate she was able to self-medicate her albuterol inhaler. LPN 1 would contact the physician. A self-medication policy was provided by the Director of Nursing on 8/5/26 at 10:16 a.m. It indicated, .POLICY: It is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed medications, as allowable under state regulations. The facility will provide instruction for all residents choosing to and capable of self- administration.PROCEDURE:. If a resident desires to participate in self -administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self -Administration of Medication Assessment observation. A physician order will be obtained specifying the resident's ability to self-administer medications and, if necessary, listing which medications will be included in the self-administration plan. The resident will be assessed for continued self-administration of medications quarterly and with any significant change of condition. The resident's care plan will be updated to include self-administration. 410 Indiana Administrative Code (IAC) 16.2-3.1-11(a)

Based on interview and record review, the facility failed to administer medications as ordered for 2 of 5 residents reviewed for unnecessary medications. (Resident B and Resident L) Findings include:1.The clinical record for Resident B was reviewed on 8/3/26 at 10:30 a.m. The resident's diagnoses include, but are not limited to, bipolar (mental disorder with shifts in mood and emotions).A physician order, dated 6/15/26, Resident B was to receive 500 milligrams of azithromycin (antibiotic) once a day.The June 2026 Medication Administration Record (MAR) indicated 500 milligrams of azithromycin was administered.A nursing progress note, dated 6/15/26, indicated Resident B had received an additional dosage of 500 milligrams of azithromycin due to previous shift nurse had already administered the daily dosage and did not sign off on the MAR. The resident was assessed with no adverse effects. The provider was notified.During a Confidential Interview, They indicated Resident B was over medicated with an antibiotic medication. She received a double dosage of the antibiotic.A medication error report was provided by the Director of Nursing on 8/3/26 at 11:58 a.m. It indicated on 6/15/26, Resident B had received a double dosage of an antibiotic, azithromycin. The resident did not have any adverse effects with receiving the double dose. 2.The clinical record for Resident L was reviewed on 8/3/26 at 1:00 p.m. The resident's diagnoses include, but are not limited to, stoke (brain bleed).A medication error report was provided by the Director of Nursing on 8/3/26 at 11:58 a.m. It indicated on 6/30/26, Resident L had received another resident's medications. The medications she had received by error were 10 milligrams of atorvastatin (cholesterol medication), 500 milligrams of metformin (diabetic medication) and 0.4 milligrams of Flomax (medication to treat enlarged prostate). The resident did not exhibit any adverse effects with these medications. There were no new orders by physician given related to medication error.An interview was conducted with the Director of Nursing on 8/3/26 at 4:00 p.m. He indicated the medication error had occurred with Resident L.A medication administration policy was provided by the Director of Nursing on 8/5/26 at 10:16 a.m. It indicated, This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual (SOM) when administering medications. Procedure.3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. 3.2 Confirm that the MAR reflects the most recent medication order.5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.1 Verify resident identification per facility policy (e.g., picture, armband, name). 5.2 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. This citation is related to Intake 3109434. 410 Indiana Administrative Code (IAC) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's medical record included a complete controlled substance records for 1 of 5 residents reviewed. (Resident B) Findings include:The clinical record for Resident B was reviewed on 8/3/26 at 10:30 a.m. The resident's diagnoses include, but are not limited to, bipolar (mental disorder with shifts in mood and emotions).A physician order, dated 12/27/24, indicated Resident B was to receive 200 milligrams of pregabalin/Lyrica (medication to treat pain) three times a day.The June 2026 Medication Administration Record (MAR) indicated Resident B had received 200 milligrams of pregabalin/Lyrica three times daily from 6/1/26 through 6/30/26.The July 2026 MAR indicated Resident B had received 200 milligrams of pregabalin/Lyrica three times a day on 7/1/26 and 7/2/26.During a Confidential Interview, They indicated Resident B does not receive the correct dose of her Lyrica medication. The controlled substance records for Resident B of the administrations of 200 milligrams of Lyrica were provided by the Director of Nursing on 8/4/26 at 9:26 a.m. The records did not include documentation the resident had received 200 milligrams of Lyrica on 6/11/26 through 7/2/26 three times a day.An interview was conducted with the Nurse Consultant on 8/5/26 at 11:38 a.m. She indicated she was unable to locate the missing controlled substance records for 200 milligrams of Lyrica for Resident B on 6/11/26 through 7/2/26.This citation is related to Intake 3109434.410 Indiana Administrative Code (IAC) 16.2-3.1-50(a)(1)

Based on interview and record review, the facility failed to ensure the dignity of residents was maintained and respected for 3 of 4 resident reviewed for dignity and 16 of 134 residents reviewed in resident council. (Residents' B, E, F, G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z).Findings include: 1. The clinical record for Resident B was reviewed on 4/9/25 at 3:27 p.m. The resident's diagnoses included, but were not limited to, dementia (progressive decline in cognitive function) and deafness. A care plan, initiated 1/29/26, indicated Resident B required assistance with Activities of Daily Living (ADL) care including bed mobility, transfers, eating, and toileting. An admission Minimum Data Set (MDS) Assessment, completed 2/4/26, indicated Resident B had no useful hearing and no speech. She was sometimes able to make herself understood and sometimes able to understand what was said. She was dependent on staff for toileting. An intervention indicated to assist with toileting and/ or incontinent care as needed. A care plan, initiated 3/13/26, indicated the resident had a communication deficit related to being deaf. The goal was for the resident to understand and make herself understood by answering simple yes and no questions. The approaches included, but were not limited to, use hand gestures as necessary and use simple communication. On 3/30/26, Resident B's family member filed a Grievance Form. The grievance form indicated that on 3/30/26 a Certified Nursing Assistant (CNA) had an attitude with Resident B. An Incident Report, filed with the Indiana Department of Health on 4/1/26, indicated Resident B's family member had reported concerns that CNA 7 had made inappropriate comment made in the presence of Resident B. During an interview on 4/14/26 at 2:20 p.m., Family Member (FM) 9 indicated he had been present on 3/30/26 when CNA 7 went off on Resident B. FM 9 felt CNA 7 had mocked Resident B. Resident B used American Sign Language (ASL) to communicate. An ASL interpreter was present during the interaction between Resident B and CNA 7. FM 9 had informed the nurse on duty about the interaction and was very upset about the situation, and requested that CNA 7 not care for Resident B again. During an interview on 4/14/2026 at 3:21 p.m., CNA 7 indicated she had cared for Resident B on 3/30/26. CNA 7 provided incontinence care for Resident B prior to therapy. The therapist had brought Resident B back from therapy because she needed to use the bathroom. CNA 7 could not speak American Sign Language. CNA 7 had seen Resident B use the gesture of pinching her nose frequently. CNA 7 had imitated the gesture and asked the interpreter who was with Resident B what that gesture meant. CNA 7 had not cared for Resident B since 3/30/26. During an interview on 4/13/26 at 3:30 p.m., Interpreter (INT) 10 indicated she had been present during the incident between Resident B and CNA 7 on 3/30/26. Resident B needed to have a bowel movement while participating in therapy. The therapists had taken Resident B back to her room and requested CNA 7 to assist her back to bed. INT 10 had stayed in the room with Resident B. CNA 7 had come into the room and began using the sign for poop and said, it's always poop, poop, poop. INT 10 had tried to intervene and felt that CNA 7 was mocking Resident B. CNA 7 had not asked INT 10 what the sign she was making meant. Resident B had asked INT 10 if there was anything wrong during the interaction. INT 10 had informed FM 9 about the incident. 2. The clinical record for Resident E was reviewed on 4/10/26 at 1:44 p.m. The resident's diagnosis included, but was not limited to, diabetes. A Quarterly Minimum Data Set (MDS) Assessment, completed 1/22/26, indicated Resident E was cognitively intact. During an interview on 4/10/26 at 1:44 p.m., Resident E indicated some of the Certified Nursing Assistances (CNA) had attitudes when they come in to work. They appear angry about something, and complain about their shifts and the people they work with. Resident E would prefer not to have to deal with those attitudes at this stage in his life. 3. The clinical record for Resident F was reviewed on 4/10/26 at 1:20 p.m. The resident's diagnosis included, but was not limited to, lung cancer. During an interview on 4/14/26 at 10:23 a.m., FM 11 indicated she had visit Resident F over the past weekend. When FM 11 entered Resident F's room she found a urinal full of urine on the bedside table and a styrofoam cup with urine in it. The bedside commode had not been emptied from the day before. Resident F's room had a foul smell. FM 11 had asked the staff to empty the bedside commode, and no one came for quite a while. FM 11 felt the care that Resident F had received over the weekend was not appropriate or respectful. 4. The January 2026, February 2026, and March 2026 resident council minutes were provided by the Executive Director on 4/13/26 at 11:16 a.m. The meeting minutes indicated the following: The resident council meeting minutes, dated 1/14/26, indicated the staff were putting residents in bed in the evenings too early resulting in residents unable to attend evening bingo. The resident council meeting minutes, dated 2/26/26, indicated the residents had concerns with being put in bed too early. The resident council meeting minutes, dated 3/12/26, indicated Certified Medications Aides (CNA) staff are talking on cell phones while providing care. A resident council meeting was conducted on 4/13/26 at 1:53 p.m. The attendees in the meeting were Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z. During the meeting, the council indicated the staff are not respectful. The residents are put in bed too early with no choice. The residents had requested to be placed in bed after activities. The staff had provided excuses; they have too many people to bathe at that hour or too many residents already in that time frame to add someone else to be placed in bed when residents requested to be placed after evening activities. That resulted in residents missing evening activities. The staff were often on their cell phones while providing care. During that time, the staff were speaking in a language other than English on their phones and with each other if there were more than one person providing care. The residents had asked, what are you saying? The staff's response, we are not talking about you. The residents want the staff to speak English while in their presence. The council had reported the concerns, and it continues to not get better. An interview was conducted with the Executive Director on 4/13/26 at 2:56 p.m. He indicated the resident council had reported concerns with staff placing them in bed too early. Education was provided to staff. The residents had reported concerns several months ago about phone usage, and the staff speaking in a language other than English. He was unaware the residents still had concerns with the staff speaking in a different language. The residents had care companions that check on them routinely, and the residents had not reported recently any concerns with the staff speaking in a language other than English. This citation is related to Intake 2964009. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)

Based on interview and record review, the facility failed to ensure follow-up with resolutions to concerns brought up in resident council meetings were reported back to the resident council members. This had the potential to effect 16 of 134 residents that attended resident council meeting. (Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z) Findings include:The January 2026, February 2026, and March 2026 resident council minutes were provided by the Executive Director on 4/13/26 at 11:16 a.m. The meeting minutes indicated the following: The resident council meeting minutes, dated 1/14/26, indicated the staff were putting residents in bed in the evenings too early resulting in residents unable to attend evening bingo. The Resident Council President had signed she had received follow up with resolutions of the concerns reported in the meeting that day. There were no documentation there was discussion with the resident council members of resolutions with the concerns reported in the previous month. The resident council meeting minutes, dated 2/26/26, indicated the residents had concerns with being put in bed too early and missing evening bingo, staff were dropping off medications in the residents' rooms and not waiting for residents to take them prior to leaving and late food services. The Resident Council President had signed she had received follow-up with resolutions of the concerns reported in the meeting that day. There were no documentation, there was discussion with the resident council members of resolutions of concerns reported in the previous month. The resident council meeting minutes, dated 3/12/26, indicated medications are left in the resident rooms without waiting for residents to taking them and Certified Medications Aides (CNA) staff were talking on cell phones while providing care. The Resident Council President had signed she had received follow-up with resolutions of the concerns reported in the meeting that day. There were no documentation, there was discussion with the resident council members of resolutions with concerns reported in the previous month. A resident council meeting was conducted on 4/13/26 at 1:53 p.m. The attendees in the meeting were Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z. During the meeting, the council indicated they had file grievances during the resident council meetings, but they never heard back with resolutions to their concerns. The Resident Council President indicated there were no discussions or communication provided by the staff with how the facility had addressed concerns that had been reported in the resident council meetings.An interview was conducted with Executive Director on 4/13/26 at 2:56 p.m. He indicated the Resident Council President did get informed of the resolutions to the concerns brought up in the resident council meetings that day of the reporting. She would sign off as she had been informed of the resolution. A grievance policy was provided by the Executive Director on 4/14/26 at 1:55 p.m. It indicated, .The Executive Director/Grievance Official will sign off on all completed concerns/grievances forms, ensuring resident and/or family satisfaction. A resident council policy was provided by the Executive Director on 4/14/26 at 1:55 p.m. It indicated, .Procedure: 7. The facility responses to concerns/suggestions will be reviewed by the Resident Council President and the resident council on their next meeting. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(l)

Based on observation, interview, and record review, the facility failed to ensure residents were able to file grievances anonymously for 16 of 134 residents reviewed during resident council. (Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z) Findings include:A resident council meeting was conducted on 4/13/26 at 1:53 p.m. The attendees in the meeting were Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z . During the meeting, the council indicated they were unable to file a grievance anonymously. If there was a location to anonymously report a grievance, they were unaware. The residents requested a grievance form from the staff at the nurse's station. The grievance forms were kept there. The forms were not in reach for residents to take without anyone knowing. There was no privacy to report a grievance without staff knowing what you put on the form. An observation was made of the 500 Hall nurses' station on 4/13/26 at 2:48 p.m. There were orange forms sitting in a tray in the corner of the nurse's station. The forms were not accessible to anyone standing outside of the nurse's station.An interview was conducted with License Practical Nurse (LPN) 2 at the nurses' station on 4/13/26 at 2:49 p.m. The LPN indicated the orange sheets were grievance forms to be filled out if someone had a grievance they would like to report. The residents did have to ask for the grievance forms if they would like to fill one out. The staff would assist with filling the form out if residents requested or the residents could fill out the forms themselves. The residents would turn the forms back into the staff at the desk after they filled them out. The staff would turn the forms in for the residents. There used to be places around the facility to anonymously turn a grievance form in, but now the residents had to ask for the forms. An interview was conducted with the Activities Assistant on 4/13/26 at 2:51 p.m. She indicated the activities staff did not have grievance forms the residents could take and fill out. If the residents had concerns the activity staff directed the residents to go to the social service's office. An interview was conducted with the Executive Director/Grievance Official on 4/13/26 at 2:56 p.m. He indicated the residents all have care companions that check on their assigned residents. The resident was able to address concerns to their care companion. The residents can also go to the nurse's station and get grievance forms to fill out to report grievances. A grievance policy was provided by the Executive Director on 4/14/26 at 1:55 p.m. It indicated, .Each resident has the right to file grievances orally or in writing; file a grievance anonymously, and to obtain a written decision regarding his or her grievance. Grievances may be submitted anonymously as preferred by a resident, representative and/or family member. Anonymity will be maintained by the Grievance Official throughout the resolution process. 410 IAC (Indiana Administrative Code) 16.2-3.1-7(a)(1)

Based on observation, interview and record review, the facility failed to ensure meal services were provided timely for 19 of 134 residents that eat food served from the kitchen. (Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, Z, BB, CC and DD) Findings include:The meals service schedule was provided by the Executive Director on 4/9/26 at 12:24 p.m. The serving schedule indicated the following breakfast, lunch and dinner scheduled times at each serving areas:Breakfast meal - the start time to prepare meal trays = 6:55 a.m.100 Hall serving time = 7:15 a.m.,200 Hall serving time = 7:30 a.m.,Main dining room = 7:45 a.m.,300 Hall serving time = 8:10 a.m.,400 Hall serving time = 8:20 a.m., and500 Hall serving time = 8:55 a.m. Lunch meal - the start time to prepare meal trays = 11:25 a.m.100 Hall serving time = 11:45 a.m.,200 Hall serving time = 12:00 p.m.,Main dining room serving time = 12:15 p.m.,300 Hall serving time = 12:35 p.m.,400 Hall serving time = 12:45 p.m., and500 Hall serving time = 1:05 p.m. Dinner meal - - the start time to prepare meal trays = 4:55 p.m.100 Hall serving time = 5:15 p.m.,200 Hall serving time = 5:30 p.m.,Main dining room serving time = 5:45 p.m.300 Hall serving time = 6:10 p.m.,400 Hall serving time = 6:20 p.m., and500 Hall serving time = 6:35 p.m. An interview was conducted with Resident CC on 4/9/26 at 11:20 a.m. She indicated the meals were served late on the 500 Hall. She preferred to eat earlier. The breakfast meals were served after 10:00 a.m., lunch normally was served at around 2:00 p.m., and dinner was served at 7:00 p.m.An interview was conducted with Resident N on 4/9/26 at 11:35 a.m. She indicated the dinner meal was often served later than it was supposed to. She lived in the 500 Hall. The staff would deliver her dinner meal trays to her room at 7:00 p.m., and at times later than that. An observation was made of breakfast room trays on the 400 Hall delivered on 4/10/26 at 9:55 a.m. A staff member indicated breakfast room trays were normally served around 8:15 a.m. to 8:30 a.m.An observation was made of Resident BB on 4/10/26 at 10:33 a.m. The resident was observed uncovering her breakfast tray. She indicated she had just received her breakfast tray at 10:30 a.m. It was always late. The staff woke her up at 5:00 a.m. to take her morning mediations, but she did not receive her breakfast until late morning.An interview was conducted with Resident G on 4/10/26 at 10:46 a.m. She indicated the meals were served late in the 500 Hall. She received her breakfast meal at 10:30 a.m. that morning.An interview was conducted with Resident DD on 4/10/26 at 11:00 a.m. He indicated all the meals were served late all the time.A resident council meeting was conducted on 4/13/26 at 1:53 p.m. The attendees in the meeting were Residents' G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z. During the meeting, the council indicated the meals were often provided late. The evenings were the worst. The dinner meals were provided at times between 7:00 p.m. and 8:00 p.m.During a kitchen tour with the Dietary Manger on 4/14/26 at 11:43 a.m. She indicated the lunch meal normally would be served at 11:30 a.m. The order of serving area from the kitchen was the following: 300 Hall, 100 Hall, 200 Hall, 400 Hall, the main dining room and the 500 Hall. The dinner meals recently had been provided late at times. The latest meals had been served were 6:30 p.m. She has had some staffing concerns on 3rd shift with vacations and call-ins, which had caused dinner meals to be served a little late at times.This citation was related to Intake 2682125. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(c)

Based on interview and record review, the facility failed to timely document meal consumption for 1 of 3 residents reviewed for nutrition (Resident B). Findings include: The clinical record for Resident B was reviewed on 4/9/25 at 3:27 p.m. The resident's diagnoses included, but were not limited to, seizure disorder and dementia (progressive decline in cognitive function). A care plan, initiated 1/30/26, indicated Resident B required assistance and/or monitoring of AM/PM care, nutrition, hydration, and elimination. The goal was that her Activities of Daily Living (ADL) needs would be met. The approaches included, but were not limited to, breakfast intake percentage and fluid consumption, lunch intake percentage and fluid consumption, dinner intake percentage and fluid consumption.An admission Minimum Data Set (MDS) Assessment, completed 2/4/26, indicated Resident B had no useful hearing and no speech. She was sometimes able to make herself understood and sometimes able to understand what was said. She required supervision with eating and her weight was 172 pounds.A care plan, initiated 2/4/26, indicated Resident B was at risk for altered nutritional status related to a history of impaired skin integrity which may have resulted in increased protein needs. Other nutritional concerns of dementia and diabetes. She had poor appetite. Her family member brought in food from outside. She has had a change in environment, decreased social interaction, weight loss and poor oral intake. The goal was for her to maintain her current weight with no significant changes. The approaches included, but were not limited to, notify physician and family of significant weight changes, and offer substitutes if 50 percent or less of meal is consumed. Meal consumption amounts had not been documented on the followings days and meal:-1/31/26, dinner not documented,-2/6/26, breakfast and lunch not documented,-2/12/26, breakfast not documented,-2/16/26, breakfast not documented,-2/21/26, breakfast and dinner not documented,-2/24/26, at breakfast not documented,-2/26/26, breakfast not documented,-3/1/26, lunch and dinner not documented,-3/3/26, lunch not documented,-3/10/26, lunch not documented,-3/11/26, lunch not documented,-3/12/26, lunch not documented,-3/14/26, breakfast not documented,-3/16/26, lunch not documented,-3/17/26, breakfast and lunch not documented,-3/19/26, lunch not documented,-3/21/26, breakfast not documented,-3/25/26, lunch not documented, -3/27/26, lunch not documented,-3/29/26, lunch not documented,-3/30/26, breakfast not documented,-4/1/26, breakfast and dinner not documented,-4/3/26, breakfast and lunch not documented,-4/5/26, dinner not documented,-4/8/26, breakfast and lunch not documented,-4/10/26, breakfast, lunch and dinner not documented, -4/11/26, lunch not documented, and-4/12/26, breakfast and lunch not documented. On 2/26/26, Resident B's weight was recorded as being 161 pounds, indicating a 6% weight loss since admission. On 3/2/26, Resident B's weight was recorded at 161 pounds.On 3/17/26, Resident B's weight was recorded at 154 pounds. On 4/2/26, Resident B's weight was 157 pounds. During an interview on 4/15/26 at 11:24 a.m., the Regional Dietician (RD) indicated Resident B had a poor appetite when she first admitted to the facility. Several interventions were attempted and her appetite was improving. Staff should document consumption of all meals. This citation relates to Intake 2964009. 410 IAC (Indiana Administrative Code) 16.3.146(a)(1)

Based on observation, interview, and record review, the facility failed to address a resident lying in another resident's bed, as care planned, for 1 of 2 residents reviewed for dementia care. (Resident 4)Findings include: The clinical record for Resident 4 was reviewed on 4/10/26 at 1:50 p.m. Her diagnosis included, but were not limited to, dementia. The behavior care plan, initiated on 10/17/25 and last revised on 2/11/26, indicated the resident expressed physical aggression without provocation while intrusively wandering. An approach was to redirect her to her room and/or quiet area away from other residents and offer calm reassurance. The behavior care plan, initiated on 5/1/25 and last revised on 2/11/26, indicated the resident had episodes of agitation directed toward others. She could become verbally and physically aggressive. An approach was to calmy redirect her away from other residents and offer to have her lay down. The behavior care plan, initiated on 1/31/24 and last revised on 2/11/26, indicated the resident would intrusively wander in and out of other residents' rooms. Approaches were to redirect her to her own room or to the dining room for mealtime or activity. An observation of Resident 4 on 4/10/26 at 1:58 p.m., indicated Resident 4 was located inside Resident 75's and Resident 124's room on the memory care unit of the facility. Resident 4 was lying down in Resident 75's bed with her eyes closed. Resident 124 was lying down in her own bed. The door to the room was open. Resident 75 entered the room and walked around a bit, while Resident 4 remained lying in Resident 75's bed. Resident 75 then shut the door to the room with Resident 4 still in Resident 75's bed. Laundry Aide 3, who was putting away clothes in the room next door, came to Resident 75's and 124's room and clarified who all three residents in the room were and whose room was whose. Resident 4 remained lying in bed at this time. Laundry Aide 3 indicated Resident 4's room was next door. Laundry Aide 3 did not redirect Resident 4 from the room or inform any of the nursing staff Resident 4 was in Resident 75's bed. Laundry Aide 3 left the room and proceeded to pass clothes to other rooms. The Memory Care Support Specialist (MCSS) came down the hallway, knocked on Resident 75's and 124's door, opened the door slightly, peaked inside, and shut the door. Resident 4 remained in the room. The MCSS was informed Resident 4 was in the room. After having been informed, the MCSS went into the room to address Resident 4 lying in Resident 75's bed. Resident 75 could be heard saying 'She doesn't belong in here,' in a raised, irritated voice, multiple times, while the MCSS was in the room. An interview was conducted with the Memory Care Unit Manger on 4/14/26 at 2:20 p.m. in the hallway, after Resident 4 was observed to be lying down in bed in Resident 117's room (not Resident 4's own room) with the door shut. She indicated when Resident 4 was found lying in another resident's bed, they would normally redirect her to her own room. After having been informed of the above occurrence on 4/10/26 at 1:58 p.m., when Resident 4 was found lying in Resident 75's bed, she indicated she thought the laundry aide should have redirected her out of the room or told another staff member she was in there. They could do an in-service to educate staff, because she was unsure the laundry aide knew what to do at that time. It was a constant thing for staff having to redirect Resident 4 out of other residents' rooms. The Behavior Management policy was provided by the Regional Director of Clinical Services on 4/14/26 at 5:45 p.m. It indicated, It is the policy of [name of facility] to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non-pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavioral expressions. Procedure: 1. Care plans should be initiated for any behavioral expression that is problematic or distressing to the resident, other resident or caregivers. Care plan interventions should include individualized and non-pharmacological interventions which address both proactive and responsive interventions.3. When a behavioral expression occurs, the staff communicates to the nurse what behavior occurred. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure medication was available for administration for 1 of 2 residents reviewed for hospitalization (Resident E).Findings include: The clinical record for Resident E was reviewed on 4/10/26 at 1:44 p.m. The resident's diagnosis included, but was not limited to, diabetes. A Quarterly Minimum Data Set (MDS) Assessment, completed 1/22/26, indicated Resident E was cognitively intact. A nursing progress note, dated 3/26/26 at 2:44 p.m., indicated the resident was scheduled for a colonoscopy on 3/30/26 at 2:45 p.m. The March Medication Administration Record (MAR) indicated Resident E received bisacodyl (laxative given as colonoscopy preparation) 20 milligrams on 3/29/26 at 8:00 p.m. He had not received colyte (medication used for cleansing bowel prior to colonoscopy) due to the medication being unavailable. A nursing progress note, dated 3/30/26 at 8:39 a.m., indicated the resident did not complete the colonoscopy preparation and the appointment needed to be rescheduled. The colyte had been out of stock at the pharmacy. During an interview on 4/10/26 at 1:44 p.m., Resident E indicated the continuity of care at the facility was poor. The facility had not ensured all the medication was available for his colonoscopy prep. He had received one of the medications, but the other medication had not come in from the pharmacy. He had to deal with the results of receiving the first medications. The colonoscopy had to be rescheduled. Appointments dealing with his health were very important to him and he would have liked to have the colonoscopy done when it was scheduled. During an interview on 4/14/2026 at 9:58 a.m., the Director of Nursing indicated the colyte for Resident E had been on backorder. The pharmacy did not normally inform the facility of medications that are on backorder. The physician was contacted and did not want an alternative treatment and the procedure was rescheduled. On 4/15/26 at 3:05 p.m., the Executive Director provided the Long-Term Care Facilities Receiving Products and Services from Pharmacy policy, last revised 8/1/24, that read .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. 1.1 If the medication shortage is discovered at the time of medication administration, Facility staff should immediately notify the Pharmacy . 410 IAC (Indiana Administrative Code) 16.3.1-25(a)

Based on interview and record review, the facility failed to timely complete a physician's ordered STAT (immediate) laboratory test as ordered, for 1 of 2 residents reviewed for laboratory services. (Resident 15)Findings include:The clinical record for Resident 15 was reviewed on 04/13/26 at 1:54 p.m. His diagnoses included, but were not limited to, chronic kidney disease. The nursing note, dated 4/6/26 at 6:51 a.m., indicated Resident 15 had an extra large amount of liquid greenish stool that night. The resident's ostomy bag was changed three times and the resident had emesis (vomiting) one time at 6:00 a.m. of a small amount of thick, clear, emesis with some undigested food present. The progress note, dated 4/6/26 and written by Nurse Practitioner (NP) 5, indicated Resident 15's chief complaint was nausea, vomiting, and diarrhea. The Assessment and Plan Diagnoses and associated orders for the visit section indicated staff were to obtain a CBC (complete blood count) and BMP (basic metabolic panel) STAT (immediate labs that prioritize emergency, urgent, procedures to ensure quick descision-making). The resident's clinical record lacked the CBC and BMP laboratory results for 4/6/26 or 4/7/26. There were results for a CBC and a BMP on 4/8/26. The nursing note, dated 4/7/26 at 12:37 p.m. and recorded as a late entry on 4/8/26 at 12:38 p.m., indicated the laboratory failed to draw the resident's labs ordered on 4/6/26. The provider was notified to request new orders to obtain the labs. The nursing note, dated 4/8/26 at 12:47 p.m., indicated Resident 15 was noted with two episodes of emesis that shift. Zofran (medication used to prevent nausea and vomiting) per standing orders with good tolerance. The NP was notified, and a verbal order was received to obtain a KUB (diagnostic evaluation of the urinary system and surrounding organs to check for kidney stones, infections, tumors, or obstruction.) The nursing note, dated 4/8/26 at 10:03 p.m., indicated a critical lab was received that indicated a BUN level of 61 and Creatinine level of 10.7. Resident 15 was assessed and no acute distress was noted at this time. The writer notified the After Hours On Call, and the NP gave a verbal order to send to the emergency room. The Director of Nursing (DON,) family were notified. The Emergency Medical Technician (EMT) was notified that the family requested he be transported to a specific hospital. An interview was conducted with the DON on 4/13/26 at 2:22 p.m. He indicated the used a specific lab provider to complete obtain labs at the facility. They came to the facility daily, Monday through Friday. For STAT labs, they entered the order into their electronic health record (EHR) and verified they received the order. The lab provider was supposed to come the same day for STAT labs, so long as there was a technician in the area. That was the process that was supposed to be followed on 4/6/26 for Resident 15's STAT lab orders. He did not know why the labs were not drawn until 4/8/26. An interview was conducted with the Regional Director of Clinical Services (RDCS)on 4/15/26 at 10:14 a.m. She indicated the facility was integrating their new lab system on 4/6/26. Somehow, the stat lab orders were not going through. They discovered the issue on 4/8/26, the day they reordered Resident 15's labs. They had a phone call with their lab provider on 4/13/26 and working out the issue. An interview was conducted with Physician 6 on 4/15/26 at 2:10 p.m. He indicated stat labs had a six to eight hour turn around time. When NP 5 saw Resident 15 on 4/6/26, the labs could have been ordered to be done the next day, on 4/7/26. Resident 15 had a history of nausea and vomiting, was unstable, didn't absorb very well, had stomach distention on and off, and tendencies to go into renal failure quickly. When the CBC and BMP labs were not done by 4/7/26, he seemed okay, so the delay may have worked in his favor, in that the critical lab results were picked up on 4/8/26. Resident 15 had chronic kidney disease for a long time. The Laboratory Procedures were provided by the RDCS on 4/15/26 at 12:20 p.m. It indicated, STAT draws are to be dispatched out and received by phlembotomist within 15-30 minutes.STAT turnaround time is defined as 5 hours. 410 IAC (Indiana Administrative Code) 16.2-3.1-49(a)

Based on interview and record review, the facility failed to ensure facility staff (Qualified Medication Aide 6 and Certified Nurse Aide 2) notified the nurse on duty of a resident experiencing a fall (Resident D) and timely notify the resident's physician of a fall with injury, resulting in Resident D experiencing moderately strong pain and a delay in the treatment of a left humerus fracture, for 1 of 2 residents reviewed for falls, and to timely inform a physician of a significant change in a lab value for 1 of 2 residents reviewed for hospitalization (Resident B). This deficient practice was corrected on 2/19/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding physician notification pertaining to fall incidents and laboratory results, reviewed all fall incidents for January 2025 to February 7, 2025 and laboratory results for January 2025 to February 18, 2025 to identity potential residents, and conducted a review of residents with physician orders for laboratory work and residents with fall incidents to ensure the medical provider had been notified and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: 1. The clinical record for Resident D was reviewed on 3/19/25 at 11:00 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. A Quarterly Minimum Data Set (MDS) assessment, dated 2/21/25, indicated Resident D was moderately cognitively impaired. A nursing progress note, dated 1/22/25 at 12:19 p.m., written by Registered Nurse (RN) 1, indicated at approximately 10:00 a.m., Resident D stated to the nurse he was having pain in his left shoulder. The nurse assessed the resident's skin and observed bruising and swelling on his left shoulder and a skin tear to his left elbow that was approximately two centimeters (cm) in length and 0.5 cm in width. The nurse cleansed the wound with a wound cleanser and a non-adhesive dressing was applied. The nurse notified the physician about the resident's left shoulder pain and received a new order for an x-ray of the left shoulder and clavicle to be performed as soon as possible. On 1/22/25 at 7:45 p.m., an Interdisciplinary Team (IDT) fall note indicated the date and time Resident D sustained a fall was on 1/21/25 at 8:30 p.m. The fall had been self-reported by the resident, he was unable to give details of the fall but stated he fell the evening before and complained of left arm and shoulder pain. Injuries sustained included a left humerus fracture. The resident was transferred to the emergency room (ER) for evaluation and treatment. A change of condition including new pain was noted. On 1/22/25 at 11:40 a.m., RN 1 documented a pain rating of 6 out of 10 for Resident D. The determined root cause of the fall was poor safety awareness, an intervention put into place was a fall mat placed next to the resident's bed. Hospital records, dated 1/22/25, indicated Resident D was admitted to the ER for an evaluation related to a fall from which he was having significant left shoulder pain. The resident also had a laceration to the left elbow and head, and loss of consciousness. The ER physician indicated the resident had a loss of consciousness in the bath the morning of 1/22/25, due to pain. Musculoskeletal assessment indicated tenderness to palpation about the left shoulder and left proximal humerus with extreme limited range of motion. An x-ray of the left shoulder performed, on 1/22/25, at the ER indicated a left proximal humerus fracture (a break in the upper part of the arm bone near the shoulder). The hospital physical therapist indicated Resident D would likely require subacute rehab again. A referral to orthopedic surgery was ordered and the resident was discharged back to the facility in stable condition. A facility reported incident was submitted to the Indiana Department of Health, on 1/23/25, by the Executive Director (ED) for a resident with an unwitnessed fall and sustained injury. An investigation file was provided by the ED on 3/20/25 at 1:30 p.m. The investigation file included a copy of the incident report, fall event, IDT fall note, witness statements from staff, and an interview with the resident. In an undated statement the ED interviewed Resident D regarding the fall he self-reported on 1/22/25. Resident D indicated he got out of his bed because he heard people talking in the hallway the night of 1/21/25. Two female staff members picked him up and put him back in bed. In a statement, dated 1/22/25, Certified Nurse Aide (CNA) 2 indicated she had been working the evening, of 1/21/25, and was walking down the hall to go on break when she overheard someone say, Hey can you help me? One of the other staff, Qualified Medication Aide (QMA) 6, came out of a room at the end of the hallway and asked to help her with a resident who had fallen. Resident D was sitting on the floor with his back against the wall near the bathroom and his legs out in front of him. The resident did not indicate he was in pain to the CNA, and she thought the nurse had already been in to see him. In a statement, dated 1/27/25, RN 20 indicated she was not notified of any falls on her shift on the date of 1/21/25. Resident D had not complained of any pain or reported any falls to her. In a statement, dated 1/23/25, Licensed Practical Nurse (LPN) 5 indicated he was not notified of any falls for Resident D, and was unaware of any falls that occurred during his evening shift. LPN 5 indicated he had been in Resident D's room multiple times that night, and the resident did not mention to him he had fallen or was in pain. In a statement, dated 1/22/25, CNA 3 indicated Resident D complained of left-sided weakness and pain while providing care. The Resident indicated he fell on night shift sometime, and he would continue to shower. As CNA 3 was transferring the resident into the shower chair, the resident had a fainting spell for about 20 seconds. Once she had gotten help he started becoming alert again and did not know what had happened. During an interview on 3/19/25 at 11:45 a.m., Resident D's Representative indicated the in January, the resident had fallen out of bed and broken his left humerus. She did not find out about the fall until she arrived at the facility, on 1/22/25, to accompany the resident to a doctor's appointment. When she arrived, the resident was yelling out in pain complaining his arm hurt, had a cut on his head, and his left shoulder appeared deformed. Resident D's Representative went to the nurse's station to ask what had happened, and staff could not provide an answer for her. In an interview with RN 1, on 3/21/25 at 10:49 a.m., she indicated, on 1/22/25, she had first seen Resident D when administering his morning medications between 8:00 a.m. and 9:00 a.m. The resident mentioned having pain in his shoulder, but did not say anything about the fall. She did not notice any physical injury to his head but noticed a bruise on his arm. In an interview with CNA 3, on 3/21/25 at 11:16 a.m., she indicated on the morning of 1/22/25, sometime after breakfast, Resident D had told her he had fallen the night before. He indicated two aides had helped put him back in bed. CNA 3 notified RN 1 that Resident D had self-reported a fall. CNA 3 indicated to RN 1 the resident had a shower due and that he wished to go through with it. RN 1 indicated to CNA 3 to go ahead and give the resident a shower. CNA 3 did not believe RN 1 went and looked at the resident at that time. CNA 3 attempted to transfer the resident so he could shower, the resident began having seizure-like activity. His eyes rolled to the back of his head, and he urinated on himself. CNA 3 found another aide for assistance so she could report the incident to the nurse. CNA 3 indicated she did notice a knot on the resident's head, and Resident D's Representative had arrived at the facility once they had got Resident D back into bed. During an interview on 3/24/25 at 11:47 a.m., Nurse Practitioner (NP) 13 indicated if there was an injury associated with a fall the medical provider wanted to be called right away. On 3/21/25 at 10:01 a.m., the ED provided the Fall Management Policy, dated 7/2001, last revised 8/2022, it indicated It is the policy of [name of corporation] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Post fall 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided .2. If the resident experienced an injury from the fall, contact the DNS/ED per facility policy. 3. The physician will be contacted immediately, if there are injuries, and orders will be obtained . 40287 2. The clinical record for Resident B was reviewed on 3/20/25 at 9:43 a.m. The diagnoses included, but were not limited to, urinary tract infection, diarrhea, and dementia. A care plan, initiated 1/24/25, indicated Resident B required assistance with toileting due to weakness, decreased mobility, incontinence, and diarrhea. The goal was for her to be free of adverse effects of incontinence. The interventions included, but were not limited to, assist with elimination, observe for signs of a urinary tract infection, such as decreased output, concentrated urine, change in mental status, and fever, and document abnormal findings and notify the physician. A Physician's Progress Note, dated 1/29/25, indicated Resident B was seen related to a low-grade fever and mild tachycardia (high heart rate). Her temperature was 99.7 degrees Fahrenheit, and her pulse was between 100 and 110 beats per minute. She had complained about some loose stools. The plan included encouraging oral hydration and obtain a basic metabolic panel (BMP). The BMP results, dated 1/30/25, included a creatinine level (measurement of kidney function) of 0.6 which was within normal limits and Blood Urea Nitrogen (BUN) of 13 which was within normal limits. A physician's order, dated 2/5/25, indicated obtaining a BMP lab STAT (right away). The BMP results, dated 2/5/25, included a creatinine level of 3.3; which was above normal limits and a BUN of 35; which was above normal limits. The BMP results were signed by the Nurse Practitioner as being seen/reviewed on 2/7/25. A physician's order, dated 2/7/25, indicated Resident B was to receive one liter of normal saline (an intravenous fluid) at 50 milliliters (ml) an hour through a midline (type of intravenous access). An Acute Visit Progress Note, dated 2/8/25, indicated Resident B was being seen due to receiving one liter of normal saline and was starting to perk up. The plan included treating her acute kidney injury with a second bag of one liter of normal saline and obtaining a BMP on 2/10/25. During an interview on 3/20/25 at 11:08 a.m., Family Member (FM) 30 indicated she had visited Resident B, on 2/6/25, and had found Resident B looking dehydrated, with sunken eyes, lethargic, and very dry. FM 30 had a meeting with facility staff, on 2/7/25, and had insisted that intravenous fluids be started. She had not been made aware that a BMP had been drawn, on 2/5/25, and that Resident B's creatinine and BUN levels had risen. She was upset the lab results had not been acted on sooner. During an interview on 3/24/25 at 2:11 p.m., the Nurse Consultant (NC) indicated the change in Resident B's, 2/5/25, BMP results should have been called to the physician when they were received. During an interview on 3/25/25 at 1:23 p.m., Nurse Practitioner (NP) 13 indicated she had seen Resident B's, 2/5/25, BMP results on 2/7/25. She would have started intravenous fluids earlier if she had been made aware of the results prior to 2/7/25. A Change of Condition Policy was provided by the Director of Nursing (DON) on 3/25/25 at 2:09 p.m. It indicated It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly . This citation relates to Complaint IN00455520. 3.1-5(a)(1) 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident D) who had fallen the night of 1/21/25, was assessed by a licensed nurse and the licensed nurse was made aware of the fall incident by the facility staff (Qualified Medication Aide 6 and Certified Nurse Aide 2), who had assisted the resident back to bed, and ensure the resident had continued monitoring afterwards. The resident experienced moderately strong pain, had skin impairments, and was later hospitalized and identified with a fractured humerus at the hospital for 1 of 3 residents reviewed for falls. This deficient practice was corrected on 2/12/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding fall incidents, reviewed all fall incidents for January until February 7, 2025 to identity potential residents, and conducted an review of residents with fall incidents to ensure assessments, resident profiles, fall interventions, and follow-up with the medical provider have been completed and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: The clinical record for Resident D was reviewed on 3/19/25 at 11:00 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. The Admission Minimum Data Set (MDS) assessment, dated 12/03/24, indicated Resident D was severely cognitively impaired. The resident had impairment in the range of motion of his lower extremity, on one side of his body. The resident's functional status of toilet transfers and sit-to-stand function was dependent assistance. The resident required partial to moderate assistance with mobility in rolling left and right, and required substantial to maximal assistance when transferring from a sit-to-lying, and lying-to-sit position. Resident D utilized a walker and a wheelchair to assist with mobility. A Quarterly MDS assessment, dated 2/21/25, indicated Resident D was moderately cognitively impaired. The resident had impairment in the range of motion of his upper and lower extremity on one side of his body. The resident's functional status of toilet transfers and sit-to-stand function was substantial to maximal assistance. The resident required substantial to maximal assistance with mobility in rolling left and right, and required substantial to maximal assistance when transferring from a sit-to-lying, and lying-to-sit position. Resident D utilized a wheelchair to assist with mobility. A fall care plan, initiated on 11/29/24, indicated the resident was at risk for falls due to a history of falls at home resulting in a right femur fracture, muscle weakness, Alzheimer's dementia, syncope and collapse. The goal was for the resident's fall risk factors to be reduced in an attempt to avoid significant fall related injury. The interventions included, but were not limited to, the use of a low air loss bed with bolsters, a fall mat on the floor next to bed (left side), anti-rollback devices to wheelchair, anti-tipper devices to wheelchair, touchpad call light, call light to be within reach, environmental changes, non-skid footwear, personal items in reach, therapy screen, and to be up and moving freely in wheelchair with assistance. A care plan, initiated on 11/29/24, indicated the resident was a new admission to the facility and required implementation of services that included, but were not limited to, assistance with activities of daily living related to weakness, fall with fracture, recent surgery, poor cognition, impaired mobility, and unsteady gait. The goal for the resident was to achieve the highest desired practicable level of physical/emotional/psychosocial well-being and functional status. Interventions included, but were not limited to, assistance with transfers, ambulation, bed mobility, toileting and/or incontinent care, eating/drinking, and bathing/hygiene, including oral/dental care, and provide fall prevention interventions. An Activities of Daily Living (ADLs) care plan, initiated on 11/29/24, indicated the resident required assistance with ADLs that included, but were not limited to, bed mobility, transfers, eating and toileting related to muscle weakness, impaired mobility, age, and a recent fall at home with right femur fracture. The goal was for the resident to improve their current functional status. Interventions included, but were not limited to, assist with ambulation as needed, assist with bed mobility as needed, and assist with transfers as needed. A nursing progress note, dated 1/22/25 at 12:27 a.m., written by Licensed Practical Nurse (LPN) 5, indicated a Certified Nurse Aide (CNA) was in Resident D's room to get clothes and a brief for the resident's roommate. Resident D was in bed and complained of being woken up and the lights being turned on. The resident did not complain of signs or symptoms of pain, and made no request for pain medication. A nursing progress note, dated 1/22/25 at 12:19 p.m., written by Registered Nurse (RN) 1, indicated at approximately 10:00 a.m., Resident D stated to the nurse he was having pain in his left shoulder. The nurse assessed the resident's skin and observed bruising and swelling on his left shoulder and a skin tear to his left elbow that was approximately two centimeters (cm) in length and 0.5 cm in width. The nurse cleansed the wound with a wound cleanser and a non-adhesive dressing was applied. The nurse notified the physician about the resident's left shoulder pain and received a new order for an x-ray of the left shoulder and clavicle to be performed as soon as possible. On 1/22/25 at 7:45 p.m., an Interdisciplinary Team (IDT) fall note indicated the date and time Resident D sustained a fall was on 1/21/25 at 8:30 p.m. The fall had been self-reported by the resident, he was unable to give details of the fall but stated he fell the evening before and complained of left arm and shoulder pain. Injuries sustained included a left humerus fracture. The resident was transferred to the emergency room (ER) for evaluation and treatment. A change of condition including new pain was noted. On 1/22/25 at 11:40 a.m., RN 1 documented a pain rating of 6 out of 10 for Resident D. The determined root cause of the fall was poor safety awareness, an intervention put into place was a fall mat placed next to the resident's bed. Hospital records, dated 1/22/25, indicated Resident D was admitted to the ER for an evaluation related to a fall from which he was having significant left shoulder pain. The resident also had a laceration to the left elbow and head, and loss of consciousness. The ER physician indicated the resident had a loss of consciousness in the bath the morning of 1/22/25, due to the pain. Musculoskeletal assessment indicated tenderness to palpation about the left shoulder and left proximal humerus with extreme limited range of motion. An x-ray of the left shoulder performed, on 1/22/25, at the ER indicated a left proximal humerus fracture (a break in the upper part of the arm bone near the shoulder). The hospital physical therapist indicated Resident D would likely require subacute rehab again. A referral to orthopedic surgery was ordered and the resident was discharged back to the facility in stable condition. A facility reported incident was submitted to the Indiana Department of Health, on 1/23/25, by the Executive Director (ED) for a resident with an unwitnessed fall and sustained injury. On 1/23/25, Nurse Practitioner (NP) 13 ordered oxycodone 2.5 milligrams (mg) for mild pain and oxycodone 5 mg for moderate pain. On 1/23/25 at 5:15 p.m., RN 24 indicated in a nursing progress note that Resident D required extensive assistance of two nurses to provide incontinence care. Resident D's Representative requested nurses perform the task due to the resident screaming at the aides who previously attempted to provide care. RN 24 noted Even with extra care with turning and repositioning, resident complained of severe pain. Oxycodone 5 mg was administered by RN 24 immediately after care. In a nursing progress note, dated 1/24/25, the facility Nurse Consultant (NC), indicated she attempted to assess bruising and skin tear to left upper extremity. Resident with sling in place and unwilling to remove for assessment at this time. On 1/26/25 at 12:18 p.m., LPN 23 indicated in a progress note that Resident D had declined to shower because of shoulder pain and was given a pain pill for relief. On 1/27/25 at 11:04 a.m., NP 22 indicated in a progress note that Resident D .is being seen by requested primary care for ongoing pain to left upper arm, which is uncontrolled, following a fall .complains of pain frequently . will discontinue oxycodone today and start Norco 5-325 mg Q4 [every 4] hours . An investigation file was provided by the ED on 3/20/25 at 1:30 p.m. The investigation file included a copy of the incident report, fall event, IDT fall note, witness statements from staff, and an interview with the resident. In an undated statement the ED interviewed Resident D regarding the fall he self-reported on 1/22/25. Resident D indicated he got out of his bed because he heard people talking in the hallway the night of 1/21/25. Two female staff members picked him up and put him back in bed. In a statement, dated 1/23/25, LPN 5 indicated he was not notified of any falls for Resident D, and was unaware of any falls that occurred during his evening shift. LPN 5 indicated he had been in Resident D's room multiple times that night, and the resident did not mention to him he had fallen or was in pain. In a statement, dated 1/22/25, Qualified Medication Aide (QMA) 6 indicated she did not witness Resident D fall or discover him on the floor. She had asked another employee (CNA 2) to assist her in moving the resident's legs up off the floor as they were off his bed, but the resident was still in bed. In a statement, dated 1/22/25, CNA 2 indicated she had been working the evening of 1/21/25 and was walking down the hall to go on break when she overheard someone say, Hey can you help me? One of the other staff (QMA 6) came out of a room at the end of the hallway and asked to help her with a resident who had fallen. Resident D was sitting on the floor with his back against the wall near the bathroom and his legs out in front of him. The resident did not indicate he was in pain to the CNA, and she thought the nurse had already been in to see him. In a statement, dated 1/22/25, CNA 3 indicated Resident D complained of left-sided weakness and pain while providing care. The resident indicated he fell on night shift sometime, and he would continue to shower. As CNA 3 was transferring the resident into the shower chair the resident had a fainting spell for about 20 seconds. Once she had gotten help, he started becoming alert again and did not know what had happened. In a statement, dated 1/22/25 at 11:55 a.m., LPN 21 indicated Resident D's representative was at the resident's bedside and had talked to Resident D, around 8:15 p.m., the evening prior. She indicated two female CNAs had picked the resident up off the floor and proceeded to ask what all follow-up had been done and why was nothing documented related to a fall. In a statement, dated 1/23/25, QMA 19 indicated to their knowledge, Resident D had not fallen and had not complained of any pain the times he was in his room or mention falling. In a statement, dated 1/27/25, RN 20 indicated she was not notified of any falls on her shift on the date of 1/21/25. Resident D had not complained of any pain or reported any falls to her. On 1/28/25, Resident D attended a consultation with an orthopedic specialist regarding the proximal fracture of his left humerus. On 1/31/25, nine days following Resident D's fall, a wound treatment order was placed instructing staff to cleanse the resident's left elbow with normal saline, pat dry, and cover with a dry dressing daily and as needed. On 2/04/25, Resident D underwent a total left shoulder replacement to surgically repair the proximal fracture of his left humerus. On 2/06/25, nursing staff began charting numerical pain scale ratings for Resident D. Prior to this date the last charted pain scale rating was documented, on 1/22/25, the morning following the resident's fall. A pain care plan, last revised on 2/25/25, indicated the resident was at risk for pain related to recent left humerus fracture, pressure ulcer to coccyx, and recent fall resulting in right femur fracture with surgical repair. The goal was for the resident to be free from adverse effects of pain. Interventions included, but were not limited to, the resident's left upper extremity to remain non weight bearing, assist with positioning for comfort, and administer medications as ordered. A care plan, initiated on 3/18/25, indicated the resident sustained a left humerus fracture due to a fall. The goal was for the resident's fracture to heal without complications. The intervention included was to administer pain medication as needed, and to notify the physician of any changes. On 3/18/25 at 10:46 a.m., Resident D was observed laying in bed while watching television with a fall mat parallel to his bed. During an interview on 3/19/25 at 11:45 a.m., Resident D's Representative indicated, in January, the resident had fallen out of bed and broken his left humerus. She did not find out about the fall until she arrived at the facility, on 1/22/25, to accompany the resident to a doctor's appointment. When she arrived, the resident was yelling out in pain complaining that his arm hurt, had a cut on his head, and his left shoulder appeared deformed. Resident D's Representative went to the nurse's station to ask what had happened, and staff could not provide an answer for her. She indicated the fracture was serious enough requiring surgery, setting back his rehab for his earlier sustained femur fracture. During a confidential interview on 3/19/25 at 12:05 p.m., they indicated, the morning of 1/22/25, Resident D had yelled out in pain saying Oh no when the aide attempted to get him up for his shower. The aide looked at the resident, laughed, and then left the room. The aide came back to try again, and Resident D indicated that his shoulder hurt. During an interview with the ED on 3/20/25 at 3:39 p.m., he indicated a fall had not been reported to nursing or management staff on the evening of 1/21/25. We (facility management) estimate the fall occurred at approximately 8:30 p.m. on 1/21/25. The following day, (1/22/25) around 11:00 a.m., Resident D was going to get a shower and demonstrated some pain. That was when the resident self-reported the fall to CNA 3. The shower was not provided since he reported pain. CNA 3 then reported the fall to RN 1, and she assessed him. Once RN 1 assessed him and the provider was notified, the resident was sent to the ER. Resident D's representative was then notified. QMA 6 found the resident on the ground and did not report the fall. When questioned about the incident, QMA 6 denied it happened. In an interview with the facility NC, on 3/20/25 at 3:50 p.m., she indicated Resident D's representative requested he be sent to the ER, and an x-ray was performed there. The resident had some decline since that fall occurred on 1/21/25. Prior to the fall, he could turn himself; pain inhibited him from turning after the humerus fracture. Resident D was incontinent and there would have been a check and change (check for incontinence) every two hours. On 1/21/25 at 9:19 p.m., urine output was charted, at 12:27 a.m. on 1/22/25, LPN 5 went into Resident D's room, and at 4:25 a.m. on 1/22/25, a bowel movement was charted. In an interview with RN 1, on 3/21/25 at 10:49 a.m., she indicated, on 1/22/25, she had first seen Resident D when administering his morning medications between 8:00 a.m. and 9:00 a.m. The resident mentioned having pain in his shoulder, but did not say anything about the fall. She did not notice any physical injury to his head but noticed a bruise on his arm. The resident told CNA 3 during shower time (the morning of 1/22/25) that he had fallen the evening before and that two aides helped him back to bed. In an interview with CNA 3, on 3/21/25 at 11:16 a.m., she indicated on the morning of 1/22/25, sometime after breakfast, Resident D had told her he had fallen the night before. He indicated two aides had helped put him back in bed. CNA 3 notified RN 1 that Resident D had self-reported a fall. CNA 3 indicated to RN 1 the resident had a shower due and that he wished to go through with it. RN 1 indicated to CNA 3 to go ahead and give the resident a shower. CNA 3 did not believe RN 1 went and looked at the resident at that time. CNA 3 attempted to transfer the resident so he could shower, the resident began having seizure-like activity, his eyes rolled to the back of his head, and he urinated on himself. CNA 3 found another aide for assistance so she could report the incident to the nurse. CNA 3 indicated she did notice a knot on the resident's head. Resident D's representative arrived at the facility once they had gotten Resident D back into bed after his episode. QMA 6 was unavailable for interview. On 3/21/25 at 10:01 a.m., the ED provided the Fall Management Policy, dated 7/2001, last revised 8/2022, it indicated It is the policy of [name of corporation] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Post fall 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided .2. If the resident experienced an injury from the fall, contact the DNS/ED per facility policy. 3. The physician will be contacted immediately, if there are injuries, and orders will be obtained . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's hair was shampooed at least weekly, properly positioned a resident to reduce the risk of skin shearing, and to provide timely incontinence care and not utilizing double briefing for 4 of 11 residents reviewed for Activities of Daily Living (ADL) care. (Resident D, Resident G, Resident L and Resident 20) Findings include: 1. The clinical record for Resident L was reviewed on 3/18/25 at 3:17 p.m. The diagnoses included, but were not limited to, history of traumatic brain injury and diabetes. A care plan, initiated 2/7/25, indicated she required assistance with ADL care including bed mobility, transfers, eating, and toileting related to weakness from a recent hospital stay. The goal was for her to improve her current functional status. The approaches included, but were not limited to, a mechanical lift for transfers with assistance of two staff, assist with bed mobility as needed, and assist with toileting and incontinent care as needed. A Quarterly Minimum Data Set (MDS) assessment, completed 2/21/25, indicated she was cognitively intact. She required total assistance with transfers, bed mobility, personal hygiene, and showers. On 3/18/25 at 3:17 p.m., Resident L indicated she had been receiving bed baths. She preferred two people assisted with bed mobility since the grab bars on her bed were smaller than she would like. At times, she felt incontinent care was lacking. On 3/21/25 at 8:55 a.m., Resident L was observed in her bed. Her hair had flakes of dry skin and there was a crust of loose dry skin on her scalp. She indicated her hair had not been washed in two weeks. She would like to have it washed more often. During an observation on 3/21/25 at 2:45 p.m., Resident L was observed in her bed after being transferred with the mechanical lift. Certified Nurse Aide (CNA) 14 and CNA 15 were in the room preparing to provide care. Resident L was lying at the top of the bed on four disposable incontinent pads. The base of her head was resting on the headboard, and her head was flexed forward with her chin down toward her chest. CNA 15 indicated Resident L had been positioned high in the bed so when the head of the bed was elevated Resident L would slide down to the right position in the bed. CNA 14 began raising the head of the bed and when the head of the was elevated to approximately 45 to 60 degrees, Resident L quickly slid down the bed to a sitting position. CNA 15 indicated Resident L had slid down to the proper position in bed. On 3/21/25 at 3:22 p.m., the Director of Nursing (DON) provided the February and March 2025 shower reports for Resident L, which indicated she received a complete bed bath on the following days: 2/11/25, 2/14/25, 2/18/25, 2/21/25, 2/28/25, 3/4/25, 3/7/25, 3/11/25, and 3/18/25. The shower reports did not indicate her hair had been washed with any of the complete bed baths received. During an interview on 3/24/25 at 2:30 p.m., the Nurse Consultant (NC) indicated residents should not intentionally slide down the bed to the proper position due to the increased risk of shearing to the skin. 51750 2. The clinical record for Resident D was reviewed on 3/19/25 at 11:00 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. A Quarterly MDS assessment, dated 2/21/25, indicated Resident D was moderately cognitively impaired. A care plan, dated 11/29/24, last revised on 2/24/25, indicated Resident requires assistance with toileting due to: Muscle weakness, impaired mobility due to surgical repair of right femur fracture, incontinence, age, impaired cognition, Alzheimer's dementia, benign prostatic hyperplasia, and pain. The goal was for Resident D to remain free of adverse effects of incontinence. Interventions included, but were not limited to, to check for incontinence every two hours and as needed. On 3/18/25 at 10:46 a.m., Resident D was observed laying in bed while watching television with a fall mat parallel to his bed. During an interview on 3/19/25 at 11:45 a.m., Resident D's Family Member indicated there were times when he was laying in bed for an hour in urine before he got changed. During an interview on 3/24/25 at 9:53 a.m., Resident D's Family Member indicated she arrived at the facility, on 3/23/25, to visit the resident. She noticed his brief needed changed. She put on his call light and a nurse came to the room and turned the call light off and indicated an aide would come in to change the resident's brief. An aide never came. So, Resident D's Family Member found a brief and wipes and changed him herself. After having put his call light on and nobody had arrived later that day, Resident D's Family Member went out to the nurse's station and three CNAs were just standing there congregating. She indicated staff were not checking his brief every two hours. During an interview on 3/24/25 at 2:50 p.m., the facility Nurse Consultant indicated staff should be performing incontinent checks on residents every two hours. The urinary output for the resident was charted once on 3/17/25 at 10:28 a.m., once on 3/18/25 at 2:21 p.m., and once on 3/19/25 at 2:33 p.m. On 3/21/25 at 3:37 p.m., the DON provided a Bowel and Bladder Program Policy, dated 3/2010, last revised 5/2019, it indicated If a resident is totally incontinent and unable to be placed on a toilet or bedpan, resident should be checked and changed every two hours. 51984 3. The clinical record for Resident 20 was reviewed on 3/20/25 at 3:14 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). A Quarterly MDS assessment, dated 1/22/25, indicated Resident 20 was moderately cognitively impaired. A current care plan, last reviewed/revised on 1/23/25, indicated Resident 20 required staff assistance with ADLs with an intervention of assistance and/or monitoring AM/PM care, nutrition, hydration, and elimination. An interview was conducted with Resident 20 on 3/19/25 at 2:30 p.m. Resident 20 indicated she did not get changed frequently. She got changed four times a day and had to wait up to three hours to get changed at times. Resident 20 indicated she was always double briefed and was under the impression that double briefing was a standard of care. An observation with Resident 20 in her room started, on 3/20/25 at 9:30 a.m., while Resident 20 finished breakfast. At 9:44 a.m., Resident 20 pushed her call light button to alert staff that she needed assistance. At 9:48 a.m., Licensed Practical Nurse (LPN) 10 came into Resident 20's room to see what she needed. Resident 20 indicated she needed to be changed. LPN 10 told her she would get someone to help her. At 10:01 a.m., a CNA went into Resident 20's room and removed her breakfast tray. No communication between the CNA and Resident 20 occurred. At 10:02 a.m., another CNA went into Resident 20's room and checked on her and her roommate. No communication between the CNA and the residents occurred. At 10:05 a.m., the Executive Director (ED) went into Resident 20's room. Resident 20 indicated to the ED she needed to be changed. The ED indicated he would look for someone to assist her. At 10:07 a.m., the ED exited the room to look for a staff member to assist Resident 20 with getting cleaned up. At 10:12 a.m., a CNA went into Resident 20's room and looked around and walked back out. No communication between the CNA and Resident 20 occurred. At 10:14 a.m., Resident 20 pushed her call light again to request assistance in being changed. At 10:15 a.m., Unit Manager (UM) 9 and LPN 10 went into Resident 20's room to check on the resident. Resident 20 requested to be changed. UM 9 and LPN 10 gathered supplies, performed hand hygiene, and donned gloves. When UM 9 removed the outer blue brief, another brief was seen in between Resident 20's legs. The brief in-between her legs was white. UM 9 indicated two briefs were placed on residents who requested double briefs, and a care plan was in place for this preference. UM 9 indicated Resident 20 was on hospice and hospice may have care planned two briefs to be placed on the resident. 52119 4. The clinical record for Resident G was reviewed on 3/21/25 at 10:00 a.m. The diagnoses included, but were not limited to, dementia and bowel and bladder incontinence. A care plan, created on 1/2/25, indicated Resident requires assistance with toileting due to: Weakness, Age, Dementia, Incontinence . The care plan approaches included, Assist with incontinent care as needed .Check every 2 hours for incontinence . A Quarterly MDS assessment, dated 2/17/25, indicated the resident was dependent on staff for toileting hygiene. On 3/20/25 at 10:24 a.m., Resident G was observed sitting in her wheelchair in the activities room next to Family Member (FM) 31. During an interview on 3/20/25 at 10:27 a.m., FM 31 indicated the resident was incontinent of bowel and bladder but could sometimes tell when she needed to have a bowel movement. The staff did not check her brief for wetness every two hours, only when she told them she needed to have a bowel movement. He had arrived that morning, approximately 20-30 minutes prior, and her brief had not been checked or changed since he arrived. During a continuous observation on 3/20/25 from 10:24 a.m. to 11:14 a.m., no staff were observed to check Resident G's brief or assisted her with toileting. During an interview on 3/20/25 at 1:05 p.m., FM 31 indicated he had been seated next to Resident G the entire time, and she had not been changed or checked for incontinence. On 3/24/25 at 1:48 p.m., the Nurse Consultant (NC) provided the Vitals Report which contained documentation of Resident G's episodes of incontinence between 2/1/25 and 3/24/25. On 3/20/25, the staff documented the resident was incontinent that morning, at 9:37 a.m., with a large amount of urine. The next documented incontinent episode was 1:50 p.m., with a large amount of urine. During an interview on 3/24/25 at 12:10 p.m., the ED indicated there was not an ADL Care Policy. The facility followed the standards of care. An interview with the NC, on 3/24/25 at 2:50 p.m., indicated staff should be performing incontinence checks every two hours. 3.1-38(a)(2)(C) 3.1-38(a)(3)(A) 3.1-38(a)(3)(B)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed when gloves were changed when performing incontinent care for 1 of 8 residents reviewed for activities of daily living, failed to maintain infection control while providing catheter care for 1 of 1 resident reviewed for catheter care, failed to ensure staff performed hand hygiene during coffee service, and to ensure medication carts were cleaned after touched by residents for 3 of 3 residents randomly observed. (Resident E, Resident F, Resident G, Resident H and Resident L) Findings include: 1. The clinical record for Resident L was reviewed on 3/18/25 at 3:17 p.m. The diagnoses included, but were not limited to, history of traumatic brain injury and diabetes. A care plan, initiated 2/7/25, indicated she required assistance with Activities of Daily Living (ADL) care including bed mobility, transfers, eating, and toileting related to weakness from a recent hospital stay. The goal was for her to improve her current functional status. The approaches included, but were not limited to, a mechanical lift for transfers with assistance of two staff, assist with bed mobility as needed, and assist with toileting and incontinent care as needed. A Quarterly Minimum Data Set (MDS) assessment, completed 2/21/25, indicated she was cognitively intact. She required total assistance with toileting. On 3/18/25 at 3:17 p.m., Resident L indicated she felt that incontinent care was lacking and was concerned about getting a urinary tract infection due to the poor incontinent care at times. During an observation on 3/21/25 at 2:45 p.m., Certified Nurse Aide (CNA) 14 provided incontinent care for Resident L. CNA 14 performed hand hygiene and prepared a basin of warm water and gathered supplies. CNA 14 then donned a pair of disposable gloves. She donned a gown and then donned a second pair of gloves. CNA 14 began performing incontinent care by undoing the incontinence brief and pulling the brief down. CNA 14 cleansed the perineal area of Resident L and removed the outer set of gloves and donned a new pair of disposable gloves over the gloves which remained on her hands. No hand hygiene was performed. CNA 14 then cleansed Resident L's buttocks and prepared the soiled brief to be removed. CNA 14 removed the outer pair of gloves and donned another pair of gloves over the existing gloves on her hands. No hand hygiene was performed. CNA 14 then applied barrier cream to Resident L's buttocks. Resident L was rolled to her back and CNA 14 doffed the outer pair of gloves, donned another pair of gloves on top of the existing gloves on her hands, and applied barrier cream to Resident L's peri area. During an interview on 3/21/25 at 3:15 p.m., the Corporate Infection Preventionist indicated the use of double gloves was not the policy of the facility and that hand hygiene should have been performed. 51750 2. The clinical record for Resident E was reviewed on 3/19/25 at 11:45 a.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy (a blockage in the urinary tract). A Quarterly MDS assessment, dated 2/07/25, indicated Resident E was severely cognitively impaired. A care plan, dated 7/26/24, last reviewed/revised on 2/11/25, indicated the Resident is at risk of transferring or becoming colonized with a Multidrug-Resistant Organism (MDRO) and requires enhanced barrier precautions (EBP) due to an indwelling medical device. The goal of the care plan was for the Resident to be compliant with enhanced precautions to decrease the risk of MDRO transmission during high contact activities. Interventions included, but were not limited to, use standard precautions including hand hygiene in addition to EBP and wear gown and gloves prior to high contact resident care activities. During an observation of urinary catheter care on 3/24/25 at 11:50 a.m., CNA 4 performed hand hygiene before donning a gown and gloves. With gloves on, CNA 4 reached into her pocket and removed two trash bags, pulled a privacy curtain closed, touched the resident's bathroom doorknob and sink handle, and touched the resident's bedside table. CNA 4 then placed clean washcloths in a basin of water with soap. CNA 4 removed her gloves and applied new gloves without the use of hand hygiene. She proceeded to cleanse the catheter tubing with the previously touched washcloths. CNA 4 did not doff her gloves, perform hand hygiene, and apply new gloves after touching high traffic surfaces before touching the clean washcloths and providing care. 52119 3. During a random observation of coffee being passed on 3/20/25 at 11:38 a.m., CNA 16 did not perform hand hygiene before initiating passing coffee to residents. She handed cups of coffee to several residents. CNA 16 then held the hand of a resident to lead her towards the back of the activities room, where another staff member assisted the resident to the restroom. She did not perform hand hygiene after. CNA 7 touched a resident's clothes and arm to assist her and then grabbed a clean cup and filled it with water and handed it to another resident. CNA 7 did not perform hand hygiene after touching the resident. During an interview with Family Member (FM) 31 on 3/20/25 at 11:38 a.m., he indicated he rarely saw the staff wash their hands or use hand sanitizer when he was present. 4. During a random observation on 3/21/25 at 8:47 a.m., Resident F placed her dirty breakfast plate on the medication cart surface in the activities room. She touched various surfaces on the cart. After several minutes, Qualified Medication Aide (QMA) 17 noticed Resident F touching the medication cart. She attempted to redirect Resident F, who became angry and swatted her arm at QMA 17. QMA 17 indicated as long as Resident F was safe, sometimes it was best to let her be, so she doesn't get too agitated. Resident F wandered away after several more minutes. On 3/21/25 at 8:57 a.m., QMA 17 went to the medication cart to retrieve medication for another resident. QMA 17 did not wipe down any surface of the medication cart before placing clean medication cups on the cart. 5. During a random observation on 3/21/25 at 9:23 a.m., Resident H began touching the medication cart located in the hallway outside the activities room. No staff intervened. Resident H walked away after several minutes. On 3/21/25 at 9:32 a.m., an unidentified CNA went up to the cart to pour a cup of water for a resident. She did not wipe down any of the items or any surface of the cart. On 3/24/25 at 8:56 a.m., the ED provided the Hand Hygiene Policy, last reviewed 12/2021, which indicated .to provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganisms on the hands of all employees . Moments of hand hygiene .Before touching a resident, Before Clean/Aseptic procedure, After body fluid exposure risk, After touching a resident, After touching resident surroundings .Indication for Hand-rubbing but not limited to: Before having direct contact with a resident and/or equipment .Before the starting [sic] a medication preparation, After each resident contact and after contact with a resident's belongings, environmental surfaces, touching items on the floor, and resident care equipment, after contact with a resident's intact skin .Before and after removing glove .After touching self or clothing during meal service . This citation relates to complaint IN00455520. 3.1-18(b)(1) 3.1-18(l)

Based on interview and record review, the facility failed to follow a resident's choices for 1 of 1 resident reviewed for choices. (Resident 30) Findings include: The clinical record for Resident 30 was reviewed on 3/21/25 at 1:07 p.m. The diagnoses included, but were not limited to, muscle weakness, and obesity. A Minimum Data Set (MDS) assessment indicated Resident 30 was cognitively intact. An interview was conducted with Resident 30 on 3/19/25 at 11:33 a.m. She indicated there were days she did not get put to bed until 9:30 p.m.-10:00 p.m. Resident 30's preference was to be put to bed between 7:15 p.m. to 7:30 p.m. An interview with Unit Manager (UM) 9, on 3/21/25 at 1:57 p.m., indicated she did not see preferences in Resident 30's care plan about choices for bedtime. She indicated there should be a care plan in place for Resident 30's choice of bedtime. A document entitled Preferences for Customary Routine and Activities, completed on 4/22/24, noted Resident 30 indicated it was very important for her to choose her own bedtime and it be just after dinner. During an interview with Certified Nurse Aide (CNA) 8 on 3/21/25 at 2:47 p.m., they indicated Resident 30 does want to be put to bed after evening meal between 7:15 p.m.-7:30 p.m., but it does not happen at times due to other situations happening. 3.1-3(u)(1)

Based on interview and record review, the facility failed to accurately document urinary output as ordered for a resident with an indwelling catheter for 1 of 1 resident reviewed for catheters. (Resident E) Findings include: The clinical record for Resident E was reviewed on 3/19/25 at 11:45 a.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy (a blockage in the urinary tract). A Quarterly Minimum Data Set (MDS) assessment, dated 2/07/25, indicated Resident E was severely cognitively impaired. A care plan, dated 7/06/25, indicated Resident E required assistance with morning and evening care. The goal was for the resident to have Activities of Daily Living (ADLs) needs met. Interventions included, but were not limited to, documentation of bowel and urinary output every shift. A physician order, dated 3/14/25, indicated Foley catheter (indwelling tube that drains urine from the bladder) care, nurse to record output every shift. The recorded urine output was not documented for two out of three shifts on 2/15/25, and one out of three shifts on 2/16/25 and 2/17/25. Urinary output was not documented for any shift on 3/21/25 and 3/22/25. Urine output volume was documented as Large on 3/15/25 and 3/16/25, Medium on 3/20/25, and Large on 3/23/25. During an interview on 3/24/25 at 2:50 p.m., the facility Nurse Consultant (NC) indicated nursing should be documenting urinary output by milliliter (mL) for residents with indwelling urinary catheters. On 3/21/25 at 3:37 p.m., the Director of Nursing (DON) provided a Bowel and Bladder Program Policy, dated 3/2010, last revised 5/2019, it indicated .Urinary output from indwelling urinary catheters will be documented. It is recommended that catheter care be performed every shift or as indicated per physician orders . 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure the availability of medications to administer as ordered for 1 of 1 resident reviewed for care planning and 1 of 5 residents reviewed for unnecessary medications. (Resident 47 and Resident 182) Findings include: 1. The clinical record for Resident 182 was reviewed on 3/18/25 at 3:30 p.m. The diagnoses included, but were not limited to, pneumonia. The resident was admitted to the facility on [DATE]. An interview was conducted with Resident 182's Representative on 3/18/25 at 3:22 p.m. He indicated Resident 182 was admitted to the facility at approximately 5:00 p.m., on 3/17/25. The resident was still waiting, as of that afternoon, for the facility's pharmacy to deliver the resident's medications. A physician order, dated 3/17/25, indicated Resident 182 was to receive 5 milligrams of finasteride (medication for benign prostatic hyperplasia) once a day. A physician order, dated 3/17/25, indicated the resident was to receive 500 milligrams of hydroxyurea (oral anticancer medication) once a day. A physician order, dated 3/17/25, indicated the resident was to receive 500 milligrams of levofloxacin (antibiotic) twice a day. A physician order, dated 3/17/25, indicated the resident was to receive 25 milligrams of metoprolol (blood pressure medication) once a day. A physician order, dated 3/17/25, indicated the resident was to receive 0.4 milligrams of tamsulosin (medication for benign prostatic hyperplasia) once a day. A physician order, dated 3/17/25, indicated the resident was to receive 200-62.5-25 micrograms of Trelegy inhaler once a day. The March 2025 Medication Administration Record (MAR) indicated the following days that the resident's medications were not available to administer: 5 milligrams of finasteride - 3/18/25 and 3/19/25 = documented as awaiting for pharmacy, 500 milligrams of hydroxyurea - 3/18/25, 3/19/25, and 3/20/25 = documented as awaiting for pharmacy, 500 milligrams of levofloxacin - 3/17/25 - 8:00 p.m. dosage and 3/18/25 - 8:00 a.m. dosage = documented as awaiting for pharmacy, 25 milligrams of metoprolol - 3/18/25 = documented as awaiting for pharmacy, 0.4 milligrams of tamsulosin - 3/18/25 = documented as awaiting for pharmacy, and 200-62.5 -25 micrograms of Trelegy inhaler - 3/19/25, 3/19/25, and 3/20/25 = documented as awaiting for pharmacy. An interview was conducted with the Nurse Consultant on 3/24/25 at 2:47 p.m. She indicated the pharmacy had not received all Resident 182's medication orders that were sent over to them upon admission, on 3/17/25. The pharmacy delivers medications at 9:00 p.m. and 3:00 a.m. The staff recognized, on 3/20/25, that the resident's medications were not here yet. They should have followed up earlier to obtain the medications. 51984 2. The clinical record for Resident 47 was reviewed on 3/24/25 at 10:53 a.m. The diagnoses included, but were not limited to, chronic pain. A Quarterly Minimum Data Set assessment indicated Resident 47 was moderately cognitively impaired. A physician's order, dated 12/27/24, indicated the resident was to receive a buprenorphine 15 microgram/hour patch (pain patch) every Friday. The old patch was to be removed before placing the new patch on. The March 2025 MAR for Resident 47 indicated the buprenorphine patch was not administered on 3/14/25 and 3/21/25. An interview was conducted with Unit Manager (UM) 9 on 3/24/25 at 11:06 a.m. She indicated when the last patch was placed, the nurse was to request and re-order from the pharmacy. If the pharmacy was out of stock, they ordered it from their supplier, then it was sent to the pharmacy for delivery to the facility. This patch was not in the facility's EDK (emergency drug kit; a collection of essential medications and supplies used in emergency situations to provide immediate care). A Re-ordering medications policy was provided by the Nurse Consultant on 3/23/25 at 3:45 p.m. It indicated . Purpose of Policy: To provide a procedure for re-ordering medications .Procedure: Medications should be re-ordered when there is a 3-day supply remaining on the card .Medications are to be re-ordered using the re-supply button in matrix .Effect of Non-Compliance: Medications unavailable for resident use. A medication policy was provided by the Executive Director on 3/25/25 at 9:19 a.m. It indicated .6.1 If any item ordered by facility is not received, and the reason for missing item is not evident, facility should contact pharmacy immediately . 3.1-25(g)(2) 3.1-25(g)(3)

Based on interview and record review, the facility failed to administer a synthetic opioid pain patch in accordance with the physician order, the manufacturer's specifications, or accepted professional standards to prevent a significant medication error for 1 of 3 residents reviewed for medication regimen. (Resident C) This deficient practice resulted in the resident having two opioid pain patches applied simultaneously, the resident experienced a significant change in consciousness that required emergent administration of an opioid overdose medication, and hospitalization . This deficient practice was corrected on 12/31/24, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding synthetic opioid pain patches, conducted competency check offs for medication administration for nursing staff, and conducted a review of residents who received a synthetic opioid pain patch with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: The clinical record for Resident C was reviewed on 1/2/25 at 11:00 a.m. The diagnoses for Resident C included, but were not limited to, quadriplegia. A Quarterly MDS (Minimum Data Set) assessment, dated 11/6/24, indicated the resident was cognitively impaired. Resident C was receiving pain management. A physician order, dated 6/8/24, indicated the resident was to receive four milligrams of Narcan [medication that can reverse opioid overdose] in nostril for drug sedation as needed. A physician order, dated 7/17/24, indicated the resident was to receive 15 milligrams (mg) of morphine twice a day as needed for pain. A physician order, dated 7/17/24, indicated the resident was to receive one 75 micrograms (mcg) fentanyl (synthetic opioid medication) patch every three days for pain. The order was discontinued on 12/27/24. The November 2024 Medication Administration Record (MAR) indicated the 75 mcg fentanyl patch was administered with the location of the patch on the following days: 11/23/24 placed on the right chest, 11/28/24 placed on the right upper back, and 11/30/24 placed on the chest. The MAR did not include documentation of the removal of the fentanyl patches. A November 2024 controlled substance administration record indicated nursing staff placed a fentanyl 75 mcg patch on Resident C five times in eight days on 11/23/24, 11/24/24, 11/27/24, 11/28/24, and 11/30/24. The record did not include documentation of the removal of the fentanyl patches. Resident C's clinical record did not include documentation to indicate the resident was monitored for a change of condition after receiving the pain patch five times within the eight-day period. A medication error report, dated 12/26/24, indicated Qualified Medication Aide (QMA) 10 administered the fentanyl patch to Resident C on 11/24/24 in error. The patch was supposed to be administered on 11/26/24. After, QMA 10 administered a fentanyl patch, on 11/28/24, in error. The patch was supposed to be administered on 11/30/24. The resident's previous fentanyl patches were not removed prior to administration of the new fentanyl patches on 11/24/24 and 11/28/24. The report indicated the measures taken for prevention of reoccurrence was demotion of QMA 10 to a Certified Nurse Aide (CNA). The December 2024 MAR indicated Resident C received a fentanyl 75 mcg patch on the following days and location of the patch: 12/21/24 placed on the chest and, on 12/24/24, placed on right side of the chest. The MAR did not include documentation of the removal of the fentanyl patches. On 12/24/24 at 9:13 p.m., Resident C received 15 mg of morphine as needed with a pain level of eight for generalized pain. A December 2024 controlled substance administration record for Resident C indicated nursing staff placed a fentanyl 75 mcg patch on 12/21/24 at 8:00 p.m. and 12/24/24 at 8:00 p.m. A nursing progress note, dated 12/25/24 at 4:32 a.m. indicated, this writer was providing care for resident roommate when she [Resident C] was observed to be gargling and foaming at the mouth, resident was extremely difficult to arouse and was incoherent with responding to verbal commands, resident eyes closes, skin cool clammy and ashen in color, 2 [two] fentanyl patches were in place on right and left side of resident chest, one dated 12/21 and one dated 12/24, old patch was removed, and nasal narcan spray administered at 4:07 a.m. x 1 [times one] dose, resident started to become more coherent within 5 [five] min [minutes] were resident vitals WNL [within normal limits], [blood pressure] 150/68, P [pulse] 79 RR [respiration rate] 16 post Narcan, resident agitated and in pain, 911 called and resident to be sent to [name of hospital] for further evaluation , voicemail left for emergency contact, DNS [Director of Nursing Services] and MD [medical doctor] notified of change in condition . A reportable incident to the Indiana Department of Health, dated 12/26/24, indicated a medication error had occurred on 12/25/24 at 4:01 a.m. Resident C was sent to the hospital for evaluation. The investigation for the medication error was provided by the Executive Director on 1/3/25 at 8:56 a.m. It included, but was not limited to, the following: A written statement by Licensed Practical Nurse (LPN) 11, dated 12/26/24, indicated on 12/24/24 upon administering prescribed medication [75 mcg fentanyl patch] to resident [C]. Resident's roommate started yelling saying that she was in pain in her chest. I stopped to check the roommate and forgot to take off other patch amongst the chaos in the room. A medication error report, dated 12/25/24, indicated fentanyl patch was not removed when applying new patch. The medication error resulted in resident needed to be narcan [sic] & sent to hospital. The report indicated the measures taken for prevention of reoccurrence was presence of two nurses with the removal and application of fentanyl patches. An in-service was conducted with staff, on 12/26/24, for medication errors. The hospital records, dated 12/25/24 through 12/27/24, indicated the following, .found pt [patient] unresponsive and realized pt was wearing 2 [two] fentanyl patches. Pt still wearing one fentanyl patch on arrival, removed by .ED [emergency department] staff .RNs [Registered Nurses] at [name of facility] admin [administered] intranasal narcan. Pt vitally stable on arrival .Patient seen and examined. Patient was brought into the ED as she was found to be unresponsive at ECF [extended care facility] though the patient has no recollection that she was at the ECF. Patient was confused at the time of admission thinking that she had come from home. Patient was noted to have 2 [two] fentanyl patches on at the ECF and they were removed and patient was given a dose of Narcan .and she became much more responsive .1. Increased somnolence-secondary to narcotic patch .Appears to be at baseline mentation at this time .5. Chronic pain - patient was found to have 2 fentanyl patches on at the time of admission. Received narcan prior to admission. Continue morphine and Lyrica. Will resume fentanyl patch tomorrow .Principal Problem: toxic metabolic encephalopathy suspected to be secondary to narcotic overdose. Mentation now appears to be at baseline. Seen by neurology who has cleared her for discharge . Resident C was discharged on [DATE]. An interview was conducted with Resident C on 1/3/25 at 11:38 a.m. She indicated she could not recall the incident. She no longer received fentanyl patches. An interview was conducted with the Director of Nursing Services (DNS) and Float Director of Nursing Services (FDNS) on 1/3/25 at 2:49 p.m. They indicated a medication error had occurred on 12/24/24. Nursing staff had placed a 75 mcg fentanyl patch on Resident C, as ordered, but had not removed the previous one. Resident C had two fentanyl patches on. FDNS indicated emergency medical services (EMS) was notified and administration of Narcan was initiated. Resident C was sent to the hospital for evaluation. The resident remained in the hospital for a couple of days, but it was not due to wearing two fentanyl patches. During her hospital stay, blood levels for fentanyl were not even obtained. On 11/24/24 and 11/28/24, medication errors had also occurred with the resident's fentanyl patches. The nursing staff had administered the fentanyl patches to Resident C prior to the 72 hours as ordered. The staff did not remove the previous fentanyl patches prior to administering the new fentanyl patches, so the resident was also on those days wearing two patches. After hospitalization , Resident C's fentanyl patch order was discontinued. An email statement by Physician 13, dated 1/3/25, was provided by the FDNS at 1/3/25 at 2:54 p.m. It indicated the following, .I have reviewed the chart and this is my thought on this. After removing the patch for 24 hours, the concentration of fentanyl in the serum gradually decreased to about 50% after 17 hours (range:13-22 hours). These results indicated that the fentanyl continued to be released into the blood from the skin after drug withdrawal. But this also indicates that if a patch was still in place after the 72 hour mark the concentrations were likely decreasing at rapid rates. Meaning that I don't think that the fentanyl patch that was older was likely contributing much to the newer patch that was in place. It doesn't mean that the patches should not be removed, removing a patch at the 72 hour mark increases the rate of fentanyl blood concentration more rapidly allowing the second patch to have less total blood concentration at the 24-hour mark from when it is first put in place. That being said it likely was not contributing significantly. Despite the MRI [tube like machine to see images of organs and tissues in body] a being negative it is curious that the CTA [computed tomography angiography - diagnostic imaging procedure that uses X-ray technology and computer processing to create detailed images of blood vessels and surrounding tissues] indicated a possible acute or subacute thrombus [clot]. Partial occlusion may have attributed for part of her symptoms. Simply saying that someone gets narcan and wakes up is not enough to indicate that it was entirely the opiates fault. Especially in a fentanyl patch, it remains in the blood for 17 hours as stated above. Which would mean one or two doses of narcan would only last an hour and a half and she would still have over 50% of the original concentration in her blood despite taking both patches off immediately upon arrival. That would mean that narcan would need to be continually infused over the next 17 hours to remain effective. I think this is a deficiency that the hospital team is overlooking in blaming the fentanyl entirely A medication administration procedure policy was provided by the Executive Director on 1/3/25 at 8:56 a.m. It indicated the following, .3. Medications to verify order with label .10. Perform the 5 [five] rights of medication: Right Resident, Right Medication, Right Dose, Right Route, Right Time .19. Medication administration will be recorded on the MAR/EMAR . after given The website Drugs.com at https://www.drugs.com/cdi/fentanyl-transdermal-patch.html , retrieved on 1/7/25 at 5:00 p.m., updated December 21, 2023, indicated the following, .Fentanyl Transdermal Patch .How is this medicine (Fentanyl Transdermal Patch) best taken? . Take off old patch first . Put patch on clean, dry, healthy skin on the chest, back, upper leg, or upper arm . Put the patch in a new area each time you change the patch . What do I do if I miss a dose? .Do not apply double dose or extra patches The website National Library of Medicine at https://www.ncbi.nlm.nih.gov/books/NBK470415/ , retrieved on 1/7/25 at 5:05 p.m., updated July 21, 2023, indicated the following, .Formulas of Opiates and Delivery . The transdermal delivery of opiates like fentanyl has been widely accepted in healthcare settings for analgesic relief. This route of administration is favored because the drug levels take 4 to 6 hours to peak and there is a long elimination half-life, thus making the drug suitable for use in patients with chronic continuous pain . However, the topical formulation of fentanyl can contribute toward the toxicity of parenteral or oral opiates . Evaluation . Laboratory Studies . Patients with drug overdose usually undergo several investigations. Drug screens are readily available but often do not change the initial management of straightforward cases . In patients with opiate toxicity or overdose, the following blood work is usually performed: Complete blood cell count . Comprehensive metabolic panel . Creatine kinase [CK] level [Elevated CK levels may indicate muscle, heart, or brain damage or degeneration] . Arterial blood gas determinations . Starting Dose of Naloxone . In patients who have taken large doses of . fentanyl, much larger doses of naloxone are usually required to reverse the toxicity . If the patient fails to respond to a total of 10 mg of naloxone, the diagnosis of opiate toxicity should be reconsidered This citation is related to Complaint IN00449972. 3.1-48(c)(2)

Based on interview and record review, the facility failed to timely notify a resident representative of a fall for 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/2/25 at 2:10 p.m. The diagnoses included, but were not limited to, Alzheimer's disease and hypertension. A Quarterly Minimum Data Set (MDS) assessment, completed 11/27/24, indicated she had severely impaired cognition, was able to transfer from a sitting to standing position, and walk with supervision and/or touch assistance of staff. She did not use a wheelchair and received scheduled pain medications. A care plan, last reviewed 12/19/24, indicated Resident B was at risk for falls due to a history of falls, impaired cognition, and utilization of certain medications. The goal was to reduce her risk factors to attempt to avoid significant fall related injuries. The approaches included, but were not limited to, keep personal items in reach, non-skid footwear, and environmental changes. A nursing progress note, dated 12/11/24 at 8:57 p.m. [recorded as a late entry on 12/13/24 at 1:06 a.m.], indicated Resident B was found in another resident's room, lying on the floor on her left side. Resident B was assessed, and no injuries were noted at that time. Her vital signs were stable. A nursing progress note, dated 12/12/24 at 11:46 a.m., indicated Resident B was noted to have pain in her left lower extremity. An as needed dose of Tylenol was administered. The Nurse Practitioner assessed Resident B, and a new order was received for Tylenol 650 milligrams (mg) four times daily for three days. A nursing progress note, dated 12/12/24 at 1:54 p.m., indicated the physician had ordered a STAT (right away) X-Ray of Resident B's pelvis due to acute pain. The X-Ray provider had been notified. A nursing progress note, dated 12/12/24 at 8:01 p.m., indicated a positive X-Ray had been received, the on-call provider was notified, and Resident B had been sent to an acute care hospital for treatment. Resident B was admitted to the acute care hospital on 12/12/24 for a left femoral neck fracture (hip fracture). During an interview on 1/2/25 at 3:02 p.m., Family Member (FM) 10 indicated she had not been made aware of Resident B's fall, on 12/11/24, until when she came to visit Resident B on 12/12/24. She had found Resident B sitting in a wheelchair, which was not normal for Resident B. Resident B was rocking back and forth, rubbing her leg and crying. The physician ordered an X-Ray, which showed Resident B had a fractured hip. On 1/3/25 at 8:56 a.m., the Executive Director (ED) provided a copy of the Incident Report submitted to the Indiana Department of Health (IDOH), on 12/12/24, and the investigation file. The investigation file included a statement, dated 12/13/24, from Registered Nurse (RN) 6 which indicated she had been the nurse caring for Resident B on 12/11/24. Resident B had been found on the floor and RN 6 had assessed Resident B and started neurological checks. Resident B did not display signs or symptoms of pain after being found on the floor. Resident B had walked to the dining room after being assisted from the floor. RN 6 had not documented the fall in the clinical record on 12/11/24. A statement from Certified Nurse Aide (CNA) 8 was included in the investigation file. The statement indicated CNA 8 had cared for Resident B during the night shift on 12/11/24. CNA 8 had provided care multiple times throughout the night. Resident B had not shown signs or symptoms of discomfort and was able to turn in bed with ease. A statement from Physical Therapist (PT) 7, dated 12/16/24, indicated PT 7 provided treatment for Resident B on 12/12/24 prior to lunchtime. PT 7 had been informed by the nurse caring for Resident B that Resident B had difficulty getting up that morning. PT 7 attempted to have Resident B do a sit to stand transfer using the handrail in the hallway. Resident B was able to stand with minimal assistance and had started to take steps using the handrail. PT 7 had asked Resident B about pain and Resident B nodded her head to indicate yes and indicated the pain was in her left thigh. The nurse had given Resident B pain medications and PT 7 escorted Resident B to the dining room using a wheelchair. A statement from RN 9, dated 12/18/24, indicated RN 9 had not been made aware that Resident B fell , on 12/11/24, during report from the night shift nurse. RN 9 had been informed that Resident B did not want to get up and walk to breakfast on 12/12/24. RN 9 had observed Resident B in the dining room during breakfast and had not noted any signs or symptoms of pain. Therapy had treated Resident B after breakfast and made RN 9 aware of Resident B having pain in her left leg. An Activities Assistant had informed RN 9 of Resident B's fall on 12/12/24. RN 9 had informed the Nurse Practitioner of the fall on 12/12/24 and received new pain medication orders. The physician was informed of the fall and ordered a STAT X-Ray of the pelvis. FM 10 had come to visit and was made aware of the fall and the new orders received. The X-Ray results were positive for a left hip fracture and Resident B was sent to an acute care hospital for treatment. During an interview on 1/3/25 at 11:24 a.m., the ED and the Director of Nursing Services indicated that FM 10 should have been made aware of Resident B's fall when it happened on 12/11/24. This citation is related to Complaint IN00449466. 3.1-5(a)(1) 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a resident received the correct amount of [MEDICATION NAME] (liquid pain medication) which resulted in the use of [MEDICATION NAME] (medication used to reverse the effects of a narcotic overdose) for 1 of 4 residents reviewed for medication administration. (Resident #C) Findings include: The clinical record for Resident #C was reviewed on 4/20/16 at 11:45 a.m. [DIAGNOSES REDACTED]. The April 2016 Medication Administration Record [REDACTED].Order .[MEDICATION NAME] ([MEDICATION NAME]) .concentrate; 10 mg (milligrams)/ml (per 1 milliliter) .Amount to Administer: 10 mg (milligrams); oral .Frequency .Every 12 Hours .Scheduled Date .4/10/2016 .Scheduled Time .9:00 AM .Charted Date - Time .4/10/2016 11:44 AM .Reasons/Comment .Late Administration: Administered late .Comment: backed up The narcotic count sheet, dated 3/29/16, included, but was not limited to, the following: (name of pharmacy) .(Resident #C's name) .[MEDICATION NAME] 10 mg(milligrams)/ml (per 1 milliliter) .Give 1ml (milliliter) (10 mg)(10 milligrams) sublingually (underneath the tongue) every 12 hours .Date .4/9 (4/9/16) .Time .9P (9:00 p.m.) .Amt (amount) Given .1ml (milliliter) .Qty (quantity) Remain 9 (9 milliliters) .Date .4/10 (4/10/16) .Time .(9A with a line through it) 1pm (1:00 p.m.) .Amt (amount) Given .10 .Qty (quantity) Remain .0 .(RN (Registered Nurse) #1's name) The Event Report dated 4/11/16 at 9:43 a.m., included, but was not limited to, the following: .Event Date: 04/10/2016 09:42AM .Description .Resident found unresponsive .Event Details .SBAR (Situation, Background, Assessment, Recommendations) Physician Communication Tool .Background .Not responding to stimuli .Unable to follow commands .Skin .Pale .Extremities .Cold (extremities) - hands and feet .Problem .Based on assessment, the bedside clinician concludes: Resident was cyanotic (appearance of a blue or purple coloration of the skin) with bits of apnea (cessation of breathing), residents hands and feet cold. Resident not responsive to any stimuli .The problem seems to be .Cardiac .Neurologic .Respiratory Mental status change .Problem undetermined .Resident unstable, likely to get worse, bedside clinician requests - Hospice notified The nurses note, dated 4/10/16 at 3:00 p.m., recorded as a late entry on 4/11/16 at 10:34 a.m., included the following: Found resident unresponsive, cyanotic with bouts of apnea. Hands and feet cold to touch. Resident would not respond to any stimuli. VS (vital signs) out of normal range. Contacted the DON (Director of Nursing) (DON's first name),and (sic) Hospice. Hospice contacted MD (medical doctor). Family (first name of Resident #C's son) notified. Hospice felt it would benefit resident to be sent out for eval (evaluation) and tx (treatment). Resident transferred (sic) out at 9:30 pm to (name of hospital). The physician order, dated 4/10/16 at 4:30 p.m., indicated the following: [MEDICATION NAME] 0.4 mg (milligrams)/ml (per 1 milliliter) .IM (intramuscularly) now The nurses note, dated 4/10/16 at 5:00 p.m., recorded as a late entry on 4/11/16 at 10:49 a.m., included the following: [MEDICATION NAME] was administered to Resident around 4:30 pm. Resident vomited large amounts of undigested food about 5:00 pm. DON, writer, hospice present . The document titled, RESIDENT EVENT INVESTIGATION QUESTIONNAIRE, included, but was not limited to, the following: (Resident #C's name) .Date of Event .3:01 p (p.m.) .How often do you care for this resident .(RN #1's name) x (times) (division sign) (1) .Did anything occur that may have been construed by he resident .Med (medication) Error .Do you have ay idea of how this injury .may have occurred .Med Error .In your own words, tell me or write down exactly happened (sic) with this resident to the best of your knowledge .4/10/16 at 3pm (3:00 p.m.) (LPN (Licensed Practical Nurse) #3's name) and (RN #1's name) were counting Narcotics and an error was made on resident (Resident #C's first name) - Resident's order was to give [MEDICATION NAME] 10 mg (milligrams)/ml (per 1 milliliter) at 9A (9:00 a.m.)/9 pm (9:00 p.m.)(sic) resident was given 9 ml (milliliters) at 1 pm (1:00 p.m.) .Was first aid administered .[MEDICATION NAME] 0.4 mg (milligrams)/ml (per 1 milliliter) IM (intramuscularly) now .Summary of investigation .9 ml (milliliters(sic) [MEDICATION NAME] given at approximatley (sic) 1 pm (1:00 p.m.) on 4/10/16 (curvy line) med (medication) error noted - 4/10/16 at 4pm (4:00 p.m.) resident was unresponsive, MD (medical doctor) (sic) hospice, DNS (Director of Nursing) et (and) family called .N.O. (new order) [MEDICATION NAME] (sic) 0.4 mg (milligram)/ml (per 1 milliliter) given in (L with circle around it) (left) hip - At 5 pm (5:00 p.m.) resident vomitted (sic) a large amt (amount) of yellow undigested food .Signature of Investigator .(DON's signature) The Hospice note, dated 4/10/16 at 4:45 p.m., included, but was not limited to, the following: (name of hospice company) .(Resident #C's name) .Medications Changes .Staff discovered patient received too much medication @ (at) 1300 (1:00 p.m.) et (and) was gasping for breath at 1625 (4:25 p.m.), (sic) received (sic)[MEDICATION NAME] 0.4 mg (milligrams) at 1630 (4:30 p.m.) per office of (name of physician) .Mental Status .Lethargic .Gastrointestinal .Vomiting .at 1650 (4:50 p.m.) .Respiratory .using accessory muscles .Pain .moaning (c with line over it) with each breath .Received 90 mg (milligrams) [MEDICATION NAME] (instead of 10 mg) at 1300 (1:00 p.m.), scheduled dose from AM 0900 (9:00 a.m.) .other staff recognized problem at 1500 (3:00 p.m). Phoned (physician name) staff and hospice before 1600 (4:00 p.m.) The hospital document titled, Inpatient Record, dated 4/11/2016 at 9:27 a.m., included, but was not limited to, the following: .85 yo (year old) female admitted to inpatient hospice .Transferred from ECF (Extended Care Facility) yesterday for close monitoring after receiving [MEDICATION NAME]. Patient has not received any opioid medications since 1300 (1:00 p.m.) on 4/10/2016 .Minimally responsive During an interview on 4/20/16 at 3:10 p.m., the Director of Nursing indicated, on 4/10/16 around 4:00 p.m., LPN #1 called her and told her someone had gotten too much medication. The DON indicated, when asked how much [MEDICATION NAME] was given to Resident #C, RN #1 told her she gave what was left in the bottle, 9 ml (milliliters). The DON indicated when she looked at the bottle, it was empty. The DON indicated RN #1 told her she did not have her glasses and saw the 10 and that is what she gave. The DON indicated she administered 1 milliliter of [MEDICATION NAME], per physicians order, intramuscularly around 4:30 p.m. and Resident #C vomited undigested food around 5:00 p.m. During an interview on 4/20/16 at 4:10 p.m., the DON indicated there was not a policy/procedure regarding narcotic overdoses. This Federal tag relates to Complaint IN 324 3.1-25(b)(9) 3.1-48(c)(2)

Based on interview and record review, the facility failed to timely notify a resident's physician of her inability to take her medications and notify of her medical symptoms resulting in delayed hospitalization for 1 of 1 resident reviewed for hospitalization . (Resident #D) Findings include: The clinical record for Resident #D was reviewed on [DATE] at 2:00 p.m. The [DIAGNOSES REDACTED]. The [DATE], 5:30 p.m. nurses note indicated, Resident's BP (blood pressure) was assessed by the dinning room ,[DATE](bp). Writer assisted resident to bed for further assessment. Will continue to monitor. This nurse's note was written by RN #12. The [DATE], 5:30 p.m. nurse's note indicated, Writer in dining room for meal service, res.(resident) able to communicate with staff members without difficulty. As meals were being served, writer noted resident to be leaning slightly to the right side of her chair and was beginning to lay her head on the table. Writer asked resident if she was feeling okay, resident continued to look at writer with no verbal response. Vitals assessed, BP (blood pressure) elevated, all other vitals WNL (within normal limits). Small amount of emesis noted to pant leg. Resident then removed from the dining and taken to 400 nurse for review of status and orders. Slight facial drooping noted to right side of face, face flushed, right side of body rigid. Resident began to have difficulty sitting upright, writer and 400 hall nurse assisted resident into bed, where large amounts of emesis occurred. Reviewed code status and nurse began contacting (name of doctor's office) and daughter for orders and notification. Res. resting in bed with eyes closed at this time while obtaining orders from MD. Awaiting new orders at this time. This nursing note was recorded as a late entry on [DATE] at 3:19 p.m. by RN #11. The [DATE], 5:55 p.m. nurse's note indicated, Resident was laid down in bed, notified (name of physician's office) of elevated BP and spoke to (name of physician call center staffperson) for possible orders. (Name of physician's office) said writer should give her PRN (as needed) [MEDICATION NAME] (anti-nausea medication) and the wait for thirty minutes to give the antihypertensive medication. This note was recorded as a late entry on [DATE] at 1:49 p.m. by RN #12. The [DATE], 6:20 p.m. nurse's note indicated, Writer attempted to give resident medication ([MEDICATION NAME]) crushed in apple sauce as ordered. Resident took medications in her mouth but refused to swallow and spit them on the floor. Will continue to try to offer. This note was recorded as a late entry on [DATE] at 1:56 p.m. by RN #12. The [DATE], 6:30 p.m. nurse's note indicated, Writer tried to give resident the PRN medications [MEDICATION NAME] crushed in apple sauce again and resident spit them out. Resident's BP at this time was ,[DATE]. Will continue to offer medication and monitor BP. This note was recorded as late entry on [DATE] at 2:00 p.m. by RN #12. The [DATE], 6:40 p.m. nurse's note indicated, Writer called AHA again told them that resident spit out medication [MEDICATION NAME] and HTN, AHA said try to give just [MEDICATION NAME] and [MEDICAL CONDITION](hypertension) medication and observe if she will be able to swallow. Resident spit them out again. At this time resident was tearful, diaphoretic, and pale. Will continue to monitor for elevated BP. This note was recorded as a late entry on [DATE] at 2:08 p.m. by RN #12. The [DATE], 7:20 p.m. nurse's note indicated, Approx. (Approximately) 7:20pm nurse on 400 hall asked this writer to come to room to assess resident and attempt to give PRN medications. This nurse attempted to give these meds crushed in applesauce to resident. Res was unable to swallow and spit the medications out. Writer assessed BP and results were ,[DATE]. Writer noted that resident was becoming diaphoretic and flushed. Res has no s/s (signs/symptoms) of facial drooping or one sided weakness. Writer spoke w/400 hall nurse and it was decided that it would be best to call (name of physician's office) and 911 and send her to ER for eval (evaluation) r/t (related to) resident's wishes as documented in her POST form. This note was recorded as a late entry on [DATE], at 1:12 p.m. by RN #13. The [DATE], 7:30 p.m. nurse's note indicated, Writer got another nurse to attempt (sic) administer [MEDICATION NAME] and [MEDICATION NAME] medication but resident refused from that nurse as well. At this time resident BP was ,[DATE]. Resident was diaphoretic. Both nurse and writer agreed that resident needed to be sent out to ER. Will continue to monitor for elevated BP. This note was recorded as a late entry on [DATE], at 2:24 p.m. by RN #12. The [DATE] 7:35 p.m. nurse's note indicated, CNA (Certified Nursing Assistant) was providing care to resident ready to be sent out. Will continue to monitor for elevated V/S (vital signs). This note was recorded as a late entry on [DATE] at 2:34 p.m. by RN #12. The [DATE], 7:40 p.m. nurse's note indicated, (Name of physician's office) was called and spoke to Angel who gave order to send her out. 911 was called immediately. Writer tried to call daughter numerous times and left message but did not speak to her. Tried to call daughter's work but co worker stated that she was not there at that time. EMTs arrived at approx. 7:50pm. While EMTs were assessing resident, res daughter called back and asked if there was anything that could be done in house instead of sending resident to hospital. Daughter specifically asked if facility had IM [MEDICATION NAME] to administer. Writer went to facility EDK (emergency drug kit) and checked for IM [MEDICATION NAME] but noted that there was only tablets. At that time daughter stated it was ok to send resident out. This note was recorded as a late entry on [DATE] at 2:30 p.m. by RN #13. The [DATE], 7:50 p.m. nurse's note indicated, EMT arrived at this time. Resident transferred to (name of hospital) ER via stretcher. Report was called to ER nurse. This note was recorded as a late entry on [DATE] at 2:58 p.m. by RN #12. The [DATE], 11:00 p.m. nurse's note indicated, Staff called (name of hospital) @ 11 pm to find out how she was doing. Nurse reported that she was admitted for possible stroke. This note was recorded as a late entry on [DATE] at 12:30 p.m. by RN #12. An interview was conducted with RN #13 on [DATE] at 1:08 p.m. She indicated, after 7:00 p.m., RN #12 asked her if she would help give medications to Resident #D. She indicated she hadn't seen Resident #D all day, and didn't know what was going on with her. She indicated she assessed Resident #D, who was kind of rocking in her bed. She indicated Resident #D was holding onto the side rail of her bed, was getting really sweaty, wouldn't talk and usually did. She indicated she didn't notice Resident #D leaning to the right side or facial drooping. She indicated Resident #D gripped her hands during assessment. She indicated she assessed her for stroke because she knew her blood pressure was high. She indicated during her assessment she checked her vitals, heart sounds, looked at her face, arms, and legs, turned her to the sides, and palpated her abdomen. She indicated Resident #D's blood pressure was so high, she didn't want to waste any time, and felt more comfortable calling 911. RN #11 and RN #12 no longer worked at the facility and were unavailable for interview. A telephone interview was conducted with the physician's office call center supervisor on [DATE] at 1:44 p.m. She indicated there were a total of 3 telephone calls from the facility to the call center on [DATE], regarding Resident #D. She indicated the facility informed of vomiting and trouble with blood pressure, but no information on right sided facial drooping or being nonverbal. She indicated Resident #D was sent to the hospital at the last phone call, at 7:34 p.m. Three transcribed telephone conversations from [DATE] were provided by the physician's office call center on [DATE] at 2:20 p.m. The times were 5:46 p.m., 5:50 p.m., and 7:34 p.m. There was no telephone conversation at 6:40 p.m. as indicated in the [DATE], 6:40 p.m. nurses note. None of the 3 conversations referenced the [DATE], 5:30 p.m. nurse's notes symptoms of leaning to the right side, laying her head on the table, no verbal response, slight right side facial drooping, face flushed, right side body rigidity, or difficulty sitting upright. The 5:46 p.m. conversation between the physician's call center and the facility was made by RN #12. It included orders for 12.5 mg of [MEDICATION NAME] (anti-nausea medication) and to reattempt blood pressure medicine ,[DATE] hour afterwards. The 5:50 p.m. conversation was made by RN #12 to inform of Resident #D's current order for [MEDICATION NAME]. The call center indicated, So you can go ahead and give her the [MEDICATION NAME] instead of the [MEDICATION NAME]. The 7:34 p.m. phone conversation was made by RN #13. It indicated, I have a resident who.um.her blood pressure is ,[DATE] and we can't get her to swallow any pills to get her.uh.I know my associate had called earlier.um.so we kind of really want to send her out. I just need the ok from you guys. There were no calls made between 5:50 p.m. and 7:34 p.m. to inform the physician of Resident #D's inability to swallow her anti-nausea and blood pressure medication. An interview was conducted with the DON (Director of Nursing) on [DATE] at 10:24 a.m. She indicated she was at the facility on [DATE], when Resident #D was in the dining room, but she did not see her in there. She indicated it was common for her to have episodes of high blood pressure, to vomit, and to be difficult to arouse. She indicated she couldn't determine whether nursing staff acted appropriately to Resident #D's medical symptoms. She indicated if she (DON) saw the symptoms RN #11 documented in her nurse's note and considered Resident #D really different from normal, she would have informed the physician. She indicated she possibly would have expected the physician to be notified of right sided body rigidity, right sided facial drooping, and being nonverbal. She indicated she would have expected RN #12 to call the physician's office back ,[DATE] minutes after the order for antinausea medication to inform them of Resident #D's inability to swallow her blood pressure medication. She indicated she saw Resident #D briefly in the hallway and didn't see any right sided facial drooping. The [DATE] Department of Fire and Emergency Patient Care Record for Resident #D's transportation to the hospital indicated they received the call at 7:38 p.m., were on the scene at 7:44 p.m., at the patient at 7:46 p.m., and at the hospital at 8:07 p.m. It indicated, BP-,[DATE], s/s-neurological stroke symptoms w/weakness/paralysis, protocol used-suspected stroke, primary impression-stroke/[MEDICAL CONDITIONS], duration-3 hours, barriers of care-altered mental status, skin-bilateral forearms and hands were red with piticii (sic), asst (assessment) time:.were dispatched to ecf (extended care facility) on increased bp. u/a (upon arrival) found (age, race, and gender of Resident #D) lying supine in bed in care of (name of) crew. Crew stated pt was in dining room around 1700 hours for dinner and staff noticed that she was slumped over to the right side and that she had right sided facial droop. Pt was awake but not alert with obvious right sided facial droop and pt's forearms and hands bilaterally where (sic) red with what appeared to be piticii (sic). pt was unable to answer any questions and attempted to pull away from vitals being taken. Unknown reason for two and a half hour delay in contacting 911. Vitals obtained and pt was hypertensive. Loaded to cot, covered, secured, amd moved to.20 g (gauge) IV to left AC (antecubital-inner elbow) was attempted but unsuccessful. 20 g IV right hand with lock established, dex ([MEDICATION NAME]) 137 mgdl (milligrams per deciliter). 12-lead NSR (normal sinus rhythm). Transport to (name of hospital) started. Pupils were reactve but sluggish. Vitals repeated and bp increased. Radio report to (name of hospital) with stroke alert called and we were assigned (room #). Pt condition monitored and comfort measures taken. Bruising noted to pt chest and inside of right thigh. u/a report given and care turned over. An interview was conducted with NP (Nurse Practitioner) #14, from Resident #D's physician's office, on [DATE] at 11:05 p.m. He indicated he remembered Resident #D, and that she had uncontrolled hypertension. He indicated if he was given the information in RN #11's [DATE], 5:30 p.m. nurse's note, I would have sent her out right away. I know this patient, and those are classic symptoms of stroke and cardiovascular issues. I would have sent any patient out with those symptoms right away. The [DATE], 8:16 pm emergency room hospital records indicated, Patient presents with Possible CODE STROKE pt slumped over to right with right sided weakness. The history is provided by the nursing home and the EMS (emergency medical staff) personnel.Pt was evaluated by provider at 20:17 (8:17 p.m.).presents to the ED (emergency department) with right sided facial droop x 1700. Per EMS, pt was seen in the nursing home at dinner with a facial droop. Per pt's daughter pt has a hx (history) of [MEDICAL CONDITION]. Pt's (family member) sts (states)the pt has a hx of weakness and uncoordination. Neurological: positive for facial asymmetry Physical exam: Pupils pin point and to slight left.No response to verbal stimuli. Mild reflexive grip but not on command.Petechiae noted.Scattered petechiae rash on the hands and some old ecchymosis. Radiology Results: Impression: large [MEDICATION NAME] hematoma the left basal ganglia with extension into the ventricular system. Assessment/Plan: Extensive acute [MEDICATION NAME] hemorrhage-CT showed [MEDICATION NAME] hematoma the left basal ganglia. ED discussed with neurosurgery who believe pt is inoperable. Comfort care. [MEDICATION NAME] drip, [MEDICATION NAME] prn (as needed). Pt is comatose. The hospital records further indicated Resident #D died on [DATE] at 10:30am. An interview was conducted with Family Member #10, Resident #D's POA (power of attorney) on [DATE] at 3:34 p.m. She indicated she didn't understand why the facility waited so long to call 911. She indicated the first time she was contacted by the facility on [DATE] was approximately 7:40 p.m. She indicated she had no idea Resident #D was unconscious. This federal tag relates to Complaint #IN 650. 3XXX,[DATE](a)(2)

Based on interview and record review, the facility failed to recognize and address a resident's skin condition for 1 of 1 resident reviewed for skin conditions and to timely address a resident's medical symptoms resulting in delayed hospitalization for 1 of 1 resident reviewed for hospitalization . (Resident #D) Findings include: 1. a) The clinical record for Resident #D was reviewed on [DATE] at 2:00 p.m. The [DIAGNOSES REDACTED]. The [DATE], 5:30 p.m. nurses note indicated, Resident's BP (blood pressure) was assessed by the dinning room ,[DATE](bp). Writer assisted resident to bed for further assessment. Will continue to monitor. This nurse's note was written by RN #12. The [DATE], 5:30 p.m. nurse's note indicated, Writer in dining room for meal service, res.(resident) able to communicate with staff members without difficulty. As meals were being served, writer noted resident to be leaning slightly to the right side of her chair and was beginning to lay her head on the table. Writer asked resident if she was feeling okay, resident continued to look at writer with no verbal response. Vitals assessed, BP (blood pressure) elevated, all other vitals WNL (within normal limits). Small amount of emesis noted to pant leg. Resident then removed from the dining and taken to 400 nurse for review of status and orders. Slight facial drooping noted to right side of face, face flushed, right side of body rigid. Resident began to have difficulty sitting upright, writer and 400 hall nurse assisted resident into bed, where large amounts of emesis occurred. Reviewed code status and nurse began contacting (name of doctor's office) and daughter for orders and notification. Res. resting in bed with eyes closed at this time while obtaining orders from MD. Awaiting new orders at this time. This nursing note was recorded as a late entry on [DATE] at 3:19 p.m. by RN #11. The [DATE], 5:55 p.m. nurse's note indicated, Resident was laid down in bed, notified (name of physician's office) of elevated BP and spoke to (name of physician call center staffperson) for possible orders. (Name of physician's office) said writer should give her PRN (as needed) [MEDICATION NAME] (anti-nausea medication) and the wait for thirty minutes to give the antihypertensive medication. This note was recorded as a late entry on [DATE] at 1:49 p.m. by RN #12. The [DATE], 6:20 p.m. nurse's note indicated, Writer attempted to give resident medication ([MEDICATION NAME]) crushed in apple sauce as ordered. Resident took medications in her mouth but refused to swallow and spit them on the floor. Will continue to try to offer. This note was recorded as a late entry on [DATE] at 1:56 p.m. by RN #12. The [DATE], 6:30 p.m. nurse's note indicated, Writer tried to give resident the PRN medications [MEDICATION NAME] crushed in apple sauce again and resident spit them out. Resident's BP at this time was ,[DATE]. Will continue to offer medication and monitor BP. This note was recorded as late entry on [DATE] at 2:00 p.m. by RN #12. The [DATE], 6:40 p.m. nurse's note indicated, Writer called AHA again told them that resident spit out medication [MEDICATION NAME] and HTN, AHA said try to give just [MEDICATION NAME] and [MEDICAL CONDITION](hypertension) medication and observe if she will be able to swallow. Resident spit them out again. At this time resident was tearful, diaphoretic, and pale. Will continue to monitor for elevated BP. This note was recorded as a late entry on [DATE] at 2:08 p.m. by RN #12. The [DATE], 7:20 p.m. nurse's note indicated, Approx. (Approximately) 7:20pm nurse on 400 hall asked this writer to come to room to assess resident and attempt to give PRN medications. This nurse attempted to give these meds crushed in applesauce to resident. Res was unable to swallow and spit the medications out. Writer assessed BP and results were ,[DATE]. Writer noted that resident was becoming diaphoretic and flushed. Res has no s/s (signs/symptoms) of facial drooping or one sided weakness. Writer spoke w/400 hall nurse and it was decided that it would be best to call (name of physician's office) and 911 and send her to ER for eval (evaluation) r/t (related to) resident's wishes as documented in her POST form. This note was recorded as a late entry on [DATE], at 1:12 p.m. by RN #13. The [DATE], 7:30 p.m. nurse's note indicated, Writer got another nurse to attempt (sic) administer [MEDICATION NAME] and [MEDICATION NAME] medication but resident refused from that nurse as well. At this time resident BP was ,[DATE]. Resident was diaphoretic. Both nurse and writer agreed that resident needed to be sent out to ER. Will continue to monitor for elevated BP. This note was recorded as a late entry on [DATE], at 2:24 p.m. by RN #12. The [DATE] 7:35 p.m. nurse's note indicated, CNA (Certified Nursing Assistant) was providing care to resident ready to be sent out. Will continue to monitor for elevated V/S (vital signs). This note was recorded as a late entry on [DATE] at 2:34 p.m. by RN #12. The [DATE], 7:40 p.m. nurse's note indicated, (Name of physician's office) was called and spoke to Angel who gave order to send her out. 911 was called immediately. Writer tried to call daughter numerous times and left message but did not speak to her. Tried to call daughter's work but co worker stated that she was not there at that time. EMTs arrived at approx. 7:50pm. While EMTs were assessing resident, res daughter called back and asked if there was anything that could be done in house instead of sending resident to hospital. Daughter specifically asked if facility had IM [MEDICATION NAME] to administer. Writer went to facility EDK (emergency drug kit) and checked for IM [MEDICATION NAME] but noted that there was only tablets. At that time daughter stated it was ok to send resident out. This note was recorded as a late entry on [DATE] at 2:30 p.m. by RN #13. The [DATE], 7:50 p.m. nurse's note indicated, EMT arrived at this time. Resident transferred to (name of hospital) ER via stretcher. Report was called to ER nurse. This note was recorded as a late entry on [DATE] at 2:58 p.m. by RN #12. The [DATE], 11:00 p.m. nurse's note indicated, Staff called (name of hospital) @ 11 pm to find out how she was doing. Nurse reported that she was admitted for possible stroke. This note was recorded as a late entry on [DATE] at 12:30 p.m. by RN #12. An interview was conducted with RN #13 on [DATE] at 1:08 p.m. She indicated, after 7:00 p.m., RN #12 asked her if she would help give medications to Resident #D. She indicated hadn't seen Resident #D all day and didn't know what was going on with her. She indicated she assessed Resident #D, who was kind of rocking in her bed. She indicated Resident #D was holding onto the side rail of her bed, was getting really sweaty, wouldn't talk and usually did. She indicated she didn't notice Resident #D leaning to the right side or facial drooping. She indicated Resident #D gripped her hands during assessment. She indicated she assessed her for stroke because she knew her blood pressure was high. She indicated during her assessment she checked her vitals, heart sounds, looked at her face, arms, and legs, turned her to the sides, and palpated her abdomen. She indicated Resident #D's blood pressure was so high, she didn't want to waste any time, and felt more comfortable calling 911. RN #11 and RN #12 no longer worked at the facility and were unavailable for interview. A telephone interview was conducted with the physician's office call center supervisor on [DATE] at 1:44 p.m. She indicated there were a total of 3 telephone calls from the facility to the call center on [DATE], regarding Resident #D. She indicated the facility informed of vomiting and trouble with blood pressure, but no information on right sided facial drooping or being nonverbal. She indicated Resident #D was sent to the hospital at the last phone call, at 7:34 p.m. Three transcribed telephone conversations from [DATE] were provided by the physician's office call center on [DATE] at 2:20 p.m. The times were 5:46 p.m., 5:50 p.m., and 7:34 p.m. None of the 3 conversations referenced the [DATE], 5:30 p.m. nurse's notes symptoms of leaning to the right side, laying her head on the table, no verbal response, slight right side facial drooping, face flushed, right side body rigidity, or difficulty sitting upright. The 5:46 p.m. conversation between the physician's call center and the facility was made by RN #12. It included orders for 12.5 mg of [MEDICATION NAME] (anti-nausea medication) and to reattempt blood pressure medicine ,[DATE] hour afterwards. The 5:50 p.m. conversation was made by RN #12 to inform of Resident #D's current order for [MEDICATION NAME]. The call center indicated, So you can go ahead and give her the [MEDICATION NAME] instead of the [MEDICATION NAME]. The 7:34 p.m. phone conversation was made by RN #13. It indicated, I have a resident who.um.her blood pressure is ,[DATE] and we can't get her to swallow any pills to get her.uh.I know my associate had called earlier.um.so we kind of really want to send her out. I just need the ok from you guys. There were no calls made between 5:50 p.m. and 7:34 p.m. to inform the physician of Resident #D's inability to swallow her anti-nausea and blood pressure medication. An interview was conducted with the DON (Director of Nursing) on [DATE] at 10:24 a.m. She indicated she was at the facility on [DATE], when Resident #D was in the dining room, but she did not see her in there. She indicated it was common for her to have episodes of high blood pressure, to vomit, and to be difficult to arouse. She indicated she couldn't determine whether nursing staff acted appropriately to Resident #D's medical symptoms. She indicated if she (DON) saw the symptoms RN #11 documented in her nurse's note and considered Resident #D really different from normal, she would have informed the physician. She indicated she possibly would have expected the physician to be notified of right sided body rigidity, right sided facial drooping, and being nonverbal. She indicated she would have expected RN #12 to call the physician's office back ,[DATE] minutes after the order for antinausea medication to inform them of Resident #D's inability to swallow her blood pressure medication. She indicated she saw Resident #D briefly in the hallway and didn't see any right sided facial drooping. The [DATE] Department of Fire and Emergency Patient Care Record for Resident #D's transportation to the hospital indicated they received the call at 7:38 p.m., were on the scene at 7:44 p.m., at the patient at 7:46 p.m., and at the hospital at 8:07 p.m. It indicated, BP-,[DATE], s/s-neurological stroke symptoms w/weakness/paralysis, protocol used-suspected stroke, primary impression-stroke/[MEDICAL CONDITIONS], duration-3 hours, barriers of care-altered mental status, skin-bilateral forearms and hands were red with piticii (sic), asst (assessment) time:.were dispatched to ecf (extended care facility) on increased bp. u/a (upon arrival) found (age, race, and gender of Resident #D) lying supine in bed in care of (name of) crew. Crew stated pt was in dining room around 1700 hours for dinner and staff noticed that she was slumped over to the right side and that she had right sided facial droop. Pt was awake but not alert with obvious right sided facial droop and pt's forearms and hands bilaterally where (sic) red with what appeared to be piticii (sic). pt was unable to answer any questions and attempted to pull away from vitals being taken. Unknown reason for two and a half hour delay in contacting 911. Vitals obtained and pt was hypertensive. Loaded to cot, covered, secured, amd moved to.20 g IV to left AC was attempted but unsuccessful. 20 g IV right hand with lock established, dex 137 mgdl. 12-lead NSR. Transport to (name of hospital) started. Pupils were reactve but sluggish. Vitals repeated and bp increased. Radio report to (name of hospital) with stroke alert called and we were assigned (room #). Pt condition monitored and comfort measures taken. Bruising noted to pt chest and inside of right thigh. u/a report given and care turned over. An interview was conducted with NP (Nurse Practitioner) #14, from Resident #D's physician's office, on [DATE] at 11:05 p.m. He indicated he remembered Resident #D and that she had uncontrolled hypertension. He indicated if he was given the information in RN #11's [DATE], 5:30 p.m. nurse's note, I would have sent her out right away. I know this patient, and those are classic symptoms of stroke and cardiovascular issues. I would have sent any patient out with those symptoms right away. The [DATE], 8:16 pm emergency room hospital records indicated, Patient presents with Possible CODE STROKE pt slumped over to right with right sided weakness. The history is provided by the nursing home and the EMS (emergency medical staff) personnel.Pt was evaluated by provider at 20:17 (8:17 p.m.).presents to the ED (emergency department) with right sided facial droop x 1700. Per EMS, pt was seen in the nursing home at dinner with a facial droop. Per pt's daughter pt has a hx (history) of [MEDICAL CONDITION]. Pt's (family member) sts (states)the pt has a hx of weakness and uncoordination. Neurological: positive for facial asymmetry Physical exam: Pupils pin point and to slight left.No response to verbal stimuli. Mild reflexive grip but not on command.Petechiae noted.Scattered petechiae rash on the hands and some old ecchymosis. Radiology Results: Impression: large [MEDICATION NAME] hematoma the left basal ganglia with extension into the ventricular system. Assessment/Plan: Extensive acute [MEDICATION NAME] hemorrhage-CT showed [MEDICATION NAME] hematoma the left basal ganglia. ED discussed with neurosurgery who believe pt is inoperable. Comfort care. [MEDICATION NAME] drip, [MEDICATION NAME] prn (as needed). Pt is comatose. The hospital records further indicated Resident #D died on [DATE] at 10:30am. An interview was conducted with Family Member #10, Resident #D's POA (power of attorney) on [DATE] at 3:34 p.m. She indicated she didn't understand why the facility waited so long to call 911. She indicated the first time she was contacted by the facility on [DATE] was approximately 7:40 p.m. She indicated she had no idea Resident #D was unconscious. 1. b) The clinical record for Resident #D was reviewed on [DATE] at 2:00 p.m. The [DIAGNOSES REDACTED]. Resident #D was transferred from the facility to the hospital on [DATE]. The [DATE], [DATE], [DATE], [DATE], and [DATE] weekly skin assessments indicated Resident #D had no marks, bruises, discolorations, or rashes. The February, 2015 and March, 2015 progress notes and shower sheets did not reference any marks, bruises, discolorations or rashes on Resident #D. An interview was conducted with Family Member #10, the POA (power of attorney) for Resident #D, on [DATE] at 3:34 p.m. She indicated Resident #D had a massive bruise on her chest when observed at the hospital on [DATE]. She indicated the bruise was approximately ,[DATE] inches in length and 3 inches wide. She indicated the bruise was yellow and green, and looked like it had been there a while, based on the color. She indicated a few weeks prior to [DATE], the facility informed her of a fall the resident had, but did not inform her of any bruising. The [DATE] Patient Care Record from the Department of Fire and Emergency who transported Resident #D from the facility to the hospital indicated, Narrative.Bruising noted to pt (patient) chest and inside of right thigh. The [DATE] hospital note indicated, Skin Integrity: petechiae; bruising. Skin location: lower arm; upper arm; chest; lower leg; upper leg. An interview was conducted with the DON (Director of Nursing) on [DATE] at 3:59 p.m. She indicated she was unaware of any bruising to Resident #D or any event that would have caused bruising to her chest or thigh. The February, 2015 Skin Management Program policy was provided by the DON on [DATE] at 2:00 p.m. It indicated, A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and weekly. Alterations in skin integrity will be reported to the physician and family member(s). All alterations in skin integrity will be documented in the medical record.When a new alteration in skin integrity is identified such as a bruise, skin tear, abrasion, rashes: skin event will be opened, treatment order obtained as indicated, IDT (Interdisciplinary Team) note to identify root cause and initiate preventative interventions if applicable. This federal tag relates to Complaint #IN 650. 3XXX,[DATE](a)

Based on observation, record review and interview the facility failed to ensure resident's received treatment and services to prevent or aide in the treatment of [REDACTED]. with pressure ulcers in a sample of 6. (Residents "A", "D" and "C"). Resident A's pressure ulcers worsened by increasing from stage 2 to unstageable, worsened in measurement and condition, a new unstageable ulcer formed on the left heel and the resident had increased pain and was hospitalized for [REDACTED]. Findings include: 1. The record for Resident "A" was reviewed on 07-15-13 at 12:20 p.m. [DIAGNOSES REDACTED]. The record indicated the resident received [MEDICAL CONDITION] treatments three times a week (Monday - Wednesday - Friday) at a local oncology clinic. These [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. At the time the resident was readmitted to the facility, the resident was assessed with [REDACTED]. The right gluteal, which measured 5 cm (centimeters) by 6 cm and no depth, left gluteal, which measured 1.5 cm by 3 cm with no depth, the left great toe which measured 1 cm by 1 cm - and presented as a black scab, and the right heel which measured 4.2 cm by 4.0 cm with an intact necrotic scab. The resident's MDS (Minimum Data Set) assessment, dated 06-11-13, also indicated the resident was admitted to the facility from the local area hospital with 2 Stage two pressure ulcers and 2 unstageable areas. The resident's plan of care, originally dated 06-07-13 indicated "Resident has impaired skin integrity stage 2 left inner gluteal." Approaches to this plan of care included "assess for pain, treat as ordered, notify MD (Medical Doctor) of unrelieved/worsening pain, assess wound weekly documenting measurements and description, notify MD of worsening or no change in wound or for signs of infection, observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, pressure reducing/redistribution cushion in chair as ordered, pressure reducing/redistribution mattress on bed ROHO (a special device for pressure reduction) overlay, supplements as ordered, treatment as ordered, turn and reposition frequently." The plan of care, originally dated 06-07-13 for the wound to the resident's right gluteal area, included the same approaches as the left gluteal area. The resident's plan of care, originally dated 06-07-13 indicated the "resident had impaired skin integrity, unstageable area to right heel." Approaches to this area included "assess for pain, treat as ordered. Notify MD of unrelieved/worsening pain, assess wound weekly documenting measurements and description, float heels when in bed, multipodous boots when out of bed (discontinued 06-20-13), notify MD of worsening or no change in wound or for signs of infection, observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, pressure reducing/redistribution cushion in chair as ordered, pressure reducing/redistribution mattress on bed, ROHO overlay, treatment as ordered, turn and reposition frequently." The plan of care, originally dated, 06-07-13 indicated the "resident had impaired skin integrity with an unstageable area to the left great toe." Approaches to this plan of care included, assess for pain, treat as ordered. Notify MD of unrelieved/worsening pain, assess wound weekly documenting measurements and description, float heels when in bed, multipodous boots when out of bed, notify MD of worsening or no change in wound or for signs of infection, observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, pressure reducing/redistribution cushion in chair as ordered, pressure reducing/redistribution mattress on bed, ROHO overlay, treatment as ordered, turn and reposition frequently." Upon admission, the resident had a physician ordered treatment for [REDACTED]. The admitting nurse verified and received additional orders on 06-04-13, to include Multipodous boot (bilaterally) when up, a pressure relief mattress to bed and a pressure relief cushion to the wheelchair at all times. During an interview on 07-17-13 at 2:10 p.m., the Assistant Director of Nurses indicated the residents pressure areas measurements were as follows on 06-06-13 (two days after admission): Right gluteal - Stage 2 - 5.2 cm by 6.1 cm, with red granulation and scant serosanguinous drainage. Left gluteal - Stage 2 - 1.6 cm by 3.0 cm by < (less than) 0.1 cm. Right heel 4.1 cm by 4.0 cm - no odor, no drainage - black scab. Left Great toe 1 cm by 1 cm - black scab. On 06-07-13 the nursing staff received additional physician treatment orders which instructed the nursing staff to apply [MEDICATION NAME] to bilateral gluteal wounds every shift and as needed for soilage, a ROHO overlay on mattress, skin prep to right heel wound every day and "allow time to dry before applying sock," and Multipodous boots on bilaterally when up out of bed and skin prep to the left heel every day for prevention. The nursing progress note, dated 06-27-13 at 2:15 p.m., indicated "While providing care to res. (resident), nurse noted wound bed changed in condition. Measured and received treatment change. Treatment to bilateral glutes performed as new order received." The clinical record indicated the new physician order, dated 06-27-13 which instructed the nursing staff to "Clean right and left gluteal wounds, pat dry apply Santyl (a chemical debridement treatment), to wound beds and [MEDICATION NAME] to periwounds and cover with foam dressing every day." Review of the Wound Skin Evaluation Report on 07-15-14 at 2:55 p.m., indicated on 06-28-13 the resident's ulcer to the right gluteal was assessed and measured as follows: "4.9 by 4.8 by 0.1 an unstageable ulcer with yellow slough and brown necrotic (tissue) with no odor and no drainage." The report also indicated the resident now presented with a black necrotic area to the left heel which measured 2.0 cm by 3.2 cm with no depth and assessed as unstageable. The resident's left gluteal wound measured 1.0 cm by 1.5 cm by 0.1 cm with pink/red granulation with no drainage and no odor - Stage 2. The report, dated 07-05-13 indicated the right gluteal remained unstageable and measured 4.6 cm by 5.5 cm by 0.1, with 70 % slough and 30 % necrotic brown with scant serosanguinous drainage, the left gluteal area measured 1.0 by 1.3 cm by 0.1 with pink granulation - no odor, no drainage and a Stage 2. The area to the resident's left great toe was identified as "healed." The nursing progress note dated 07-05-13 at 4:30 p.m., indicated the resident "returned from Chemo. ([MEDICAL CONDITION]) ... res. (resident) states he 'feel fine.' Res. (resident) up in w/c (wheelchair) and wants to attend dining room for supper." A subsequent notation, dated 07-06-13 at 11:12 a.m., and documented by the Director of Nurses, indicated, "This writer explained to resident wife that the fact that resident goes to [MEDICAL CONDITION] 3 times a week and spend an average of 8 hours 3 times a week sitting on one spot for [MEDICAL CONDITION] is a huge factor not helping the wound to heel (sic) fast enough. This writer explained to resident wife that facility already called chemo ([MEDICAL CONDITION]) center and explained to them why is so important to keep resident off his buttock during [MEDICAL CONDITION]. This writer explained to resident wife that resident is compromised due to [MEDICAL CONDITION] drug. Resident wife said 'I do understand that his [MEDICAL CONDITION] may cause his wound not heal fast enough, but cannot just understand why his wound is not healing.'" An additional notation, dated 07-06-13 at 2:46 p.m. indicated "resident alert and oriented. Tx. (treatment) to gluteal done as ordered. New order to send patient to hospital received. Several attempts to call oncology office not successful. (Spouse) here complained about wound on the gluteal. Education provided but she was not happy. DON (Director of Nurses) aware of wife concern. Wife accompanied him to hospital." Review of the hospital record on 07-12-13 at 1:00 p.m., indicated the following dated 07-06-13, "C/O (complains of) back pain RT (related to) 'an ulcer.' Skin warm, dry, and intact anteriorly with ecchymotic areas to limbs. digital photos taken. Pt. (patient) rolled with assistance. There was a dry gauze dressing held in place by diaper with a brown stain. At the coccyx is roughly a 4 by 6 inch area of tenderness, eschar, ulceration and discolored skin. there is an area of black with yellow eschar roughly 2 by 4 inches. Surrounding skin is red and spongy. There is a superficial nickel sized ulcer in the area as well. Heels are soft with black areas to heels bilaterally, and to left plantar surface. Black spot on right great toenail." Continued review of the emergency room documentation indicated "Skin: skin decubitus ulcer with necrosis, purulent drainage and [DIAGNOSES REDACTED]." The hospital wound nurse report, dated 07-06-13 contained the following measurements: "Left heel - unstageable 4.0 cm by 1.5 cm with 100 % of thin layer black eschar." "Right heel - unstageable 2.0 cm by 1.5 cm black necrotic tissue." "Right coccyx/sacrum - unstageable 9.0 cm by 3.0 cm - 100 % brown/black necrotic tissue. Non blanchable." "Left coccyx/sacrum - unstageable 4.5 cm by 3.2 cm - 100 % purple fluid filled bulla (a blister), unblanchable." A document from the local [MEDICAL CONDITION] Center, dated 07-08-13 (after the resident was transported to the local hospital emergency roiagnom on [DATE]), indicated "I also informed treating nurses of your request for positioning patient off his right buttock when here." However, from the time the resident returned to the facility on [DATE], until the time the resident was transported to the local hospital emergency room for evaluation and treatment, the clinical record lacked routine nursing assessments of the resident's condition and the wounds upon return to the facility, after the resident sat for an extended period of time at [MEDICAL CONDITION]. In addition the record lacked documentation of any type of continuity of care between the facility and the [MEDICAL CONDITION] clinic related to the resident's condition at the facility in regard to wound care, the need for pressure reducing devices while receiving [MEDICAL CONDITION] or the status of the resident upon completion of the [MEDICAL CONDITION] treatment received while away from the facility. A review of the facility "Discharge/Appointment/Transfer" records dated, 06-17-13, 06-19-13, 06-21-13, 06-24-13, 06-26-13, 06-28-13, 07-01-13, 07-03-13, 07-03-13 lacked documentation of the resident's wounds, physician orders, progress notes or any new [DIAGNOSES REDACTED]. During interview on 07-15-13 at 10:00 a.m., the Director of Nurses verified there had not been ongoing communication between the facility nursing staff and the local area [MEDICAL CONDITION] clinic in regard to the resident's wound condition and the need for repositioning and pressure relieving devices during treatment until recently. 2. The record for Resident "D" was reviewed on 07-15-13 at 12:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. At the time the resident was admitted to the facility, the resident was assessed with [REDACTED]. A review of the resident's current plan of care, dated 07-05-13 indicated approaches to the resident's pressure ulcer to the right gluteal included "assess for pain, treat as ordered. Notify MD of unrelieved/worsening pain, notify MD or worsening or no change in wound or for signs of infection, observe for signs of infection, redness, pain, drainage,malodorous drainage, fever, increase in size/depth of wound, pressure reducing/redistribution cushion in chair as ordered and on bed." A review of the resident treatment administration record for July 2013 indicated and instructed the nursing staff "clean rt. (right) gluteal wound with NS (normal saline), pat dry, apply skin prep to wound edges and allow time to dry. Then cover with [MEDICATION NAME] dressing every three days and PRN (as needed) for displacement." Observation on 07-15-13 at 9:45 a.m., the resident was transferred from the wheelchair to bed for a skin assessment. The resident was positioned to the right side and the incontinent brief was removed. The resident did not have the physician ordered treatment to her gluteal area. The Treatment Administration Record for July 2013 indicated the last time the resident received the physician ordered treatment was July 11, 2013. During this observation, Certified Nurses Aide #10 indicated, "(Name of resident) didn't have the dressing on when I got her up this morning." 3. The record for Resident "C" was reviewed on 07-12-13 at 9:45 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was alert and oriented. A review of the resident's current plan of care dated 05-08-13 indicated the "resident had impaired skin integrity: presents with stage 2 to gluteal. As of 07-05-13 area healed." Approaches to this plan of care included "turn and reposition frequently." Observation on 07-15-13 at 10:15 a.m., the resident was seated in the wheelchair in the hallway. The resident indicated she had been seated in the wheelchair "since a little after 9:00 (a.m.)." Continuous observations on 07-15-13, the resident remained seated in the wheelchair until 1:00 p.m., when a request was made to perform a skin assessment. The resident and family member agreed and the resident was transferred from the wheelchair via a mechanical lift to the bed. The resident's slacks were removed as well as the incontinent brief. The resident's bilateral buttocks were bright red with indentations noted in groin, hip, and across the abdomen areas. The resident was incontinent of stool. This Federal tag relates to Complaint IN 204. 3.1-40(a)(2)

A. Based on observation, record review, and interview, the facility failed to implement appropriate fall interventions to prevent injury of a resident who was identified as high fall risk on admission. This deficient practice affected 1 of 13 residents reviewed for falls in a sample of 24 residents reviewed. (Resident N) B. Based on observation, record review, and interview, the facility failed to properly store chemicals out of reach of residents. This deficient practice impacted 3 of 5 units and had the potential to affect 49 of 120 residents residing in the facility who were identified with a history of confusion and were ambulatory or mobile in a wheelchair without assistance. C. Based on observation, record review, and interview, the facility failed to secure sharp objects on 1 of 1 dementia unit. This deficient practice had the potential to affect 36 residents residing on the locked dementia unit who were identified as ambulatory or mobile in a wheelchair without assistance of 120 residents residing in the facility. Findings include: A1. On 4/24/12 at 1:20 P.M., Resident N's record was reviewed. [DIAGNOSES REDACTED]. Resident N was admitted to the facility on [DATE]. An admission "Fall Risk Assessment," no date, included, but was not limited to, "New Admission: yes... History of falls: yes... Resident receives medications in the following categories: Antihypertensives and Narcotics... Resident has [DIAGNOSES REDACTED]. An admission "Minimum Data Set" screening dated 3/8/12, included, but was not limited to, "Brief Interview Mental Status (BIMS: 12 (moderately impaired)...Section G: Functional Status: Bed mobility, transfer, toilet use, and personal hygiene... extensive assistance with 2 or more staff... Locomotion on/off unit... total dependence with 1 staff person..." An "Occupational Therapy Progress Report" dated 3/9/12 through 3/15/12, included, but was not limited to, "Patient's progress as follows: Transfer: General: The patient is able to safely perform wheelchair to recliner transfers requiring CG (contact guard assist: contact with patient due to unsteadiness)... Reason for continuation of care: Remaining impairments in pain, strength, endurance, and balance impacting ADL (activities of daily living) safety and participation..." A "Physical Therapy Progress Report" dated 3/10/12 through 3/16/12, included, but was not limited to, "Long Term Goal: Supervision with all functional transfers... Precautions: High fall risk due to generalized weakness and balance deficit, history of multiple lower extremity deep vein thrombosis, and Coumadin (blood thinner) therapy..." A "Nursing Progress Notes" dated 3/11/12 at 5:00 P.M., included, but was not limited to, "Resident is on fall follow up due to he fell trying to get to his wheelchair... found on floor by aide... will continue to monitor..." Documentation was lacking to indicate new interventions were placed to prevent further falls. A "Interdisciplinary Team (IDT) Progress Notes: dated 3/12/12 at 9:52 A.M., included, but was not limited to, "Fall: IDT met for fall review... on 3/11/12 at 3:35 P.M., resident (Resident N) told nurse he was attempting to transfer from his recliner to his wheelchair and fell ... found sitting on his bottom (buttocks)... Resident was placed on hourly rounding..." A "Hourly Rounding" dated 3/12/12, included, but was not limited to, "Date: 3/12/12 at 10:00 A.M.... hourly rounding initiated..." A "Fall Care Plan" dated 3/12/12, included, but was not limited to, "Problem start date: 3/12/12... Resident (N) is at risk for fall due to: decline in mobility, cognition issues, needs assistance with all ADL needs... Approach Start Date: 3/12/12: Call light in reach, environmental changes, keep personal items within reach and clean/clutter free, non skid footwear, gripper socks when no shoes are worn, personal items in reach, place on hourly rounding, and therapy screen..." There was no "Nursing Progress Notes" dated 3/15/12 regarding the following fall. A "IDT Progress Notes" dated 3/16/12 at 9:49 A.M., included, but was not limited to, "IDT met to review fall that occurred on 3/15/12 at 10:29 P.M.... Resident had an unwitnessed fall in his room... found laying on his back beside the bed... Resident noted to be confused... gripper socks on... Immediate intervention: 15 minute checks for 24 hours... Pain medication recently increased with increased confusion noted after change... M.D. notified to review resident's medications... 72 hour follow up and neuro checks initiated... Resident currently in physical, occupational, and speech therapies for strengthening..." The "Approaches" dated 3/16/12 added to the 3/12/12"Fall Care Plan" included, 15 minute checks for 24 hours and medication review..." An "M.D. Visit" dated 3/16/12, no time, included, but was not limited to, "AMS (Acute Mental Status)/Lethargy due to medications... discontinue Neurontin and decrease Norco to PRN (as needed) only..." A "Nursing Progress Notes" dated 3/17/12 at 3:40 P.M., included, but was not limited to, "Resident had an unwitnessed fall... found in his room in the wheelchair tilted over on his left side to the floor... complained of left side pain, resident was confused... M.D. and family notified..." Documentation was lacking to indicate new interventions were placed to prevent further falls. A "Nursing Progress Notes" dated 3/19/12 at 8:05 A.M., included, but was not limited to, "Resident is confused ambulated self to recliner and dressed self when asked how he got into his recliner resident stated he did not remember..." Documentation was lacking to indicate new interventions were placed to prevent further falls. An "IDT Progress Notes" dated 3/19/12 at 11:12 A.M., included, but was not limited to, "IDT met for fall review: On 3/17/12 at 3:40 P.M., resident had an unwitnessed fall... he was found in his room, wheelchair on the floor, tipped over... We will remove wheelchair from room when resident is in room or recliner so resident will not be persuaded to transfer without assistance..." The "Approach" dated 3/19/12 added to the 3/12/12 "Fall Care Plan" included, will remove wheelchair from room so he will not try to transfer self..." A "Nursing Progress Notes" dated 3/31/12 at 11:15 A.M., included, but was not limited to, "Resident noted to transfer self from bed to recliner (unassisted)... Educated resident to utilize call light for assistance..." Documentation was lacking to indicate new interventions were placed to prevent further falls. A "Nursing Progress Notes" dated 4/1/12 at 8:30 A.M., included, but was not limited to, "Patient (Resident N) was found sitting on floor at about 11:45 P.M. in his room... patient did indicate pain in his left hip... after a brief passive range of motion on both upper and lower extremities , patient assisted back to bed... M.D. notified... patient's son notified..." A "Nursing Progress Notes" dated 4/1/12 at 11:30 A.M., included, but was not limited to, "Resident found to be in extreme pain... M.D. and family notified... to emergency room to rule out left hip fracture..." An "IDT Progress Notes" dated 4/2/12 at 8:53 A.M., included, but was not limited to, "IDT met for fall review: On 3/31/12 at 11:45 P.M., resident found on floor in his room... he was in bed prior to fall... 15 minute checks were initiated..." Documentation was lacking to indicate new interventions were placed to prevent further falls. On 4/27/12 at 10:00 A.M., all information regarding fall interventions for Resident N were requested from the DoN. On 4/27/12 at 1:00 P.M., the charting for Resident N's hourly rounding was received. No further documentation was received regarding fall interventions for Resident N. A summary from the "Nursing Progress Notes" regarding Resident N's falls and interventions placed by the facility is as follows: 3/11/12 at 3:35 P.M., resident (Resident N) told nurse he was attempting to transfer from his recliner to his wheelchair and fell ... No immediate intervention. On 3/12/12 at 10:00 A.M., hourly rounding initiated. 3/15/12 at 10:29 P.M.... Resident had an unwitnessed fall in his room... found laying on his back beside the bed... gripper socks on... Immediate intervention: 15 minute checks for 24 hours... Pain medication reviewed and decreased on 3/16/12, no time. 3/17/12 at 3:40 P.M., Resident had an unwitnessed fall... found in his room in the wheelchair tilted over on his left side to the floor... On 3/19/12, no time, wheelchair removed from room. 3/31/12 at 11:45 P.M., found sitting on floor in his room... Intervention: Assisted back to bed, pain medication... 4/1/12 sent to emergency room with fractured left hip. The "Nursing Progress Notes" indicated Resident N was hosptalized on [DATE] for a left hip fracture and returned to the facility on [DATE] at 7:24 P.M. After injury, the following interventions were added to his care plan, "Fall Care Plan" dated 3/12/12, included "Approach" dated 4/9/12, "bed and wheelchair alarms..." A2. On 4/23/12 at 2:30 P.M., the facility fall management policy and procedure was requested from the Executive Director. On 4/24/12 at 9:00 A.M., the Executive Director provided, "Fall Management Program" dated 3/10. The "Fall Management Program" included, but was not limited to, "Policy: It is the policy of American Senior Communities to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls..." B1. On 4/23/12 at 10:30 A.M., tour was initiated on the 100 unit with LPN #1. At that time, LPN #1 indicated 7 of 20 residents residing on the 100 unit had a history of [REDACTED]. On 4/23/12 at 10:45 A.M., tour of the locked Memory Care Unit was initiated with LPN #10 . At that time, LPN #10 indicated 36 of 36 residents residing on the locked Memory Care Unit had confusion and were ambulatory or used a wheelchair without assistance. On 4/23/12 at 11:00 A.M., tour of the 400 unit was initiated with LPN #2. At that time, LPN #2 indicated 6 of 14 residents residing on the 400 unit had a history of [REDACTED]. On 4/24/12 at 10:00 A.M., environmental tour was initiated with the Maintenance Supervisor. On 4/24/12 at 10:10 A.M., an aerosol can of Puricit Odor Eliminator was observed on a linen cart located on the 100 unit. In an interview at that time, the Maintenance Supervisor indicated he was aware all chemicals should not be left unattended in resident areas. The Maintenance Supervisor removed the chemical from the linen cart. On 4/24/12 at 10:20 A.M., on the locked Memory Care Unit, 2 open 4 ounce bottles of Medi-Pak Performance Instant Hand Sanitizer were observed in an unlocked drawer in a portable baking cart located in the activity area of the unit. At that time, the Maintenance Supervisor indicated all drawers are to be locked in the Memory Care Unit at all times. Staff were made aware by the Maintenance Supervisor and all drawers were then secured. On 4/24/12 at 10:30 A.M., on the 400 Unit, 1 open 4 ounce bottle of Medi-Pak Performance Instant Hand Sanitizer was observed on the medication cart in the hallway of the unit. At that time, in an interview, the Maintenance Supervisor indicated he would remind staff to keep the hand sanitizer locked in the medication cart. C1. On 4/24/12 at 10:20 A.M., on the locked Memory Care Unit, the drawers in the kitchenette area were unlocked. 2 metal cookie cutters with sharp edges were observed in the one unlocked drawer. At that time, the Maintenance Supervisor indicated all drawers and cabinets were to be locked in the Memory Care Unit. He instructed staff to lock the drawers/cabinets. On 4/24/12 at 11:00 A.M.., the Material Safety Data Sheets were requested for the hand sanitizer and odor eliminator from the Maintenance Supervisor and the facility policy on chemical storage. On 4/24/12 at 2:00 P.M., the Material Safety Data Sheets for the hand sanitizer and odor eliminator and a document titled "Safety" no date, were received from the Executive Director. The "Medi-Pak Performance Instant Hand Sanitizer" Material Safety Data Sheet included, but was not limited to, "Hazardous Components: Denatured Ethyl Alcohol... Possible Routes of Entry into the Body: Eyes, Ingestion, Inhalation... Signs and Symptoms of Exposure: Possible watering, burning and redness... Swallowed: Possible gastrointestinal irritation or disturbance... Inhalation: Possible giddiness or loss of consciousness..." The bottle was marked, "Keep Out of Reach of Children." The "Ready To Use Odor Eliminator" Material Safety Data Sheet included, but was not limited to, "Hazards Identification: Caution: May be mildly irritating to eyes and skin, may cause abdominal discomfort, nausea, vomiting, and diarrhea..." The aerosol can was marked, "Keep Out of Reach of Children." A document titled, "Safety" no date, included, but was not limited to, "All cleaning supplies must be kept in locked storage rooms... Cleaning supplies in remote locations, i.e., activity room, general public areas, nursing stations... should be in locked storage when not in use..." This federal tag relates to Complaint IN 010. 3.1-45(a)(2)