Every finding on record at Alpha Home - A Waters Community

Based on record review and interview, the facility failed to ensure a notice of transfer or discharge (required notice which instructs how to appeal a discharge) and bed hold policy were provided to a resident's representative at the time of a hospital discharge and a 30-day notice was provided for a facility-initiated discharge for 1 of 3 residents reviewed for discharge (Resident E). Findings include:Resident E's record was reviewed on 4/24/26 at 11:12 a.m. Census information indicated the resident was admitted to the facility on [DATE] and discharged on 11/25/25. Diagnoses on the resident's profile included, but were not limited to schizoaffective disorder bipolar type a chronic mental health condition combining symptoms of schizophrenia [hallucinations and delusions] with mood episodes), dementia (decline in mental ability severe enough to interfere in daily life) in other diseases classified elsewhere unspecified severity with behavioral disturbance, and post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events). A history and physical, dated 6/2/25, indicated the resident had safety risk factors including a history of childhood maltreatment, impulsive tendencies, and history of aggression. The treatment plan included diagnoses of schizoaffective disorder bipolar type, major neurocognitive disorder due to other medical condition with behavioral disturbance, and post-traumatic stress disorder. A comprehensive Minimum Data Set (MDS) assessment, dated 9/4/25, indicated the resident had a severe cognitive impairment and exhibited verbal behavioral symptoms directed towards others one to three days of the assessment period. An interdisciplinary note, dated 11/7/25, indicated the resident exhibited a pattern of challenging behaviors including approaching the nurse's station demanding unavailable food items. When the resident was notified they were unable to provide the items, the resident became verbally aggressive, using profanity and making threats. The resident loudly accused fellow residents of drug use, threatened a new staff member, was found screaming in her room demanding popcorn and claiming to have five babies in her tummy. The resident refused medication and became verbally aggressive when approached by staff. The resident answered the phone when another resident's family called and used inappropriate language. The resident called 911 and claimed she was being poisoned. The resident was physically aggressive including throwing items and threatening to overturn the medication cart when her food requests were not met. The note lacked documentation a 30-day notice of transfer or discharge was issued due to the resident's behaviors. A care plan note, dated 11/18/25, indicated a care plan meeting was conducted with the resident's representative. The resident's behaviors were discussed, and the staff requested information from the resident's representative regarding what interventions worked previously. The note lacked documentation the resident's representative was issued a 30-day notice of transfer or discharge or was told the resident needed to seek alternative placement. A progress note, dated 11/25/25 at 1:15 p.m., indicated the nurse came into the door of the resident's unit when the resident attempted to get out of the door. The nurse tried to stop the resident's exit when the resident hit the nurse in the face with a closed fist and grabbed the top of the nurse's head. The nurse called for help, 911 was called, and the resident was transferred to a behavior facility. The daughter was called and made aware of the transfer. The note lacked documentation the daughter was provided the notice of transfer and discharge, including information on how to appeal the discharge, or the bed hold policy. A discharge MDS assessment, dated 11/25/25, indicated the resident had an unplanned discharge to a short-term hospital, with return anticipated. A bed hold policy, dated 11/25/25, indicated the resident was being transferred to the hospital due to physical aggression towards a staff member. The bed hold policy was provided to the resident. The form lacked documentation the bed hold policy was provided to the resident representative considering the resident's cognitive status. The resident's record lacked documentation a notice of transfer or discharge was provided with the hospitalization. A Social Services Director (SSD) progress note, dated 11/25/25 at 2:21 p.m., indicated, This note serves to document the recent incident involving the resident, who exhibited aggressive behavior resulting in the need for emergency intervention. The resident was transported to [hospital name] following an aggressive outburst that involved striking two staff members. Incident Details: The resident has a history of aggressive outbursts, and it is important to note that upon their return from a previous psychiatric hospitalization, both the resident and their Power of Attorney (POA) were informed of the facility's policy regarding violence. Specifically, it was communicated that any escalation to violent behavior towards staff or other residents would necessitate an immediate discharge to a hospital, with no option for return to our facility. Communication with POA: Upon the recent incident, the Interdisciplinary Team (IDT) attempted to contact the resident's POA to discuss the situation and inform them of the necessary actions being taken. Unfortunately, the POA did not respond. Consequently, IDT reached out to the resident's second daughter to explain the circumstances and the decision to transport the resident to the hospital. The daughter expressed a desire to pick up the resident, but it was clarified that without explicit consent from the POA for her to do so, the facility must proceed with the transport to the hospital. We informed the daughter that she would have the option to sign an Against Medical Advice (AMA) form if she chooses to take the resident from the hospital instead of admitting her. Next Steps: 1. Transport to [name of local hospital] Hospital: The resident will be safely transported to the hospital for evaluation and care. 2. Communication with Family: We will continue to attempt to communicate with the POA to ensure they are informed and involved in the ongoing care decisions for the resident. Conclusion: The safety of our residents and staff is our utmost priority. We will adhere to our established protocols in managing aggressive behavior and will ensure that all appropriate parties are kept informed throughout this process. Further updates will be provided as more information becomes available. The note lacked documentation the notice of transfer or discharge or bed hold policy were provided to the resident's representative at the time of the transfer or later. The note lacked documentation a 30-day notice of transfer or discharge had been issued to the resident's representative prior to the hospital transfer. The SSD note, dated 11/25/25, was the last progress note in the resident's record. The record lacked documentation of further communication with the resident's representative or the psychiatric facility. A Social Worker's note from the acute psychiatric facility, dated 12/2/25, indicated the Social Worker received a return call from the resident's representative. The representative stated the resident was supposed to return to the facility and she had not received a 30-day notice of transfer or discharge. A Social Worker's note from the acute psychiatric facility, dated 12/8/25, indicated the Social Worker called the facility and spoke with the DON. The DON indicated the resident was still taking intramuscular (IM) (injections into the muscle), and the resident had refused IM medications at the facility. The Social Worker told the DON they needed to give the resident's representative a 30-day notice of transfer or discharge and speak to the resident's representative. During an interview, on 4/27/26 at 10:12 a.m., the Administrator indicated a 30-day notice of transfer or discharge was not issued. During an interview, on 4/27/26 at 11:22 a.m., the psychiatric hospital Social Worker indicated the resident was still at their facility and had been there since November 2025. Their facility is supposed to be short term, but the nursing facility refused to re-admit the resident. The resident's daughter had not received any discharge paperwork or a 30-day notice of transfer or discharge prior to the hospitalization. During an interview, on 4/27/26 at 11:58 a.m., the Social Services Director (SSD) indicated the resident was confused. The SSD thought when a confused resident was sent to the hospital, the notice of transfer or discharge and bed hold policy were sent with the ambulance. She was not sure if they were provided to the resident representatives at a later time. The SSD thought the resident had been admitted to another nursing facility and was not aware the resident remained in the psychiatric facility. The SSD indicated she thought the intent was for the resident to return to the facility from the psychiatric unit, and then the facility would have issued the 30-day notice of transfer or discharge. During an interview, on 4/27/26 at 1:52 p.m., the DON indicated the resident's representative was not provided with the notice of transfer or discharge or bed hold policy with this transfer because the resident's family member had not come into the facility. The DON indicated the notice of transfer or discharge and bed hold policy should have been provided with all hospitalizations. The forms were normally given to the resident if they were alert and oriented or to the resident's representative if the resident was confused. The resident had not been issued a 30-day notice of transfer or discharge. During an interview, on 4/28/26 at 11:28 a.m., the resident's representative indicated they were not provided any paperwork, including a notice of transfer or discharge or bed hold policy, when the resident was transferred on 11/25/25. The resident had been in the psychiatric hospital since 11/25/25. The resident's representative indicated they would have appealed the facility's discharge of the resident if they had known it was an option, or how to appeal, but they had not received the notice of transfer of discharge with the appeal information. The resident was not issued a 30-day notice of transfer or discharge. On 4/27/26 at 10:30 a.m., the Regional Director of Operations provided an undated document titled, Transfer and Discharge Policy and Procedure and indicated it was the policy currently being used by the facility. The policy indicated, .GUIDELINE: The facility shall permit each resident to remain in the facility unless such transfer or discharge is made in recognition of the resident's rights to receive considerate and respectful care; to receive necessary care and services and to participate in the development of the Comprehensive Care Plan and in recognition of the rights of other residents in the facility. PROCEDURE.2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/ responsible party.5. The resident may be transferred from the facility when it's been determined that: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.7. Before a facility transfers a resident to a hospital or a therapeutic leave, the nursing facility will provide information to the resident/responsible party that specifies the duration of the bed-hold policy and the facility's policies regarding bed-holds. On 4/28/27 at 2:05 p.m. the Indiana Department of Health (IDOH) form titled, Notice of Transfer or Discharge, was accessed at https://forms.in.gov. The form included resident information, information regarding where the resident was being transferred, and the reason for the transfer. The form indicated, Bed Hold Policy: The facility must attach a copy of the facility's bed hold policy to this Notice of Transfer or Discharge and provide contact information for a facility employee to contact about the bed hold policy.Appeal Rights: You have the right to appeal the health facility's decision to transfer you. If you think you should not have to leave this facility, you may file a written request for a hearing with the Indiana State Department of Health postmarked within ten (10) days after you receive this notice. If you request a hearing, it will be held within twenty-three (23) days after you receive this notice, and you will not be transferred from the facility earlier than thirty-four (34) days after you receive this notice of transfer or discharge, unless the facility is authorized to transfer you as an emergency transfer.If you wish to appeal this transfer or discharge, please fill out the attached State Form.and return to the address below. This citation is related to Intake 2695301. 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(iii) 410 IAC 16.2-3.1-12(a)(26)

Based on record review and interview, the facility failed to ensure a resident was allowed to return to the facility after a psychiatric hospitalization for 1 of 3 residents reviewed for transfer and discharge (Resident E). Findings include:Resident E's record was reviewed on 4/24/26 at 11:12 a.m. Census information indicated the resident was admitted to the facility on [DATE] and discharged on 11/25/25. The resident was hospitalized from [DATE] to 7/25/25 and 7/31/25 to 8/28/25. Diagnoses on the resident's profile included, but were not limited to schizoaffective disorder bipolar type a chronic mental health condition combining symptoms of schizophrenia [hallucinations and delusions] with mood episodes), dementia (decline in mental ability severe enough to interfere in daily life) in other diseases classified elsewhere unspecified severity with behavioral disturbance, and post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events). The facility assessment, dated 6/27/24, indicated the facility provided care for residents with bipolar disorder, schizophrenia, post-traumatic stress disorder, and behavior that required interventions. A history and physical, dated 6/2/25, indicated the resident had safety risk factors including a history of childhood maltreatment, impulsive tendencies, and history of aggression. The treatment plan included diagnoses of schizoaffective disorder bipolar type, major neurocognitive disorder due to other medical condition with behavioral disturbance, and post-traumatic stress disorder. A comprehensive Minimum Data Set (MDS) assessment, dated 9/4/25, indicated the resident had a severe cognitive impairment and exhibited verbal behavioral symptoms directed towards others one to three days of the assessment period. A progress note, dated 7/3/25 at 2:10 a.m., indicated the resident stood at the exit door punching in numbers to attempt to exit. The nurse asked the resident if she wanted a snack, and the resident told the nurse to shut up. A progress note, dated 7/3/25 at 3:15 a.m., indicated the resident continued to try to put in the numbers on the keypad to exit the unit. The resident had placed the walker in front of the door blocking staff from entering or exiting the unit. When staff asked the resident to move, the resident became angry and refused. The resident said if staff did not quit asking them to move there would be trouble. A progress note, dated 7/3/25 at 1:21 p.m., indicated the resident had been sitting by the door all day and refused to take their medicine or eat any meals. The staff called administration to the unit to attempt to calm the resident down. The resident cursed at staff, called them names, and threatened to spray staff with a bottle of body wash. A progress note, dated 7/3/25 at 4:45 p.m., indicated the resident was at the door banging on it to get out. When other residents walked by or spoke to her the resident jumped up with fist drawn up and stated, I will hit you. Staff redirected residents away from the resident. A progress note, dated 7/3/25 at 5:56 p.m., indicated the resident stated she was in labor and needed to go to the hospital. If anyone approached the resident, she stated she would punch them. The staff attempted to contact the resident's power of attorney (POA), but there was no answer. A progress note, dated 7/3/25 at 7:35 p.m., indicated the resident tried to go out the door with staff. The resident pushed the walker into the staff member several times and raised her fist. A progress note, dated 7/3/25 at 7:55 p.m., indicated, .Staff was waiting on other staff to bring her supplies. Staff open the door and DON [Director of Nursing] and police was at the door. Police escort resident out of the door. A progress note, dated 7/25/25, indicated the resident was re-admitted to the facility.A progress note, dated 7/31/25 at 3:04 a.m., indicated the resident was observed attempting to push a chair into another resident. Staff was present and intervened. The resident went to her room and stayed there. A progress note, dated 7/30/25 at 1:31 p.m., indicated the resident had verbal aggression, including profanity towards staff, during the shift. The resident threatened staff, made unrealistic demands, asked to exit the unit several times, stood by the door, and refused all medications except Haldol (antipsychotic medication). Management was notified. A progress note, dated 7/31/25 at 3:04 a.m., indicated the resident was observed attempting to push a chair into another resident. Staff was present and intervened. The resident went to her room and stayed there. A progress note, dated 7/31/25 at 4:50 a.m., indicated the resident was transferred to an acute psychiatric hospital. A progress note, dated 8/28/25, indicated staff went to the acute psychiatric facility to transport the resident back to the facility. The resident was resistant to the transport, hit and kicked staff members, and kicked the seats in the van. The resident yelled curse words and threatened to kill the staff members. An interdisciplinary note, dated 11/7/25, indicated the resident exhibited a pattern of challenging behaviors including approaching the nurse's station demanding unavailable food items. When the resident was notified they were unable to provide the items, the resident became verbally aggressive, using profanity and making threats. The resident loudly accused fellow residents of drug use, threatened a new staff member, was found screaming in her room demanding popcorn and claiming to have five babies in her tummy. The resident refused medication and became verbally aggressive when approached by staff. The resident answered the phone when another resident's family called and used inappropriate language. The resident called 911 and claimed she was being poisoned. The resident was physically aggressive including throwing items and threatening to overturn the medication cart when her food requests were not met. The note lacked documentation a 30-day notice of transfer or discharge was issued due to the resident's behaviors. A care plan note, dated 11/18/25, indicated a care plan meeting was conducted with the resident's representative. The resident's behaviors were discussed, and the staff requested information from the resident's representative regarding what interventions worked previously. The note lacked documentation the resident's representative was issued a 30-day notice of transfer or discharge or was told the resident needed to seek alternative placement. A progress note, dated 11/25/25 at 1:15 p.m., indicated the nurse came into the door of the resident's unit when the resident attempted to get out of the door. The nurse tried to stop the resident's exit when the resident hit the nurse in the face with a closed fist and grabbed the top of the nurse's head. The nurse called for help, 911 was called, and the resident was transferred to a behavior facility. The daughter was called and made aware of the transfer. The note lacked documentation the daughter was provided the notice of transfer and discharge, including information on how to appeal the discharge, or the bed hold policy. A discharge MDS assessment, dated 11/25/25, indicated the resident had an unplanned discharge to a short-term hospital, with return anticipated. A Social Services Director (SSD) progress note, dated 11/25/25 at 2:21 p.m., indicated, This note serves to document the recent incident involving the resident, who exhibited aggressive behavior resulting in the need for emergency intervention. The resident was transported to [hospital name] following an aggressive outburst that involved striking two staff members. Incident Details: The resident has a history of aggressive outbursts, and it is important to note that upon their return from a previous psychiatric hospitalization, both the resident and their Power of Attorney (POA) were informed of the facility's policy regarding violence. Specifically, it was communicated that any escalation to violent behavior towards staff or other residents would necessitate an immediate discharge to a hospital, with no option for return to our facility. Communication with POA: Upon the recent incident, the Interdisciplinary Team (IDT) attempted to contact the resident's POA to discuss the situation and inform them of the necessary actions being taken. Unfortunately, the POA did not respond. Consequently, IDT reached out to the resident's second daughter to explain the circumstances and the decision to transport the resident to the hospital. The daughter expressed a desire to pick up the resident, but it was clarified that without explicit consent from the POA for her to do so, the facility must proceed with the transport to the hospital. We informed the daughter that she would have the option to sign an Against Medical Advice (AMA) form if she chooses to take the resident from the hospital instead of admitting her. Next Steps: 1. Transport to [name of local hospital] Hospital: The resident will be safely transported to the hospital for evaluation and care. 2. Communication with Family: We will continue to attempt to communicate with the POA to ensure they are informed and involved in the ongoing care decisions for the resident. Conclusion: The safety of our residents and staff is our utmost priority. We will adhere to our established protocols in managing aggressive behavior and will ensure that all appropriate parties are kept informed throughout this process. Further updates will be provided as more information becomes available. The following Social Worker progress notes were provided by the acute psychiatric hospital. -A note, dated 11/28/25, indicated the Social Worker placed a call to the facility to speak with the DON to find out if the resident was able to return to the facility. The DON did not answer, and the Social Worker left a message. -A note, dated12/1/25, indicated the Social Worker called the facility and asked to speak to the DON. The DON was in a meeting, and the Social Worker left a voicemail. -A note, dated 12/2/25 at 2:25 p.m., indicated the Social Worker called the facility and requested to speak to the DON. The DON did not answer. The Social Worker called the facility a second time and again requested to speak to the DON. The receptionist indicated the DON was busy and also indicated the resident was not allowed back. The receptionist indicated the resident had been asked not to come back and her representative came and picked up her belongings. -A note, dated 12/2/25 at 3:28 p.m., indicated the Social Worker spoke with the DON at the facility. The DON stated she was busy and she did not like the Social Worker being rude to her. The Social Worker indicated she was not rude to her and had, in fact, been trying to reach the DON for a week. The DON requested the Social Worker send her the clinical information for the resident. -A note, dated 12/2/25 at 4:01 p.m., indicated the Social Worker received a return call from the resident's representative. The representative stated the resident was supposed to return to the facility and she had not received a 30-day notice of transfer or discharge. -A note, dated 12/5/25, indicated the Social Worker called the facility and requested to speak to the DON. The DON did not answer, and the Social Worker left a voicemail. The Social Worker also sent an e-mail and faxed the clinical information as the DON had previously requested. -A note, dated 12/8/25, indicated the Social Worker called the facility and spoke with the DON. The DON indicated the resident was still taking intramuscular (IM) (injections into the muscle), and the resident had refused IM medications at the facility. -A note, dated 12/10/25 at 9:50 a.m., indicated the Social Worker called the facility and was told the resident was removed from their care. The Social Worker asked to speak to the DON but was told she was busy. The Social Worker left a voicemail for the DON to ask if they had made other arrangements for the resident. -A note, dated 12/10/25 at 12:11 p.m., indicated the DON called the Social Worker and stated the facility would not take the resident back until she was stabilized with oral medications. The DON also stated the resident had been aggressive while at the acute psychiatric facility. The Social Worker asked where in the notes it had stated the resident was aggressive, but the DON stated she did not have time for this to look. The Social Worker told the DON the resident had not exhibited aggressive behavior at the psychiatric facility. -A note, dated 12/16/25, indicated a care conference was held with the Social Worker and the facility. The facility attendees included the Administrator, Nurse Practitioners (NPs), and the Clinical Director. They reviewed the resident's medical record and the plan for the resident to receive monthly injections. The facility said the resident had been discharged to the community. The Social Worker told them this had not been mentioned before, and the resident had been in the acute psychiatric facility since 11/25/25. The facility would not confirm if they had officially discharged the resident or not. -An e-mail from the DON to the Social Worker, dated 1/9/26, indicated she was checking to see if there were any updates regarding the resident. The Social Worker responded with the clinical update and asked how long the facility wanted the resident compliant on her medications. -A note, dated 1/15/26, indicated the Social Worker called the facility and asked to speak to the DON. The DON was not available. -A note, dated 2/3/26 at 2:45 p.m., indicated the Social Worker called the facility to speak with the DON. The DON had not responded to the Social Worker's emails or calls. The Social Worker was hung up on. -A note, dated 2/3/26 at 2:55 p.m., indicated the Social Worker received a call back from the Social Services Director (SSD) at the facility. The SSD indicated she had been sending out referrals for the resident for awhile. During an interview, on 4/27/26 at 10:12 a.m., the Administrator indicated they had not re-admitted the resident to the facility because she was admitted to another skilled nursing facility (SNF). She had been discharged from the acute psychiatric hospital to another SNF. During an interview, on 4/27/26 at 11:22 a.m., the psychiatric hospital Social Worker indicated the resident was never discharged to another SNF, and she had never been notified of another SNF willing to accept the resident. The resident had been in their care at the acute psychiatric facility since 11/25/25 because the facility refused to re-admit her. The facility had not provided any assistance with a discharge plan for the resident. The Social Worker had repeatedly tried to contact them, but they would not answer her phone calls, and eventually they stopped responding completely. The resident was stable, and there was not much else they were able to do for her. The psychiatric hospital had given the resident's representative a deadline, of 5/8/26, to find alternative placement for the resident as the hospital was not a long-term care placement. The Social Worker was not sure where the resident was going to be discharged . During an interview, on 4/27/26 at 11:58 a.m., the SSD indicated they had a care plan meeting with the resident and the resident's representative where they discussed what would happen if the resident's aggressive behaviors continued. On 11/25/25, the interdisciplinary team determined the resident was not going to be re-admitted to the facility after the hospitalization due to the previous conversation they had with the resident's representative about the resident's behavior. The DON told the SSD the resident had been discharged to another SNF, and she thought that was where the resident currently resided. She was not aware the resident was still at the acute psychiatric hospital. During an interview, on 4/27/26 at 1:52 p.m., the DON indicated she thought the resident was discharged from the acute psychiatric hospital to another SNF. She had received a call from the SNF at least a month ago and told the acute psychiatric hospital. The DON indicated she was not aware the resident remained in the acute psychiatric hospital. The DON was not able to provide documentation regarding another SNF contacting the DON or the DON notifying the acute psychiatric hospital. During an interview, on 4/27/26 at 2:00 p.m., the psychiatric hospital Social Worker indicated the resident would have most likely been able to be discharged mid-December 2025 if the facility had accepted her back. The other SNF never accepted the resident. The Social Worker indicated she had a contact which was a liaison for the other SNF's corporation, and they had never accepted the resident. The DON told her she had reached out to this other SNF, but there was never an acceptance. Around mid-December, the facility ceased communication with her. During an interview, on 4/28/26 at 11:28 a.m., the resident's representative indicated she had never been talked to about the other SNF by the facility or the acute psychiatric hospital. There was never a plan for the resident to discharge to another SNF. On 4/27/26 at 10:30 a.m., the Regional Director of Operations provided an undated document titled, Transfer and Discharge Policy and Procedure and indicated it was the policy currently being used by the facility. The policy indicated, .The facility will provide provisions for continuity of care and in non-emergency situations a care plan meeting will be held with the appropriate parties to determine a relocation plan. On 4/27/26 at 10:30 a.m., the Regional Director of Operations provided an undated document titled, Transfer and Discharge Policy and Procedure and indicated it was the policy currently being used by the facility. The policy indicated, .GUIDELINE: The facility shall permit each resident to remain in the facility unless such transfer or discharge is made in recognition of the resident's rights to receive considerate and respectful care; to receive necessary care and services and to participate in the development of the Comprehensive Care Plan and in recognition of the rights of other residents in the facility. PROCEDURE.2. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given to the resident/ responsible party.5. The resident may be transferred from the facility when it's been determined that: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.7. Before a facility transfers a resident to a hospital or a therapeutic leave, the nursing facility will provide information to the resident/responsible party that specifies the duration of the bed-hold policy and the facility's policies regarding bed-holds. This citation is related to Intake 2695301.

Based on observation, interview, and record review, the facility failed to provide activities as scheduled on the posted monthly activity calendar, failed to deliver activities with adequate staff engagement or supervision, and failed to implement a structured, individualized or meaningful activity program to meet the needs of residents with dementia. This deficient practice had the potential to affect 21 of 21 residents who resided in the secured memory care unit and 5 of 5 residents who attended and participated in the Resident Council Meeting. Findings include:1. The facility failed to provide activities as scheduled on the activity calendar. The posted calendar for Monday through Friday listed the following routine activities each day:11:00 a.m. Daily Chronicle, 1:30 p.m. Daily Prayer & Scripture, 2:30 p.m. daily activity (balloon toss, bowling, tic-tac-toe, etc.), 4:00 p.m. Snack & Chat, and a 5:00 p.m. evening activity such as bingo or a white board game. On Tuesday 12/2/25 the calendar listed the following activities: 10:30 a.m., Coffee Social, 11:00 a.m. Daily Chronicle, 11:45 a.m. Nails, 1:30 p.m. Daily Prayer & Scripture, 2:30 p.m. Bowling, 3:00 p.m. Color by Number, 4:00 p.m. Snack & Chat, and 5:00 p.m. Bingo. Observations on 12/2/25 indicated the following: No Coffee Social was observed. The daily Chronicle was not read/discussed. No Daily Prayer or Scripture was provided. At 1:52 p.m. Activity Assistant (AA) 9 was observed on her personal cell phone while 5 residents sat unoccupied around the tables. There was a puddle of liquid on the floor beneath a resident's chair that was not being cleaned up. No Color by Number was provided. On Wednesday 12/03/2025 the calendar listed the following: 10:30 a.m. Coffee Social, 11:00 a.m. Daily Chronicle, 11:45 a.m. Hand Washing, 1:30 p.m. Daily Prayer & Scripture, 2:30 p.m. Balloon Toss, 3:00 p.m. Sing Along, 4:00 p.m. Snack & Chat, and 5:00 p.m. [NAME] Board Game.During observations on 12/3/25 the following was observed: At 10:32 a.m., only two residents were present in the activity room with the television on, and no other residents were invited to participate in the scheduled coffee social. They were provided coffee, but no social/discussion/visiting/reminiscing aspect was facilitated. At 11:05 a.m., no activities were occurring, and no activity staff were present in the room. No Hand Washing activity was observed/provided. At 1:32 p.m., prayer was conducted; however, the television was left on, no scripture was read, no residents participated and no additional residents were observed to be invited. The 2:30 p.m. Balloon Toss did not occur. The 3:00 p.m. Sing Along did not occur. On Thursday 12/4/25 the activity calendar listed the following activities: 10:30 a.m. Coffee Social, 11:00 a.m., Daily Chronicle, 11:45 a.m. Thursday Crafting, and 2:30 p.m. Tic-Tac-Toe. On Thursday 12/4/25, the following was observed: No Coffee Social was observed. The Daily Chronicle was not read/discussed. No Daily Prayer or Scripture was provided. Between 11:21 a.m. and 12:19 p.m., no crafting activity occurred. Residents were seated with coloring books but were not actively engaged or led in any structured craft. At 3:09 p.m., the Gift Ball Game had already been completed, and only one resident was actively engaged in a table top Tic-Tac-Toe game. 2. On 12/2/25 at 1:52 p.m., AA 9 was observed using her personal cell phone while residents sat without engagement. On 12/3/25 at 11:05 a.m., no activity or nursing staff were present in the main dining room. Only an unidentified hospice aide sat with two residents while the rest of the residents sat idle. On 12/3/25 at 11:37 a.m., AA 7 left the main dining room while 5 residents were left unsupervised and unoccupied. She was gone for more than 10 minutes. On 12/03/25 at 12:04 p.m. no activity or nursing staff were present in the main dining room while 7 residents were seated unoccupied. On 12/3/25 at 1:37 p.m., the activity aide was observed working on a laptop rather than facilitating activities. On 12/4/25 at 1:32 p.m., AA 7 read a short, printed prayer without turning the TV off. No scripture was read/discussed. 3. The facility failed to individualize activities to meet the needs of residents with dementia.Observations during the survey showed that activities were not adapted to meet cognitive, behavioral, and sensory needs: Resident 56 made repeated attempts to stand, reached across tables, and fidgeted due to lack of meaningful engagement; staff did not provide individualized sensory items or mobility-based activities targeted to her needs. Cross Reference F604 and F744. Multiple residents were left with only the television playing for extended periods of time.Multiple residents were not invited to attend activities that did take place.Activity programming lacked dementia-stage specific (early, middle late) adaptations.No integrated sensory programming was available/facilitated. 4. On12/3/25 at 10:09 a.m., the Resident Council Minutes were reviewed and revealed, repeated requests to change/improve/add activities to the facility programming.In January 2025 the residents complained of being sad and lonely especially over the weekend. Throughout the year, there were repeated requests to include off-campus outings.Age and culturally appropriate accommodations such as X-Box and Apple TV Games were requested. Several months complained that activities often started late, therefore there wasn't as much time, or activities scheduled did not happen at all.The residents are frustrated when a staff led activity is started late. Sometimes we feel anxious waiting for the activity to begin. We just leave and return to our rooms. February 2025, .7 out of 11 residents attending the meeting stated we need to have activity led programs especially on the weekends, ideas are; baking and cooking, challenging things to do, painting. April 2025, .When the residents shared future activity requests ie; cinema, park, grilling outside/eating outside, socializing, your [Administrator's] response was, 'I am going to have an answer but you might not like the answer.' Why? [Administrator] addressed his statement. He wanted the residents to know that he may not be able to grant requests immediately. Funding is an issue. July 2025, .Residents continue to ask for activity outings. October 2025, .Discussed Activity Staff accountability, follow the activity calendar strictly. During a Resident Council Meeting Interview on 12/4/25 at 10:30 a.m., The Resident Council President, Secretary, and three other residents who regularly attended the meetings were present. The above issues/concerns were discussed and the group indicated there were several concerns that had not been addressed. Overall, Resident Council felt that they were not listened to or taken seriously. The Resident Council expressed their continued requests for Activity Program improvement. They provided ideas which included, but were not limited to: Resident Volunteer led activities for the memory care unit, more weekend activities led by staff, more meaningful/purposeful engaging such as helping arrange, decorate and collaborate activities, outdoor walking path, baking/cooking activities, volunteers coming in to teach new skills/lessons, animal therapy/pet visits, live music, and X-Box/Apple games for younger residents. During an interview on 12/5/25 at 11:45 a.m., the Administrator and Social Service Director indicated the activity department and life enrichment programming for the facility needed improvement. The Administrator expressed his desire to start a new Dementia-specific program in the coming New Year, and the entire activity department was to receive additional education and training to help improve the program. The Administrator wanted to focus on hiring additional staff for more meaningful and enthusiastic engagement. A Dementia Care and Services/Programming policy was requested but not provided. The Administrator indicated that a focus moving forward was to establish Dementia-Centered programming and implement a new policy with current best practices special care needs. 3.1-33(a)

Based on observations, interviews, and record review, the facility failed to provide documented responses, follow-up, or written resolutions to several recurring concerns raised by the Resident Council. This practice failed to ensure residents' concerns were acknowledged and resolved, and resulted in continued unmet needs related to environmental, dietary, nursing, and activity services and had the potential to affect 5 of 5 residents who participated in the Resident Council Meeting. Findings include:On 12/3/25 at 10:09 a.m., the Resident Council Meeting Minutes were reviewed from January 2025 through November 2025. There were repeated concerns with minimal or no response from the facility. This concerns included, but were not limited to, the following: 1. Maintenance Concerns:Residents consistently reported unresolved maintenance issues across several months, including: Cold water during showers Very cold dining room temperatures Broken lights, leaking bathrooms, damaged nightstands, missing trash cans Furniture repairs not completedNo documented response or resolution appeared in the Action Forms or minutes. 2. Nursing Issues:Residents consistently reported concerns with nursing which included, but were not limited to: Medication refusals not respected by nursing staff. Staff ignoring call lights or slow call-light response across several months. Residents missing showers or not being assisted as requested. No documented response or resolution appeared in the Action Forms or minutes. 3. Dietary Concerns:Residents consistently reported dietary concerns which included, but were not limited to: Poor quality meals Small portions Untimely delivery of room-tray meals Cold foodNo documented evidence showed the facility responded in writing or provided corrective action. 4. Activities Concerns:Residents repeatedly asked for and/or had recurring concerns which included, but were not limited to: Weekend activity staffing Activities starting on time More creative or challenging activities Activity Staff engagement Off Campus outings More resident involvement with activitiesNo documented evidence showed the facility responded in writing or provided corrective action. 5. Resident Store Request:In February, residents requested opening a resident-run store in the activity room. There was no documented response. During a Resident Council Meeting interview, on 12/4/25 at 10:30 a.m., the Resident Council President, Secretary, and three other residents who regularly attended the meetings were present. The above issues/concerns were discussed and the group indicated there were several concerns that had not been addressed. Overall, the Resident Council felt that they were not listened to or taken seriously. The Resident Council expressed their continued concerns and repeated requests related to ongoing maintenance, laundry, dining/dietary and Activity Programming. During the meeting, the residents expressed their continued interest in wanting to establish a Resident-Run store in the activity room for things like Bingo prizes, and to avoid having to use the more expensive vending machines. During an interview on 12/5/25 at 11:45 a.m., the Administrator indicated he was the main staff responsible for ensure Resident Council concerns/suggestions were responded to or follow up on. The Administrator indicated he attended many of the meetings and did his best to address the concerns, but some were missed. On 12/3/25 at 2:30 p.m., the Regional Director of Operations provided a copy of current facility policy titled, Resident Council, revised 3/1/16. The policy indicated, .The Resident Council is an independent, organized group of residents who meet on a regular basis to create change, address quality and dignity of care provided in the facility, plan activities and discuss other matters brought before the council. The role of the Resident Council is to improve the quality of life of the residents who reside in the facility and to take part in actions to maintain a positive living environment. A designated staff member is appointed by the administrator and council members and acts as an advisor to the group and assists the council president and secretary as needed. The facilitator creates the environment and the enthusiasm that encourages action to happen within the council. It is vital to establish an atmosphere of trust and responsibility for concerns to be voiced. This encourages members to openly discuss issues that impact them and/or other residents. If a resident has a personal concern, they are afforded a private time and place to share that concern.to the Staff Facilitator. The council group members who voice a concern usually expect a timely response about the resolution to their concern. This must happen. The Administrator monitors this process. 3.1-3(k)3.1-3(l)

Based on observations, interviews, and record review, the facility failed to provide individualized, person-centered dementia care for multiple residents with cognitive impairment by: Responding to behaviors with restraint-like practices instead of dementia-appropriate interventions, using as needed (PRN) medications before nonpharmacological interventions, and failing to provide meaningful activities or engagement. This deficient practice had the potential to effect 21 of 21 residents residing on the secured memory care unit.Findings include:1. During a continuous observation on 12/1/25 from 11:00 a.m., until lunch was served around 12:45 p.m., Resident 56 was observed in the main dining/activity room. She had been moved from her wheelchair and placed in a large, heavy, wooden chair which was pushed all the way to the table. Resident 56 made repeated attempts to stand, but she was unable to move the chair, so she sat back down. She was not offered activity engagement, sensory stimulation, and/or other meaningful interventions. During a continuous activity observation on 12/2/25 from 2:30 p.m. until 2:50 p.m., the following was observed: Resident 56, was seated quietly at a table and interacted with place mats and a doll before the scheduled bowling activity began. When the bowling activity started, noise and stimulation in the room increased (pins falling, cheering, plastic balls hitting the floor). Resident 56 was observed to have increased signs of overstimulation and anxiety as she started to make repeated attempts to stand and walk away or grab at the activity materials. Staff failed to recognize Resident 56's increased signs of distress and repeatedly told her to sit back down, until she was eventually moved to a table at the back of the room, but positioned in a heavy chair stuck under the table so she could not move freely. Staff continued the same Bowling activity and did not redirect Resident 56 to a quieter area or provide an individualized, calming alternative. During a continuous observation on 12/3/25 from 11:00 a.m. until 12:00 p.m. the following was observed: Resident 56 was seated in a wheelchair in the main dining/activity room. She made repeated attempts to stand up from her wheelchair. Eventually, an unidentified Hospice aide, and Activity Aide (AA) 7 placed Resident 56 into a larger, heavier chair and lifted the table to wedge the arms of the chair underneath, preventing her from pushing back or standing. She appeared frustrated, as evidence by, pursing her lips, curling her hand into a fist, shaking her head no, and feeling/searching around the edge of the table for a solution. Resident 56 was not offered a sensory alternative, a waking break, or other person-centered intervention. On 12/3/25 at 3:30 p.m., Resident 56's record was reviewed. She was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to; dementia with behavioral disturbance and generalized anxiety. A review of the resident's nursing progress notes revealed Ativan/Lorazepam administration with no documented rationale and/or no documented person-centered nonpharmacological interventions/redirections attempted for the following dates: On 2/4/25 at 10:00 a.m., as needed (PRN) Lorazepam administered with no documented rationale and no details on attempted redirection strategies. On 2/5/25 at 7:24 a.m., PRN Lorazepam administered for Resident restless, going in and out of peers rooms, also trying to get into staff pockets. No documented details on attempted redirection strategies provided. On 2/6/25 8:29 a.m., PRN Lorazepam administered for Resident was agitated to calm her down and prevent from hurting self. No documented details on attempted redirection strategies provided. On 2/7/25 at 8:12 a.m., PRN Lorazepam administered for Resident was agitated. No documented details on attempted redirection strategies provided. On 2/18/25 at 12:16 p.m., PRN Lorazepam administered for Resident with agitation/anxiety, pacing very fast up and down hall. No documented details on attempted redirection strategies provided. On 2/21/25 at 4:57 a.m., PRN Ativan administered for pacing up and down hallway at a fast pace and entering other resident's room. Later at 6:26 a.m., the PRN was charted as ineffective as Resident 56 continued to pace the hallway with redirection unsuccessful. No documented details on attempted redirection strategies provided. On 2/24/25 at 11:04 p.m., PRN Ativan administered for up pacing hallway at a fast pace. No documented details on attempted redirection strategies provided. On 3/5/25 at 8:05 a.m., PRN Ativan administered for walking dangerously fast, going in and out of peers rooms, taking pictured off the wall, trying to grab medication cards off med cart, redirection only increases agitation, PRN given. No documented details on attempted redirection strategies provided. On 3/17/25 at 12:00 p.m., PRN Lorazepam (Ativan) administered with no documented rationale and no alternative interventions. On 3/31/25 at 7:19 p.m., PRN Lorazepam administered for resident agitated and pacing up and down the hall rapidly. No documented details on attempted redirection strategies provided. On 4/2/25 at 1:39 p.m., PRN Lorazepam administered for, Resident with agitation and running up and down the hall. No documented details on attempted redirection strategies provided. On 4/9/25 at 2:03 a.m., PRN Lorazepam administered for Resident up wandering, trying to go in different resident's room. No documented details on attempted redirection strategies provided. On 4/22/25 at 9:30 a.m., PRN Lorazepam administered for, Resident agitated, bending over and walking fast, running at times. No documented details on attempted redirection strategies provided. On 4/23/25 at 11:30 a.m. PRN Lorazepam administered for, Resident walking fast, almost running up and down hall, leaning forward with hands behind back. No documented details on attempted redirection strategies provided. On 4/30/25 at 10:30 a.m., PRN Lorazepam administered for, Resident anxious/running up and down hall. No documented details on attempted redirection strategies provided. On 5/1/25 at 1:18 a.m., PRN Lorazepam administered with no documented rationale and no details on attempted redirection strategies. On 5/1/25 at 10:11 p.m., PRN Lorazepam administered for, trotting down the hall not easily redirected. No documented details on attempted redirection strategies provided. On 5/12/25 at 7:58 p.m., PRN Lorazepam administered for, Resident with increased anxiety and running up and down main hall. No documented details on attempted redirection strategies provided. On 6/9/25 at 7:15 a.m., PRN Lorazepam administered for, running up and down hall; almost fell a couple times, resident became agitated with any redirection. No documented details on attempted redirection strategies provided. On 7/2/25 at 2:37 p.m., PRN Lorazepam administered for, Resident running up and down hall agitated. (No details on attempted redirection strategies). At 6:49 p.m., the PRN was documented as ineffective. On 7/5/25 at 9:30 a.m. PRN Lorazepam administered for, running up and down hall; almost fell a couple times, resident became agitated with any redirection. No documented details on attempted redirection strategies provided. On 7/21/25 at 7:00 a.m., PRN Lorazepam administered for, Resident running up and down main 200 hall, anxious. No documented details on attempted redirection strategies provided. On 7/30/25 at 1:53 p.m., PRN Lorazepam administered for, complaint of agitation and running up and down the hall, lack of safety awareness. No documented details on attempted redirection strategies provided. On 8/5/25 at 2:46 a.m., PRN Lorazepam administered for, Resident up wandering into others rooms, redirection semi-successful, resident get agitated with staff when they redirect her and her pace is getting quicker. No documented details on attempted redirection strategies provided. On 8/11/25 at 12:36 p.m., PRN Lorazepam administered for, Resident is anxious. No documented details on attempted redirection strategies provided. On 8/20/25 at 10:30 a.m., PRN Lorazepam administered for, Resident running up and down hall, agitated if staff tried to slow resident down. No documented details on attempted redirection strategies provided. On 8/27/25 at 7:30 a.m., PRN Lorazepam administered for, Resident running up and down hall, agitation with redirection. No documented details on attempted redirection strategies provided. Resident 56 had a comprehensive care plan, initiated on 6/22/22, which indicated, she had episodes of wandering (but not trying to elope) as evidence by walking the halls throughout the day and at night. Interventions included, but were not limited to: Document any wandering activity and interventions attempted. Did the interventions work or fail. She had a comprehensive care plan, initiated 1/11/23, which indicated she had limited activity involvement as a result of: Cognitive impairment secondary her diagnosis of dementia and She takes pleasure in walking for most of her available free time. Interventions include, but were not limited to: Provide activity programming consistent with physical & psychosocial abilities. This includes: energy level, cognitive functioning, medical condition & mood/behavior patterns, and Develop an activity plan centering around the resident's interests & history that takes lifetime values, attitudes, leisure patterns & psychosocial well-being into consideration. She had a comprehensive care plan, initiated on 4/22/24, which indicated, she was at risk for behavioral disturbances related to her diagnoses of schizoaffective bipolar type and required the use of an antipsychotic medication. An intervention for this plan of care indicated, one on one as needed. She had a comprehensive care plan, initiated on 2/8/21, which indicated, she was at risk for increased anxiousness related to her diagnosis of generalized anxiety disorder and used an anxiolytic medication. Interventions for this plan of care included, but were not limited to: encourage family involvement, monitor for effectiveness of interventions, offer choices. Cross reference F604. 2. Throughout the survey period minimal to no activity engagement was observed in the secured memory care unit. No dementia-friendly and/or sensory stimulation programming was observed. Throughout the week activities that were listed on the calendar were not implemented.Staff were not observed to ask/invite residents to participate. According to the Activity Calendar, every morning at 10:30 was Coffee Social. Although coffee was offered to residents already in the main activity/dining room, no meaningful social interaction, conversation, remising etc. was facilitated. The Daily Chronicle was scheduled every morning for 11:00 a.m. Although a few singles pages of the Daily Chronicle were printed off and observed on the dining room table tops on 12/3/25 only, reading/reviewing the chronicle was not observed. On Monday, Wednesday, and Friday, Handwashing was listed as an activity at 11:45 a.m., and was never observed. Scripture and Prayer were listed as a daily activity for 1:30 p.m. and only conducted on one day as observed. On 12/3/25 at 3:00 p.m., Sing Along was the scheduled activity, but was not implemented. On 12/4/25 at 1:32 p.m., Activity Aide 7, read off a printed prayer that lasted less than two minutes. No scripture was read. During an interview on 12/5/25 at 11:45 a.m., the Administrator and Social Service Director indicated the activity department and life enrichment programming for the facility needed improvement. The Administrator expressed his desire to start a new Dementia-specific program in the coming New Year, and the entire activity department was to receive additional education and training to help improve the program. The Administrator wanted to focus on hiring additional staff for more meaningful and enthusiastic engagement. A Dementia Care and Services/Programming policy was requested but not provided. The Administrator indicated that a focus moving forward was to establish Dementia-Centered programming and implement a new policy with current best practices special care needs. 3.1-37

Based on record review and interview, the facility failed to complete a new level of care assessment for a resident when her 30 days expired for 1 of 5 residents reviewed for PASRR (Pre-admission Screening and Resident Review) (Resident 69). Findings include:On [DATE] at 10:38 a.m., A record review was completed for Resident 69. She had the following diagnoses which included, but were not limited to, anxiety disorder, low back pain, esophagitis (inflammation of esophagus), pain, and major depressive disorder. She had a level 1 PASRR dated [DATE]. The PASRR indicated she was approved to have a 30-day exempt. She should have had a new level of care assessment for any date past [DATE] if she remained in the facility. On [DATE] at 11:32 a.m., during an interview, the Regional Nurse Consultant (RCS) indicated she would investigate it. No additional information was provided by the survey exit. An undated policy, titled, Guidelines for PASRR Process was provided by the RNC on [DATE] at 10:30 a.m. It indicated, .PASRR is a federally mandated process that requires all states to pre-screen all residents regardless of their payer source or age who are seeking admission to a Medicaid funded nursing facility. 3.1-16(d)

Based on observation, interview, and record review, the facility failed to ensure a resident was clean and appropriately dressed and groomed and failed to ensure a resident's bedding was appropriately changed when soiled for 1 of 1 resident reviewed for concerns with Activities of Daily Living (ADLs) (Resident 13). Findings include:On 12/1/25 at 10:47 a.m. Resident 13's room was observed. There were several brown stains on the sheets and the room smelled strongly of body odor. Resident 13 was observed as he self-propelled out of the bathroom in his wheelchair. He had on a navy-blue shirt with a basketball on it and a pair of red basketball shorts were around his thighs, revealing that the resident was not wearing anything underneath the shorts. The Resident had below the knee amputations on both legs, so when he self-transferred into the bed, he would scoot his bare bottom across the sheets. He indicated he did all his own ADL care normally, but the staff would help if he needed them too. On 12/2/25 at 2:41 p.m. Resident 13 was observed as he lay in bed awake and resting. The resident had his blanket wrapped around his legs, so his pants were unable to be seen, but he had on the same shirt as the observation on 12/1/25. He also had what appeared to be the same sheets as were on his bed as the observation on 12/1/25, based on the stains observed. The resident's pillowcase also appeared to be soiled. A yellow, brown colored ring was observed around where his head lay on the pillow. On 12/3/25 at 12:38 p.m. Resident 13 was observed as he sat up at the side of the bed eating his lunch. The resident was wearing the same navy-blue shirt and red basketball shorts as were observed initially on 12/1/25 and then again on 12/2/25 making this the third day in a row he was observed wearing the same outfit. Additionally, his pillowcase and sheets appeared to have been the same as the two days prior, based on the stains observed. On 12/4/25 at 12:04 p.m. Resident 13 was observed as he lay in bed with his eyes closed. The resident's lower body was covered but his shirt appeared to be different than the shirt he had been wearing on previous observations. However, his sheets and pillowcase appeared to be the same as the three days prior, based on the stains observed. On 12/3/25 at 2:13 p.m. Resident 13's medical record was reviewed. He was a long-term care resident whose diagnoses included, but were not limited to, schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia with a mood disorder like bipolar) and major depressive disorder. Resident 13's most current Minimum Data Set (MDS) assessment, dated 9/5/25, indicated his ADL assistance level for all tasks were supervision (oversight, encouragement or cueing) and set up help. Resident 13 had an active order for behavior monitoring every shift that was recorded on the Medication Administration Record. The behaviors to be monitored included but were not limited to refusal of care. Resident 13's MAR for the month of June was reviewed and showed that the resident had not exhibited any behaviors for the entire month. A shower sheet, dated 6/7/25, indicated Resident 13 had refused a shower. The record lacked documentation for this refusal and any subsequent interventions used. Resident 13's MAR for the month of August was reviewed and showed that the resident had not exhibited any behaviors for the entire month. A shower sheet, dated 8/2/25, indicated Resident 13 had refused a shower. The record lacked documentation for this refusal and any subsequent interventions used. Resident 13's MAR for the month of September was reviewed and showed that the resident had not exhibited any behaviors for the entire month. A shower sheet, dated 9/9/25, indicated Resident 13 had refused a shower. A shower sheet, dated 9/16/25, indicated Resident 13 had refused a shower.A shower sheet, dated 9/30/25, indicated Resident 13 had refused a shower because he took one himself in the sink. The record lacked documentation for those refusals and any subsequent interventions used. No shower sheets for the month of October were provided. Resident 13's MAR for the month of November was reviewed and showed that the resident had not exhibited any behaviors for the entire month. A shower sheet, dated 11/2/25, indicated Resident 13 had refused a shower.A shower sheet, dated 11/12/25, indicated Resident 13 had refused a shower.A shower sheet, dated 11/16/25, indicated Resident 13 had refused a shower.A shower sheet, dated 11/19/25, indicated Resident 13 had refused a shower.A shower sheet, dated 11/21/25, indicated Resident 13 had refused a shower.A shower sheet, dated 11/23/25, indicated Resident 13 had refused a shower.A shower sheet, dated 11/26/25, indicated Resident 13 had refused a shower.The record lacked documentation for those refusals and any subsequent interventions used. During an interview on 12/5/25 at 11:30 a.m. the Regional Nurse Consultant (RNC) indicated she was recently made aware of the ADL concerns with Resident 13 and they were planning to reeducate all staff on appropriate monitoring and documentation of behaviors, because it did not reflect the resident's actual condition or behaviors. On 12/5/25 at 10:55 a.m. a copy of a current facility policy titled, Activities of Daily Living (Routine Care), was provided. This policy indicated, . Residents are given routine daily care and HS [bedtime] care by a C.N.A. or a nurse to promote hygiene, provide comfort and provide a home like environment. ADL care is provided throughout the day evening and night as care planned and/or as needed. ADL care of the resident includes: Assisting the resident and personal care such as bathing, showering, showering, dressing.hair care.Assisting in maintenance of.immediate environment of the resident. Monitoring for any.behavioral changes in the resident. Do all required ADL documentation required per policy and regulations. 3.1-38(a)(3)

Based on record review and interview, the facility failed to code the resident's Minimum Data Set (MDS) assessment correctly for the types of medications that residents receive for 3 of 5 residents reviewed for accuracy (Resident 3, 69, and 6). Findings include:1. A record review was completed for Resident 3 on 12/3/25 at 11:36 a.m. She had the following diagnoses which included, but were not limited to, heart failure, depression, type 2 diabetes mellitus (DM), neuropathy (nerve pain), and hypertension. Resident 3 had an order, dated 10/2/25, for furosemide (a diuretic) 40 milligrams (mg) daily for Congestive Heart Failure (CHF). She had an order, dated 10/2/25, for metformin HCl 500 mg two times daily for DM. Her MDS, dated [DATE], did not indicate she was taking a diuretic or an oral hypoglycemic (blood sugar) medication. She had a care plan, dated 10/6/25, indicating she had a diagnosis of DM type II with risk for hypo/hyperglycemia (low or high blood sugar). She had a care plan, dated 10/6/25, indicating she was at risk for dehydration related to diuretic therapy. 2. A record review was completed for Resident 69. She had the following diagnoses which included, but were not, limited to anxiety disorder, low back pain, esophagitis (inflammation of esophagus), pain, and major depressive disorder. Her MDS, dated [DATE], indicated she received hypnotic medication. Resident 69's record lacked an order for a hypnotic. 3. On 12/3/25 a record review was completed for Resident 6. He had the following diagnoses which included but were not limited to dementia, chronic kidney disease, depression, and essential hypertension. He was prescribed an antidepressant, citalopram hydrobromide 10 mg one time daily dated 11/22/25. He was prescribed an oral hypoglycemic agent, sitagliptin 25 mg daily. His MDS, dated [DATE], did not indicate he was receiving an antidepressant or a hypoglycemic agent. He had a care plan, dated 9/17/23, diagnosed diabetes with risk for hypo/hyperglycemia. On 12/3/25 at 11:36 a.m., during an interview, the Regional Clinical Director indicated they were aware of some MDS coding issues and were working on it. She also indicated there was no policy for MDS accuracy. They referred to the RAI (Rai Instrument Assessment) for information.

Based on record review and interview, the facility failed to properly reconcile medications for a resident who was discharging home for 1 of 3 residents reviewed (Resident 67). Findings include: On 12/2/25 a record review was completed for Resident 67. She had the following diagnoses which included but were not limited to congestive heart failure, chronic kidney disease, arthritis, physical debility, and low back pain. She discharged home on 9/16/25. The record indicated the resident was sent home with medications. The record lacked documentation of the reconciliation of the resident's medications at discharge. The resident had a discharge care plan indicating she wanted to return home. The resident's Medication Administration Record indicated she took the following medications:a.) Aspirin 81mgb.) Atorvastatin 20mg (for high cholesterol)c.) Folic acid (a supplement)d.) Methotrexate 2.5mg (for arthritis)e.) Montelukast 10mg (for asthma)f.) Spironolactone (diuretic)g.) Torsemide 20mg (diuretic)h.) Vitamin D3 50mcg (micrograms) (a supplement)i.) Breztri aerophere 4.8 mcg/act (actuation) (asthma)j.) Eliquis 2.5mg (blood thinner)k.) Metoprolol succinate extended release 24 hr (hour) 25mg (for heart failure)l.) Certrazine 10mg (for allergies) On 12/3/25 at 11:30 a.m., during an interview, the Regional Nurse Consultant (RCS) indicated the medications went home with the resident but she could not find the reconciliation documentation. A policy was requested and was not provided at the time of exit.

Based on observation, interview, and record review, the facility failed to ensure residents were free from the use of physical restraints when staff placed a resident, (Resident 56) in a heavy immobile chair and positioned the table over the arms of the chair to prevent her from standing or moving freely. This deficient practice constituted a restraint by restricting the resident's ability to move freely for 1 of 1 resident reviewed for restraints. Findings include: On 12/1/25 at 11:03 a.m., Resident 56 was observed in the main dining/activity room. She had been moved from her wheelchair and placed in a large, heavy, wooden chair which was pushed all the way up to the table so the chair arms were placed under the table. Resident 56 made repeated attempts to stand, but she was unable to move the chair, so she sat back down. On 12/2/25 at 2:30 p.m., Resident 56 was seated in her wheelchair at a table during a scheduled bowling activity. As the activity began, she attempted multiple times to stand. Staff repeatedly told her to sit down and I can't let you go anywhere. Activity Aide (AA) 8 and Certified Nursing Aide (CAN) 11 moved Resident 56 to a large wooden chair at the back of the room. They pushed the chair tightly against the table and lifted the table up to slide the armrests underneath, immobilizing the chair. Resident 56 attempted to stand several times, but the chair could not move. She appeared frustrated, as evidence by, pursing her lips, curling her hand into a fist, shaking her head no, and feeling/searching around the edge of the table for a solution. During a continuous observation on 12/3/25 from 11:00 a.m. until 12:00 p.m. the following was observed: Resident 56 was seated in a wheelchair in the main dining/activity room. She made repeated attempts to stand up from her wheelchair. Eventually, an unidentified Hospice aide, and AA 7 placed Resident 56 into a larger, heavier chair and lifted the table to wedge the arms of the chair underneath, preventing her from pushing back or standing. She appeared frustrated, as evidence by, pursing her lips, curling her hand into a fist, shaking her head no, and feeling/searching around the edge of the table for a solution. During an interview on 12/4/25 at 3:09 p.m., AAs 7 and 10 indicated, Resident 56 was hard to redirect and wanted to stand up and walk constantly, but they were afraid she would fall so staff put her in the two heavy wooden chairs because Resident 56 couldn't not move those by herself, and it kept her from getting up without assistance. On 12/3/25 at 3:30 p.m., Resident 56's record was reviewed. She was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to; dementia with behavioral and generalized anxiety.The record lacked any physician order, assessment or care plan for the use of physical restraints. She had a comprehensive care plan, initiated 2/8/21, which indicated she was at high risk for falls related to impaired mobility and impaired cognition. Interventions included, but were not limited to, staff to assist with transfers when they observe her trying to transfer. She had a comprehensive care plan, initiated 1/11/23, which indicated she had limited activity involvement as a result of: Cognitive impairment secondary her diagnosis of dementia and She takes pleasure in walking for most of her available free time. Interventions include but were not limited to; Provide activity programming consistent with physical & psychosocial abilities. This includes: energy level, cognitive functioning, medical condition & mood/behavior patterns. On 12/4/25 at 3:28 p.m., the Regional Director of Operations (RDO) provided a copy of current facility policy titled, Guidelines for Physical Restraints/Seclusion, dated 5/17/23. The policy indicated, It is the policy of the facility to use physical restraint only as a last resort and only after every other alternative to a physical restraint (based on assessment) that seemed to have the potential for being used successfully, has been tried, and has failed. A physical restraint is NEVER to be used for staff convenience or for discipline. If the resident cannot remove the physical restraint device on command-and using the proper technique for removal-the device is considered a physical restraint. 3.1-3(w)

Based on record review and interview, the facility failed to obtain a urine culture and sensitivity after a resident was found on the floor next to her bed for 1 of 3 residents reviewed (Resident 2).Findings include: On 12/4/25 at 11:48 a.m., a record review was completed for Resident 2. She had the following diagnoses which included but were not limited to history of cardiac arrest, type 2 diabetes, neuropathy (nerve pain), hypertension, generalized anxiety, and muscle weakness.On 7/25/25 at 6:56 p.m., Resident 2 was found on the floor next to her bed. She was not injured. The Interdisciplinary team recommended labs, a complete blood count (CBC), basic metabolic profile (BMP), a urinalysis (UA), and a culture and sensitivity (C&S). The facility completed the STAT (as soon as possible) CBC, BMP, and urine. It was recommended to obtain another C&S. On 7/25/25 the labs were complete, and a culture was indicated with results to follow. The culture was not completed. On 12/4/25 at 2:01 p.m., during an interview with the Regional Nurse Consultant (RCS), she indicated the lab was unable to get a C&S and recommended obtaining another urine sample. She indicated this was not completed and Resident 2 was started on a prophylactic antibiotic to treat the urinary tract infection.A policy titled, Guideline for Incidents/Accidents/Falls was provided by the RCS on 12/4/25 at 2:45 p.m. It indicated, The nurse will notify the resident's attending physician/Nurse Practitioner, Director of Nursing (DON), Administrator, and the resident's responsible party/power of attorney (POA). The physician will be notified of changes of condition related to the fall that may have been identified. Orders for treatment and any interventions will be obtained.3.1-49(c)

Based on observation, interview, and record review, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding the residents' care for 2 of 2 residents (Residents 24 and 6) reviewed for dialysis services. Findings include:1. On 12/2/25 at 2:41 p.m. Resident 24 was observed in his room as he sat in his wheelchair speaking with another resident. Resident 24 indicated the staff did not do any type of assessment or vitals when he got back from dialysis treatments, they only welcomed him back and helped him get settled when needed. On 12/3/25 at 9:18 a.m. Resident 24's medical record was reviewed. He was a long-term care Resident whose diagnoses included but were not limited to end stage renal disease (kidney disease). Resident 24 had an active order initiated on 4/10/24 that indicated he would receive dialysis treatment every Monday, Wednesday, and Friday. The medical record lacked documentation of communication between the facility and the dialysis center. 2. On 12/3/25 at 9:50 a.m., a record review was completed for Resident 6. He had the following diagnoses which included but were not limited to dementia, chronic kidney disease, depression, and essential hypertension. His medical record lacked documentation of communication to the local hospital regarding his vital signs and assessments with dialysis. During an interview on 12/4/25 at 11:54 a.m. the Regional Director of Operations (RDO) indicated they do not have a communication form that they used consistently right now, but they realized the lack of communication and were planning to look at the process they currently had and would overhaul it. 3.1-37(a)

Based on record review, and interview, the facility failed to prevent the development of a stage II (partial thickness skin loss involving the dermis) coccyx wound that progressed to an unstageable (a full-thickness tissue loss where the base of the ulcer is obscured by slough [yellow, tan, gray, green, or brown tissue]) that resulted in actual harm when the resident required hospitalization and wound debridement for 1 of 3 residents reviewed for pressure ulcers (Resident B). Findings include: A confidential concern during the survey indicated a family member was not happy with Resident B's care while in the facility. Concerns included the resident was not being repositioned, or having his brief changed. Resident B had been in the facility for 30 days and in that time had developed a bed sore near his anus that had worsened. Resident B's clinical record was reviewed on 5/27/25 at 2:15 p.m. The diagnoses included nontraumatic intracerebral hemorrhage (stroke), aphasia (difficulty in communicating and understanding verbal and written language), dysphagia (difficulty swallowing), and pressure ulcer. The resident was admitted to the facility on [DATE]. On 3/17/25, an Admission/re-admission Screener indicated the resident had no skin impairment upon admission. A progress note, dated 3/17/25 at 8:00 p.m., indicated Resident B was brought to the facility on a stretcher by emergency medical services (EMS), post hospitalization for altered mental status and right hemiparesis. He was non-verbal and did not follow commands. The resident's skin tone and turgor were normal, and there were no skin issues noted. On 3/17/25, a Baseline Care Plan indicated the resident required 1-person physical assistance for ADL's, bed mobility and transfers, and required no mobility devices. The resident was always incontinent of bowel and bladder. On 3/17/25, a Braden Scale for Predicting Pressure Sore Risk assessment indicated the resident was at high risk for skin breakdown. A progress note, dated 3/18/25, indicated Resident B required maximum assistance of 2 staff members for transfers, and he used a wheelchair for mobility propelled by the staff. The resident was non-verbal, had right-sided hemiparesis, aphasia and dysphagia, and was non- ambulatory. A mechanical lift was used for transfers and to obtain his weight. On 3/18/25, an initial new admission skin evaluation was completed. Documentation indicated, due to co-morbidities, the resident was at increased risk for skin breakdown. Recommendations included: good hygiene and skin care to prevent skin breakdown, and application of emollients daily. There were no open wounds on assessment of the skin, keep the resident's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure on any bony prominence by adhering to turning protocols The admission and state-optional Minimum Data Set (MDS) assessments, completed on 3/24/25, assessed Resident B as having no speech, rarely/never made himself understood, the resident usually understood others, and had no fall history in the past 6 months. The resident required extensive physical assistance from two plus people for bed mobility, transfers, toilet use, and mobility devices included a wheelchair. Resident B was at risk of developing pressure ulcers/injuries, had no current pressure wounds or skin problems, and did not have applications of ointments or medications to the skin. On 3/24/25, a Weekly Skin Check assessment indicated the resident had no skin breakdown. A care plan for Resident B, dated 3/25/25, indicated he was incontinent of bladder and bowel, and the goal was for him to be clean, dry and odor free. Interventions included peri care after every incontinent episode, and staff were to assist the resident with toileting as needed. A care plan for Resident B, dated 3/25/25, indicated he was at risk for skin breakdown related to impaired mobility, and the goal was for him to be free of skin breakdown. Interventions included performing a Braden scale assessment quarterly and as needed, keeping the resident clean and dry, and completing skin assessments per facility policy. A progress note, dated 3/26/25 at 4:00 p.m., indicated Resident B was alert to self, non-verbal, incontinent of bowel and bladder, dependent of staff for ADL assistance, and transferred with 2 persons assist. The resident continued with bolus tube feedings via peg tube site. Medication Administration Records (MARs), dated March 2025, lacked documentation of physician's orders for preventive skin care. The clinical record lacked documentation that emollients (substances, often found in moisturizers, that soften and soothe the skin) or barrier creams had been used per the Wound NP recommendations on 3/18/25, or nursing interventions to include turning and repositioning, keeping the resident clean and dry, or off-loading had been initiated. On 3/28/25, a Weekly Wound Evaluation indicated the resident had an in-house acquired Stage 2 wound on his right buttock that measured 5.0 centimeters (cm) by (x) 3.0 cm x 0.1 cm. Nursing progress notes, dated 3/28/25, lacked documentation a stage 2 pressure wound had been identified on Resident B's coccyx, the root cause of the wound, the physician or family had been notified, or nursing interventions had been initiated. A physician order, on 3/30/25, indicated to cleanse a right buttock/coccyx wound with wound cleanser, and pat dry, apply collagen particles (a type of wound dressing to promote healing) to the wound bed and cover with silicone super absorbent foam, and change the dressing daily and as needed. The order was discontinued on 4/1/25. A wound assessment, on 4/1/25, indicated the resident was seen for a new DTI on the coccyx, that measured 9.0 cm x 5.5 cm x 0.1 cm. Exposed tissues included: subcutaneous, dermis, and dark maroon/purple discoloration noted in the wound bed. New recommendations included a low air loss (LAL) mattress, strict incontinence management, and offloading in bed. All preventative measures were discussed with the staff. A physician order, on 4/2/25, indicated to cleanse the right buttock/coccyx wound with Dakin's solution (a care product containing sodium hypochlorite - a form of household bleach), and pat dry, apply Medihoney (medical grade honey with antibacterial actions, promoting a moist environment, and aides in debridement -removal of dead skin) to the wound bed, and cover with silicone super absorbent foam. Staff were to change the dressing daily and as needed. The order was discontinued 4/16/25. A wound assessment, on 4/9/25, indicated the resident was seen for an unstageable (where the base of the wound cannot be seen due to slough or eschar) coccyx wound that measured 10.0 cm x 5.5 cm x 2.0 cm. A surgical debridement was performed to remove necrotic tissue and keep the wound in an active state of healing. A grievance, dated 4/10/25, indicated Resident B's family member was concerned about a large wound on the resident's coccyx. A wound assessment, on 4/15/25, indicated the resident was seen for an unstageable coccyx wound, that measured 9.0 cm x 5.0 cm x 2.0 cm. Exposed tissues included: subcutaneous, dermis, and adipose. A surgical debridement was performed to keep the wound in an active state of healing. A physician order, on 4/17/25, indicated to apply a nickel thick amount of Santyl External Ointment (a debriding agent) topically to the coccyx wound base every day for wound care, bolster the wound with lightly packed normal saline moistened gauze, and cover with bordered foam dressing. Staff were to change the dressing daily and as needed. A care plan for Resident B, dated 4/17/25, indicated his skin integrity was impaired related to an unstageable pressure ulcer to the coccyx. Interventions included, notify the physician and family of change in condition, observe for signs and symptoms of increase in size of the area, observe vital signs as indicated, pressure reducing mattress on the bed, and treatment as ordered. An update to the care plan, dated 4/23/25, indicated the goal was for the resident's wound to resolve without complications. Interventions included administering nutritional supplements for wound healing as ordered. A wound assessment, on 4/22/25, indicated the resident was seen for a coccyx wound that was worsening, and measured 7.5 cm x 5.0 cm x 3.5 cm. There was undermining from 12 o'clock to 3 o'clock measuring 2.0 cm. Exposed tissues included: subcutaneous, dermis, adipose, bone, and black discoloration noted in the wound bed. The resident was experiencing an increase in pain, and wound cultures were obtained at bedside. A surgical debridement was performed to keep the wound in an active state of healing. A physician order, on 4/23/25, indicated to cleanse a coccyx wound with Dakin's 0.125% solution, apply skin prep on the surrounding tissue, apply a nickel thick amount of Santyl with Dakin's moistened gauze packed into the wound, and cover with boarder foam dressing. Staff were to change the dressing daily and as needed. A progress note, dated 4/24/25 at 3:51 p.m., indicated a Registered Nurse (RN) from an infectious disease doctor's office had called and informed the facility the infectious disease doctor wanted Resident B was sent immediately to a local medical center emergency room (ER) via ambulance. A progress note, dated 5/2/25 at 3:44 p.m., indicated facility staff had contacted Resident B's spouse for follow-up information regarding his recent trip to the hospital. The spouse indicated she was considering moving Resident B to another facility when he was discharged from the hospital. During an interview on 5/27/25 at 2:50 p.m., Wound NP 5 indicated she had been asked to assess Resident B after he had developed a stage II pressure ulcer on his coccyx and within a week deteriorated to a Deep Tissue Injury (a pressure-related injury to sub-cutaneous tissue under intact skin, as a result of prolonged compression of bony prominences on underlying soft tissue, particularly muscle). Wound NP 5 and a colleague saw the resident weekly where they measured and documented a description of the wound. The coccyx wound subsequently deteriorated to an unstageable pressure wound, which they surgically debrided to remove slough and help with wound healing on more than one visit. During Wound NP 5's fourth visit she observed the coccyx wound to be worsening. She suggested the resident be seen by an infectious disease doctor associated with a local hospital. During an interview on 5/28/25 at 11:58 a.m., the Regional Nurse Consultant indicated Resident B had a standard pressure reducing mattress on his bed upon admission, that had been changed to a LAL mattress at the recommendation of Wound NP 5 on 4/1/25. The Regional Nurse Consultant indicated after reviewing Resident B's clinical record, she had no further information or documentation to provide regarding the prevention or treatment of Resident B's pressure wound on his coccyx. There was no documentation to indicate preventative measures were in place prior to the development of the pressure ulcer, if the wound was preventable or not, or that a personalized skin care plan was developed before the coccyx wound was identified. During an interview on 5/28/25 at 12:41 p.m., Licensed Practical Nurse (LPN) 6 indicated upon admission to the facility, and during his first assessment by Wound NP 5, Resident B had no skin breakdown. The resident was incontinent of bladder and bowel and was totally dependent on staff for his ADL needs, he relied on staff to check and change him as needed. A few weeks later, Qualified Medication Aide (QMA) 13 reported she had observed blood on Resident B's bottom after she had changed his brief. A LAL mattress was provided after the wound was identified. LPN 6 indicated the management team were responsible for creating and updating care plans. On 5/28/25 at 3:30 p.m., the Regional Nurse Consultant provided a policy titled, Guidelines For Prevention/Treatment Of Pressure Injuries, dated 10/9/23, and indicated the policy was the one currently being used in the facility. The policy indicated, .A Risk Assessment is considered the starting point for prevention of pressure injury .It is important to note that an [at risk] resident can develop a pressure injury within hours of the onset of pressure. For this reason the [at risk] resident must be identified, and have specific interventions put promptly in place and care planned in an effort to prevent formation of a pressure injury .If upon any assessment an actual pressure ulcer/pressure injury is found immediate steps will be taken to ensure that a treatment is in place as well as any appropriate interventions related to area[s]. These will be added to the resident's care plan .Protecting and monitoring the condition of the resident's skin is important for preventing pressure sores and for identifying Stage 1 sores early so they can be treated before they worsen .Skin must be cleaned promptly after every episode of incontinence pH balanced skin cleaners should be used. Moisturizers are recommended as well This citation relates to Complaint IN00459052. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation and interview, the facility failed to ensure medication and biologicals were stored according to facility policy for 1 of 1 treatment carts observed for medication and biological storage. Findings include: During a random observation on 5/28/25 at 12:31 p.m., an unlocked treatment cart containing tubes and bottles of biological (medications used to treat skin conditions and wounds) was positioned near the nurse's station, outside the main dining room, and near the entry to the 100 hallway. The top drawer of the treatment cart was opened exposing insulin and blood glucose testing supplies to include a box of exposed lancets (small disposable needles), bottles of blood glucose strips, packaged dressings, and alcohol pads. There was a plastic medication cup with unidentified pills and capsules sitting unsecured on top of the treatment cart. There were 8 residents observed sitting in the main dining room within view of the treatment cart, and Resident H was standing beside the treatment cart. Licensed Practical Nurse (LPN) 7 was observed sitting down inside the nurse's station approximately 12 feet away and out of sight of the treatment cart. A visitor stood near the unsecured treatment cart talking to Resident H for over 2 minutes, before the nurse was observed walking out of the nurse's station towards the treatment cart. When LPN 7 observed the treatment cart with the top drawer opened, she quickly grabbed the cart, shut the drawer and locked the cart, and stored it inside the nurse's station. On 5/28/25 at 12:35 p.m., LPN 7 indicated she should not have left the treatment cart unlocked but got caught up with another resident and had forgotten about it. On 5/28/25 at 3:30 p.m., the Regional Nurse Consultant provided a Medication Storage In The Facility policy, dated March 2023, and indicated the policy was the one currently being used in the facility. The policy indicated, .3. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access: a. Licensed Nurse .7. External medications including ointments for skin irritations and medication for application to wounds should be kept in a treatment cart, or in a separate drawer in the medication cart which is labeled as such 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were individualized and implemented, and fall follow-up assessments and interventions were completed for 1 of 3 residents reviewed for falls (Residents B). Findings include, A confidential concern during the survey indicated Resident B had fallen out of bed while an aide was providing care on an unknown date, and there were questions concerning whether the staff member had been qualified to provide care. Resident B's clinical record was reviewed on 5/27/25 at 2:15 p.m. The diagnoses included, nontraumatic intracerebral hemorrhage (stroke), aphasia (difficulty in communicating and understanding verbal and written language), dysphagia (difficulty swallowing), and pressure ulcer. An admission physician's note, dated 3/17/25, indicated Resident B had been hospitalized with right sided weakness and aphasia following a large left-sided intercranial hemorrhage. The resident was unsteady on his feet, and staff were to utilize fall precautions per facility policy. A Fall Risk Review, dated 3/17/25, indicated Resident B was at high risk for falls. A progress note, dated 4/10/25 at 8:05 a.m., indicated Resident B had rolled out of bed during check and change. The incident was witnessed by CNA 11 and a nurse, and there were no injuries. An electronic physician notification, dated 4/10/25 at 8:51 a.m., indiated Resident B had a fall. Per the nurse, the resident was rolled off the bed by an aide around 5:30 a.m. The nurse reported the resident was non-verbal, at his prior level of alertness, and had expressed pain, although the resident was not able to express where the pain was located. Review of a grievance on 4/10/25 indicated, Resident B's family member was upset he had fallen out of bed, and wanted to know why a new staff member was working with the resident. The admission and state-optional MDSs (Minimum Data Set) assessments, completed on 3/24/25, assessed Resident B as having no speech, rarely/never made himself, usually understood others, and had no fall history in the past 6 months. The resident required extensive physical assistance from two plus people for bed mobility, transfers, toilet use, and mobility devices included a wheelchair. A care plan, dated 3/25/25, indicated Resident B had the potential for falls related to new surroundings and his goal was to have no falls. Interventions included call light in reach, encourage the resident to ask for assist with transfer or ambulation as needed, and keep paths free of clutter. Resident B's clinical record lacked documentation that fall follow up was completed to include 72 hours of assessments with vital signs, a Post Fall Review assessment, or updates to the care plan. During an interview on 5/28/25 at 12:08 p.m., the Director of Nursing (DON) indicated, on 4/10/25, Resident B was being turned onto his side during care, and he rolled off the bed. The Certified Nursing Aide (CNA) was a newly hired aide, and she had been caring for the resident by herself. In her opinion, the fall was potentially the result of a low air loss mattress (LAL) that was on the bed. Before the fall, the care plan lacked resident specific interventions and was not updated after the fall. The DON indicated that MDS Nurse 10 was responsible for the development of care plans. During an interview on 5/28/25 at 12:39 p.m., Licensed Practical Nurse (LPN) 6 indicated Resident B had required total care per staff for his ADL (activities of daily living) care to include turning and repositioning every 2 hours. On 4/10/25, LPN 6 had been instructed during shift report to document fall follow up for Resident B after he had fallen out of bed. LPN 6 indicated CNA 11 had been providing care and changing Resident B's brief by herself when the resident fell out of bed. LPN 6 indicated the management team, to include the DON, were responsible for creating and updating care plans. On 5/28/25 at 3:30 p.m., the Regional Nurse Consultant provided a Guidelines For Incidents/Accidents/Falls policy, dated 6/30/23, and indicated the policy was the one currently being used in the facility. The policy indicated, .9. Documentation of the physical and mental status of the resident[s] involved will be completed each shift [every 8 hours minimally] over at least the next 72 hours or until the resident[s] condition improves .11. All falls will have a site investigation by appropriate staff in an effort to determine the [root cause] of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. Note: Each fall needs a new care plan interventions rolled out .Residents are assessed for FALL RISK upon admission, re-admission, quarterly and when there is a change of condition to include a fall .15. Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place This citation relates to Complaint IN00459052. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when transportation staff were not trained on new bus equipment and failed to install a safety lap belt, which resulted in actual harm when a resident slid out from his wheelchair on the bus and sustained a L1 vertebra fracture with a 20% height loss for 1 of 2 residents reviewed for falls (Resident 11). The deficient practice was corrected by 1/18/24 prior to the start of the survey and was therefore Past Noncompliance. Findings include: On 9/24/24 at 11:18 a.m., Resident 11's medical record was reviewed. He had diagnoses which included, but were not limited to, history of a stroke, weakness/paralysis of his left side, vascular dementia, muscle wasting and atrophy, chronic pain syndrome and wedge compression fracture of the L1 vertebra. An Interdisciplinary team (IDT) progress note, dated 1/18/24 at 12:22 p.m., indicated, Resident 11 had been in transit on the facility bus to a dental appointment when he slid out of his wheelchair and landed on his butt, on the floor of the bus. At the time of his fall, he complained of pain in his left shoulder/elbow and stated he hit his head on the wheelchair. Resident 11 was assisted back into his wheelchair on the bus and returned to the facility.Upon investigation, it was noted that he was not properly secured into the bus prior to leaving facility A nursing progress note, dated 1/22/24 at 3:28 p.m., indicated, .He complains that pain is worse in left knee since his fall on 1/19/24. X-rays were ordered of left elbow and left knee last week. Staff have no other complaints for him today. Assessment: He has a history of left sided hemiplegia and hemiparesis along with osteoarthritis resulting in chronic pain. He takes Percocet, acetaminophen, and Lyrica for pain relief. Recent x-ray of left elbow was negative for acute injury but did show osteoarthritis. A x-ray of right knee was completed with no acute injury noted. Reordered left knee x-ray today STAT A nursing progress note, dated 1/23/24 at 8:39 a.m., indicated Resident 11's left knee x-ray results were reviewed with no acute findings. A nursing progress not, dated 2/5/24 at 2:40 p.m., indicated two coffee ground emesis noted after eating his meals. He was assessed by the ADON and an order was given to send out to hospital for evaluation and treatment. Resident 11's corresponding Hospital Record, dated 2/5/24 at 9:42 p.m., indicated, (through a translator) .patient reports that he had acute onset of nausea that started this morning and has worsened throughout the day. Is unable to eat anything due to the nausea but is willing to try taking some water. He vomited 3 times and denies blood. However, called facility in nurse related that there was concerns of coffee-ground emesis which prompted them to call EMS . per nurse that was contacted over night she reports that he was in his usual state of health prior to today. Also notes that he had a fall out of his wheelchair while on a bus to a doctor's appointment on January 19th Incidentally CT abdomen and pelvis also revealed acute to subacute compression fracture of L1 with visible lucent fracture lines and mild height loss as well as chronic rib fractures. admitted for further medical management On 9/26/24 at 11:07 a.m., the Director of Nursing (DON) provided a copy of the investigation which included but was not limited to the following: The DON's written statement, dated 1/18/24, indicated, .writer was notified upon bus return that Resident had fallen out of wheelchair during transport. Writer went out to the bus, assessed resident and ensured resident was alright. ADON [Assistant Director of Nursing] took resident into facility. Upon inspection, it was noted that resident had not been properly secured/buckled in. Writer reeducated Administrator [ADM], Bus Driver and Maintenance Director on proper securement of residents prior to transporting residents. New skill validations created that are specific to our bus and verified with all drivers by DON. All drivers to have second person (whom is verified to check off on them) verify the resident is properly secured prior to leaving the facility. Both maintenance and bus driver were educated that next time to have ADON or DON ride along and assess resident if another fall is to happen on the bus during transport The Bus Driver's witness statement, dated 1/18/24, indicated, .I was driving [Resident 11] to . an appointment. I was stopped at the stop light when resident yelled out. I looked back and saw him sitting on the floor. I then immediately put on the brake, assisted him back to the wheelchair and called my supervisor at 11:37 a.m. I then moved the vehicle to a parking lot adjacent to where I was at the light and waited on my supervisor to arrive. My supervisor arrived, spoke with resident and told me to bring resident back to facility. Once back at the facility I was met by DON, ADON, and Administrator The Maintenance Director 's witness statement dated 1/18/24 indicated, .At 11:37 a.m., I received a phone call from [Bus Driver] requesting me to get to his location because a resident had fallen on the bus. I arrived to [Bus Driver] at approximately 11:40 a.m., and got on to the bus and asked resident if he was alright. He stated his head hurt. I then directed [Bus Driver] to get resident back to facility. I returned to facility and notified DON, ADON and ADM On 9/26/24 at 11:55 a.m., the Bus Driver and Maintenance Directors employee files were reviewed. The Bus Driver's file lacked documentation of job-specific orientation and/or training/education for transportation via facility bus. During an interview on 9/26/24 at 9:56 a.m., Regional Consultant (RC) 8 indicated, job-specific and/or training for the facility bus and transportation safety was not found in the employee files. The new facility bus was delivered on 1/3/24 by a dealership associate who reviewed basic functions with the Administrator and RC 8 at the time of delivery. On 9/26/24 at 10:42 a.m., the facility bus was observed with RC 8, the DON, ADON, Maintenance Director (MD) and current facility bus driver present. The DON indicated, after Resident 11's she was called to the bus where she and the ADON assessed him. The ADON assisted the Resident back inside while the DON investigated how he slid out of the wheelchair. The DON indicated, the lap-belt was found still in its original packaging, inside a covered storage bin located behind the last seat of the bus. The DON indicated the cross-belt was used to secure the resident but had been buckled into the adjacent seat's clip, across the aisle which was incorrect. During an interview on 9/26/24 at 11:00 a.m., the DON indicated she pulled the buses safety card and created a full and detailed skills validation and training checklist which she had the bus driver, MD and Administrator complete on 1/18/24. On 9/26/24 at 12:55 p.m., the DON provided a copy of current, but undated facility policy, which had been signed by the Bus Driver and MD as documentation of education on the use of seat belts. The policy was titled, Use of Seat Belts, and indicated, .transport driver and passengers must wear safety seat belts at all times during transport . place seatbelt around resident's lap area and lock The deficient practice was corrected by 1/18/24 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included staff education, skills validation and ongoing monitoring was put in place. 3.1-45(a)

Based on interviews and record review, the facility failed to ensure Resident Council grievances were followed up on and reported back to the Resident Council for review and approval. This deficient practice had the potential to effect 4 of 54 residents who attended the Resident Council meeting. Findings include: On 9/24/24 at 10:00 a.m., the Resident Council minutes were reviewed. A meeting was held on 2/22/24 with new and old business which indicated, Residents want to go out for outings like eating/shopping. There was no documentation of a response to the Resident Council's request. A meeting was held on 3/21/24 which indicated, old business was not discussed and they requested more outing again. Two separate grievances were hand written on behalf of two residents related to wanting to go on more outings and general nursing care concerns. There was no documentation of a response to the Resident Councils requests, and/or the individual grievances. The next meetings were held on 6/20/24, 7/18/24, and 8/15/24 which discussed general care concerns which included, but were not limited to items of call light response time, staff speaking different language and using earbuds or cell phones etc. There was no documentation of responses to the Resident Councils minutes. On 9/25/24 at 10:00 a.m., a Resident Council meeting was held with Residents 25, 33, 29, and 41. All four residents agreed and indicated, it seemed like with the Activity staff turn-over many of their concerns and grievances were not responded to in a timely manner and sometimes were not responded to at all. During an interview on 9/26/24 at 9:24 a.m., the Activity Director (AD) indicated Residents did complain since she had started that sometimes they did not receive responses. The AD indicated the process after Resident Council meetings should include the submission of response forms to the appropriate department heads so that at the next meeting, the residents could have a response and review it to determine if they accepted it or not. On 9/25/24 at 1:56 p.m., Regional Consultant (RC) 8 provided a copy of current facility policy titled, Resident Council Policy, revised 2/9/16. The policy indicated, .The role of the Resident Council is to improve the quality of life of the residents who reside in the facility and to take part in actions to maintain a positive living environment . Participation and involvement in the Resident Council gives the resident a sense of being in control which results in a positive impact on their physical and mental health. Some objectives of the council are as follows: improves communication between staff and residents . helps identify quality of life issues . It is vital to establish an atmosphere of trust and responsibility for concerns to be voiced. This encourages members to openly discuss issues that impact them and/or other residents . The council group members who voice a concern usually expect a timely response about the resolution to their concern. This must happen. The Administrator monitors this process . A concern is any issue identified by the group that requires a response from the facility in the form of a resolution to some degree that satisfies the group with an explanation a comment 3.1-3(l)

Based on observation and interview, the facility failed to date medications when opened for 1 of 3 medication carts reviewed (medication cart 300) and 1 of 3 treatment carts (treatment cart 3). Findings include: 1. On 9/23/24 at 10:21 a.m., the 300-hall treatment cart was observed with Qualified Medication Assistant (QMA) 13. Resident 5 had a Lantus pen (insulin, used to treat diabetes) in the treatment cart. It lacked a date to indicate when it was opened. Resident 36 had a Humalog pen (insulin) in the treatment cart. It lacked a date to indicate when it was opened. 2. On 9/23/24 at 10:32 a.m., the 300-hall medication was observed with QMA 13. It contained Resident 5's flonase (used for allergies) in the cart with no date to indicate when it was opened. Resident 21 had a bottle of ear drops in the cart. It lacked a date to indicate when it was opened. A policy titled; Medication Storage in the Facility was provided by the Regional Nurse Consultant (RCS) on 9/26/24 at 9:53 a.m. It lacked information regarding the dating of medications when opened. The RCS indicated this was the only policy she could find. 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 5 of 5 residents reviewed for MDS accuracy (Resident 9, 47, 12, 11, and 33). Findings include: 1. On 9/26/24 at 10:00 a.m., a record review was completed for Resident 9. She had the following diagnoses which included, but were not limited to, hypertension (high blood pressure) (HTN), diabetes mellitus type 2 (blood sugar disorder) (DM), and weakness. She had a physician's order for aspirin 81mg (antiplatelet) by mouth daily. Her Minimum Data Set (MDS) assessment, dated 8/20/24, indicated she took an anticoagulant (blood thinner). She did not have an order for an anticoagulant. Her aspirin should have been coded as an antiplatelet on the MDS. She had a care plan, dated 9/8/22, that indicated she was at risk for abnormal bleeding related to the daily use of aspirin with an increased risk for bruising and/or bleeding. 2. On 9/25/24 at 11:21 a.m., a record review was completed for Resident 47. He had the following diagnoses which included, but were not limited to, major depressive disorder, post-traumatic stress disorder (PTSD), and dementia (neurological decline disease). Resident 47's MDS, dated [DATE], indicated he did not require a PASRR (pre-admission screening and resident review) Level II. He had a notice of PASRR, dated 2/10/22, which indicated he required a Level II based on his diagnoses. He had a care plan, dated 9/24/22, which indicated he had a Level II in place related to a mental health condition. 3. On 9/26/24 at 10:15 a.m, a record review was completed for Resident 12. She had the following diagnoses which included hyperlipidemia (HLD), hypertension (HTN), and atherosclerotic heart disease (ASHD) (ASHD is caused by plaque buildup in the coronary arteries, which supply blood to the heart). Her MDS, dated [DATE], indicated she took an anticoagulant. She did not have an order for an anticoagulant. She had an order for aspirin 81mg daily and Plavix (is an antiplatelet drug you can take to prevent blood clots. It keeps platelets in your blood from coming together and making clots). The MDS, dated [DATE], did not indicate she was on an antiplatelet. Her care plan, dated 10/10/18, indicated she took a low dose of aspirin and Plavix. 4. On 9/24/24 at 11:17 a.m., a record review was completed for Resident 11. He had the following diagnoses which included but were not limited to ASHD, HLD, and old myocardial infarction (MI) (which is also known as a heart attack). He took aspirin 81mg daily which is an antiplatelet. His MDS, dated [DATE], indicated he took and anticoagulant instead of an antiplatelet. His care plan, dated 4/3/23, indicated he was on aspirin. 37981 5. On 9/24/24 at 1:47 p.m., Resident 33's record was reviewed. Her diagnoses included, but were not limited to, supraventricular tachycardia (irregularly fast or erratic heartbeat), chronic respiratory failure (long-term condition that occurs when the body's respiratory system can't effective function), and age-related debility (physiological decline). Her MDS assessment, dated 8/15/24, indicated she was on an anticoagulant (blood thinner). A review of her orders indicated she was not on a anticoagulant. During an interview, on 9/25/24 at 3:20 p.m., the Director of Nursing (DON) indicated Resident 33 was not on an anticoagulant for the 8/15/24 MDS. During an interview with the Regional Nurse Consultant on 9/26/24 at 10:46 a.m., she indicated there was no policy for MDS accuracy. They follow the rap instrument assessment (RAI) manual. 3.1-31(d)(3)(i)

Based on observation, interview, and record review the facility failed to ensure dignity for a female resident with long facial hair for 1 of 1 resident reviewed for dignity (Resident 33). Findings include: During an interview, on 9/23/24 at 11:10 a.m., Resident 33 indicated she did not like the long hair on her face and would prefer to be shaved. She indicated she was unable to do it alone and needed assistance with this task. The hair on her face was observed to be long. During an interview, on 9/24/24 at 11:42 a.m., Resident 33 indicated she talked with the facility staff yesterday about wanting to have the facial hair removed, but nothing had happened yet. Her long facial hair was still intact. On 9/24/24 at 1:47 p.m., Resident 33's record was reviewed. Her diagnoses included, but were not limited to, supraventricular tachycardia (irregularly fast or erratic heartbeat), chronic respiratory failure (long-term condition that occurs when the body's respiratory system can't effective function), and age-related debility (physiological decline). A care plan, dated 11/6/23, indicated Resident 33 had a self-care deficit with impaired dressing and grooming. An intervention was to recognize she may have fluctuations in her normal day to day Activities of Daily Living (ADL) assistance and staff support needs due to my chronic disease process and /or any acute exacerbations. A care plan, dated 11/6/23, indicated Resident 33 had late loss ADLs and required staff assist with ADL's. On 9/24/24 at 2:58 p.m., Resident 33 was observed in her power wheelchair, in the main lobby of the facility, talking with a friend. The issue with her facial hair was not resolved and was still present on her face. A progress note, dated 9/24/24 at 3:05 p.m., indicated the DON spoke with Resident 33 about wanting to be up by 9:30 a.m. for the Resident Council meeting. She was asked at this time if she wanted assistance with shaving. Resident 33 indicated she was waiting for a certain staff member to help her. During an interview, on 9/25/24 at 10:54 a.m. Resident 33 indicated unidentified staff members had been to her room yesterday (9/24/24), and the day before (9/23/24), to ask if she wanted her facial hair removed. She told them yes, but no one had come back to do it. She indicated she was hesitant about doing it herself because she nicked her face once. Her facial hair was observed to be long. During an interview, on 9/25/24 at 11:26 a.m., the Director of Nursing (DON) indicated she just found out Resident 33 preferred only a certain staff member to shave her face. She indicated she created a new care plan of the same. A new care plan, dated 9/25/24, indicated Resident 33 had indicated she preferred to have her facial hair shaved only by specific staff of her choice. An intervention was to reassess as needed for changed in her daily preferences. During an interview, on 9/26/24 at 10:31 a.m., the DON indicated Resident 33's face had been shaved. The person she preferred for facial grooming was Qualified Medication Assistant (QMA) 16. On 9/26/24 at 1:30 p.m., QMA 16's actual schedule was reviewed. She worked the evening shift from 3:00 p.m. to 11:00 p.m. on 9/23/24 to 9/25/24. A current policy titled, Guidelines for Observing and Implementing - Resident Rights, dated 7/12/23, was provided by Regional Consultant 9. A review of the policy indicated, .Each resident has the right to be treated with dignity and respect .The preference and goals of the resident should be honored 3.1-3(a) 3.1-3(t)

Based on observation, interview and record review, the facility failed to treat a resident with Diabetes Meletus as ordered by the hospital discharge instructions for diabetic medication and diabetic wound care resulting in Resident B having significant risk of hypo/[CONDITION(S)] and wound deterioration or infection and the facility also failed to ensure care was given for diabetic wound care, IV antibiotics (Resident E), and non-pressure wound care (Resident C and D) for 4 of 9 residents reviewed for quality of care. The Immediate Jeopardy began on 3/18/22 at 7:14 p.m. when Resident B was admitted to the facility from the local hospital. The resident's hospital discharge paperwork indicated the resident was receiving Accuchecks and insulin on a sliding scale at the hospital and received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge notes indicated the Accuchecks, insulin, and wound treatments should have been continued at the facility. The facility failed to continue to assess and document the resident's wounds after admission. The nurses did not receive orders for wound treatments or document any treatments to the wounds. There were no orders for Accuchecks (rapid blood sugar testing) or diabetic medication since admission, and the facility failed to assess the residents blood sugar since admission. The physician was not notified of the missing diabetic care orders or the wounds. A medication for [CONDITION(S)] in the lower extremities was ordered but needed clarification for the missing dosage. The facility failed to obtain the clarification and the medication was not administered. The Administrator, Director of Nursing, and the Regional Nurse Consultants were notified of the immediate jeopardy at 3:20 p.m. on 4/5/22. The immediate jeopardy was removed, but noncompliance remained at a lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy, on 4/7/22 when the facility audited all the diabetic residents and residents with new admissions for medication, diet, and wound care orders and completed nursing staff education for the new admission process. Findings include: 1. On 4/5/22 at 10:05 a.m., during an observation and interview, Resident B was lying in bed watching television. Both of his legs were wrapped in gauze, from his knees to his ankles. There was no date or time on the bandages. His toes were blackened with dark crusty patches and his right great toe appeared to be partially missing. Both feet appeared swollen. The right foot was swollen, much larger than the left. The right foot was ashen gray, and the left foot was bright red and shiny. The toenails were long and yellow brown in color. The resident indicated the wounds were from his diabetes and he was unable to wear shoes comfortably. He had stopped taking his diabetic pills at home because he thought he didn't need them That was what caused his problems and landed him in the hospital. The facility had wrapped gauze on his legs a couple times. They did not do any kind of daily treatments like he had in the hospital. He had a lot of pain in his legs, they hurt all the time. He rated his pain as 6 out of 10. They gave him some Advil or something like that. It helped a little bit. On 4/5/22 at 3:15 p.m., the medical record was reviewed for Resident B. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/18/22 at 7:14 p.m., in a progress note Licensed Practical Nurse (LPN) 11 indicated Resident B had arrived to the facility by stretcher. He was alert and oriented and a full code. He was a fall risk, needed assistance of one, and used a walker to ambulate. The resident was continent of bowel and bladder and used a urinal. The medical history included diabetes, hypertension (high blood pressure) and coronary artery (heart disease) with surgery in 2001. Diet was no more than 3,000 milligrams (mg) salt per day and no more than 75 grams (gm) of carbohydrates per meal, regular consistency, and thin liquids. He had 2 plus (+) [CONDITION(S)] (swelling) to bilateral lower extremities. Resident B had ulcers on both lower legs and vascular disease. His right buttocks had an open area with instructions to cleanse with soap and water, pat dry, apply sensicare ointment, and cover with methiplex border (type of bandage). His right lower extremity had an area with instructions to cleanse with mild soap and water, apply [MEDICATION(S)] alginate, abd (padded dressing), and secure with kerlix (gauze wrap) and stretch net. His toes had wounds with instructions to apply [MEDICATION(S)] to all toes. His left dorsal foot had a blister with instructions to allow [MEDICATION(S)] to dry, secure with kerlix and stretch net. The dressings should be changed every other (qod) day and as needed (prn). Resident positive for [CONDITION(S)] (infection in wounds). Resident B's last blood sugar was 152. Resident had no complaint of pain or discomfort. A review of Resident B's hospital transfer documents, dated 3/18/22, indicated the following: Future clinic visits were scheduled on 3/25/22 at 12:00 p.m. for a Lab Blood Draw, on 3/25/22 at 12:30 p.m. to check-in for the appointment, and on 3/25/22 1:00 p.m. for the Geriatrics Practitioner appointment. On 3/28/22 at 11:45 a.m. for a Lab Blood Draw, on 3/28/22 at 12:45 p.m. for the appointment check in, and on 3/28/22 at 1:00 p.m. for the Geriatrics Practitioner appointment. An appointment for Vascular surgery was to be scheduled in 1 to 2 weeks. The reasons the patient was admitted to the hospital were skin infection and ulcers on his legs due to vascular disease. He was diagnosed with [CONDITION(S)] which improved with antibiotics ([MEDICATION(S)] and [MEDICATION(S)]). The [CONDITION(S)] ([CONDITION(S)] resistant staph aureous) screening was positive. The hospital transfer documents, dated 3/18/22, indicated Resident B was to continue taking these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] acetaminophen (Tylenol) 650 milligrams (mg) by mouth every 6 hours aspirin [MEDICATION(S)] coated 325 mg by mouth once a day [MEDICATION(S)] (blood pressure medicine) 40 mg by mouth every p.m. [MEDICATION(S)] (vitamin D3) 50 mg by mouth every day [MEDICATION(S)] (blood thinner) 75 mg by mouth daily [MEDICATION(S)] (sleep aid) 6 mg by mouth every p.m., as needed multivitamin with minerals, [MEDICATION(S)] cap one by mouth daily [MEDICATION(S)] ([MEDICATION(S)]) 3350 powder one packet by mouth daily [MEDICATION(S)]/[MEDICATION(S)] (reduces blood pressure and improves circulation) one tablet twice a day sennosides (stool softener) tab give 8.6 mg by mouth twice a day [MEDICATION(S)] (blood pressure and fluid retention) 12.5 mg by mouth daily The hospital transfer documents, dated 3/18/22, indicated Resident B was on a modified diet of low salt with no more than 3,000 mg of salt per day, and limited carbohydrates with no more than 75 gram (g) per meal The hospital transfer documents, dated 3/18/22, indicated Resident B's Hgb A1C (indicates high blood sugar over a 3 month period, diabetes) was 7.7 % with a diabetic range of 6.5% or higher and a normal range of below 5.7%. Resident B indicated he was prescribed [MEDICATION(S)] (diabetic pill) but had not taken it for several weeks. Will restart [MEDICATION(S)] on discharge. QID [four times a day] glucose checks, sliding scale insulin correction 1:60 and PCP [primary care physician] follow-up. A hospital physician summary notation, dated 3/17/22 at 12:39 p.m., indicated, .States he can't tell much difference in his right leg after stenting yesterday. He had initially declined to consider SNF [skilled nursing facility], but after I spoke with him today about whether he thinks he can take care of his wounds himself. He agreed that he cannot and that it would be better if he had assistance with wound care. He also agreed that he needs to have better nutrition and get stronger prior to returning home. In view of all this he is now agreeable to short-term SNF after discharge, but 'I don't want to die there'. The hospital medication list from the hospital transfer paperwork had ink check marks beside each medication. A handwritten notation beside the [MEDICATION(S)] order indicated, Need clarification on strength. The Admission Assessment form completed by LPN 11, on 3/18/22 at 6:30 p.m., included but was not limited to: Diet was no more than 75 gm of carbs per meal, regular consistency, and thin liquids. Skin had LLE (left lower extremity) vascular ulcers, right buttock OA [open area], RLE [right lower extremity] vascular ulcers. Resident had ulcers of vascular disease to the bilateral lower extremity (BLE), the right buttocks, has an OA, RLE had a wound, treatment was in place. The resident had a telehealth progress note for Admission, on 3/23/22 at 1:28 p.m., entered by the facility physician. The note indicated the resident was seen for chief complaint of [CONDITION(S)] right lower limb, [CONDITION(S)], diabetes II with [CONDITION(S)] and alcoholic liver disease. Resident B was seen and examined for new admission. The current medications were listed. There was no descriptions of the resident's wounds and no treatment orders listed. No orders for diabetic medication, labs or blood sugars were ordered. There were no new orders. Weekly skin check documentation, dated 3/25/22 and 4/1/22, indicated the resident had existing areas of loss of skin integrity and no new loss of skin integrity. The form indicated the existing areas were to be updated on the Weekly Wound Evaluation for each existing area of loss. There were no Weekly Wound Evaluations in the medical record. There was no wound description or measurements. There was no record of treatments. A review of the resident's current physician orders did not include any dressing change orders or treatment orders for the resident's wounds on the bilateral legs or buttocks. There was no order for [MEDICATION(S)]. The resident did not have orders for blood glucose testing, Accuchecks or any diabetic medication. There were no orders for the resident to return to the hospital clinic on 3/25/22 and 3/28/22, or to schedule an appointment in 1-2 weeks with the vascular surgery clinic. There was no documentation in the record that indicated the resident had returned to the hospital clinic since his admission to the facility. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's diet order was General diet, regular texture, thin liquid consistency. There was no code status order. The resident had not received any [MEDICATION(S)] and it was not listed as a medication order. The resident's code status was blank on the Face Sheet and electronic record information bar. A review of Resident B's Baseline Care Plan Code Status section was blank, advanced directive indicated n/a (not applicable). Section 3A Special Treatment/ Health conditions indicated receives a treatment to his legs. Section 3H Safety Risks indicated receives a treatment to legs daily. Section 4A Dietary indicated Diet order: General. The resident did not have a comprehensive care plan for wound care/skin integrity or diabetes. On 4/4/22 the Minimum Data Set (MDS) Coordinator entered a new Care Plan for Resident B on 4/4/22. The focus was Diabetes with risk for hypo/[CONDITION(S)] and the goal was Will have no s/sx of hypo/[CONDITION(S)] daily. The interventions were to provide antidiabetic medicines per order; check blood sugars per order; perform labs per order; monitor for signs and symptoms (s/sx) of [CONDITION(S)] such as, but not limited to be flushed, fruity breath, thirst, and/or diaphoretic; monitor for s/sx of [CONDITION(S)] such as pale, clammy, cool, thready pulse, lethargy; Notify MD and family as needed; and observe and report any signs of skin breakdown for example the feet and lower extremities. During an interview, on 4/4/22 at 4:00 p.m., the Director of Nursing (DON) indicated Resident B was admitted on [DATE]. Only the Director of Nursing (herself) or the Assistant Director of Nursing (ADON) did all the resident admissions. She had done Resident B's admission herself. He did not need blood sugars or diabetic medication according to his hospital discharge. There was a list of medications to continue. Those were the ones entered for his orders. The [MEDICATION(S)] was not ordered because there was no strength given. She was unsure if anyone followed up on the missing strength. He did not receive any blood sugars or diabetic medication. They had not ordered any treatments for his legs. He had gauze on them because he liked for them to be wrapped and would ask the nurses to do it. There was no order for it. The dressing was not documented. He did not have orders to see wound care or be treated by them. They had never seen him. He had not had any labs done that she knew of. He did not get blood sugar checks/Accuchecks, and none had been done. He was diabetic but wasn't getting any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . He did receive insulin and Accuchecks in the hospital, but it had not been ordered at the facility. On 4/4/22 at 4:20 p.m., during an observation and interview, Resident B was lying on his bed, an unidentified staff member was removing the gauze dressing from his left leg. The right leg bandage was still intact. The resident's calf had 4 quarter sized blackened areas with inflammation (bright red tissue) around the perimeter of the blackened tissue. He was able to wiggle his toes and lift his legs to command to help with visualization. There was swelling noted to the left calf and foot. The foot was bright red and shiny. He indicated his pain was a 6/10 all the time. During the observation he was eating a one pound canned ham, directly from the can. During an interview, on 4/5/22 at 8:40 a.m., the DON indicated her and the ADON did do all the facility admissions but recently they had been having new hire nurses do the admissions and that was what happened with Resident B's admission. It was completed by one of the other nurses. They were training them to do admissions during orientation. She did not know if Resident B had been out to any clinic appointments since admission. During an interview, on 4/5/22 at 8:58 a.m., Qualified Medication Aid (QMA) 8 indicated she normally worked a different hall. She had worked the other hall yesterday and it was her first time working with Resident B. He was pretty quick and easy as far as medication pass. She had remembered him talking about going home. She did not know if he was confused. They found physician orders and what treatments to give during medication pass from the MAR, she could only remember 4 residents with Accuchecks yesterday. Resident B was not one of them. It would surprise me to know that he was a diabetic, because he did not have any orders for Accuchecks or insulin. She indicated she was unaware he had [CONDITION(S)]. It was important to have full accurate order sets in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 4/5/22 at 9:09 a.m., Licensed Practical Nurse (LPN) 9 and QMA 10 indicated they were the care givers for another hall. They both indicated they had never cared for Resident B before. Together they checked his orders and indicated he had never had an Accuchecks done in the facility since admission. He did not receive Accuchecks or receive any diabetic medication. During an interview, on 4/5/22 at 10:54 a.m., the DON indicated she contacted the physician on 4/4/22 and the Nurse Practitioner (NP) would see Resident B on 4/5/22. The physician and NP only did telehealth (video) visits, they wouldn't come into the facility. The physician had done a telehealth visit with the resident after admission. He had access to the hospital discharge papers and did not order anything additionally. Standards of practice did not trigger them to contact the physician for additional orders for wound care or diabetic medications or blood sugars. His [CONDITION(S)] was healed. They only put dressings on because he wanted them to. He had stopped his own diabetic medication at home before he went to the hospital. During an interview, on 4/5/22 at 11:45 a.m., the DON indicated she had no answer to whether the resident had gone to appointments at the clinic or not. She was trying to get in touch with transportation to see if they took him anywhere. He did refuse some things. There is no documentation of the resident going out for any appointments or returning with any physician notes. If it happened there should be notes. On 4/5/22 at 12:53 p.m., the DON provided a written statement she indicated was from the facility transporter. The transporter had not taken Resident B to any appointments. She indicated the hospital picked up the residents themselves. They had not come to take him. The appointments were canceled. He had another appointment for 4/22/22, to go to the vascular clinic. She indicated the admission note, in the resident record, entered by LPN 11 was based on the report she had gotten from the hospital when Resident B was being transferred to the facility. The DON had not done that admission, she was mistaken. LPN 11 had done it. She did not know why the admission note wasn't consistent with the resident's physician orders. On 4/5/22 at 2:46 p.m., the Administrator provided a current, undated policy, titled Admission Guidelines. This policy indicated .All applicants for admission will be individually assessed for reasonable accommodation, ensuring that no barriers to admission of whole diagnostic groups or conditions occurs. The pre-admission evaluation of each prospective resident must ensure that only those individuals are admitted whose medical/psychosocial needs can be met by the facility. The facility must have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An evaluation of each resident shall be made, prior to admission, which shall include personal or telephone interviews with the resident, the resident's physician, or the representative of the facility from which the resident is being transferred, if applicable. At the time each individual is admitted , the facility must have physician's orders for immediate care that are based on a physical examination performed by a currently licensed attending physician or his /her designee, written on the day of admission or within 30 days prior to admission On 4/5/22 at 2:46 p.m., the Administrator provided a current, undated policy, titled Physician's Orders- (Following Physician Orders). This policy indicated It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. The facility must have orders upon admission from the physician for: dietary, drugs (if necessary), routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. AS assessments are completed, orders will be received from the physician to address significant findings of the assessments. Orders that accompany the resident on admission will be clarified by the physician through action of the nurse who will contact the physician for clarification upon the resident's admission According an article from the American Diabetes Association, titled, Glycemic Targets: Standards of Medical Care in Diabetes-2022, dated 12/16/21and retrieved on 4/5/22 at https://doi.org/10.2337/dc22-S006, indicated, The American Diabetes Association (ADA) 'Standards of Medical Care in Diabetes' includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care .Glycemic control is assessed by the A1C measurement, continuous glucose monitoring (CGM) using either time in range (TIR) and/or glucose management indicator (GMI), and blood glucose monitoring (BGM). A1C is the metric used to date in clinical trials demonstrating the benefits of improved glycemic control. Individual glucose monitoring is a useful tool for diabetes self-management, which includes meals, exercise, and medication adjustment, particularly in individuals taking insulin. CGM serves an increasingly important role in the management of the effectiveness and safety of treatment in many patients with type 1 diabetes and in selected patients with type 2 diabetes. Individuals on a variety of insulin regimens can benefit from CGM with improved glucose control, decreased [CONDITION(S)], and enhanced self-efficacy The immediate jeopardy that began on 3/18/22 was removed on 4/7/22 when the facility audited all the diabetic residents and residents with new admissions for medication, diet, and wound care orders and completed nursing staff education for the new admission process. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. 2. On 4/4/22 at 10:31 a.m., during an observation and interview, Resident E was watching television seated in a recliner in her room. An intravenous (IV) pole was on her right. A completed bag of IV antibiotic medication hung on the pole. There was no date or time on the tubing or hang time on the bag. A PICC (peripherally inserted central catheter) was visible in the resident's upper right arm. The dressing was dated 3/22/22. Her left foot was wrapped in an ACE bandage (compression bandage). A tubing connected the bandage to a wound vacuum (vac) machine to the resident's left. There was no date or initials visible on the dressing. The Resident indicated she had come to the facility for rehab and IV antibiotics. She had surgery on her foot because of an infection and sore from her diabetes. She was supposed to go home soon, maybe a week or so, because her two or three weeks of antibiotics would be finished. Her PICC line dressing had not been changed since she came to the facility. That dressing she had on was done at the hospital. The wound vacuum (vac) dressing was supposed to be changed on Monday, Wednesday, and Friday. It had not been done yet that day. They had told her the Director of Nursing (DON) was supposed to do the dressing change. On 4/7/22 at 9:00 a.m., during an observation and interview, Resident E was observed up in the recliner having breakfast. She indicated the wound vac dressing was changed on Monday and was supposed to be changed on Wednesday (4/6/22) but it was not done. The resident's left foot was wrapped in ace wrap and had visible drainage on it. There was no date on the bandage. The wound vac was not turned on. The resident indicated they had turned off the wound vac yesterday because it was beeping. The nurse did not know how to fix it. The PICC line dressing had been changed on Monday, that was the only time it was changed at the facility since her admission. The clear plastic dressing covering the IV catheter had a gauze pad over the insertion site and it was not possible to assess the site. There was no date on the dressing. The IV pump was beeping, and the message bar indicated infusion complete. There was still approximately one fourth of the fluid still in the bag. The tubing was not connected to the resident's arm. There was no date or time on the tubing or start time on the bag. The resident indicated the nurse had disconnected her from the pump so she could go to the bathroom. On 4/7/22 at 8:46 a.m., the medical record was reviewed for Resident E. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 3/23/22 with a target date of 6/20/22, indicated Resident E had a surgical wound on admission and a pressure ulcer on the bottom of her left foot related to disease process, diabetes and non-compliance with treatment regimen, history of ulcers. The goal indicated the resident's pressure ulcer would show signs of healing and remain free from infection through the review date. The weekly Wound evaluations indicated: On admission, 3/22/22 the left foot, surgical wound measurements were 4 cm (centimeters) by 4.5 cm by 0 (depth) cm. On 3/26/22 the left foot, surgical wound measurements were 8.8 cm by 3.28 cm by 1.40 cm. On 3/28/22 the left foot, surgical wound measurements were 8.8 cm by 3.28 cm by 1.40 cm. A review of Resident E's physician orders included, but were not limited to: -[MEDICATION(S)] HCl Solution (antibiotic) 1 gram (gm)/50 milliliters (ml) intravenously every 8 hours for Infection related to [CONDITION(S)] until 04/12/2022 at 10:00 p.m. -Dakins (1/2 strength) Solution 0.25 % (an antibacterial bleach solution) Apply to left bottom foot topically one time a day every Monday, Wednesday, Friday related to Diabetes Mellitus foot ulcer ordered 4/8/2022 at 9:00 a.m. -May use normal saline (salt water) wet to dry as needed (PRN) due wound vacuum (vac) malfunction, vac removal every 8 hours as needed for Wound Care Management, active order date 3/22/2022 at 6:30 p.m. -Negative pressure therapy (wound vac) to left foot. Ordered to change on Monday, Wednesday, and Friday and PRN due to dislodgement, Active order date 3/22/2022 at 6:30 p.m. -Flush PICC line before and after IV antibiotic infusion every 8 hours for Infection left foot, active order date 3/25/2022 at 6:00 a.m. There were no physician orders for PICC line dressing changes. There were no care plans for IV therapy/antibiotic treatment or diabetic care in the medical record. Progress notes, dated 4/6/22 at 9:43 p.m., indicated Resident E remained on IV antibiotic for infection in left foot. No adverse reaction to antibiotic therapy noted. Midline to right upper arm flushed well with normal saline and was patent. On 4/7/22 at 10:33 a.m., the resident was observed still seated in the recliner. Resident E's left foot rested on the lower bar of the overbed table. A pool of serosanguinous (blood) fluid, approximately half the size of the resident's foot was on the floor, under her foot. On 4/7/22 at 10:45 a.m., during an observation and interview the DON talked to the resident about when her wound was last cared for. The DON indicated wound care should have been done yesterday. If it was documented as having been done yesterday, she would be having disciplinary action with the nurse. The PICC line dressing should have been changed every 7 days and not be occlusive (unable to see the insertion site). It should have only had gauze from the packet used for the initial (first) dressing. There should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Tubing should have been dated when hung. She would have Licensed Practical Nurse (LPN) 9 change the dressing. On 4/7/22 at 10:00 a.m. Resident E's Treatment Administration Record (TAR) was reviewed. The Record was initialed by the DON for Wednesday 4/6/22 at 9:00 a.m., which indicated the DON had changed Resident E's wound vac dressing. On 4/7/22 at 11:26 a.m., LPN 9 indicated she would be changing Resident E's wound vac dressing about 12:30 or 1:00 p.m., since she was busy. On 4/7/22 at 1:13 p.m., during an observation with LPN 9, Resident E was seated in the recliner in a laid-back position with the footrest up. The left foot dressing had been removed and was in a small trash can under the resident's foot. Bloody drainage dripped from the foot into the can. A washcloth covered the top of the resident's foot. There was still a puddle of red drainage on the floor, about the size of an orange. The wound on left outer aspect of foot was gapping open approximately 2 inches wide and 5 inches long. It appeared around a half an inch deep. LPN 9 did not take any measurements during the dressing application. On 4/11/22 at 2:35 p.m., Resident E was observed from the doorway as she slept in the recliner. The IV pole had 2 small IV bags hanging on the pump. The pole was pushed away from the resident. The infusion was complete. There was no date or time on the tubing. During an observation and interview, on 4/12/22 at 2:27 p.m., Resident E's IV pump hung on the pole with a completed IV bag and tubing in place. There was no date or time on the IV tubing. The wound vac was not connected to the resident's foot. The resident indicated it was beeping the evening before and the nurse could not fix it. She thought there was an air leak in the tubing or something. The nurse took the wound vac off and put on a wet to dry dressing. No one had come back to put the wound vac back on. On 4/5/22 at 2:46 p.m., the Administrator provided a current, undated policy titled, Admission Guidelines. This policy indicated, .All applicants for admission will be individually assessed for reasonable accommodation, ensuring that no barriers to admission of whole diagnostic groups or conditions occurs. The pre-admission evaluation of each prospective resident must ensure that only those individuals are admitted whose medical/psychosocial needs can be met by the facility. The facility must have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An evaluation of each resident shall be made, prior to admission, which shall include personal or telephone interviews with the resident, the resident's physician, or the representative of the facility from which the resident is being transferred, if applicable. At the time each individual is admitted , the facility must have physician's orders for immediate care that are based on a physical examination performed by a currently licensed attending physician or his /her designee, written on the day of admission or within 30 days prior to admission On 4/5/22 at 2:46 p.m., the Administrator provided a current, undated policy titled, Physician's Orders- (Following Physician Orders). This policy indicated, .It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. The facility must have orders upon admission from the physician for: dietary, drugs (if necessary), routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. AS assessments are completed, orders will be received from the physician to address significant findings of the assessments. Orders that accompany the resident on admission will be clarified by the physician through action of the nurse who will contact the physician for clarification upon the resident's admission 3. During a confidential interview it was indicated, the biggest concern related to Resident C's care at the facility, was how bad her foot and legs got. They weren't that bad in the hospital, then all of the sudden she got sent back to the hospital with black feet. She did originally have an ulcer on the bottom of her foot, but when she got back to the hospital, they were gangrene and black and looked like they were rotted off. Resident C was supposed to have a follow up doctor's appointment on 3/28/22 but the DON didn't do anything about it. On 4/13/22 at 3:58 p.m., Resident C's medical record was reviewed. She was admitted to the facility on [DATE] after a 4 day hospital stay where she was treated primarily for a foot fracture sustained durin

Based on observations, interviews, and record reviews, the facility failed to ensure for 2 of 7 residents reviewed for abuse were protected from abuse by a staff member, Certified Nursing Assistant (CNA) 23 which resulted in actual harm when CNA 23 was rough with Resident 29 during a transfer causing an acute injury and increased pain in his left wrist, and resulted in actual psychosocial harm when Resident 26 was angry, embarrassed, and pursued with increased urgency a transfer out of the facility due to verbal abuse from CNA 23. The facility failed to prevent psychosocial harm from residents overhearing verbal abuse to other residents 3 of 7 residents reviewed for abuse (Residents 39, 29, 26, 25, 53, 9, and 30). Findings include: 1. On 6/1/22 at 10:00 a.m., Resident 39 was interviewed. He indicated Resident 29 was hurt by Certified Nursing Assistant (CNA) 23. CNA 23 left marks all over his arm, and when his girlfriend came in to visit, she raised hell over it. CNA 23 was suspended then too, but they let him come back to work. On 6/1/22 at 10:40 a.m., Resident 29 was observed sitting up in his wheelchair beside his bed. At this time, he indicated his wrist hurt. His left wrist was observed resting across his lap. The wrist area was swollen and when Resident 29 lightly pressed it with his other hand he indicated it was tender to touch. Resident 29 indicated Certified Nursing Assistant (CNA) 23 had been too rough with him during a transfer a couple weeks ago when he yanked him up out of his wheelchair which caused his wrist to swell up and start hurting. Resident 29 indicated he usually had pain on his left side because that was the side which was taken out during his stroke, but the pain in his wrist was new and had not gone away since the incident with CNA 23. Resident 29 indicated he used to think CNA 23 was a pretty good worker, even if he was always in a hurry and sometimes made you feel like a pest. After Resident 29 complained about the pain in his wrist and what happened, everyone was really serious for the first few days, they got me an x-ray, and ice packs, but when the x-ray came back, they said it was fine and the pain was from his arthritis, so they let CNA 23 come back and everything went back to normal including CNA 23 caring for Resident 29. During a confidential interview, it was indicated CNA 23 was a serial abuser. They heard about the alleged incidents upon return to work, that CNA 23 had hurt Resident 29's arm and yelled at Resident 26. Also, CNA 23 yelled at Resident 25 all the time, but when that was investigated previously, and he was suspended and came back to work anyway. As for Resident 29, he knew exactly what happened to him. Everyone tried to say, he's making it up for attention, but that was simply not true. Yes, he would get fixated on certain things and had a distracted attention span because of his stroke, but he was telling the truth. Staff upon hire were told if you were suspended over allegations of abuse that was that and you would be fired. But not since CNA 23 had been suspended 3 or 4 times over abuse allegations. During an interview on 6/1/22 at 3:05 p.m., Licensed Practical Nurse (LPN) 19 indicated he was the nurse on shift when the concern with Resident 29's wrist was brought to his attention. Resident 29's girlfriend had been in to visit and came to him with the concern. He went to look at Resident 29's wrist and found it to be swollen, and the Resident complained of great pain when it was touched or tried to move. Resident 29 had constant pain on that side anyway, so staff had to be extra careful and gentle when moving his affected side. On 6/1/22 at 10:50 a.m., Resident 29's medical record was reviewed. He had admitted to the facility on [DATE] with active and current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Progress Note, dated 2/14/22 at 10:00 a.m., indicated a telehealth video visit was conducted for his recent admission, medication refill, and covid screening. He takes [MEDICATION(S)] 7.5/325mg for chronic bilateral LE pain. States pain is constant and aching. Medication does help with pain. He requires prescription today Nursing Progress Note, dated 2/18/22 at 11:28 a.m., indicated a telehealth video visit was conducted for .Chronic pain secondary to [CONDITION(S)] (stroke) and [CONDITION(S)] . [Resident 29] states he has severe, chronic pain after experiencing MCA/[CONDITION(S)]. He states his pain is 10/10 without his [MEDICATION(S)] and relived to 6/10 with his medication. Pain described as severe, debilitating and constant located at his back right lower extremity [which would be his lower left leg]. He denies associated constipation. He has no other complaints today. No h/a, dizziness, confusion, lethargy, sob, cp/abdominal pain today. No other concerns [Resident 29's] Chronic pain is well controlled with [MEDICATION(S)] Nursing Progress Note, dated 2/21/22 at 7:22 p.m., indicated Resident 29 complained of general right-sided pain, and received his as needed pain medication. Nursing Progress Note, dated 2/22/22 at 10:58 a.m., indicated Resident 29 complained of chronic right-sided pain he endorsed as nerve pain in the right arm/leg. Stated the pain was sharp at times and achy at other times. An order was placed to increase his [MEDICATION(S)]. Nursing Progress Note, dated 2/25/22 at 5:09 p.m., indicated a telehealth video visit was conducted for general medical management and ongoing right sided pain in his upper and lower extremities. Pain had been present for several weeks and described and dull, achy, and progressive. The telehealth NP indicated the chronic pain and body aches were likely muscle atrophy/spasms related to his stroke and gave instructions to monitor pain and address if not improved in the next week. Nursing Progress Note, dated 3/15/22 at 11:00 a.m., indicated a telehealth video visit was conducted for regularly scheduled medical management and indicated Resident 29's pain was well controlled with the current medication regimen. Nursing Progress Note, dated 4/5/22 at 6:27 a.m., indicated Resident 29 complained of generalized leg pain and was administered medication which was affective. Nursing Progress Note, dated 4/7/22 at 11:02 a.m., indicated Resident 29 complained of generalized pain all over, and was administered pain medication which was effective. Nursing Progress Note, dated 4/14/22 at 5:12 a.m., indicated Resident 29 complained of generalized leg and back pain and was administered pain medication which was effective. Nursing Progress Note, dated 5/4/22, indicated Resident 29 initially complained of pain in his left wrist after a transfer, a stat x-ray was ordered, additional pain medication, and ice were also ordered. A change of condition nursing progress note was entered on 5/4/22 at 6:07 p.m., which indicated, .On call ordered a stat [as soon as possible] x-ray of left wrist, ibuprofen, 600 mg (milligrams) every 6 hours as needed for pain and apply ice pack to left wrist every 2 hours off for 1 hour A telehealth Nurse Practitioner (Np) visit was conducted on 5/4/22 at 7:37 p.m., using synchronous video call. At this time Resident 29's wrist was evaluated. Left arm/wrist is noted to be in the extended position with moderate swelling/redness and limited ROM with wrist flexion due to pain/swelling . New orders were given at this time to perform a STAT (immediate) x-ray, elevate, ice and immobilize until x-ray results returned, continue [MEDICATION(S)] every 6 hours as needed for pain, and complete a follow up x-ray for further assessment. A nursing progress note, dated 5/4/22 at 11:43 p.m., indicated Resident 29's left wrist was observed swollen shortly after dinner by his caregiver, an assessment of the affected left wrist was done, MD (medical doctor) on-call ordered a stat x-ray of the left wrist, ibuprofen, and ice pack as needed. Resident 29 indicated the swollen wrist happened during a transfer sometime on 5/3/22. The initial x-ray results were received, on 5/5/22 at 6:48 a.m. and indicated no definite radiographic evidence of acute fracture or dislocation, but if there were persistent symptoms, follow up x-ray may be obtained as clinically warranted. On 5/5/22 at 10:32 a.m., a telehealth video visit was conducted for follow up to Resident 29's continued complaint oof left wrist pain. The resident continued to endorse pain, swelling and limited range of motion (ROM) and stated he could not complete therapy due to the pain. Nursing Progress Note, dated 5/11/22 at 6:32 a.m., indicated Resident 29 complained of arm pain, and was administered pain medication which was effective. Nursing Progress Note, dated 5/18/22 at 4:08 a.m., indicated Resident 29 was noted to be yelling out, and asked for his pain medication for his legs and wrist and stated, I'm really hurting bad. Nursing Progress Note, dated 5/19/22 at 10:31 p.m., indicated Resident 29 continued to complaint of pain to his left hand, upon assessment swelling was noted, and an ice pack was applied. Nursing Progress Note, dated 5/20/22 at 5:46 p.m., indicated a telehealth video visit was conducted for pain management. Voltern gel was requested for pain relief which was ordered at that time. Nursing Progress Note, dated 5/33/22 at 8:11 a.m., Resident 29 continued to complain of pain in his left hand. The record lacked documentation that a follow up x-ray had been completed as indicated in the summary of the initial x-ray and follow up NP visit. Resident 29 had Pain Assessments completed upon admission on 2/7/22, 2/8/22 and again on 2/10/22. A Pain Assessment was completed on 5/4/22 after the allegation of abuse. Each assessment summarized Resident 29's pain as generalized aching throbbing, chronic all over. The 5/4/22 assessment indicated Resident 29's wrist appeared to be red and swollen. Actual worked nursing scheduled were reviewed and revealed CNA 23 had been on duty, assigned to the hall where Resident 29 resided on both 5/3/22 and 5/4/22. Resident 29's Point of Care (POC) responses entered by the assigned CNA caregiver who completed the tasks during that shift were reviewed from 5/3 to 6/3/22. On 5/3/22 and 5/4/22 CNA 23 transferred Resident 29. After returning from his suspension, CNA 23 transferred Resident 29 on 5/15, 5/19, 5/28, and 5/29. CNA 23 wrote a witness statement, dated 5/4/22, which indicated he had provided personal care and transferred Resident 29 into his wheelchair but never noticed any swelling or pain in his arm. CNA 23 indicated the last person to have physical contact with Resident 29 before he complained of pain was therapy, and therapy should have reported the injury. On 6/6/22 at 11:10 a.m., the Therapy Program Manager (TPM) was interviewed in regard CNA 23's witness statement and Resident 29's therapy participation. The TPM indicated even though he was new to the building, he had already heard rumors from staff and residents that CNA 23 had a bad mouth. He had heard the aid referred to as, mouth of the south. The TPM worked with Resident 29 a couple of days after the incident and noted some swelling in his left wrist and hand, so when they worked, he had to be careful when repositioning in order not to cause additional pain. As this time, the TPM provided copies of Resident 29's therapy progress notes. A Physical Therapy (PT) note, dated 5/3/22 at 12:37 p.m., indicated Resident 29 had participated in PT with no complaints of pain and no indication of injury to his left wrist. A PT note on the following day, dated 5/4/22 [time-stamp not provided], indicated, .pt [patient] presented [with] increased swelling on Left hand and elbow, unable to perform standing A Speech Therapy (ST) note, dated 5/5/22 at 12:42 p.m., indicated, .resident seen in his room and up in his wheelchair. New injury to hand with no recollection of procedures in place to improve it During an interview on 6/2/22 at 11:26 a.m., the Regional Director of Operations (RDO) indicated the facility planned to re-open the investigation into the abuse allegation related to Resident 29 and CNA 23. During an interview on 6/3/22 at 9:20 a.m., the RDO indicated Resident 29 had been sent to the hospital for further evaluation of his left wrist, but upon his arrival, indicated it was his shoulder that hurt instead. An x-ray had been completed on the left shoulder, and the hospital had not completed an x-ray on his left wrist. Resident 29 refused to be returned to the facility and insisted to be sent to a different facility. So, he was transferred the same day to a sister facility. Because an x-ray had not been completed on his wrist at the hospital, the RDO indicated another mobile x-ray would be completed as soon as possible. On 6/3/22 at 8:18 p.m., the x-ray results of Resident 29's wrist were received and indicated the presence of soft tissue swelling. 2. On 6/1/22 at 10:00 a.m., Resident 39 was interviewed. He indicated he had remaining concerns that CNA 23 was still working at the facility and continued to verbally abuse Resident 26, whose room was near Resident 39. Over the holiday weekend on 5/29/22, CNA 23 went off on Resident 26 again. Resident 26 had an incontinence accident and CNA 23 kept going up and down the hall and in and out of his room while getting him cleaned up screaming things like, G------ it man! You're too old for this s---! I can't believe you s--- yourself again, you're a f------ baby man! I should be up at the track the way you you've got me running around like this! This went on the whole time it took to get Resident 26 cleaned up. It was at least 10 minutes. Resident 39 indicated Resident 26 was so angry he was visibly shaking and asked Resident 39 to go with him to report it to management. Monday was a holiday, and no management was at the facility. So, first thing Tuesday morning Resident 39 went with Resident 26 to the Social Service Director (SSD). When they reported it to the SSD, she took over and notified the Administrator and Director of Nursing (DON). Resident 39 indicated all he knew at this time, was CNA 23 was suspended again but it probably wouldn't do any good since this was like his 3rd suspension. On 6/1/22 at 10:10 a.m., Resident 53 was interviewed. She indicated she knew who CNA 23 was and she had the same concerns she had shared during the previous survey visit. Resident 53 indicated she did overhear CNA 23 yelling at another resident over the holiday weekend, 5/29/22, after he had an incontinence accident. On 6/2/22 at 9:35 a.m., Resident 26 was observed as he sat up in his bed. He indicated he did not like CNA 23 at all. CNA 23 screamed and yelled at him all the time because he would have accidents on himself. It embarrassed him because the whole hall could hear it. Resident 26 wanted to get the hell out of this place, if he was going to be treated like that. Resident 26 indicated the last incident happened the previous weekend on 5/29/22. CNA 23 had yelled at him before as well, but he was fed up with it and wanted out of the building. During a follow up interview on 6/2/22 at 9:45 a.m., Resident 29 indicated, we've been warning yall about him [CNA 23]. Resident 29 indicated he had heard CNA 23 yell up and down the hall, especially at Resident 26. The aid said things like, I can't believe you f------ s--- on yourself! Man, I don't get paid enough to keep wiping you're a-- like this! It seemed like CNA 23 was just burnt out, he had a really short fuse, and you did not want to be on the wrong side when it went off. At this time Resident 29's roommate indicated he heard CNA 23 yell up and down the hall all the time. It was really off-putting, and he was thankful that he could still do most everything for himself because he did not want to have to ask CNA 23 for help. A state reportable incident was filed on 5/31/22 (two days after the incident occurred). The reportable indicated, Resident 26 reported the incident to the SSD. CNA 23 told him, You are too d--- old to be doing this s--- you know. I should be at the Indy 500 the way you have got me running! An investigation conducted and substantiated. The employee was terminated and reported to the Attorney General's office. Resident 39 and 26 both submitted confidential witness statements on 5/31/22 which were signed by the Administrator. During an interview on 6/2/22 at 10:50 a.m., Resident 26's family member indicated Resident 26 had seemed more depressed lately when she talked with him on the phone. The last conversation they had, there was an increased sense of urgency in Resident 26's voice when he told her he wanted to move out of the facility because of a recent incident between him and a staff member. Resident 26's family indicated she lived in another state at the moment but was looking for available placement for Resident 26 to transfer closer to her. On 6/2/22 at 2:05 p.m., with the Administrator present Resident 26 was re-interviewed and confirmed the story that CNA 23 had yelled and cursed at him for having an accident on himself. Resident 26's record was reviewed on 6/2/22 at 3:00 p.m. The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. According to the MDS he was moderately cognitively impaired with a BIMS score of 11 of 15. There were no recently coded concerns related to behaviors, and he was frequently incontinent of both bowel and urine. 3. On 6/1/22 at 10:10 a.m., Resident 53 was interviewed. She indicated she knew who CNA 23 was and she had the same concerns she had shared during the previous survey visit. Resident 53 demanded CNA 23 to come off her caregiver assignment after he roughly transferred her from her wheelchair to her bed, and her knee whacked the side of the bed. Even though CNA 23 came off her assignment, he still came in to help her roommate, Resident 25. CNA 23 cussed at her all the time for falling. Even though Resident 25 was deaf, Resident 53 did not like to hear it, and it upset her on behalf of her roommate. On 6/2/22 at 2:00 p.m., with the Administrator present Resident 53 was re-interviewed and confirmed the previously stated allegation that CNA 23 was verbally abusive toward her roommate, Resident 25, and that because he had hurt her knee a while ago during a transfer, she had him taken off her assignment. Resident 53's record was reviewed on 6/2/22 at 3:00 p.m. Resident 53 had a current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 53's most recent comprehensive assessment was a significant change Minimum Data Set (MDS) assessment dated [DATE]. According to the MDS she was cognitively intact with a BIMS (brief interview for mental status) score of 14 of 15, with no recently coded concern related to behaviors. 4. On 6/2/22 at 2:10 p.m., with the Administrator present Resident 9 indicated she had wanted to say something when survey was at the facility the last time during the Resident Council Meeting, but everyone had been treating her so good, she was afraid to say anything about CNA 23, and then have staff retaliate against her. Resident 9 indicated, yes, it was true, CNA 23 was really mean, and went all around cussing and fussing at everyone. Resident 9's room was near Resident 26's and Resident 30's. Resident 9 heard CNA 23 yell at Resident 26 for having an accident on himself and had overheard him belittling Resident 30 for being too fat. On 6/2/22 at 2:20 p.m., with the Administrator present Resident 30 with hesitation and anxiety, asked Do I have to tell the truth? The Administrator patiently and gently encouraged her to tell the truth. Resident 30 indicated, yes, CNA 23 was mean and told her things like she was too big, and made her roommate cry all the time. During an interview on 6/3/22 at 12:25 p.m., the RDO indicated another state reportable had been submitted related to a new allegation. When the Administrator conducted a follow up interview with Resident 9 related to the previous verbal abuse allegation, Resident 9 indicated she overheard CNA 23 say sexuality explicit things towards Resident 30. He told the resident he wanted to stick his d--- between her t------ and get off that way. During a follow up interview on 6/3/22 at 2:26 p.m., the RDO and Administrator indicated the investigation into the sexual verbal abuse had been conducted and would be substantiated. The RDO and Administrator both agreed they knew Resident 9 very well, had no reason to doubt her, and trusted what she said was true. The investigation was substantiated, and the CNA would be terminated. During the investigation it was determined the statement CNA 23 made to the resident was delivered with the intention of being a joke, and they did not believe he had any plans to act against Resident 30 or any other resident. The content of the joke, and language of the joke however were absolutely intolerable and inappropriate. Resident 9's record was reviewed on 6/2/22 at 3:00 p.m. The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. According to the MDS she was cognitively intact with a BIMS score of 15 of 15 and there were no recently coded concerns related to behaviors. Resident 30's record was reviewed on 6/2/22 at 3:00 p.m. The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. According to the MDS she was cognitively intact with a BIMS score of 13 of 15 and there were no recently coded concerns related to behaviors. Resident 30 had a comprehensive care plan dated 3/23/22 for manipulative behaviors, the record lacked documentation of any recent or recurring behaviors. CNA 23's employee file was requested and provided by the Administrator on 6/3/22 at 11:25 a.m. and reviewed at this time. A CNA specific job orientation checklist was present from the time of CNA 23's hire on 8/13/20. The orientation checklist only included the CNA's initials and signature. There was no preceptor's initials or signature to signify the individual skills had been checked off, and there was no nursing supervisor signature, that his skills had been checked off. Further his file included 5 Disciplinary Action Reports, 3 of which were specifically related to allegations of abuse or mistreatment. A Disciplinary Action Report, dated 4/4/22, indicated he had been suspended for allegations of verbal abuse. A Disciplinary Action Report, dated 5/4/22, indicated he had been suspended for allegations of abuse. A Disciplinary Action Report, dated 5/31/22, indicated, suspended, waiting results of investigation. During an interview on 6/2/22 at 10:30 a.m., the RDO indicated there was no specific policy that included details or spoke to employee disciplinary actions. That staff disciplinary actions would be made as needed on a case-by-case incident. However, it was his personal expectation that there was a no tolerance policy when it came to abuse. If someone was suspended for abuse, then they would be termed (fired). As part of the plan of correction (POC) for two abuse deficiencies related to reporting abuse, and investigating abuse cited during the annual recertification survey on 4/13/22, the Administrator/DON/Designee were to educate staff on the Abuse Prevention Program. In-Services were held on 5/5/22 and 5/6/22. The sign in sheets for the In-Service were included in the POC binder and indicated handwritten in all caps at the top of the page, ALL EMPLOYEES. CNA 23 was not included on any of the 4 pages of staff sign-ins. As a part of the POC for two previously cited abuse deficient (F609 for reporting abuse, and F610 for investigating abuse), the Administrator/DON/Designee educated staff on the Abuse Prevention Program. In-Services were held on 5/5/22 and 5/6/22 and included the following material which served as the current facility policy and expectation: An undated policy titled, Abuse Prevention Program. The policy indicated, .This facility will not tolerate resident abuse or treatment [mistreatment] by anyone, including staff member, other residents, consultants, volunteers, staff or other agencies, family members, legal guardians, friends of other individuals . Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being . Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability . Sexual Abuse: Including, but not limited to, sexual harassment, sexual coercion or sexual assault. Physical Abuse: hitting, slapping, kicking, etc. It also includes controlling behaviors through corporal punishment An undated policy titled, Dignity. The policy indicated, .As an extension of appropriate interactions between staff and residents, the following will be practices of the facility. NOTE: Depending on scope and severity; what appears to be a dignity issue often can be interpreted and even meet the criteria for abuse. Conversations 1.) Staff will be polite and respectful at all times. 2.) Staff will not speak in a manner that could be interpreted as even minimally condescending/critical or argumentative not in a volume any louder that is absolutely necessary as this can be interpreted as meting criteria for abuse. 6.) Staff will not make reference to a malodorous field caused by the resident. This includes commenting on the smell of bad breath, body odor, urine or BM [bowel movement] . this could cause the resident embarrassment. Care 1.) Staff will maintain resident privacy during all personal care . 3.) Should a resident have an episode of incontinence, staff will change them upon discovery of the episode 3.1-27(a)(1) 3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure 2 of 7 residents were free of physical abuse from CNA 23. (Resident 29 and Resident 53). The deficient practice resulted in Resident 29 experiencing a soft tissue injury to the left wrist with increased pain. The facility failed to ensure 3 of 7 residents were free of verbal abuse by CNA 23. (Resident 26, Resident 25, and Resident 30). The deficient practice resulted in 5 of 7 residents overhearing the abuse and experiencing negative reactions or outcomes (Resident 29, Resident 39, Resident 53, Resident 9, and Resident 30). Findings include: 1. On 6/1/22 at 10:00 a.m., Resident 39 was interviewed. He indicated Resident 29 was hurt by Certified Nursing Assistant (CNA) 23. CNA 23 left marks all over his arm, and when his girlfriend came in to visit, she raised hell over it. CNA 23 was suspended then too, but they let him come back to work. On 6/1/22 at 10:40 a.m., Resident 29 was observed sitting up in his wheelchair beside his bed. At this time, he indicated his wrist hurt. His left wrist was observed resting across his lap. The wrist area was swollen and when Resident 29 lightly pressed it with his other hand he indicated it was tender to touch. Resident 29 indicated Certified Nursing Assistant (CNA) 23 had been too rough with him during a transfer a couple weeks ago when he yanked him up out of his wheelchair which caused his wrist to swell up and start hurting. Resident 29 indicated he usually had pain on his left side because that was the side which was taken out during his stroke, but the pain in his wrist was new and had not gone away since the incident with CNA 23. Resident 29 indicated he used to think CNA 23 was a pretty good worker, even if he was always in a hurry and sometimes made you feel like a pest. After Resident 29 complained about the pain in his wrist and what happened, everyone was really serious for the first few days, they got me an x-ray, and ice packs, but when the x-ray came back, they said it was fine and the pain was from his arthritis, so they let CNA 23 come back and everything went back to normal including CNA 23 caring for Resident 29. During a confidential interview, it was indicated CNA 23 was a serial abuser. They heard about the alleged incidents upon return to work, that CNA 23 had hurt Resident 29's arm and yelled at Resident 26. Also, CNA 23 yelled at Resident 25 all the time, but when that was investigated previously, and he was suspended and came back to work anyway. As for Resident 29, he knew exactly what happened to him. Everyone tried to say, he's making it up for attention, but that was simply not true. Yes, he would get fixated on certain things and had a distracted attention span because of his stroke, but he was telling the truth. Staff upon hire were told if you were suspended over allegations of abuse that was that and you would be fired. But not since CNA 23 had been suspended 3 or 4 times over abuse allegations. During an interview on 6/1/22 at 3:05 p.m., Licensed Practical Nurse (LPN) 19 indicated he was the nurse on shift when the concern with Resident 29's wrist was brought to his attention. Resident 29's girlfriend had been in to visit and came to him with the concern. He went to look at Resident 29's wrist and found it to be swollen, and the Resident complained of great pain when it was touched or tried to move. Resident 29 had constant pain on that side anyway, so staff had to be extra careful and gentle when moving his affected side. On 6/1/22 at 10:50 a.m., Resident 29's medical record was reviewed. He had admitted to the facility on [DATE] with active and current diagnoses which included, but were not limited to, hemiplegia and hemiparesis (paralysis and muscle weakness) following cerebral infarction (stroke), muscle wasting and atrophy, and abnormal posture. Nursing Progress Note, dated 2/14/22 at 10:00 a.m., indicated a telehealth video visit was conducted for his recent admission, medication refill, and covid screening. . He takes Percocet 7.5/325mg for chronic bilateral LE pain. States pain is constant and aching. Medication does help with pain. He requires prescription today Nursing Progress Note, dated 2/18/22 at 11:28 a.m., indicated a telehealth video visit was conducted for .Chronic pain secondary to CVA (stroke) and hemiplegia . [Resident 29] states he has severe, chronic pain after experiencing MCA/CVA. He states his pain is 10/10 without his Norco and relived to 6/10 with his medication. Pain described as severe, debilitating and constant located at his back right lower extremity [which would be his lower left leg]. He denies associated constipation. He has no other complaints today. No h/a, dizziness, confusion, lethargy, sob, cp/abdominal pain today. No other concerns [Resident 29's] Chronic pain is well controlled with Norco Nursing Progress Note, dated 2/21/22 at 7:22 p.m., indicated Resident 29 complained of general right-sided pain, and received his as needed pain medication. Nursing Progress Note, dated 2/22/22 at 10:58 a.m., indicated Resident 29 complained of chronic right-sided pain he endorsed as nerve pain in the right arm/leg. Stated the pain was sharp at times and achy at other times. An order was placed to increase his Gabapentin. Nursing Progress Note, dated 2/25/22 at 5:09 p.m., indicated a telehealth video visit was conducted for general medical management and ongoing right sided pain in his upper and lower extremities. Pain had been present for several weeks and described and dull, achy, and progressive. The telehealth NP indicated the chronic pain and body aches were likely muscle atrophy/spasms related to his stroke and gave instructions to monitor pain and address if not improved in the next week. Nursing Progress Note, dated 3/15/22 at 11:00 a.m., indicated a telehealth video visit was conducted for regularly scheduled medical management and indicated Resident 29's pain was well controlled with the current medication regimen. Nursing Progress Note, dated 4/5/22 at 6:27 a.m., indicated Resident 29 complained of generalized leg pain and was administered medication which was affective. Nursing Progress Note, dated 4/7/22 at 11:02 a.m., indicated Resident 29 complained of generalized pain all over, and was administered pain medication which was effective. Nursing Progress Note, dated 4/14/22 at 5:12 a.m., indicated Resident 29 complained of generalized leg and back pain and was administered pain medication which was effective. Nursing Progress Note, dated 5/4/22, indicated Resident 29 initially complained of pain in his left wrist after a transfer, a stat x-ray was ordered, additional pain medication, and ice were also ordered. A change of condition nursing progress note was entered on 5/4/22 at 6:07 p.m., which indicated, .On call ordered a stat [as soon as possible] x-ray of left wrist, ibuprofen, 600 mg (milligrams) every 6 hours as needed for pain and apply ice pack to left wrist every 2 hours off for 1 hour A telehealth Nurse Practitioner (Np) visit was conducted on 5/4/22 at 7:37 p.m., using synchronous video call. At this time Resident 29's wrist was evaluated. . Left arm/wrist is noted to be in the extended position with moderate swelling/redness and limited ROM with wrist flexion due to pain/swelling . New orders were given at this time to perform a STAT (immediate) x-ray, elevate, ice and immobilize until x-ray results returned, continue oxycodone every 6 hours as needed for pain, and complete a follow up x-ray for further assessment. A nursing progress note, dated 5/4/22 at 11:43 p.m., indicated Resident 29's left wrist was observed swollen shortly after dinner by his caregiver, an assessment of the affected left wrist was done, MD (medical doctor) on-call ordered a stat x-ray of the left wrist, ibuprofen, and ice pack as needed. Resident 29 indicated the swollen wrist happened during a transfer sometime on 5/3/22. The initial x-ray results were received, on 5/5/22 at 6:48 a.m. and indicated no definite radiographic evidence of acute fracture or dislocation, but if there were persistent symptoms, follow up x-ray may be obtained as clinically warranted. On 5/5/22 at 10:32 a.m., a telehealth video visit was conducted for follow up to Resident 29's continued complaint oof left wrist pain. The resident continued to endorse pain, swelling and limited range of motion (ROM) and stated he could not complete therapy due to the pain. Nursing Progress Note, dated 5/11/22 at 6:32 a.m., indicated Resident 29 complained of arm pain, and was administered pain medication which was effective. Nursing Progress Note, dated 5/18/22 at 4:08 a.m., indicated Resident 29 was noted to be yelling out, and asked for his pain medication for his legs and wrist and stated, I'm really hurting bad. Nursing Progress Note, dated 5/19/22 at 10:31 p.m., indicated Resident 29 continued to complaint of pain to his left hand, upon assessment swelling was noted, and an ice pack was applied. Nursing Progress Note, dated 5/20/22 at 5:46 p.m., indicated a telehealth video visit was conducted for pain management. Voltern gel was requested for pain relief which was ordered at that time. Nursing Progress Note, dated 5/33/22 at 8:11 a.m., Resident 29 continued to complain of pain in his left hand. The record lacked documentation that a follow up x-ray had been completed as indicated in the summary of the initial x-ray and follow up NP visit. Resident 29 had Pain Assessments completed upon admission on [DATE], 2/8/22 and again on 2/10/22. A Pain Assessment was completed on 5/4/22 after the allegation of abuse. Each assessment summarized Resident 29's pain as generalized aching throbbing, chronic all over. The 5/4/22 assessment indicated Resident 29's wrist appeared to be red and swollen. Actual worked nursing scheduled were reviewed and revealed CNA 23 had been on duty, assigned to the hall where Resident 29 resided on both 5/3/22 and 5/4/22. Resident 29's Point of Care (POC) responses entered by the assigned CNA caregiver who completed the tasks during that shift were reviewed from 5/3 to 6/3/22. On 5/3/22 and 5/4/22 CNA 23 transferred Resident 29. After returning from his suspension, CNA 23 transferred Resident 29 on 5/15, 5/19, 5/28, and 5/29. CNA 23 wrote a witness statement, dated 5/4/22, which indicated he had provided personal care and transferred Resident 29 into his wheelchair but never noticed any swelling or pain in his arm. CNA 23 indicated the last person to have physical contact with Resident 29 before he complained of pain was therapy, and therapy should have reported the injury. On 6/6/22 at 11:10 a.m., the Therapy Program Manager (TPM) was interviewed in regard CNA 23's witness statement and Resident 29's therapy participation. The TPM indicated even though he was new to the building, he had already heard rumors from staff and residents that CNA 23 had a bad mouth. He had heard the aid referred to as, mouth of the south. The TPM worked with Resident 29 a couple of days after the incident and noted some swelling in his left wrist and hand, so when they worked, he had to be careful when repositioning in order not to cause additional pain. As this time, the TPM provided copies of Resident 29's therapy progress notes. A Physical Therapy (PT) note, dated 5/3/22 at 12:37 p.m., indicated Resident 29 had participated in PT with no complaints of pain and no indication of injury to his left wrist. A PT note on the following day, dated 5/4/22 [time-stamp not provided], indicated, .pt [patient] presented [with] increased swelling on Left hand and elbow, unable to perform standing A Speech Therapy (ST) note, dated 5/5/22 at 12:42 p.m., indicated, .resident seen in his room and up in his wheelchair. New injury to hand with no recollection of procedures in place to improve it During an interview on 6/2/22 at 11:26 a.m., the Regional Director of Operations (RDO) indicated the facility planned to re-open the investigation into the abuse allegation related to Resident 29 and CNA 23. During an interview on 6/3/22 at 9:20 a.m., the RDO indicated Resident 29 had been sent to the hospital for further evaluation of his left wrist, but upon his arrival, indicated it was his shoulder that hurt instead. An x-ray had been completed on the left shoulder, and the hospital had not completed an x-ray on his left wrist. Resident 29 refused to be returned to the facility and insisted to be sent to a different facility. So, he was transferred the same day to a sister facility. Because an x-ray had not been completed on his wrist at the hospital, the RDO indicated another mobile x-ray would be completed as soon as possible. On 6/3/22 at 8:18 p.m., the x-ray results of Resident 29's wrist were received and indicated the presence of soft tissue swelling. 2. On 6/1/22 at 10:00 a.m., Resident 39 was interviewed. He indicated he had remaining concerns that CNA 23 was still working at the facility and continued to verbally abuse Resident 26, whose room was near Resident 39. Over the holiday weekend on 5/29/22, CNA 23 went off on Resident 26 again. Resident 26 had an incontinence accident and CNA 23 kept going up and down the hall and in and out of his room while getting him cleaned up screaming things like, G------ it man! You're too old for this s---! I can't believe you s--- yourself again, you're a f------ baby man! I should be up at the track the way you you've got me running around like this! This went on the whole time it took to get Resident 26 cleaned up. It was at least 10 minutes. Resident 39 indicated Resident 26 was so angry he was visibly shaking and asked Resident 39 to go with him to report it to management. Monday was a holiday, and no management was at the facility. So, first thing Tuesday morning Resident 39 went with Resident 26 to the Social Service Director (SSD). When they reported it to the SSD, she took over and notified the Administrator and Director of Nursing (DON). Resident 39 indicated all he knew at this time, was CNA 23 was suspended again but it probably wouldn't do any good since this was like his 3rd suspension. On 6/1/22 at 10:10 a.m., Resident 53 was interviewed. She indicated she knew who CNA 23 was and she had the same concerns she had shared during the previous survey visit. Resident 53 indicated she did overhear CNA 23 yelling at another resident over the holiday weekend, 5/29/22, after he had an incontinence accident. On 6/2/22 at 9:35 a.m., Resident 26 was observed as he sat up in his bed. He indicated he did not like CNA 23 at all. CNA 23 screamed and yelled at him all the time because he would have accidents on himself. It embarrassed him because the whole hall could hear it. Resident 26 wanted to get the hell out of this place, if he was going to be treated like that. Resident 26 indicated the last incident happened the previous weekend on 5/29/22. CNA 23 had yelled at him before as well, but he was fed up with it and wanted out of the building. During a follow up interview on 6/2/22 at 9:45 a.m., Resident 29 indicated, we've been warning yall about him [CNA 23]. Resident 29 indicated he had heard CNA 23 yell up and down the hall, especially at Resident 26. The aid said things like, I can't believe you f------ s--- on yourself! Man, I don't get paid enough to keep wiping you're a-- like this! It seemed like CNA 23 was just burnt out, he had a really short fuse, and you did not want to be on the wrong side when it went off. At this time Resident 29's roommate indicated he heard CNA 23 yell up and down the hall all the time. It was really off-putting, and he was thankful that he could still do most everything for himself because he did not want to have to ask CNA 23 for help. A state reportable incident was filed on 5/31/22 (two days after the incident occurred). The reportable indicated, Resident 26 reported the incident to the SSD. CNA 23 told him, You are too d--- old to be doing this s--- you know. I should be at the Indy 500 the way you have got me running! An investigation conducted and substantiated. The employee was terminated and reported to the Attorney General's office. Resident 39 and 26 both submitted confidential witness statements on 5/31/22 which were signed by the Administrator. During an interview on 6/2/22 at 10:50 a.m., Resident 26's family member indicated Resident 26 had seemed more depressed lately when she talked with him on the phone. The last conversation they had, there was an increased sense of urgency in Resident 26's voice when he told her he wanted to move out of the facility because of a recent incident between him and a staff member. Resident 26's family indicated she lived in another state at the moment but was looking for available placement for Resident 26 to transfer closer to her. On 6/2/22 at 2:05 p.m., with the Administrator present Resident 26 was re-interviewed and confirmed the story that CNA 23 had yelled and cursed at him for having an accident on himself. Resident 26's record was reviewed on 6/2/22 at 3:00 p.m. The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. According to the MDS he was moderately cognitively impaired with a BIMS score of 11 of 15. There were no recently coded concerns related to behaviors, and he was frequently incontinent of both bowel and urine. 3. On 6/1/22 at 10:10 a.m., Resident 53 was interviewed. She indicated she knew who CNA 23 was and she had the same concerns she had shared during the previous survey visit. Resident 53 demanded CNA 23 to come off her caregiver assignment after he roughly transferred her from her wheelchair to her bed, and her knee whacked the side of the bed. Even though CNA 23 came off her assignment, he still came in to help her roommate, Resident 25. CNA 23 cussed at her all the time for falling. Even though Resident 25 was deaf, Resident 53 did not like to hear it, and it upset her on behalf of her roommate. On 6/2/22 at 2:00 p.m., with the Administrator present Resident 53 was re-interviewed and confirmed the previously stated allegation that CNA 23 was verbally abusive toward her roommate, Resident 25, and that because he had hurt her knee a while ago during a transfer, she had him taken off her assignment. Resident 53's record was reviewed on 6/2/22 at 3:00 p.m. Resident 53 had a current diagnosis which included but was not limited to bipolar disorder, and a comprehensive care plan (dated 3/10/22) for manipulative behaviors related to the bipolar disorder, the record lacked documentation of the recent or ongoing behaviors. Resident 53's most recent comprehensive assessment was a significant change Minimum Data Set (MDS) assessment dated [DATE]. According to the MDS she was cognitively intact with a BIMS (brief interview for mental status) score of 14 of 15, with no recently coded concern related to behaviors. 4. On 6/2/22 at 2:10 p.m., with the Administrator present Resident 9 indicated she had wanted to say something when survey was at the facility the last time during the Resident Council Meeting, but everyone had been treating her so good, she was afraid to say anything about CNA 23, and then have staff retaliate against her. Resident 9 indicated, yes, it was true, CNA 23 was really mean, and went all around cussing and fussing at everyone. Resident 9's room was near Resident 26's and Resident 30's. Resident 9 heard CNA 23 yell at Resident 26 for having an accident on himself and had overheard him belittling Resident 30 for being too fat. On 6/2/22 at 2:20 p.m., with the Administrator present Resident 30 with hesitation and anxiety, asked Do I have to tell the truth? The Administrator patiently and gently encouraged her to tell the truth. Resident 30 indicated, yes, CNA 23 was mean and told her things like she was too big, and made her roommate cry all the time. During an interview on 6/3/22 at 12:25 p.m., the RDO indicated another state reportable had been submitted related to a new allegation. When the Administrator conducted a follow up interview with Resident 9 related to the previous verbal abuse allegation, Resident 9 indicated she overheard CNA 23 say sexuality explicit things towards Resident 30. He told the resident he wanted to stick his d--- between her t------ and get off that way. During a follow up interview on 6/3/22 at 2:26 p.m., the RDO and Administrator indicated the investigation into the sexual verbal abuse had been conducted and would be substantiated. The RDO and Administrator both agreed they knew Resident 9 very well, had no reason to doubt her, and trusted what she said was true. The investigation was substantiated, and the CNA would be terminated. During the investigation it was determined the statement CNA 23 made to the resident was delivered with the intention of being a joke, and they did not believe he had any plans to act against Resident 30 or any other resident. The content of the joke, and language of the joke however were absolutely intolerable and inappropriate. Resident 9's record was reviewed on 6/2/22 at 3:00 p.m. The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. According to the MDS she was cognitively intact with a BIMS score of 15 of 15 and there were no recently coded concerns related to behaviors. Resident 30's record was reviewed on 6/2/22 at 3:00 p.m. The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. According to the MDS she was cognitively intact with a BIMS score of 13 of 15 and there were no recently coded concerns related to behaviors. Resident 30 had a comprehensive care plan dated 3/23/22 for manipulative behaviors, the record lacked documentation of any recent or recurring behaviors. CNA 23's employee file was requested and provided by the Administrator on 6/3/22 at 11:25 a.m. and reviewed at this time. A CNA specific job orientation checklist was present from the time of CNA 23's hire on 8/13/20. The orientation checklist only included the CNA's initials and signature. There was no preceptor's initials or signature to signify the individual skills had been checked off, and there was no nursing supervisor signature, that his skills had been checked off. Further his file included 5 Disciplinary Action Reports, 3 of which were specifically related to allegations of abuse or mistreatment. A Disciplinary Action Report, dated 4/4/22, indicated he had been suspended for allegations of verbal abuse. A Disciplinary Action Report, dated 5/4/22, indicated he had been suspended for allegations of abuse. A Disciplinary Action Report, dated 5/31/22, indicated, suspended, waiting results of investigation. During an interview on 6/2/22 at 10:30 a.m., the RDO indicated there was no specific policy that included details or spoke to employee disciplinary actions. That staff disciplinary actions would be made as needed on a case-by-case incident. However, it was his personal expectation that there was a no tolerance policy when it came to abuse. If someone was suspended for abuse, then they would be termed (fired). As part of the plan of correction (POC) for two abuse deficiencies related to reporting abuse, and investigating abuse cited during the annual recertification survey on 4/13/22, the Administrator/DON/Designee were to educate staff on the Abuse Prevention Program. In-Services were held on 5/5/22 and 5/6/22. The sign in sheets for the In-Service were included in the POC binder and indicated handwritten in all caps at the top of the page, ALL EMPLOYEES. CNA 23 was not included on any of the 4 pages of staff sign-ins. As a part of the POC for two previously cited abuse deficient (F609 for reporting abuse, and F610 for investigating abuse), the Administrator/DON/Designee educated staff on the Abuse Prevention Program. In-Services were held on 5/5/22 and 5/6/22 and included the following material which served as the current facility policy and expectation: An undated policy titled, Abuse Prevention Program. The policy indicated, .This facility will not tolerate resident abuse or treatment [mistreatment] by anyone, including staff member, other residents, consultants, volunteers, staff or other agencies, family members, legal guardians, friends of other individuals . Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being . Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability . Sexual Abuse: Including, but not limited to, sexual harassment, sexual coercion or sexual assault. Physical Abuse: hitting, slapping, kicking, etc. It also includes controlling behaviors through corporal punishment An undated policy titled, Dignity. The policy indicated, .As an extension of appropriate interactions between staff and residents, the following will be practices of the facility. NOTE: Depending on scope and severity; what appears to be a dignity issue often can be interpreted and even meet the criteria for abuse. Conversations 1.) Staff will be polite and respectful at all times. 2.) Staff will not speak in a manner that could be interpreted as even minimally condescending/critical or argumentative not in a volume any louder that is absolutely necessary as this can be interpreted as meting criteria for abuse. 6.) Staff will not make reference to a malodorous field caused by the resident. This includes commenting on the smell of bad breath, body odor, urine or BM [bowel movement] . this could cause the resident embarrassment. Care 1.) Staff will maintain resident privacy during all personal care . 3.) Should a resident have an episode of incontinence, staff will change them upon discovery of the episode 3.1-27(a)(1) 3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure residents choice of code status was documented in the medical record for 5 of 59 residents reviewed for advanced directives (Resident D, W, M, BC and N) which resulted in immediate jeopardy when the facility failed to follow the Cardiopulmonary Resuscitation (CPR) procedure for an unresponsive resident without respirations and no code status recorded resulting in death (Resident D). The Immediate Jeopardy began on [DATE] when Resident D was found unresponsive, and the nurse was unable to determine the resident's code status from the medical record. The nurse left the resident unattended and called the hospice company and the Director of Nursing (DON) for guidance. The DON indicated the resident was a full code and to initiate CPR. The nurse took the Code Cart to the resident's room but failed to initiate CPR or call 911, when she took a call from hospice and during the conversation determined the Resident was a DNR. CPR was not initiated. No DNR paperwork was signed so the resident should have been a Full Code. The Interim Administrator, Director of Nursing, Regional Director of Operations, and Regional Nurse Consultant were notified of the immediate jeopardy on [DATE] at 5:47 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On [DATE] at 9:39 a.m., during a random observation of the 100 Hall, Resident D was observed sitting in a wheelchair in his room, with an overbed table in front of him. A breakfast meal tray was on the table, in front of the resident. He was eating. On [DATE] at 3:00 p.m., Resident D's medical record was reviewed. The resident had been admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The demographics bar of the electronic record did not list a code status. There was no code status listed in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A General Progress Note, dated [DATE] at 11:31 p.m., indicated, resident arrived via stretcher. He is alert and able to voice his wants and needs. Staff assisted him to and from the bathroom. medications inputted and pharmacy notified. Resident continues on pain medication. Called [sic] placed to [Company Name] hospice to let them know that he is here. He will be hospice during his stay. He has [CONDITION(S)] and has no options at this time. Staff continues to assist him as needed. Will continue to follow up as needed. A Hospice Care Plan, dated [DATE], with a target date of [DATE] indicated Resident D received hospice services from [Name of Company] Hospice. The goal indicated Resident D's wishes for hospice services would be respected thru the next review date. The interventions included educate family/resident as needed on the end of life care process. Hospice services as ordered. Invite Hospice to all care plan meetings. Keep hospice CNA/nurse updated on any care changes. Keep hospice notified of all transfers and discharges. Notify Hospice nurse of any new orders and changes in condition. Observe for pain. On [DATE] at 9:31 p.m., a Nursing Progress Note indicated, Resident found laying [sic] in the bed[sic] with a change in skin tone, non-responsive to physical touch and sound, respirations 0, Spo2 [oxygen saturation] 10%, HR [heart rate] 0, BP [blood pressure] ,d+[DATE] .MD [medical doctor], Family, nursing management, hospice notified. Notification of death permit completed; body picked up by [Name] funeral home in [City Name]. On [DATE] at 10:32 p.m., an Advance Directive Discussion (Admission) form was initiated in the patient care record. It was blank, never completed. The status shows in progress. During an interview, on [DATE] at 9:42 a.m., the Director of Nursing (DON) indicated Resident D had passed away last night, it was expected. He was hospice. He was young. The doctor said had he been treated when he was first diagnosed , they could have cured him, but he was too far advanced. He was a do not resuscitate (DNR). He did yell out a lot, his pain probably was not controlled. On [DATE] at 9:08 a.m., Resident D's paper chart and hospice admission booklet were reviewed. The admission booklet appeared to be questions and answers related to the company and hospice care. It did not contain any advanced directives or code status information. The resident's face sheet was blank in the area which indicated code status. The face sheet indicated Resident was his own responsible party. The advanced directive section tab in the hard chart contained nothing. On [DATE] at 10:55 a.m., during an interview, the DON indicated the DNR- post form should have been in the front of the chart, clearly visible and ready for staff to be able to check. Resident D did not have a post form in his chart. Licensed Practical Nurse 21 had called hospice, on the phone and asked his code status, when they found him blue in the bed. Hospice told them not to attempt resuscitation. The documentation was not in his record. The DON called hospice and asked them to fax over the documentation for his DNR, at that time, but they were still waiting for it. On [DATE] at 3:13 p.m., during an interview LPN 21, indicated she had usually worked evening and night shifts. She usually worked the 100 hall and was familiar with Resident D. He had been admitted to the facility due to [CONDITION(S)] and was receiving hospice services. The hospice had done admission paperwork for him on Wednesday ([DATE]). She had received report from day shift that nothing was unusual, he was OK. She gave him his 4:00 p.m. medications and he had asked for lorazepam (anxiety medication) and when smoke time was. She said she would check on him after she finished medication pass. The CNA came and told her he had a fall, when she went down to check on him, and he was already back in bed. She didn't know if he put himself back in bed, but he was capable of doing so. She initiated vital signs, and neuro checks. They were all within normal limits (WNL). He just didn't say anything about the fall just worried about smoking. No new injuries, he had some previous areas. She guessed he had a lot of [CONDITION(S)], where he had been weeping and then some area opened on bilateral lower extremities. The fall was unwitnessed, so we assumed he hit head that's why neuro checks were initiated. On the next 15 minutes check, still asking when it was time to go smoke, but at that time it was dinner time, so she moved the tray to him. Dinner was already in the room. When she came back, still checking on him for fall follow up, he had eaten a little bit of the hot dog all of the fruit and all of his juice. Did not go out to go smoke. Then she came back to check, he was still eating slow, then he stopped asking about smoking and he was just eating really slow, which was his usual, she told him she would take him out to smoke later. He had 2 falls. One before dinner and one after dinner. She went back to continue neuro checks, this time he was on the floor, right in front of his bed, laying on his right side facing the door, his eyes were closed. He was non-responsive to verbal stimuli, he just looked lifeless, his color hadn't changed it was still kind of pink, and his eyes were closed. She flipped him onto his back and shook him, but he still did not respond. She did a sternal rub, but no response. She thought he was a hospice resident and had to look for a code status. There was no code status documented so she called the DON and hospice to determine the resident was a DNR. She could not remember the timeline exactly, just that there was a fall before dinner, and a fall after dinner. The dinner tray had already been picked up, before the second fall. Dinner was about 5:30 p.m. Hospice had given a booklet to her on Wednesday before they left, after they had completed the admission. It was a bound booklet and she put it on his chart binder. It did not contain any orders or code status. On [DATE] at 3:40 p.m., during an interview the DON indicated when LPN 21 called her she was driving in her car. Her first thing was to always say, we don't have code status, start CPR. LPN 21 grabbed the crash cart. She pulled over into a parking lot to check the medical record and couldn't find anything, so told her to start CPR. On [DATE] at 3:57 p.m., LPN 21 indicated when the DON spoke to her on the phone, she did not tell her to initiate CPR, she did get the crash cart and was putting the oxygen on him, but that's when hospice called her back and told her he was a DNR. She never made any compressions. She was the one who found him, he was still warm, the last time she would have laid eyes on him would have been no more than 30 minutes prior because of the neuro check follow ups. She remembered waiting for that open window so she could get other stuff done. On [DATE] at 4:32 p.m., during a telephone interview, the [Name of Company] Hospice Director indicated the Hospice Admission Nurse had completed the hospice admission assessment, for Resident D, in the facility on [DATE]. Any signed paperwork had not been returned to facility, he passed away before the next hospice visit, so his chart did not contain all the forms. The Hospice Admission Nurse would have printed the forms out when she returned to the office. Then the physician would have signed off on the orders, and the forms would have been returned to the facility at the next visit. When the Hospice Admission Nurse completed the assessment, for Resident D, she talked to the resident about his advanced directive, but she did not feel he was mentally able to make a commitment or sign anything, at that time. The facility had been informed by the Hospice Nurse, when she was leaving and gave them the bound hospice information guide, he would be a full code, because they had nothing in writing to make him a DNR. Hospice had spoken to his sister, who thought he had that in writing at one time, but she did not have a copy of it. (Name of Hospital), where he came from, had nothing signed in writing for him to be a DNR, even though they had referred him for hospice and comfort care. So, until they could get a post form signed, legally he had to be a full code. The Hospice Director had talked to the DON yesterday about the resident and told her he should have been a full code. It was her understanding he was coded at the time he was found unresponsive. On [DATE] at 1:12 p.m., the Assistant Director of Nursing provided a current, undated policy, titled, Advance Directives Policy and Procedure. This policy indicated .Determine on admission whether the resident/legal representative has a advanced directive and if not, determine whether the resident/legal representative wishes to formulate an advance directive .Establish mechanisms for documenting and communicating resident choices to the IDT [intradisciplinary team] .Upon admission the facility will provide written information to the resident/legal representative concerning the resident's rights to make decisions regarding medical care including the right to accept/refuse medical treatment and the right to formulate advance directives .Upon admission, the facility must determine if the resident executed an advance directive or has given other instructions to indicate what care is desired in case of subsequent incapacity The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility assessed all residents for code status. Residents with DNR were reviewed for signed post forms. Nursing staff were in-serviced on CPR and code status. The facility initiated a plan to ensure residents admitted to the facility had documented code status. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. 3.,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure a resident's environment was safe from hazardous conditions to prevent the resident from falling, after the resident was observed in his room, by several staff members, not wearing shoes or grip socks, with multiple environmental hazards present, and screaming out loudly for several hours which resulted in an immediate jeopardy when the resident sustained 2 falls in one shift and died within hours of the last fall for 1 of 4 residents reviewed for falls (Resident D). The immediate jeopardy began on [DATE] when the resident's environment was observed in a hazardous condition which later that day resulted in 2 falls on the same shift, and the resident was found unresponsive on the floor, without respirations, resulting in the resident's death. The Interim Administrator, Director of Nursing, Regional Director of Operations, and Regional Nurse Consultant were notified of the immediate jeopardy on [DATE] at 5:47 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On [DATE] at 9:39 a.m., during a random observation of the 100 Hall, Resident D was observed sitting in a wheelchair in his room, with an overbed table in front of him. A breakfast meal tray was on the table, in front of the resident. He was eating. The room was in disarray. A wet sheet was lying on the floor at the foot of the bed. On the floor, in front of the overbed table, was a large puddle of oatmeal. A door sign which read yellow zone was sticking out of the oatmeal, standing up at an angle. There were multiple puddles of liquid on the floor beside the wheelchair. Plastic silverware was on the floor throughout the room in several places. On [DATE] at 9:47 a.m., Resident D was observed up walking around the room. He wore only gray nylon athletic shorts, no shirt, socks, or shoes. A black pair of plastic sandals were on the floor in the middle of the room. He came to the doorway and indicated he needed a broom to clean his room. He was then observed bending over scooping oatmeal up with the door sign. On [DATE] at 9:50 a.m., Licensed Practical Nurse (LPN) 3 went into Resident D's room. Resident D was standing on the wet sheet, which was now covered in a moderate amount of food debris. The bed and bedside table also had spilled food and debris visible from the doorway, and hall. LPN 3 asked Resident D if he was still eating breakfast. Resident D answered No. LPN 3 removed the meal tray and dishes from the overbed table and placed it on a plastic tiered cart, in the hallway. On [DATE] at 11:45 a.m., while standing in the dining room, loud shrill screaming was heard, from the direction of the 100 hall. On [DATE] from 11:50 a.m. through 12:15 p.m., during a continuous observation, Resident D was observed sitting in a chair, by the window. He was screaming, a very shrill scream at intervals of 1 to 2 minutes, repeatedly. He would bend forward and dip his head to the floor as he screamed out. The resident continued to wear only shorts, no shirt, socks, or shoes. The room was now observed with smeared food and liquids over a large area, from in front of the door to the bed. A cup, plastic lid, a straw, 3 spoons, a fork, and 4 wadded napkins were also observed on the floor. Several unidentified employees passed up and down the hall. At 12:00 p.m., Resident D was still screaming and could be heard to the Nursing Station (10 rooms away). LPN 3 and Qualified Nurse Aid (QMA) 5 were observed at the Nurses' Station charting on computers and talking. At 12:06 p.m., an unidentified dietary aid pushed a plastic 3 tiered cart onto the 100 hallway and called out You all's lunch trays are here. Certified Nurse Aid (CNA) 13, came out of the Nurses' Station and went to the 100 hall, where he delivered meal trays to each of the residents. Resident D continued to scream out. At 12:15 p.m., QMA 5 entered Resident D's room and closed the door. On [DATE] at 2:47 p.m., Resident D was observed, from the hallway, through the open door. He was sitting on the edge of the bed wearing long gray cloth pants. He was not wearing a shirt, shoes, or socks. He continued to scream out, no discernable words, just yelling out. The Screams could be heard from greater than 50 feet away in the Nurses' Station and Dining Room. Several unidentified employees passed up and down the hall without stopping to check on Resident D. On [DATE] at 3:00 p.m., Resident D's medical record was reviewed. The resident had been admitted to the facility on [DATE]. The diagnoses included, but were not limited to, pneumonia, [CONDITION(S)], and abdominal pain. The prescribed medications included, but were not limited to, [MEDICATION(S)] (narcotic pain medication) ,d+[DATE] milligrams (mg) give 1 tablet every 4 hours for pain, [MEDICATION(S)] (narcotic pain medication) give 10 mg every 4 hours as needed for shortness of breath or pain last given on [DATE] at 10:00 p.m., and [MEDICATION(S)] (blood thinner/anticoagulant) 40 mg inject subcutaneously (under skin) one time a day for anticoagulated. On [DATE] at 11:31 p.m., a General Progress Note indicated, resident arrived via stretcher. He is alert and able to voice his wants and needs. Staff assisted him to and from the bathroom. medications inputted and pharmacy notified. Resident continues on pain medication. Called [sic] placed to [Company Name] hospice to let them know that he is here. He will be hospice during his stay. He has [CONDITION(S)] and has no options at this time. Staff continues to assist him as needed. Will continue to follow up as needed. A nursing care plan, dated [DATE] with a target date of [DATE], indicated Resident D had a potential for falls due to new surroundings. The goal was for no falls to have occurred. The interventions included call light in reach, coordinate care with hospice, encourage to ask for assistance with transfers or ambulation, keep paths free of clutter, and therapy screen quarterly and as needed. On [DATE] at 8:37 a.m., a Physician Telehealth Visit note indicated .Chief complaint: C/o pain to bilateral feet and finger, numbness and burning XXX[AGE] year old male with [CONDITION(S)]. Resides in skilled nursing facility under hospice for symptom management. He is sitting up in chair for visit. He is anxious and asking for additional pain medications for pain to feet and fingers. He is taking [MEDICATION(S)] [narcotic pain medication] concentrate and [MEDICATION(S)] [narcotic pain medication] prn [as needed] pain An initial fall risk assessment, dated [DATE], indicated Resident D's fall risk was a 9, with a score of 10 or greater being at risk. On [DATE] at 5:10 p.m., a fall risk assessment was entered into the electronic record, due to a significant change. The resident scored a 10 at that time. On [DATE] at 5:40 p.m., a nursing note indicated, CNA reported to Nurse that PT [patient] had a unwitnessed fall, when entering to room PT was sitting in bed, he stated that had slipped in the water in bathroom, Pt didn't have on proper footing at the time of fall, Pt reported that his pain was per usual PRN [as needed] given and proven effective, slip grip socks applied, neuro checks started, no rotation or shorting of any extremities, hospice, family and management notified. On [DATE] at 5:10 p.m., a Change in Condition report indicated on [DATE] at 7:33 p.m. the resident had the following vital signs that were electronically linked from the vital signs assessed on [DATE]. The blood pressure was ,d+[DATE], pulse 100, respirations 22. No concerns or physician recommendations were reported. On [DATE] at 9:31 p.m., a Nursing Progress Note indicated, Resident found laying [sic] in the bed[sic] with a change in skin tone, non-responsive to physical touch and sound, respirations 0, Spo2 [oxygen saturation] 10%, HR 0, BP ,d+[DATE]. MD, Family, nursing management, hospice notified. Notification of death permit completed; body picked up by [Name] funeral home in [City Name]. During an interview, on [DATE] at 9:42 a.m., the Director of Nursing (DON) indicated Resident D had passed away last night, it was expected. He was a hospice resident. He was young. The doctor indicated he was advanced. He was a do not resuscitate (DNR). He did yell out a lot. His pain probably was not controlled. During an interview on [DATE] at 3:13 p.m., Licensed Practical Nurse (LPN) 21 indicated she had usually worked evening and night shifts. She usually worked the 100 hall and was familiar with Resident D. He had been admitted to the facility due to [CONDITION(S)] and was receiving hospice services. The hospice had done admission paperwork and for him on Wednesday ([DATE]). She had received report from day shift that nothing was unusual, he was OK. She gave him his 4:00 p.m. medications and he had asked for lorazepam [anxiety medication] and when smoke time was. She said she would check on him after she finished medication pass. The CNA came and told her he had a fall, when she went down to check on him, and he was already back in bed. She didn't know if he put himself back in bed, but he was capable of doing so. He had on some jogging pants dark in color, no shirt. She went to get him a gown, initiated vital signs, and neuros, they were all WNL (within normal limits), at 4:00 he had that pain pill, maybe that's why he wasn't in pain. The bed was in lower position, but not lowest. The bed was straight. He had nothing on his feet. He just didn't say anything about the fall just worried about smoking. No new injuries, he had some previous areas. She guessed he had a lot of [CONDITION(S)], where he had been weeping and then some areas opened on bilateral lower extremities. The fall was unwitnessed, so we assumed he hit head that's why neuro checks were initiated. On the next 15 minutes check, he was still asking when it was time to go smoke, but at that time it was dinner time, so she moved the tray to him, dinner was already in the room. When she came back, still checking on him for fall follow up, he had eaten a little bit of the hot dog, all of the fruit and all of his juice. Did not go out to go smoke. Then she came back to check, he was still eating slow, then he stopped asking about smoking and he was just eating really slow, which was his usual, she told him she would take him out to smoke later. He had 2 falls. One before dinner and one after dinner. She went back to continue neuro checks, this time he was on the floor- right in front of his bed, laying on his right side facing the door, his eyes were closed. He was non-responsive to verbal stimuli, he just looked lifeless, his color hadn't changed it was still kind of pink, his eyes were closed. She flipped him onto his back and shook him, but he still did not respond, did sternal rub, no response. I thought he was a no code. I had to leave him and go to the computer and see what his code status was, but it didn't say anything. So, I looked in the hospice binder, it didn't say anything. Then I grabbed my cell phone and went back to the room start calling everyone, called [DON], told her I didn't know code status, she didn't know it either. Then called hospice they told me he was a DNR. LPN 21 indicated she did not remember the timeline exactly, just a fall before dinner, and a fall after dinner. The dinner tray had already been picked up, before the second fall. Dinner was about 5:30 p.m. His vital signs, and the neuro checks she completed were on the front of his hard chart, but they weren't there when she looked again. It was possible the funeral home took his paperwork and took the vital sign sheet with them. Resident did not usually yell out on her shift. She thought he did it when he needed pain medication. Hospice had given a booklet to her on Wednesday before they left, after they had completed the admission. It was a bound booklet and she put it on his chart binder. It did not contain any orders or code status. No explanation was provided for the inconsistencies in the charting such as only documenting one fall, the documentation having vitals from a different date, or the resident being documented as found in the bed unresponsive instead of the floor. On [DATE] at 3:40 p.m., the DON provided a paper document, dated [DATE] and timed from 5:40 p.m. to 6:17 p.m., for Resident D with vital signs, recorded 7 times as within normal ranges. On [DATE] at 8:40 a.m., the Administrator (ADM) provided a current, undated policy, titled Incidents/Accidents/Falls. This policy indicated It is the policy of this facility to ensure that any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has immediate attention and their safety is established, a written report will be entered into Risk Management The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility audited all residents' records for falls to ensure assessments, notification as appropriate, and updated the residents' care plans and ensured proper footwear (non-skid socks) was provided. The staff was in-serviced on falls, physician notification, and sending residents to the hospital. The facility implemented a process to monitor for falls, physician notification, and transfers to the hospital. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaints IN 332 and IN 253. 3.,d+[DATE](a)(1) 3.,d+[DATE](a)(2)

Based on interview and record review, the facility failed to ensure a resident had a complete assessment after a fall and changes in condition and was sent out of the facility for treatment to the emergency room in when ordered by the physician for 1 of 4 residents reviewed for falls (Resident C). This resulted in immediate jeopardy when Resident C experienced a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy began on 5/5/21 at 6:40 a.m., when a Resident C had an unwitnessed, undocumented fall. The record lacked documentation of a complete set of assessments by not recording blood pressures for 7 of 9 assessments and the neuro checks ended at 11:00 a.m. Initial communication with the physician recorded at 6:40 a.m. gave instructions to send the resident to the emergency room (ER). The record lacked documentation of what time the resident left the facility, but an ER document indicated the first blood draws in the ER were at 3:49 p.m., more than 9 hours later. At that time, Resident D was medically unstable in critical condition and required immediate life-saving intervention due to hypovolemic shock with low hemoglobin, acute kidney injury, and right upper quadrant tenderness. The Interim Administrator, Director of Nursing, Regional Director of Operations, and Regional Nurse Consultant were notified of the immediate jeopardy on 6/10/21 at 2:59 p.m. The immediate jeopardy was removed on 6/12/21, but noncompliance remained at a lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 6/7/21 at 11:27 a.m., Resident C's record was reviewed. The record indicated had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C's mental status was listed as severely impaired. A nursing progress note, dated 5/5/21 at 6:40 a.m., indicated the Director of Nursing (DON) completed an SBAR (communication technique with physicians: situation, background, assessment, recommendation). The SBAR indicated Resident C experienced a change in condition with altered mental status and uncontrolled pain in his abdomen after an unwitnessed fall. A nursing evaluation was completed and indicated Resident C was more forgetful, had a change in consciousness and used a [MEDICATION(S)] (a blood thinning medication). A new order was given by the physician to send the resident to the ER for further evaluation after the fall. On 5/5/21 at 8:02 a.m., a note text by Registered Nurse (RN) 26 indicated, the Certified Nursing Assistant (CNA) alerted the RN at 6:40 a.m. that Resident C had fallen. The resident was found lying on floor with 1/3 of his body under the bed. He was in a supine position. He was assessed and was found neurologically intact. He was assisted back to bed with no apparent injury. The resident was alert to his name only. She contacted the DON and the family about the resident's fall. The family member indicated he wanted the resident to get an MRI of his head. On 5/5/21 at 12:07 p.m., a note text by Licensed Practical Nurse (LPN) 11 indicated, resident was sent to (name of hospital) for MRI that (name of family member) had requested resident is on [MEDICATION(S)] therapy therapy [sic] spoke with ER nurse concerning basis line change in mental status (mention has been declining in his cognition over the last 2 weeks) The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/21 at 8:04 p.m., during a (name of company) Telehealth Visit with Nurse Practitioner (NP) 25. The nursing staff reports resident had a fall this morning at 0630, unwitnessed, have noticed increased confusion. Family is concerned he may have hit his head due to changed mental status with an unwitnessed fall and the recommendation to send resident to ED. This plan and any patient orders were given verbally to (name of staff member) LPN 11. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (blood thinner, [MEDICATION(S)]) tablet 4 mg, give 8 mg by mouth one time a day related to [CONDITION(S)] [CONDITION(S)], ordered 4/21/21. b. Send resident to ER for MRI for head injury, increased confusion x 2 weeks, ordered on 5/5/21 at 12:37 p.m. A document for Resident C titled, Change in Condition Evaluation, dated 5/5/21, was provided by the DON on 6/8/21 at 2:29 p.m. A review of the document indicated, Resident C had altered mental status and uncontrolled pain. There was a gradual change in level of consciousness. The physician was notified on 5/5/21 at 3:00 p.m. with recommendations to send to the ER. The most recent blood pressure was 170/80 on 5/5/21 at 12:32 p.m. There was an abdominal/GI assessment change in condition and the resident reported abdominal pain. The resident was on [MEDICATION(S)]. Since the change in condition occurred the symptoms or signs had gotten worse, and the resident should be sent to hospital. The hospital indicated he was in [CONDITION(S)] shock, and blood was too low. An untitled worksheet for neuro checks for Resident C was provided by the DON on 6/8/21 at 2:29 p.m. Resident C's neuro checks started after a fall on 5/5/21 at 6:40 a.m. and continued until the 11:00 a.m. neuro check. His blood pressure was not recorded according to the facility's policy on 5/5/21 at 6:40 a.m., 6:55 a.m., 7:10 a.m., 7:25 a.m., 7:50 a.m., 8:20 a.m., and 9:00 a.m. The neuro check document ended at 11:00 a.m., Resident C did not arrive at the emergency room until approximately 3:30 p.m. During an interview, on 6/9/21 at 3:00 p.m., the DON indicated for neuro checks, the blood pressure should have been assessed to complete assessments according to the policy. During an interview, on 6/9/21 at 3:53 p.m., the DON indicated if Resident C's physician said send the resident to the emergency room , then staff should have called 911. She did not know why the resident wasn't taken to the emergency room by 911 or why the resident was at the facility for hours after the physician indicated to send the resident to the emergency room . It would not take 9 hours for a 911 ambulance to show up. After Resident C arrived at the hospital the DON was told Residents C was internally bleeding and his blood sugar was low. No explanation for the differences in documented times of physician notification in the resident's record was provided. (Name of Hospital) provided documents on 6/10/21 at 11:44 a.m. An emergency room (ER) physician's report, dated 5/5/21 at 3:49 p.m., completed upon Resident C's arrival to the ER indicated Resident C arrived at the emergency room via ambulance, after nursing facility staff found him on the floor at 6:40 a.m. The report indicated facility staff told the hospital staff, [Resident C] is not following commands like before. A RN (Registered Nurse) Emergency Department Triage (a process to determine the severity of a condition) note, dated 5/5/21 at 4:01 p.m., indicated Resident C was brought to the ER for [CONDITION(S)] (low blood pressure), confusion, and falls. In the ER, Resident C was found to be hypotensive (low blood pressure) with SBP (systolic blood pressure, a measurement of the maximum amount of blood pressure during one heartbeat, normal is 120) in the 50 - 60 range and [CONDITION(S)] (slow heart rate) in the 50s (an adult normal heart rate range is 60 to 100 beats per minute). The note indicated Resident C required, immediate life-saving interventions due to hypovolemic shock (life-threatening condition with loss of 20% of blood or body fluid). Laboratory results, dated 5/5/21 at 3:49 p.m., indicated Resident C had a critical hemoglobin (hgb) (oxygen carrying component of a red blood cell) level of 5.8. Resident C's red blood cell (RBC) level was 3.3 (RBC levels are considered low if below 4.29). His INR (measurement of how long it takes the blood to clot) was supratherapeutic (a greater level than would actually be used in treatment) was 3.9. Resident C's acute kidney injury, measured by his eGFR (estimated kidney filtration rate), was low at 29.0 and his creatinine levels were 2.18 on admission (normal levels are below 1.2). While still in the ER, Resident C was given 2-liters (approximately 68 ounces) of intravenous (inside a vein) fluid and 1 unit of packed RBC. His heart rate and rhythm ranged from 40 to 50s, irregular and bradycardic (slow). He was started on [MEDICATION(S)] (an intravenous medication used to stimulate the heart muscle and improve blood flow by helping the heart pump better). At 4:35 p.m., his blood pressure increased to 81/61. Resident C was admitted to the MICU (Medical Intensive Care Unit) on 5/5/21 at 7:39 p.m. After arrival to the MICU, he received an additional 2 units of packed RBC, and 3 units of fresh frozen plasma (FFP) (the liquid portion of whole blood). A current policy, titled, Incidents/Accidents/Falls, was provided by the DON on 6/9/21 at 10:55 a.m. A review of this policy indicated, .In the case of a fall, the resident will have a head to toe assessment to include a pain assessment .unwitnessed fall must have neuro checks started and continued per policy .The physician will be notified of any changes of condition related to the fall that have been identified. Orders for treatment and any interventions will be obtained A current policy, titled, Change in Resident's Condition or Status, was provided by the DON on 6/9/21 at 10:55 a.m. A review of this policy indicated, .The nurse will notify the resident's attending physician when the resident is involved in any accident or incident that results injury including injuries of unknown origin .There is a significant change in the resident's physical, mental or psychological status A current policy, titled, Neuro Checks, was provided by the DON on 6/9/21 at 1:12 p.m. A review of this policy indicated, .Always do neuro checks if the fall was unwitnessed by a staff member .Notify physician and Director of Nursing/Designee with any abnormal findings immediately .Unless ordered otherwise by the physician neuro checks are to be completed as follows: BP (blood pressure)/ Pulse/Pupil Checks (look for pupils to constrict with light) every 15 minutes for 2 hours, every 30 minutes for 2 hours, every 60 minutes for 4 hours, and vital signs and neurological checks every 8 hours and 16 hours .until 72 hours have elapsed The immediate jeopardy that began on 5/5/21 was removed on 6/12/21 when the facility audited all residents' records to determine if changes of condition occurred and treatment and/or notification occurred as appropriate. The staff was in-serviced on medical emergency, physician notification, and sending residents to the hospital. The facility implemented a process to monitor for timely assessments, physician notification, and transfers to the hospital. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 892. 3.1-37(a)

Based on interview and record review, the facility failed to ensure physician order's and care plans were followed resulting in a resident receiving the wrong diet, choking and being admitted to the surgical intensive care unit at the hospital for 1 of 3 residents reviewed for dietary orders (Resident C). Findings include: A document provided by the Director of Nursing on 10/6/17 at 2:45 p.m., dated 9/6/17 at 18:28 (6:28 p.m.) indicated, LPN (Licensed Practical Nurse) 8 wrote, res (resident) was observed in the dining room at the dinner table with a pale face and cyanotic (bluish or purplish discoloration of the skin or mucus membranes due to low oxygen saturation) lips and extremities, res still had a pulse and respiration, EMT (emergency medical technicians) were called, res transferred (sic) to (name of hospital) via stretcher, DON, Family, and MD were notified. On 10/6/17 at 11:48 a.m., the Administrator brought documentation, titled, Root Cause Analysis Incident Date 9/6/17. It indicated, Resident was given food tray that included chicken nuggets. Resident had choking incident. EMS (emergency medical services) was called. Resident was transported to hospital due to SOB (shortness of breath) and decreased mental status, and Nursing attempted to give Dietary Manager a print out of the order but Dietary Manager indicated that he wrote the order down. Dietary Manger did not check (software used by the facility). Dietary Manager gave dietary staff a copy of the diet print out that had the wrong diet on the slip. On 10/6/17 at 2:45 p.m., the Director of Nursing (DON) provided documentation of nursing progress notes that indicated on 9/7/17 at 4:26, LPN 9 wrote, .Res was admitted to the 5th floor, SICU (Surgical Intensive Care Unit). During an interview on 10/6/17 at 10:50 a.m., the Speech Language Pathologist (SLP) 4 indicated she upgraded Resident C to thin liquids, and would never have upgraded her foods to regular diet because the resident had problems with chewing and manipulating the bolus of food in her mouth. During an interview on 10/6/17 at 11:15 a.m., the Dietary Manager (DM) indicated there was a miscommunication between himself and one of the therapists. He indicated the therapist had upgraded Resident C to thin liquids, but he, misunderstood and upgraded the whole diet to thin liquid and regular food. During an interview on 10/6/17 at 2:40 p.m., Cook 6 indicated Resident C's food was sent out as regular food and thin liquid, and an aide brought the food back and indicated the food was wrong. Cook 6 looked at the Menu information sheet left for her by the DM, and indicated to the aide the food order was correct. She indicated the Resident received chicken nuggets, green beans, tater tots and yellow cake. On 10/6/17 at 11:00 a.m., the SLP provided documentation of Speech Therapy notes that indicated on 9/6/17 at 2:45 p.m., .SLP educated DON/nursing/family/CNAs/dietary manager regarding recommendations for upgrade to thin liquids and continuation of pureed solids and all verbalized understanding. Order placed on this for pureed solids with thin liquids in on (name of computer software used by the facility) and in written form by nursing and faxed to the doctor, and .SLP educated nursing/family regarding recommendations for upgrade to thing liquids and all agreed. Order placed on this date by nursing, and, .Pt (patient)was referred to skilled ST (Speech Therapy) after recent hospitalization due to choking incident on a chicken nugget per nsg (nursing) which resulted in aspiration pneumonia due to emesis .Oral Phase = Profound (Pt (patient) continues to have increased oral groping and [DIAGNOSES REDACTED] movements which effects ability to masticate (chew) which makes pt (patient) unsafe to trial solid consistencies .[DIAGNOSES REDACTED]. During an interview on 10/6/17 at 11:31 a.m., the DON indicated the facility called 911 because Resident C was choking and still moved air but was struggling to breathe. The hospital admitted the resident. During an interview on 10/6/17 at 11:38 a.m., the DON indicated the DM did not follow the facility policy by not checking the resident's orders in the (facility software on the computer). During an interview on 10/6/17 at 2:44 p.m., the DON indicated the therapist should not be communicating with the DM, the therapist should have communicated with nursing. During an interview on 10/6/17 at 2:45 p.m., the Clinical Director of Clinical Reimbursement indicated prior to the 9/6/17 choking event, Resident C was already diagnosed with [REDACTED]. On 10/6/17 at 11:48 a.m., the Administrator brought documentation, with a start date of 9/6/17 at 13:59 (1:59 p.m.), a verbal order was received by physician that indicated, Pureed texture, Thin Liquids consistency. On 10/6/17 at 2:25 p.m., the DON provided documentation of the physician's dietary orders as follows: Start date: 5/24/17 to 9/6/17: Regular/General Diet, Pureed texture, Nectar Thick liquids consistency. Start date: 9/6/17 to 9/12/17: Regular/General Diet, Pureed texture, Thin Liquids consistency. On 10/6/17 at 1:35 p.m., the Administrator provided Resident C's care plans, the care plans pertinent to the 9/6/17 event were as follows: Date Initiated: 9/29/17: Focus: Resident weight will be stabilized, as much as possible, while maintaining the choice of the resident and residents son regarding meals and all nourishment. Interventions: Date Initiated: 10/2/17: Resident will be given diet as ordered, and Date Initiated: 11/08/16, Revision on: 8/21/17: Focus: (Resident C) is edentulous and does not wear dentures. Able consume a pureed diet without difficulty, and Date Initiated: 11/2/16, Revision on: 5/17/17, Focus: Risk for SOB (shortness of breath) due to dx (diagnosis): [MEDICAL CONDITIONS]. On 10/6/17 at 11:48 a.m., the Administrator brought documentation, dated, 9/7/17, written by the DON, and indicated it was the facility's investigation of Resident C's, 9/6/17, choking event. The documentation indicated, in part, The ST (speech therapist) wrote an order for [REDACTED]. The charge nurse notified the doctor of the ST order and he concurred. The ST verbalized the order to the DM, and .When the ST verbalized to the DM that the diet was now Regular Diet pureed with thin liquids, the DM went to his department and wrote it down as Regular Diet with thin liquids. The puree specifications was not transcribed onto the information sheet or Diet Card. Therefore, when the meal was dished up it was served as a Regular Diet with thin liquids, and, The DM stated stat he should have checked the actual order and would do so in the future. On 10/6/17 at 2:45 p.m., the Administrator provided a Job Description of Dietary Manager, it included, Process diet changes and new diets as received from nursing services. On 10/6/17 at 2:45 p.m., the Administrator provided a policy, titled, Diet Orders, dated, 2017, it indicated, Each resident will have a diet order prescribed by the physician . and, Diet orders are clearly communicated, using a designated diet order communication form to Dining Services, and, All diet order communication forms received by the Dining Service are confirmed for accuracy by the Dining Services Manager . On 10/6/17 at 2:45 p.m., the Administrator provided a policy, titled, Physician order [REDACTED]. This Federal tag relates to Complaint IN 740 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure interventions to prevent a fall resulting in a large laceration to Resident #21's head, failed to ensure a wheelchair was maintained to safely transport Resident #40, and failed to ensure an environment free of potential hazards for 4 of 6 residents reviewed for accidents/hazards (Residents #21, #40, #28, and #25). This deficient practice had the potential to affect all residents who utilized handrails in the 200 and 300 hallway. Findings include: 1. During interview of Resident #21 on, 8/18/14 at 10:22 a.m., the resident indicated she had a fall recently and hit her head. During interview of LPN #10 on, 8/19/14 at 9:50 a.m., the LPN indicated the resident had a fall in the past 30 days. During review of Resident #21's clinical record on 8/21/14 at 10:25 a.m., documentation indicated on 6/17/14 at 7:50 p.m., "The nurse called to room (...) to find resident on floor (with) blood on floor. Dr (...) notified of fall and about a 2 inch gash on left side of face....Ambulance here to transfer." A nurses noted indicated the resident returned from the emergency roiagnom on , 6/18/14 at 12:40 a.m. Another nurses note on 6/18/14 at 2:30 a.m., indicated the resident "...has a 9.5 cm (centimeter) X .16 cm laceration left lateral brow on head from fall on 6/17/14." On 6/23/14 at 11:25 p.m., nurses notes documented "Call light answered, resident on floor on knees using 1/2 side rails to get up. Forehead against closet door. Noted sm (small) amt (amount) blood from raising hematoma with 2 cm (centimeter) laceration above right eye brow.." A nurses note on, 6/24/14 at 12:10 p.m. indicated "...No further bleeding but hematoma increasing in size (and) c/o (complaints of HA (headache) increasing. Call placed to Med Exchange again." 6/24/14 at 1:05 a.m., documentation indicated the resident was transferred to the emergency room and returned on 6/24/14 at 6:30 a.m. from the emergency room . A nurses note indicated on, 6/25/14 at 6:30 a.m., "Resident sitting (up) in w/c (wheel chair) alert and oriented to person and place. Hematoma above R (right) eye et (and) purplish discolorations (down) right eye. Discoloration (purple) on (L) (left) cheek area.." Documentation in the nurses notes on, 8/18/14 at 6 a.m., was noted of "Res (resident) screaming help-able to stand up and placed in bed.... no injuries noted - denies any pain or discomfort.." A "care plan meeting form" was noted, dated 6/24/14, identifying the resident as "continues to be a fall risk." A plan of care, with interventions to address the resident as a risk for falls and /or having falls was lacking. During interview of the MDS (minimum data set) coordinator on, 8/21/14 at 2:20 p.m., the coordinator indicated a significant change in condition assessment had been completed on, 6/24/14, due to the resident's hospitalization after a fall on 6/17/14. The MDS coordinator, after looking in the careplan book and in the computer, was unable to find a careplan addressing the resident with a risk of falls or with current falls. The MDS coordinator presented a "Fall Risk Assessment", dated 6/24/14, identifying the resident as a high risk for falls. During interview of the DON (Director of Nursing) on 8/21/14 at 2:20 p.m. the DON indicated, "The only thing I can tell you is she is at risk for falls." As to approaches or interventions to address falls, the DON indicated "we ask her to use her call light." 2. On 8/22/14 9:15 a.m. CNA #6 was pushing Resident #40 in a wheelchair. Resident was heard saying, "Oh, Oh". The CNA stopped the wheelchair and repositioned the residents feet from under the w/c. The CNA stated, "You need to move your feet." Foot rests were lacking on the wheelchair. The CNA began pushing the wheelchair again and the resident's legs and feet were observed dragging under the wheel chair. The CNA stopped again, repositioned the resident's feet and began pushing the wheelchair.. During review of Resident #40's clinical record on 8/22/14 at 9:50 a.m., documentation indicated on the the resident's careplan as self-care deficit..requiring extensive assist with activities of daily living (ADL), cognitive function/dementia impaired thought process..dementia, ensure resident is wearing appropriate footwear when mobilizing in the wheel chair." Dates to identify when these approaches were initiated were lacking. A quarterly assessment, dated 6/2/14, indicated the resident's functional status as "need for extensive assist and one person physical assist in all areas. A Dermatological progress note, dated 8/7/14, indicated, "...muscle strength is decreased on right and left feet...range of motion was limited on right and left heel." 3. During an observation, with the maintenance person present, on 8/19/14 at 10:15 p.m., water temperature in Resident #28's bathroom sink was 123.9 degrees Fahrenheit and was 123.4 degrees Fahrenheit in Resident #5's bathroom sink. During interview on 8/19/14 at 10:15 a.m., the maintenance person indicated "try to keep the water temperatures at 110 degrees Fahrenheit or less." Resident #28's clinical record was reviewed on 8/22/14 at 12 p.m. An annual MDS (minimum data set) dated, 6/19/14, indicated the resident as requiring total dependence with personal hygiene. Resident #5's clinical record was reviewed on 8/22/14 at 1 p.m. An admitted was noted of, 5/9/14. The resident admission assessment indicated the resident was independent with bed mobility, transfers, walking/locomotion, eating and toileting. During an interview on 8/22/14 at 11:38 A.M., with the Maintenance Supervisor and the Administrator present, the Maintenance Supervisor indicated he didn't have a system for ongoing maintenance repairs. He indicated if he saw something was broken he would fix it or if staff filled out a work order he would fix it. He indicated he did not have the observed broken/damaged items on a work order list to be repaired. 4. During initial tour on 8/18/14 at 7:30 A.M. and during the environmental tour on 8/22/14 at 11:38 A.M., with the Maintenance Supervisor and the Administrator present, the following observations were made: Observations of the 200 hall: The end cap of the hand rail outside of room 207 was missing from the left corner exposing sharp edges. The end caps were missing from the hand rails exposing sharp edges on the area between rooms 208 and 210. Observations of 300 hall: The end cap was missing from the handrail outside of room 310 exposing sharp ends. A policy titled "Preventive Maintenance Schedule Environmental Services" identified as current by the Administrator on 8/22/14 at 2:00 P.M., indicated, "It is the policy of the environmental services department to maintain a preventive maintenance schedule for each piece of equipment in the environmental service department. The preventive maintenance will be completed by the facility environmental service department or the facility designated service provider. It will be the responsibility of the environmental service supervisor to monitor regularly scheduled preventative maintenance on all equipment in the environmental service. It is the responsibility of the environmental service supervisor to insure that required repairs are completed in a timely manor. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to identify and implement plans of action to correct quality deficiencies related to restorative/specialized services to ensure safe eating and prevent decline in strength, transferring skills, locomotion skills, and range of motion. The facility failed to identify and implement corrective measures to prevent/prohibit and/or investigate allegations of resident abuse and failed to ensure criminal background checks for 7 staff prior to beginning employment. The facility failed to identify and implement corrective action plans related to care plan revisions, infection control, and notification of Medicare Non-Coverage of services for 15 of 38 residents residing in the facility ((Residents #41, #32, #28, #34, #6, #A, #55, #35, #32, #47, #46, #2, and #48, Employees CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, Dietary #1 and Housekeeping #1) Finidngs include: 1. Resident #41's record was reviewed on 9/12/2013 at 3:35 P.M. Resident #41 had [DIAGNOSES REDACTED]. The record lacked documentation to indicate restorative services were provided to prevent decline in the resident ' s physical functioning (Refer to F311). The record lacked evidence to indicate Resident #41 was free from abuse (Refer to F223). The record lacked evidence that an allegation of abuser was thoroughly investigated (Refer to F225). 2. Resident #32's clinical record was reviewed on 9/11/13 at 10:15 A.M. Resident #32's [DIAGNOSES REDACTED]. The record lacked documentation to indicate therapy services were provided to prevent decline in the resident ' s ability to ambulate (Refer to F311). 3. Resident #28's record was reviewed on 9/13/13 at 9:45 a.m. Resident #28's [DIAGNOSES REDACTED]. The resident's Admission MDS (Minimum Data Set) assessment dated [DATE], indicated the resident was mildly cognitively impaired. The record lacked documentation to indicate therapy services were provided to prevent loss of ability to propel self in a wheel chair (Refer to F311). 4. Resident #34's record was reviewed on 9/16/13 at 10:30 a.m. Resident #34's [DIAGNOSES REDACTED]. The record lacked documentation to indicate a recommended speech therapy evaluation was completed to ensure safe eating (Refer to F325). The record lacked documentation to indicate an allegation of abuser was fully investigated (Refer to f225) 5. Employee records were reviewed on 9/17/2013. Documentation was lacking which indicated criminal history checks had been completed for the following employees: 1) CNA (certified nursing assistant) #4 -hire date 8/28/2013. 2) CNA #5-hire date 6/26/2013. 3) CNA #6-hire date 7/26/2013. 4) CNA #7-hire date 8/19/13. 5) CNA #8-no hire date available. 6) House Keeper #1-hire date 8/2/2013. 7) Dietary Staff #1-hire date 8/22/13. 6. Resident #6's record was reviewed on 9/13/13 at 10:50 a.m. Resident #6's [DIAGNOSES REDACTED]. Resident #6 was admitted to hospice on 3/26/13. The record lacked documentation to indicate coordination of care and specific interventions between the facility and hospice services (Refer to F279) 7. Resident #A's record was reviewed on 9/11/13 at 2:10 p.m. Resident #A's [DIAGNOSES REDACTED]. A Comprehensive Admission MDS (Minimum Data Set) assessment dated [DATE], indicated the resident was frequently incontinent of urine. The record lacked documentation to indicate a care plan had been developed to reduce/manage the resident ' s incontinence (Refer to F279). 8. During an interview at 12:15 P.M., the DON was asked what the facility's system was to track and trend the causes of infections and what was done with the results. The DON stated, "We have QA (quality assurance) meetings. If it is UTIs (urinary tract infections) the Medical Director will tell us what to monitor. No, I don't have documentation of this. I pass it on to my nurses. We don't have documentation but we would enforce hand washing." The DON indicated the facility did not have written policies and procedures which established method to monitor, investigate, document, and/or analyze the occurrences of nosocomial infections (Refer to F441). 9. Review of "Skilled Nursing facility Advanced Beneficiary Notice" letter dated 4/2/13, indicated "...reviewed your medical coverage and found services furnished (Name of Resident #55) no longer qualifies as coverage under Medicare beginning 4/19/13. The letter indicated there were efforts to contact the notifier "earlier in the day by person or telephone were unsuccessful." The letter did not indicate if Medicare was to be billed for services. The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer. The letter was signed by the resident who was severely cognitively impaired (Refer to F156). 10. Review of Resident #35 ' s "Skilled Nursing facility Advanced Beneficiary Notice" letter dated 2/27/13 (sic), indicated Medicare coverage would end beginning 3/27/13. The MDS indicated the resident last day of physical and occupation therapy was 3/28/13. The letter indicated there were efforts to contact the notifier "earlier in the day by person or telephone were unsuccessful." "...B. I do not want my bill services I continue to need for submission to the intermediary for Medicare decision (sic)." The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer. The letter was signed by the resident who was severely cognitively impaired (Refer to F156). 11. Review of Resident #32 ' s "Skilled Nursing facility Advanced Beneficiary Notice" letter dated 3/28/13, did not indicate Resident #32's date of admission. The letter indicated Medicare coverage would end beginning 4/29/13. "...B. I do not want my bill services I continue to need for submission to the intermediary for Medicare decision (sic)." The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer (Refer to F156). 12. Review of Resident #47 ' s "Skilled Nursing facility Advanced Beneficiary Notice" letter dated 4/14/13, did not indicate Resident #47's date of admission. The letter indicated "...reviewed your medical coverage and found services furnished (Name of Resident #55) no longer qualifies as coverage under Medicare beginning 4/30/13. The letter did not indicate if Medicare was to be billed for services. The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer. The letter was signed with an "X" by the resident who was severely cognitively impaired Another "Skilled Nursing facility Advanced Beneficiary Notice" letter dated 4/1513, did not indicate Resident #47's date of admission. The letter indicated "...indicated (Name of Resident #47) no longer qualifies as coverage under Medicare beginning 4/29/13. The letter indicated there were efforts to contact the notifier "earlier in the day by person or telephone were unsuccessful." The letter indicated "...B. I do not want my bill services I continue to need for submission to the intermediary for Medicare decision (sic)." The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer. The letter was signed with the resident's name who was severely cognitively impaired. 13. Review of Resident #41 ' s "Skilled Nursing facility Advanced Beneficiary Notice" letter dated 6/14/13, did not indicate Resident #41's date of admission. The letter indicated "...reviewed your medical coverage and found services furnished (Name of Resident #55) no longer qualifies as coverage under Medicare beginning 6/29/13. The letter did not indicate if Medicare was to be billed for services. The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer (Refer to F156). 14. Review of Resident #46 ' s " Skilled Nursing facility Advanced Beneficiary Notice" letter dated 5/27/13, did not indicate Resident #46's date of admission. The letter indicated "...reviewed your medical coverage and found services furnished (Name of Resident #55) no longer qualifies as coverage under Medicare beginning 6/4/13. The letter indicated there were efforts to contact the notifier "earlier in the day by person or telephone were unsuccessful." The letter did not indicate if Medicare was to be billed for services. The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer. The letter was signed by the resident who was severely cognitively impaired (Refer to F156). , 15. Review of Resident #2 ' s "Skilled Nursing facility Advanced Beneficiary Notice" letter dated 8/12/13, did not indicate Resident #2's date of admission. The MDS (Minimum Data Set) Assessment indicated the resident was admitted into the facility on [DATE]. The letter indicated "...reviewed your medical coverage and found services furnished (Name of Resident #55) no longer qualifies as coverage under Medicare beginning 3/13/13. The letter did not indicate if Medicare was to be billed for services. The letter did not indicate the name and address of the intermediary. The letter did not inform the beneficiary he/she would not have Medicare appeal rights if the bill was not submitted. There was not a signature of the Administrative Officer (Refer to F156). 16. Review of the Occupational and Physical therapy discharge note for Resident #48 indicated the resident was receiving Occupational and Physical therapy services until 6/28/13. A Medicare Non-Coverage form was not provided by the facility (Refer to F156). 17. A therapy consent form from (name of therapy company) dated 6/22/13, indicated Resident #28 was going to receive occupational and physical therapy services under Medicare Part A. A Medicare Non-Coverage form was not provided by the facility. This Federal Tag relates to complaint number IN 532. 3.1-52(b)(2)

Based on observation, interview, and record review, the facility failed to ensure residents received restorative services needed to prevent loss of ability to ambulate and decline in strength, transferring skills, locomotion skills, and range of motion for 5 of 5 residents reviewed for restorative services. (Residents #41, #32, #28, #34, and #49). Findings include: 1. Resident #41's record was reviewed on 9/12/2013 at 3:35 P.M. Resident #41 had [DIAGNOSES REDACTED]. A five day significant change Minimum Data Set Assessment Tool ((MDS) dated [DATE], indicated Resident #41 was re-admitted to the facility on [DATE], after being discharged from an acute care hospital, where he received treatment for [REDACTED]. During an observation on 9/10/2013 at 2:29 P.M., Resident #41 was observed sitting in his wheel chair in his room. Resident #41 had a therapeutic glove on his left hand/arm and leaned to the left in the wheel chair. During an interview on 9/10/2013 at 2:29 P.M., Resident #41 stated, "I was walking. Therapy is gone. They had someone in here. Had me lift my leg 20 times. I was walking in July now I can't.... They packed up on a Friday. They moved all the therapy stuff out. Nobody knows what happened to it-where it went. I came here for therapy. I was making good progress. They still charge me for rehabilitation and I ain't getting nothing. If I am going to be an invalid bed patient I am going to get the (curse word). I am not that far out. With help I can walk again but I need it every day. They won't tell me anything. I will go someplace else. I don't have a choice. Either leave and get therapy or turn into a vegetable and they are taking my money. They get money from Medicare and Medicaid and my money. They are not giving me the service. You ask them about therapy and they say tomorrow or next week. Next week or tomorrow never comes." An un-timed physician's orders [REDACTED]." A physical therapy weekly summary note dated 6/24/2013-6/28/2013, indicated Resident #41 was able to ambulate, with minimum to moderate assist, thirty feet with two repetitions per session, required minimum assistance to sit up from a flat position and to stand from a sitting position, and was independent with wheel chair mobility. This PT note indicated, "Pt (patient) is improving toward all goals of gait/transfers/balance and strength. Rehab (rehabilitation) potential is good. Cont (continue ) tx (treatment) as tolerated to achieve long term goals...." A telephone order dated 7/2/2013-4:00 P.M., indicated, "Late entry for 6/28/2013 d/c (discontinued) from skilled ot/pt (occupational therapy/physical therapy) at maximal functional level " This order indicated the facility was to provide restorative services six days a week for six weeks beginning 7/8/2013. These restorative services were to include therapeutic exercises to all extremities, left hand splint, and ambulation with platform rolling walker. A restorative nursing program therapy referral form dated 7/8/2013, indicated Resident #41 needed the following restorative programs: ROM (range of motion) exercise, splinting, and ambulation. Problems: 1) Decreased active mobility LUE (left upper extremely). 2) Decreased strength LLE (left lower extremely). 3) Decreased ambulation skills. 4) Decreased transfer skills. Precautions: Fall Risk. Resident's functional status upon d/c (discontinue) from therapy: Ambulation with PRW (platform rolling walker) x 50 feet with min (minimum) A (assist) of 1, transfers with min A of 1 using small steps, strength fair... LU/LE (left upper/lower extremities), splint with [MEDICAL CONDITION]-glove to L(left) hand/wrist. Program goals: 1) Ambulate with PRW X 75 feet with min A of 1. 2) Decrease [MEDICAL CONDITION] in L hand. 3) Transfer with CGA (contact guard assist) min A of 1 using small steps. 4) Increase strength LLE (left lower extremities) to fair. Instructions included: 1) PROM (passive range of motion) to left upper extremities with support to his shoulder, massage hand and position in splint. (Monitor splint during the day), 2) Ambulation in //( parallel bars) PRW with min (minimum) assist of 1) PRW additional sup (support) to follow with wc (wheel chair). 3) AAROM/AROM (active range of motion) exs (exercise) to BLE (bilateral lower extremities) in sitting at 25/reps (repetition)/ each, bike X 15 minutes.... Special equipment: PRW. Start Date 7/8/ 2013. Frequency and Duration 6/wk X 6 wks (8/30/2013).... Copies given to (1) Therapist, (2) Restorative aide, (3) original in chart." Range of motion program records dated July, August, and September 2013, indicated, "Daily Program Documentation for Restorative/Rehabilitation Nursing.... Goals: 1. Ambulate with personal roller walker at 75 feet with minimal assist of one. 2. Decrease [MEDICAL CONDITION] in left hand. 3. Transfer with contact guard assist min (minimum asst of one using small steps. 4. Increase strength left lower extremities to fair. Programs: ambulation, ROM, splint/brace training...." These records indicated: Week 1: July 8-14, 2013, Resident #41 received restorative ambulation services one day out of seven (July 12). The record lacked documentation ROM restorative services were provided this week. The record indicated Resident 41's progress for that week was, "Not any." Week 2: July 15-21, 2013, Resident #41 received restorative ambulation and ROM services two out of seven days (July 17 and 18). The record indicated Resident 41's progress for that week was, "Not enough." Week 3: July 22-28, 2013, Resident #41 received ambulation and ROM restorative services five out of seven days (July 22, 23, 26, 27, and July 28). The record indicated Resident 41's progress for that week was, "Not enough." The record lacked documentation splint/brace training services were provided during the month of July 2013. Week 4: July 29-August 4, 2013, the record lacked documentation which indicated Resident #41 received ambulation, ROM, or splint/brace training restorative services. The record indicated Resident 41's progress for that week was, "Not enough." Week 5: August 5-11, 2013, Resident #41 received restorative ambulation, ROM, and splint/brace training services two out of seven days (August 6 and 7). The record indicated Resident 41's progress for that week was, "Not enough restorative this week." Week 6: August 12-18, 2013, Resident #41 received ambulation restorative services and ROM services six times during the week (August 12, 12, 14, 15, 16 and August 17), and brace/splint training services four out of seven days (August 12, 13, 14, and August 15). The record indicated Resident 41's progress for that week was, "Patient did good with Range of motion." The record lacked documentation of his ambulation progress. Week 7: August 19-25, 2013, Resident #41 received ambulation and ROM restorative services six days August 19, 20, 21, 22, 23, 24, 2013). The record lacked documentation resident #41 received splint/brace training services this week. The record indicated Resident 41's progress for that week was, "Patient able to move the right side of limbs." The record lacked documentation of his ambulation progress. Week 8: August 26-September 1, 2013., Resident #41 received ambulation and ROM restorative services five out of seven days (August 26, 27, 29, 30, and August 31). The record lacked documentation brace/splint training services were provided during this week. The record indicated Resident 41's progress for that week was, "Patient doing good with ROM and can still move the right side." The record lacked documentation of his ambulation progress. This record indicated from September 2-7, 2013, Resident #41 received ambulation restorative services five out of seven days on September 3, 4, 5, 6, and September 7. The record lacked documentation which indicated Resident #41 received ROM or brace/splint services during this week. The record indicated Resident 41's progress for that week was, "Patient can move right side of limbs, but need help with left." The record lacked documentation regarding his ambulation status. A current care plan updated on 8/20/2013, indicated Resident #41 was at risk for falls due to a [DIAGNOSES REDACTED]. The goal listed was Resident #41 would not have falls or injuries from falls. Interventions listed to meet this goal included staff were to encourage him to attend and participate in therapy. During an interview on 9/12/2013 at 1:15 P.M., when asked what happened to the facility's therapy services, the Director of Nursing (DON) replied, "I don't know what happened. About two weeks ago they just pulled out of here." When asked how the facility was providing therapy services to the residents, she replied, "We have someone come in." During an interview on 9/12/2013 at 3:25 P.M., Resident #41 stated, "Therapy doctor came today. Said it may be tomorrow or Monday. He said if he got the word today he would start tomorrow. He is waiting on my doctor. First week in July they left not two weeks ago. They had me walking with a special walker to brace this arm. I could walk across the room up to three times. Now I have become a vegetable. I am getting weaker waiting on tomorrow." During an interview on 9/12/2013 at 4:00 P.M., the DON was asked to provide all documentation regarding Resident 41's therapy including, but not limited to, care plans, physician's orders [REDACTED]. During an interview on 9/13/2013 at 8:08 A.M., the facility's previous rehabilitation provider's (PRP) Staff #1 indicated their company left officially on June 30, 2013. Therapy discontinue orders had to be written because their company was leaving not because residents did not need therapy. Staff #1 stated, "I am unable to elaborate on why we are no longer there. That would be a question for the CEO.... There had to be an order to discontinue therapy for (Resident #41 named) because we left the building. I am sure the new therapy company would have picked him up. He was doing well and walking. He would have benefited from continued therapy. I don't think they have a restorative nursing program in the building." At this time, the case load of residents who were receiving therapy and would have remained on therapy if the they would not have left the building, was requested. PRP Staff #1 indicated a therapist would provide that information. During an interview on 9/13/2013 at 9:40 A.M., PRP Physical Therapist #2 indicated Resident #41 was progressing well in therapy. PRP Physical Therapist #2 stated, "He was doing well. Walking at least 30 feet. I don't have my records in front of me. If we would of stayed he would have remained on therapy." PRP Therapist #2 indicated Resident #41 had received their services prior to being sent to the hospital due to a severe urinary tract infection and pneumonia. PRP Therapist #2 stated, "When he returned from the hospital we saw a different decline. Overall weakness. His last hospital stay wiped him out. What we had hoped was we were going to be able to resolve the issues with the Administrator and we could resume therapy with the residents. That's why we didn't do permanent exit type documentation. We were not planning on exiting. Initially we thought we would resolve and come back in the door. We wrote temporary orders on physician's phone orders that the patients were to be discharged from skilled therapy but we recommended nursing write therapy restorative plans. We wanted them to write the plan. They know their staffing needs. If we wrote all these lofty goals and they couldn't do it. We wanted to base it on ROM, walking, transferring to and from toilet to keep them agile until therapy could resume.... We thought they hired someone else and we were put to the back burner. Absolutely, he would have continued to receive therapy until he would been able to be a min (minimum) assist to toilet x 1. Would have continued therapy until he was overall 50 percent mod (moderate) assist with all ADLs (activities of daily living). His brother was so exited he was walking. We didn't want him to be worse. We knew we could get him better." During an interview on 9/13/2013 at 11:19 A.M., Restorative Certified Nursing Assistant (RCNA) #1 indicated she had been providing Resident #41 with "Basically ROM." RCNA #1 stated, "He can't move his right side. We had the bars in the room. We would stand him up but they are gone." RCNA indicated she didn't know how long the bars had been gone. She indicated she did not work with Resident #41 until therapy left. RCNA #1 stated, "She told me if I could have help- stand him up. Basically, what I did was ROM until I felt he was strong enough to stand up. When I had the bike I would put him on the bike. It's all passive. I've never seen him walk. I never walked him out of the parallel bars because of safety. That's where I felt comfortable with his chair behind him. We only did it four or five times over two week time.... They gave me the paper July 8. It was on my desk. By the time I wrote it up. I was on the floor. Short of help by the time I got it started. Don't know exactly .... " RCNA #1 indicated she was the only RCNA and couldn't provide the restorative services recommended by therapy. RCNA indicated she was pulled to the floor to work as a CNA (certified nursing assistant) because the facility did not have enough staff. During an interview on 9/13/2013 at 1:02 P.M., the facility's current therapy provider's staff, PTA (physical therapy assistant) #3 stated, "One day down and three days to recover for someone my age. For these people, one day down and it is a loss. The word of mouth here is there has been a big decline. I talked to (Resident #41 named) but as not as an evaluation. I haven't seen anything with him. I am here once a week.... They don't seem to have a system to let us know who needs what." During an interview on 9/17/2013 at 12:15 P.M., the facility's current therapy provider's staff, PT (physical therapist) #4 indicated he had not evaluated Resident #41 because he had not received an order to evaluate Resident #41. PT #4 stated, "We are here for only a couple of weeks. They need to communicate with us. I told him (Resident #41) we could not do anything until we have doctor's orders. The social worker went with me last Thursday 9/12/2013. He expressed his concerns about waiting to be on services...." When asked if he was aware Resident #41 had an order for [REDACTED]. May I please see it?" PT #4 indicated the facility was aware he was the contact person and they did not notify him the order for the evaluation had been obtained. PT #4 stated, "We are only here until the end of the month. We gave them a letter telling them that. After that I don't know what is going to happen.... One week is way too long to go without therapy-severe decline." During an interview on 9/18/2013 at 1:06 P.M., the DON indicated the order probably got missed. She indicated this happened with another resident and she would check to see if it was the same nurse. A nurse's note dated 8/12/2013-2:30 P.M., indicated, "Resident A (alert) and O (oriented) X 3 (person, place, and, time). 0 agitation noted this shift. Res (resident) ext (extensive) assist with ADLs (activities of daily living) and transfers.... [MEDICAL CONDITION] noted to bil (bilateral lower ext (extremities). " An untimed nurse's note dated 9/2/2013, indicated, "Res (Resident) continues to have generalized weakness. Res unable to pivot to W/C (wheel chair)...." A physician's orders [REDACTED].M., indicated Resident #41 may have a physical therapy/occupational therapy evaluation During a telephone interview on 9/19/2013 at 4:15 P.M., PRP Physical Therapist #2 indicated Resident #41 was evaluated the day he was made aware of the order. His evaluation indicated Resident #41's current status was, "A max assist to ambulate 15 to 20 feet at the most with a platform walker and physical assistance. His transfer ability is moderate. His sit to stand ability is moderate. His static dynamic balance is poor with max assistance. He is a high risk for falls and if he attempted to stand, walk, or reach for something without max assistance and a platform walker, he would fall." PRP Physical Therapist indicated his evaluation indicated Resident #41's status had declined since the last status recorded by the previous therapy company. 2. Resident #32's clinical record was reviewed on 9/11/13 at 10:15 A.M. Resident #32's [DIAGNOSES REDACTED]. Resident #32 was admitted to the facility on [DATE]. Review of the "Physical Therapy Evaluation/Certification" dated 4/19/13, indicated Resident #32 ambulated 25 feet with a rolling walker with minimal assistance. Resident #32's short term goal was to ambulate with rolling walker seventy-five feet with minimal assistance. Resident #32's long term goal was to ambulate 125 feet to 150 feet. Review of the "Interdisciplinary Progress Note" dated 5/7/13, indicated Resident #32 was ambulating 60 feet with a rolling walker. A therapy noted dated 6/4/13, indicated Resident #2 was getting up unassisted and ambulating 50 to 60 feet using a rolling walker. A therapy note dated 6/28/13, indicated to discontinue skilled OT/PT (occupational therapy and physical therapy) due to the resident had met maximal functional level. The note indicated a recommendation for restorative nursing. Review of the "Restorative Nursing Program Therapy Referral Form" dated 7/8/13, indicated Resident #32 transfered 75 feet with a rolling walker with a minimal assist of one. Review of the "Daily Documentation for Restorative/Rehabilitation Nursing" indicated restorative nursing was not provided on July 1, 2, 3, 4, 5, 24, 25, 26, 29, 30 and 31, 2013. Restorative nursing was not provided August 1, 3, 4, 5, 8, 9, 18 and 19, 2013. A physical therapy order dated 8/20/13, indicated Resident #32 was to be seen three times a week for four weeks. A Physical Therpay note dated 8/29/13, indicated Resident #32 was unable to transfer or ambulate. During a telephone interview on 9/13/13 at 9:30 A.M., PRP PTA#1 stated, "Resident #32 on therapy. She was doing quite well when we left. We were leery of her doing ADL's (Activities of Daily Living) on her own. She was starting to get pretty close to independent/supervision/stand by assist. She was very close to being discharged ." During an interview on 9/13/13 at 11:19 A.M., RCNA#1 indicated she was supposed to start working with Resident #32 on July 8, 2013 but she was pulled to the floor a lot in July. She indicated Resident #32 would refuse at times because she was tired. RCNA #1 indicated Resident #32 "never walked" for her. RCNA #1 indicated "I don't know what she would do for therapy." During an interview on 9/16/13 at 1:40 P.M., Resident #32 was observed in her room in a wheelchair. Resident #32 indicated, "When I first came in here I was in therapy and they were teaching me how to walk with the wheelchair. Now they are teaching me how to walk again. My legs just got stiff when they stopped." During an interview on 9/16/13 at 2:00 P.M., CNA # indicated "I just help her get out of bed and transfer, I don't walk her. I don't know how far she walks I just get her up to the bathroom and bed. If she does get physical therapy it would be documented in her chart." 3. Resident #28 was observed in his room asleep in his wheelchair on 9/9/13 at 11:45 a.m. At 12:30 p.m., the resident was observed in the dining room in his wheelchair asleep. Resident #28 was observed in his room asleep in his wheelchair on 9/10/13 at 10:50 a.m. At 12:00 p.m., the resident was observed to be propelled by staff into the dining room for lunch. Resident #28's record was reviewed on 9/13/13 at 9:45 a.m. Resident #28's [DIAGNOSES REDACTED]. The resident's Admission MDS (Minimum Data Set) assessment dated [DATE], indicated the resident was mildly cognitively impaired. A therapy consent form from (name of therapy company) dated 6/22/13, indicated the resident was recommended for occupational and physical therapy services under Medicare Part A and Medicaid. Nursing notes dated 6/24/13, 6/25/13, 6/26/13, 7/1/13 and 7/22/13, indicated the resident was able to propel self in his wheel chair. A Physical therapy assessment note dated "week of 6/25-28/2013", indicated the resident indicated "I want to be able to walk better." Current mobility status indicated minimal assistance with a rolling walker and ambulated up to 60 ft (feet) with supervision. The note indicated rehabilitation potential was good. The resident was a stand by assist of one with "rolling" in bed, and minimal assistance of one for lying to sit and sit to stand from bed and wheel chair transfers to bed and toilet. The Balance dynamic stand was fair. Plan was to continue treatment per plan of care as tolerated, three times a week for four weeks with therapeutic exercise to BLE (bilateral lower extremities), therapy approved activities, gait/transfer training, improve functional mobility. A physician clarification order dated 6/25/13, indicated PT (physical therapy) three times a week for four weeks to improve functional mobility and pain management via therapy, exercises, therapeutic activity, gait/transfer training, balance activities and modalities as indicated. A physician clarification order dated 6/27/13, indicated Occupational therapy three times a week for four weeks increase independence with ADL's (Activity of Daily Living) and increase independence with wheelchair mobility, using therapeutic exercise, therapeutic activities, modalities, and self care retraining. The Occupational Therapy assessment information was not provided by the facility upon request. Review of the Restorative Nursing Program Therapy Referral form dated 7/8/13, indicated a decrease in ambulation skills and decrease strength to bilateral lower extremities. The record indicated the resident was ambulating with his rolling walker up to 75 feet with minimal assistance of one person, transfers with minimal assistance of one person and strength was fair to all extremities. The referral form indicated Occupational and Physical therapy recommended range of motion exercises and ambulation with goals provided. Instructions indicated to exercise the bilateral upper and lower extremities at 20 repetitions for each setting, bike exercises for 10 minutes for bilateral upper and lower extremities, ambulate with rolling walker up to 100 feet with minimal assistance of one person, and sit to stand from wheel chair to improve transfers. The start date was 7/8/13 six days a week for 6 weeks. Review of the "Range of Motion Program" form for July 2013, indicated the plan for the resident was to "(1) exercise bilateral upper/lower extremeties at 20 repetitions each setting and bike pedal for 10 minutes for bilateral upper/lower extremeties. (2) ambulate with rolling walker at 100 feet, contact guard assist with minimal assistance of one. (3) Sit to stand from wheel chair to improve transfers." The resident had not received services on July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2013. A weekly progress note had an "X" through the comment sections and indicated "not enough restorative". Another form titled "Daily Program Documentation for Restorative/Rehabilitation Nursing" dated July 2013 was reviewed. The form had lines through the dates of July 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 16, 19, 21, 24, 25, 29, 30 and 31, 2013, indicating the resident was not seen for mobility training and range of motion. Review of the August 2013 "Ambulation Program" form indicated the resident had not received services on August 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 18, 25 and 28, 2013. A weekly progress note dated 8/12/13 to 8/17/13, indicated the "Patient is only walking 50 ft (feet). I'm working with his ROM (range of motion) so legs can get stronger. A weekly progress note dated 8/19/13 to 8/24/13, indicated the resident was walking 50 ft. A weekly progress note dated 8/26/13 to 8/31/13, indicated the resident was still walking 50 ft. There was a 25 ft decline from 7/8/13 to 8/31/13. Review of the August 2013 "Range of Motion Program" indicated the resident had not received services on August 1, 2, 3, 4, 5, 6, 7, 11, 18, 25 and 28, 2013. There was a line through the weekly progress note for the week of 8/1/13 to 8/4/13. The weekly progress note for 8/8/13 to 8/10/13, indicated "not enough restorative." A physician order [REDACTED]. A Physical Therapy Plan of Care dated 8/15/13 indicated the resident was assessed to be moderately dependent for transfer from sit to stand, bed to wheelchair, toilet and floor. Standing dynamic balance was poor. Gait analysis indicated the resident was able to ambulate 70 feet with moderate assistance. The restorative referral form dated 7/8/13, indicated the resident was ambulating 75 ft. with minimal assistance and standing dynamic balance was fair. Review of the "Occupational Therapy Plan of Care" dated 8/23/13, indicated the resident was assessed and short/long term goals were initiated. The Neuromuscular upper extremity range of motion indicated the resident demonstrated increased difficulty with left upper extremity. The clinical observations indicated the "resident presented with decreased strength, endurance, decreased independence and safety with self care performance and safety and poor mobility. The resident was unable to propel self in the wheel chair to 20 feet without fatigue." A therapy assessment dated [DATE], indicated the resident was able to propel self "ad lib in facility" in regards to distance propelled and the strength was fair to all extremities. During an interview on 9/12/13 at 1:15 p.m., the DoN indicated she did not know what happened to the previous therapy company. The DoN indicated the company "pulled out of here." The DoN indicated they had "someone" coming in for therapy services. During an interview on 9/13/13 at 11:20 a.m., RCNA #1 indicated she was the only RCNA and she could provide the restorative services recommended by therapy. RCNA #1 indicated she had to be pulled away from her duties as a restorative aide and be put on the floor many times due to short staffing of CNAs'. RCNA #1 indicated she was using the equipment from the previous therapy company until the company had it removed on 9/10/13. During an interview on 9/13/13 at 12:00 p.m., the DoN indicated the RCNA #1 had to be pulled off of her assignment as a restorative aide due to staff quitting without notice. The DoN indicated the facility had suffered a lot this year. The DoN indicated the Board of Directors had been making cuts with staffing and they had not been able to replace staff due to money factors. The DoN also indicated she has had a difficult time finding staff with experience and skills needed for the residents. During an interview on 9/13/13 at 12:20 p.m., the current therapy provider's staff, PT (physical therapist) #4 indicated his company had signed a contract with the facility on 8/12/13. The therapist indicated the reason for the delay of assessing the resident was due to verifying insurance information. During an interview on 9/13/13 at 1:00 p.m., the current therapy provider's staff, PTA (physical therapy assistant) #3 indicated one day down would take three days to recover for someone like herself. PTA #3 indicated it would take the residents' longer to recover due to their and co-morbidities. The PTA #3 indicated she had heard there was a big decline in the facility. The PTA #3 indicated she was at the facility once a week and PT #4 was at the facility twice a week. PTA #3 indicated the facility did not have a system to notify their company of resident needs. During an interview on 9/18/13 at 2:10 p.m., the DoN indicated RCNA #1 was the only restorative aide. The DoN indicated they had put a plan into place to provide services to residents who required therapy while the facility made arrangements for another company to start. The facility did not have enough staff to meet the residents needs. RCNA #1 was frequently removed from her responsibilities of a RCNA. 4. Resident #34's record was reviewed on 9/16/13 at 10:15 a.m. Resident #34's [DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set) assessment dated [DATE], indicated the resident was cognitively intact. A dietary quarterly note dated 7/16/13, indicated the resident weight was 198. The August TAR (Treatment Administration Record) indicated the resident's resident had an 18 pound weight loss and weighed 180 pounds on 8/28/13 A physician order [REDACTED]. During an interview on 9/17/13 at 11:00 a.m., the DoN indicated she was not able to locate a speech evaluation and did not know if speech therapy had been notified of the order. During an interview on 9/17/13 at 12:15 p.m., the facility's current therapy provider staff, PT (physical therapist) #4 indicated his company was only to be in the facility for a few weeks. PT #4 indicated the facility needed to communicate with his company in regards to new referrals/physician orders. PT #4 indicated he was not aware of the speech referral for the resident. During an interview on 9/18/13 at 9:45 a.m., Resident #34 indicated she had not been seen by anyone for speech. She had indicated she spits out meat after chewing it because she cannot break it down enough to swallow. During an interview on 9/18/13 at 12:30 p.m., the DoN indicated a nurse "dropped the ball" on referring the resident to therapy. When asked if therapy was notified on 9/17/13 during their visit, the DoN indicated "I am sure they did, but I will verify". An undated policy titled, "Restorative Nursing," was provided by the DoN on 9/17/13 at 1:45 p.m. The policy indicated "The restorative nurse is trained and has an active program of restorative care which is an integral part of nursing services. This program is directed toward assisting each resident to achieve and maintain optimum level of self care and maximum level of functioning. The restorative nurse provides care daily for those who require their service. Each resident will be evaluated for his/her rehabilitative potential by the attending physician, with assistance by nursing staff and therapists as appropriate." A "Therapy Services Policy and Procedure" dated 2011, indicated "All referrals for therapy must present (sic) with a doctor's order. The orders will then be submitted to the therapy for their evaluation. The recommendations (sic) will then be given to the attending physician to verify and approve." 5. Resident

Based on record review and interview, the facility failed to ensure there was sufficient nursing staff and related services to prevent decline in a resident's ability to ambulate and a decline in strength and ability to transfer for 3 of 5 residents reviewed for restorative services (Resident #41, #32, and #28) Findings include: 1. Resident #41's record was reviewed on 9/12/2013 at 3:35 P.M. Resident #41 had [DIAGNOSES REDACTED]. A five day significant change Minimum Data Set Assessment Tool ((MDS) dated [DATE], indicated Resident #41 was re-admitted to the facility on [DATE], after being discharged from an acute care hospital, where he received treatment for [REDACTED]. During an observation on 9/10/2013 at 2:29 P.M., Resident #41 was observed sitting in his wheel chair in his room. Resident #41 had a therapeutic glove on his left hand/arm and leaned to the left in the wheel chair. An un-timed physician's orders [REDACTED]." A physical therapy weekly summary note dated 6/24/2013-6/28/2013, indicated Resident #41 was able to ambulate, with minimum to moderate assist, thirty feet with two repetitions per session, required minimum assistance to sit up from a flat position and to stand from a sitting position, and was independent with wheel chair mobility. This PT note indicated, "Pt (patient) is improving toward all goals of gait/transfers/balance and strength. Rehab (rehabilitation) potential is good. Cont (continue ) tx (treatment) as tolerated to achieve long term goals...." A telephone order dated 7/2/2013-4:00 P.M., indicated, "Late entry for 6/28/2013 d/c (discontinued) from skilled ot/pt (occupational therapy/physical therapy) at maximal functional level " This order indicated the facility was to provide restorative services six days a week for six weeks beginning 7/8/2013. These restorative services were to include therapeutic exercises to all extremities, left hand splint, and ambulation with platform rolling walker. A restorative nursing program therapy referral form dated 7/8/2013, indicated Resident #41 needed the following restorative programs: ROM (range of motion) exercise, splinting, and ambulation. Problems: 1) Decreased active mobility LUE (left upper extremely). 2) Decreased strength LLE (left lower extremely). 3) Decreased ambulation skills. 4) Decreased transfer skills. Precautions: Fall Risk. Resident's functional status upon d/c (discontinue) from therapy: Ambulation with PRW (platform rolling walker) x 50 feet with min (minimum) A (assist) of 1, transfers with min A of 1 using small steps, strength fair... LU/LE (left upper/lower extremities), splint with [MEDICAL CONDITION]-glove to L(left) hand/wrist. Program goals: 1) Ambulate with PRW X 75 feet with min A of 1. 2) Decrease [MEDICAL CONDITION] in L hand. 3) Transfer with CGA (contact guard assist) min A of 1 using small steps. 4) Increase strength LLE (left lower extremities) to fair. Instructions included: 1) PROM (passive range of motion) to left upper extremities with support to his shoulder, massage hand and position in splint. (Monitor splint during the day), 2) Ambulation in //( parallel bars) PRW with min (minimum) assist of 1) PRW additional sup (support) to follow with wc (wheel chair). 3) AAROM/AROM (active range of motion) exs (exercise) to BLE (bilateral lower extremities) in sitting at 25/reps (repetition)/ each, bike X 15 minutes.... Special equipment: PRW. Start Date 7/8/ 2013. Frequency and Duration 6/wk X 6 wks (8/30/2013).... Copies given to (1) Therapist, (2) Restorative aide, (3) original in chart." Range of motion program records dated July, August, and September 2013, indicated, "Daily Program Documentation for Restorative/Rehabilitation Nursing.... Goals: 1. Ambulate with personal roller walker at 75 feet with minimal assist of one. 2. Decrease [MEDICAL CONDITION] in left hand. 3. Transfer with contact guard assist min (minimum asst of one using small steps. 4. Increase strength left lower extremities to fair. Programs: ambulation, ROM, splint/brace training...." These records indicated: Week 1: July 8-14, 2013, Resident #41 received restorative ambulation services one day out of seven (July 12). The record lacked documentation ROM restorative services were provided this week. The record indicated Resident 41's progress for that week was, "Not any." Week 2: July 15-21, 2013, Resident #41 received restorative ambulation and ROM services two out of seven days (July 17 and 18). The record indicated Resident 41's progress for that week was, "Not enough." Week 3: July 22-28, 2013, Resident #41 received ambulation and ROM restorative services five out of seven days (July 22, 23, 26, 27, and July 28). The record indicated Resident 41's progress for that week was, "Not enough." The record lacked documentation splint/brace training services were provided during the month of July 2013. Week 4: July 29-August 4, 2013, the record lacked documentation which indicated Resident #41 received ambulation, ROM, or splint/brace training restorative services. The record indicated Resident 41's progress for that week was, "Not enough." Week 5: August 5-11, 2013, Resident #41 received restorative ambulation, ROM, and splint/brace training services two out of seven days (August 6 and 7). The record indicated Resident 41's progress for that week was, "Not enough restorative this week." Week 6: August 12-18, 2013, Resident #41 received ambulation restorative services and ROM services six times during the week (August 12, 12, 14, 15, 16 and August 17), and brace/splint training services four out of seven days (August 12, 13, 14, and August 15). The record indicated Resident 41's progress for that week was, "Patient did good with Range of motion." The record lacked documentation of his ambulation progress. Week 7: August 19-25, 2013, Resident #41 received ambulation and ROM restorative services six days August 19, 20, 21, 22, 23, 24, 2013). The record lacked documentation resident #41 received splint/brace training services this week. The record indicated Resident 41's progress for that week was, "Patient able to move the right side of limbs." The record lacked documentation of his ambulation progress. Week 8: August 26-September 1, 2013., Resident #41 received ambulation and ROM restorative services five out of seven days (August 26, 27, 29, 30, and August 31). The record lacked documentation brace/splint training services were provided during this week. The record indicated Resident 41's progress for that week was, "Patient doing good with ROM and can still move the right side." The record lacked documentation of his ambulation progress. This record indicated from September 2-7, 2013, Resident #41 received ambulation restorative services five out of seven days on September 3, 4, 5, 6, and September 7. The record lacked documentation which indicated Resident #41 received ROM or brace/splint services during this week. The record indicated Resident 41's progress for that week was, "Patient can move right side of limbs, but need help with left." The record lacked documentation regarding his ambulation status. A current care plan updated on 8/20/2013, indicated Resident #41 was at risk for falls due to a [DIAGNOSES REDACTED]. The goal listed was Resident #41 would not have falls or injuries from falls. Interventions listed to meet this goal included staff were to encourage him to attend and participate in therapy. During an interview on 9/13/2013 at 11:19 A.M., Restorative Certified Nursing Assistant (RCNA) #1 indicated she had been providing Resident #41 with "Basically ROM." RCNA #1 stated, "He can't move his right side. We had the bars in the room. We would stand him up but they are gone." RCNA indicated she didn't know how long the bars had been gone. She indicated she did not work with Resident #41 until therapy left. RCNA #1 stated, "She told me if I could have help- stand him up. Basically, what I did was ROM until I felt he was strong enough to stand up. When I had the bike I would put him on the bike. It's all passive. I've never seen him walk. I never walked him out of the parallel bars because of safety. That's where I felt comfortable with his chair behind him. We only did it four or five times over two week time.... They gave me the paper July 8. It was on my desk. By the time I wrote it up. I was on the floor. Short of help by the time I got it started. Don't know exactly .... " RCNA #1 indicated she was the only RCNA and couldn't provide the restorative services recommended by therapy. RCNA indicated she was pulled to the floor to work as a CNA (certified nursing assistant) because the facility did not have enough staff. During a telephone interview on 9/19/2013 at 4:15 P.M., PRP Physical Therapist #2 indicated Resident #41 was evaluated the day he was made aware of the order. His evaluation indicated Resident #41's current status was, "A max assist to ambulate 15 to 20 feet at the most with a platform walker and physical assistance. His transfer ability is moderate. His sit to stand ability is moderate. His static dynamic balance is poor with max assistance. He is a high risk for falls and if he attempted to stand, walk, or reach for something without max assistance and a platform walker, he would fall." PRP Physical Therapist indicated his evaluation indicated Resident #41's status had declined since the last status recorded by the previous therapy company. 2. Resident #32's clinical record was reviewed on 9/11/13 at 10:15 A.M. Resident #32's [DIAGNOSES REDACTED]. Resident #32 was admitted to the facility on [DATE]. Review of the "Physical Therapy Evaluation/Certification" dated 4/19/13, indicated Resident #32 ambulated 25 feet with a rolling walker with minimal assistance. Resident #32's short term goal was to ambulate with rolling walker seventy-five feet with minimal assistance. Resident #32's long term goal was to ambulate 125 feet to 150 feet. Review of the "Interdisciplinary Progress Note" dated 5/7/13, indicated Resident #32 was ambulating 60 feet with a rolling walker. A therapy noted dated 6/4/13, indicated Resident #2 was getting up unassisted and ambulating 50 to 60 feet using a rolling walker. A therapy note dated 6/28/13, indicated to discontinue skilled OT/PT (occupational therapy and physical therapy) due to the resident had met maximal functional level. The note indicated a recommendation for restorative nursing. Review of the "Restorative Nursing Program Therapy Referral Form" dated 7/8/13, indicated Resident #32 transferred 75 feet with a rolling walker with a minimal assist of one. Review of the "Daily Documentation for Restorative/Rehabilitation Nursing" indicated restorative nursing was not provided on July 1, 2, 3, 4, 5, 24, 25, 26, 29, 30 and 31, 2013. Restorative nursing was not provided August 1, 3, 4, 5, 8, 9, 18 and 19, 2013. A physical therapy order dated 8/20/13, indicated Resident #32 was to be seen three times a week for four weeks. A Physical Therpay note dated 8/29/13, indicated Resident #32 was unable to transfer or ambulate. During a telephone interview on 9/13/13 at 9:30 A.M., PRP PTA#1 stated, "Resident #32 on therapy. She was doing quite well when we left. We were leery of her doing ADL's (Activities of Daily Living) on her own. She was starting to get pretty close to independent/supervision/stand by assist. She was very close to being discharged ." During an interview on 9/13/13 at 11:19 A.M., RCNA#1 indicated she was supposed to start working with Resident #32 on July 8, 2013 but she was pulled to the floor a lot in July. She indicated Resident #32 would refuse at times because she was tired. RCNA #1 indicated Resident #32 "never walked" for her. RCNA #1 indicated "I don't know what she would do for therapy." During an interview on 9/16/13 at 1:40 P.M., Resident #32 was observed in her room in a wheelchair. Resident #32 indicated, "When I first came in here I was in therapy and they were teaching me how to walk with the wheelchair. Now they are teaching me how to walk again. My legs just got stiff when they stopped." During an interview on 9/16/13 at 2:00 P.M., CNA # indicated "I just help her get out of bed and transfer, I don't walk her. I don't know how far she walks I just get her up to the bathroom and bed. If she does get physical therapy it would be documented in her chart." 3. Resident #28 was observed in his room asleep in his wheelchair on 9/9/13 at 11:45 a.m. At 12:30 p.m., the resident was observed in the dining room in his wheelchair asleep. Resident #28 was observed in his room asleep in his wheelchair on 9/10/13 at 10:50 a.m. At 12:00 p.m., the resident was observed to be propelled into the dining room for lunch. Resident #28's record was reviewed on 9/13/13 at 9:45 a.m. Resident #28's [DIAGNOSES REDACTED]. A therapy consent form from (name of therapy company) dated 6/22/13, indicated the resident were going to receive occupational and physical therapy services under Medicare Part A and Medicaid. The resident's daughter had signed the form. A nursing notes dated 6/24/13, 6/25/13, 6/26/13, 7/1/13 and 7/22/13 indicated the resident was able to propel self in his wheel chair. A Physical therapy assessment note dated "week of 6/25-28/2013", indicated subjectively, the resident indicated "I want to be able to walk better". Current mobility status indicated minimal assistance with a rolling walker and ambulated up to 60 ft (feet) with supervision. The note indicated rehab potential was good. The resident was a stand by assist of one with "rolling" in bed, and minimal assistance of one for lying to sit and sit to stand from bed and wheel chair transfers to bed and toilet. The Balance dynamic stand was fair. Plan was to continue treatment per plan of care as tolerated, three times a week for four weeks with therapeutic exercise to BLE (bilateral lower extremities), therapy approved activities, gait/transfer training, improve functional mobility. Review of the Restorative Nursing Program Therapy Referral form, indicated the problems were decrease in ambulation skills and decrease strength to bilateral lower extremities. resident was ambulating with his rolling walker up to 75 feet with minimal assistance of one person, transfers with minimal assistance of one person and strength was fair to all extremities. Occupational and Physical therapy had recommended range of motion exercises and ambulation with goals provided. Instructions indicated to exercise the bilateral upper and lower extremities at 20 repetitions for each setting, bike exercises for 10 minutes for bilateral upper and lower extremities, ambulate with rolling walker up to 100 feet with minimal assistance of one person, and sit to stand from wheel chair to improve transfers. The start date was 7/8/13 six days a week for 6 weeks. Review of the range of motion restorative notes for July 2013, indicated the resident was only seen on July 12th, 17th and 18th. A weekly progress note indicated there was "not enough restorative" . Review of the Daily Program Documentation for Restorative/Rehabilitation Nursing dated July 2013, indicated the resident was seen for mobility training and range of motion on July 12th, 17th, 18th, 22nd, 23rd, 26th, 27th and 28th. Review of the range of motion notes and ambulation program notes indicated the resident was not seen from August 1 to August 7 and August 28th. A weekly progress note indicated there was "not enough restorative". A physician order [REDACTED]. A Physical Therapy Plan of Care dated 8/15/13 indicated the resident was assessed to be moderately dependent for transfer from sit to stand, bed to wheelchair, toilet and floor. Standing dynamic balance was poor. Gait analysis indicated the resident was able to ambulate 70 feet with moderate assistance. Review of the "Occupational Therapy Plan of Care" dated 8/23/13, indicated the resident was assessed and short/long term goals were initiated. The Neuromuscular upper extremitity range of motion indicated the resident demonstrated increased difficulty with left upper extremity. The clinical observations indicated the resident presented with decreased strength, endurance, decreased independence and safety with self care performance and safety and moor mobility. The resident was unable to propel self in the wheel chair to 20 feet without fatigue. Staffing schedules for August and September 2013 were reviewed on 9/3/13 at 3:00 p.m. and indicated the following: a. On 8/1/13 (Thursday), the facility was staffed with two CNAs', restorative aide and a bath aide on the day shift. The schedule indicated a need for a CNA. b. On 8/2/13 (Friday), the facility was staffed with two nurses, three CNAs' and a shower aide on the day shift. There was not a restorative aide scheduled. The schedule indicated a need for a CNA. c. On 8/3/13 (Saturday), the facility was staffed with two nurses, two CNAs' and a restorative aide on the day shift. The facility had a CNA from an agency on the schedule. There was not a wound nurse on the schedule. d. On 8/4/13 (Sunday), the facility was staffed with two nurses and three CNAs' on the day shift. There was not a wound nurse, restorative aide or a shower aide on the schedule. e. On 8/5/13 to 8/7/13 (Monday to Wednesday), the facility had four CNAs' on the schedule for the day shift. There was not a restorative aide or a shower aide on the schedule. f. On 8/6/13 (Thursday), the facility had three CNAs' on the schedule on the day shift. There was not a restorative aide or a shower aide on the schedule. g. On 8/7/13 (Friday), the facility had four CNAs' on the schedule. There was not a restorative aide or a shower aide on the schedule. h. On 8/10/13 (Saturday), the facility had two CNA's on the schedule and a restorative aide on day the shift. The schedule indicated one nurse and two CNAs' on the night shift. The schedule indicated a need for a CNA on both shifts. i. On 8/11/13 (Sunday), the facility had two nurses and three CNAs' on the day shift. There was not a wound nurse restorative aide or a bath aide on the schedule. The schedule indicated a need for a CNA. j. On 8/17/13 (Thursday), the facility had three CNAs' and a restorative aide on the day shift. There was not a bath aide on the schedule. k. On 8/18/13 (Saturday), the facility had two nurses and three CNAs' on the day shift. There was not a wound nurse, restorative aide or a bath aide on the schedule. l. On 8/19/13 (Monday), the facility had three CNAs', restorative aide and a bath aide on the day shift. The schedule also indicated there was a need for a CNA. m. On 8/22/13 (Thursday), the facility had three CNAs' and a bath aide on the day shift. The schedule indicated the restorative aide was on vacation. There was not a CNA assigned to do restorative therapy. n. On 8/24/13 (Saturday), the facility had two nurses and three CNAs on the day shift. The restorative aide was scheduled until 11:00 a.m. There was one nurse and two CNAs on the night shift. The schedule indicated a need for two CNAs' on day shift and one CNA for night shift. o. On 8/25/13 (Sunday), the facility had two nurses and three CNAs' scheduled for day shift. There was not a restorative aide or a bath aide on the schedule. There was one nurse and two CNAs' on the night shift. The schedule indicated a need for a CNA on the night shift. p. On 8/31/13 (Saturday), the facility had two nurses and three CNAs' on the day shift. There was not a restorative aide or a bath aide on the schedule. The schedule indicated a need for a CNA. q. 9/1/13, 9/7/13 to 9/8/13 and 9/14/13 to 9/15/13 (Saturday and Sunday), the facility was staffed with two nurses three CNAs' on the day shift. There was not a restorative aide or a bath aide on the schedule. r. On 9/2/13 and 9/3/13 (Monday and Tuesday), there was no restorative aide to cover Restorative Aide #1 during her vacation. s. On 9/5/13 (Thursday), there was not a restorative aide or a shower aide on the schedule. The schedule indicated "do your own showers". t. On 9/7/13 (Saturday), the schedule indicated a need for a CNA on the night shift. u. On 9/9/13 (Monday), the facility had three CNAs' on the schedule. The Schedule indicated a need for a CNA on the day shift. v. On 9/15/13 (Sunday), there was not a restorative aide and a shower aide on the schedule. Restorative Aide #1 was interviewed on 9/13/13 at 11:20 a.m. Restorative Aide #1 indicated she had to be pulled away from her duties as a restorative aide and be put on the floor many times due to short staffing of CNAs. During an interview on 9/13/13 at 11:20 a.m., RCNA #1 indicated she had to be pulled away from her duties as a restorative aide and be put on the floor many times due to short staffing of CNAs'. During an interview on 9/13/13 at 12:00 p.m., the DoN indicated the RCNA #1 had to be pulled off of her assignment as a restorative aide due to staff quitting without notice. The DoN also indicated she has had a difficult time finding staff with experience and skills needed for the residents. During an interview on 9/18/13 at 2:10 p.m., the DoN indicated RCNA #1 was the only restorative aide. The DoN indicated they had put a plan into place to provide services to residents who required therapy while the facility made arrangements for another company to start. The facility did not have enough staff to meet the residents needs. RCNA #1 was frequently removed from her responsibilities of a RCNA. This Federal Tag relates to complaint number IN 532. 3.1-17(a) 3.1-17(c)(4)

Based on observation, interview and record review the facility failed to communicate effectively with the administrator; therefore, the administrator was unaware of the high water temperatures and the unsafe side rails. (#41, #1, #4, #47, #13, #25, #12, #45, #52, #46, #21, #16, #22, #14, #47) Findings include: 1. The record for Resident #41 was reviewed on 6/26/12 at 8:55 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/18/12 at 12:30 p.m. indicated, "...alert propelling self through facility." During an observation of room safety on 6/25/12 at 10:40 a.m., the hot water from the bathroom spicket in Resident #41's room was turned on. The water temperature was extremely hot with steam rising. The water temperature registered 158 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:25 a.m., the hot water from the bathroom spicket in Resident #41's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 2. The record for Resident #1 was reviewed on 6/26/12 at 8:50 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/25/12 at 5:00 p.m. indicated, "...aox1 (awake and oriented times one) to self restless in w/c (wheelchair) has self release belt cont (continue) to unfasten (sign for with) alarm sounding propelling self throughout unit...." During an observation of room safety on 6/25/12 at 10:40 a.m., the hot water from the bathroom spicket in Resident #1's room was turned on. The water temperature was extremely hot with steam rising. The water temperature registered 158 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:25 a.m., the hot water from the bathroom spicket in Resident #1's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 3. The record for Resident #4 was reviewed on 6/25/12 at 9:10 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/2/12 at 2:00 p.m. indicated, "Resident alert / ox3 (oriented times three), sitting up in bed...non-ambulatory, uses w/c (wheelchair) for mobility, dependent for all ADL's (activities of daily living)/peri-care/transfers...." On 6/25/12 at 10:44 a.m., the hot water from the bathroom spicket in Resident #4's room registered 150 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:28 a.m., the hot water from the bathroom spicket in Resident #4's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 4. The record for Resident #47 was reviewed on 6/26/12 at 9:00 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/2/12 at 2:00 p.m. indicated, "Res. (resident) alert (sign for with) confusion, up daily in w/c (wheelchair), staff propelled...." On 6/25/12 at 10:44 a.m., the hot water from the bathroom spicket in Resident #47's room registered 150 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:28 a.m., the hot water from the bathroom spicket in Resident #47's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 5. The record for Resident #13 was reviewed on 6/26/12 at 9:10 a.m. [DIAGNOSES REDACTED]. A nurses noted dated 6/16/12 at 11:00 a.m. indicated, "Resident Alert (sic) (sign for and) oriented x 2...." The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 used a wheelchair and was independent in locomotion on the unit. On 6/25/12 at 10:46 a.m., the hot water from the bathroom spicket in Resident #13's room registered 130 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:31 a.m., the hot water from the bathroom spicket in Resident #13's room registered 130 degrees Fahrenheit on the facility's non-digital thermometer. 6. The record for Resident #25 was reviewed on 6/26/12 at 9:15 a.m. [DIAGNOSES REDACTED]. A nurses noted dated 6/24/12 at 11:00 p.m. indicated, "Res. (resident) alert, pleasantly confused. Up in w/c (wheelchair) self mobility...." During rounds with Maintenance Manager #1 on 6/25/12 at 11:34 a.m., the hot water from the bathroom spicket in Resident #25's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 7. The record for Resident #12 was reviewed on 6/26/12 at 9:25 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/15/12 at 11:00 p.m. indicated, "Alert to self and name. Up daily in w/c (wheelchair) staff propelled...." During rounds with Maintenance Manager #1 on 6/25/12 at 11:34 a.m., the hot water from the bathroom spicket in Resident #12's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 8. On 6/25/12 at 10:42 a.m., the hot water from the sprayer in the beauty shop shampoo sink which is adjacent to the 100 hall way registered 156.7 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:37 a.m., the hot water from the sprayer in the shampoo sink in the beauty shop registered 152 degrees Fahrenheit on the facility's non-digital thermometer. On 6/25/12 at 11:21 a.m. the water temperature logs were provided by Maintenance Manager #1, and he indicated the log was recent. A water temperature log entry dated June 18 without a year, indicated, "...NURSES STATION (sic) 125... 203 - 130 206 - 125... 303 129 305 125 304 126 303 130 104 126...." A water temperature log entry dated, "TUE (Tuesday) 19-2012," indicated, "...203 130 206 125... 303 129 305 125 304 125 303 130." A water temperature log entry dated, "(illegible) 20 2012," indicated, "TUB...400 - 130 NURSE STATION 130... 203 135... 303 130 305 125... 308 130 104 126...." A water temperature log entry dated, "Thur (Thursday) 21 2012," indicated, "TUB...400 - 125 NURSE STATION 125... 203 130 206 125... 303 125... 304 129 303 130 104 130... 107 125." The water temperature log lacked documentation for water temperatures for Friday, 6/22/12, Saturday, 6/23/12 or Sunday, 6/24/12. During an interview on 6/25/12 at 11:21 a.m., Maintenance Manager #1 indicated he checked the water temperatures every day or every other day. He indicated the water temperatures should not exceed 120 degrees Fahrenheit. He indicated he had not checked water temperatures today, 6/25/12. He indicated there were four water heaters in the facility. He indicated there was a water heater for the 100 hall, a water heater for the 200 hall, a water heater for the 300 hall and a water heater for the kitchen. He indicated the water gets cooler the farther down the hall from the location of the water heater. During an interview on 6/25/12 at 11:40 a.m., Maintenance Manager #1 indicated he has was not trained on adjusting the mixer valves on the hot water heaters. He indicated the mixing valves were routinely switched out every six months and a work order had been turned in. He indicated the work would be done within the week. When asked how resident safety was ensured, he indicated, "I could probably turn it down." He Indicated he did not receive instruction on the mixer valves and did not know if it would even work. During an interview on 6/25/12 at 11:51 a.m., the Administrator indicated he was not aware of any water temperature problems. He indicated the maintenance manager was to notify him if there were water temperature concerns. He indicated the water temperature concerns would be addressed in the morning meeting and the service company would be notified to evaluate the water heaters. Water temperature policies and a maintenance manager job description were requested. During an interview on 6/25/12 at 4:15 p.m., the Administrator indicated, "Oh, I'm still looking for those," in response to another request for facility policies and a maintenance manager job description. During an interview on 6/26/12 at 9:15 a.m., CNA #2 indicated the water was hot over the weekend. She indicated she mixed the hot water and the cold water. She indicated she did not report the hot water. A Job Description, tiled, "Housekeeping/Maintenance Manager," provided by the Administrator on 6/25/12 at 4:45 p.m. indicated, "...Maintenance Manager is responsible for ensuring that...is clean, orderly, and in a state of good repair, both inside and out, and provides reasonable comfort for all residents...must comply with the standards of the Indiana Administrative Code, Indiana State Department of Health, and any other applicable local, state and federal laws and regulations regarding facility care and maintenance...Reports To: Administrator...." No policies regarding water temperatures were presented by the end of the day at 4:45 p.m. on 6/25/12. On 6/26/12 at 10:54 a.m., Maintenance Manager #1's employee file was reviewed and lacked documentation on training for facility water heaters. On 6/26/12 at 10:30 a.m., an undated facility policy was provided by the Administrator titled, "Water Temperature Monitoring." The policy indicated, "Policy: It is the policy of this facility to assure the water temperatures remain within safe parameters for the safety of the residents and staff...The water temperatures will be monitored daily...should be no warmer than 120 degrees. A Preventative maintenance Log will be kept by the month and reviewed...Any discrepancies must be addressed by the maintenance department and reported to Administration...." 9. The record for Resident #41 was reviewed on 6/26/12 at 8:55 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/18/12 at 12:30 p.m. indicated, "...alert propelling self through facility." A "Bed Rail Safety Assessment" dated 6/6/12 indicated, "All bed rails must be assessed for safety upon initiation of rails and quarterly thereafter. Is resident non ambulatory? (Y with a check mark)ambulatory?...Is resident unaware of safety issues? (Y with a check mark)...Is resident on medications which require increased safety precautions? (Y with a check mark)...Side rails are used for: (Safety with a check mark)...." A large handwritten "X" was marked over the questions regarding safety measures. The safety measures portion indicated, "Bed rails are properly installed according to manufacture's instructions...If half rails are used, the gap between rails is not large enough to allow for entrapment...." During an observation on 6/26/12 at 1:25 p.m., Resident #41's bed was observed with bilateral half side rails up. The side rails had a cloth cover over them; however, the cloth was ripped exposing gaps in the side rails that were 7.5 inches. The resident was not in the bed at the time of the observation. 10. The record for Resident #1 was reviewed on 6/26/12 at 8:50 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/25/12 at 5:00 p.m. indicated, "...aox1 (awake and oriented times one) to self restless in w/c (wheelchair) has self release belt cont (continue) to unfasten (sign for with) alarm sounding propelling self throughout unit...." A "Bed Rail Safety Assessment" dated 4/17/12 indicted, "All bed rails must be assessed for safety upon initiation of rails and quarterly thereafter. Is resident non ambulatory? (N with a check mark)ambulatory?...Is resident unaware of safety issues? (Y with a check mark)...Is resident on medications which require increased safety precautions? (Y with a check mark)...Side rails are used for: (Safety with a check mark)...." A large handwritten "X" was marked over the questions regarding safety measures. The safety measures portion indicated, "Bed rails are properly installed according to manufacture's instructions...If half rails are used, the gap between rails is not large enough to allow for entrapment...." During an observation on 6/26/12 at 1:25 p.m., Resident #1's bed was observed with bilateral half side rails up. The side rails had a cloth covering over them; however, the cloth was ripped exposing gaps in the side rails that were 7.5 inches. The resident was not in the bed at the time of the observation. 11. The record for Resident #45 was reviewed on 6/26/12 at 3:00 p.m. [DIAGNOSES REDACTED]. A "Bed Rail Safety Assessment" form dated 3/25/12 indicated, "All bed rails must be assessed for safety upon initiation of rails and quarterly thereafter...Is resident non ambulatory? (Y with a check mark)...Is resident unaware of safety issues? (Y with a check mark)...Is resident on medications which require increased safety precautions? (Y with a check mark)...Sire rails are used for: (Safety with a check mark)...." A large handwritten "X" was marked over the questions regarding safety measures. The safety measures portion indicated, "Bed rails are properly installed according to manufacture's instructions...If half rails are used, the gap between rails is not large enough to allow for entrapment...." During an observation on 6/26/12 at 2:50 p.m., Resident #45 was in bed with eyes closed. The bed had four half side rails raised. Two half side rails at the head of the bed on each side and two half side rails at the foot of the bed on each side were raised. The gap between the top half rail and the bottom half rail was 12 inches on each side. During an interview on 6/26/12 at 3:15 p.m., the DoN indicated staff were doing a hall by hall sweep to assess for the needs of side rails. She indicated unsafe rails and rails without medical doctor's orders were going to be removed. During an observation on 6/26/12 at 4:27 p.m., Resident #45's bed had both the upper side rail and the lower side rail on one side of the bed removed. The upper side rail and the lower side rail on the side of the bed near the door still remained and were raised with the 12 inch gap between the rails. During an interview on 6/26/12 at 4:33 p.m., the DoN indicated the rails would be removed, and the resident would be re-assessed for the need to have side rails. 12. Resident # 52's record was reviewed on 6/28/12 at 9:10 A.M. Current [DIAGNOSES REDACTED]. During an interview with LPN # 8, on 6/26/12 at 10:30 A.M., she indicated side rails were not used for Resident # 52. During an observation of side rails on facility beds on 6/26/12 at 1:30 P.M., full length side rails with a gap of 6 inches in the rail were observed on Resident # 52's bed. During an interview with LPN # 8, at that time, she indicated she did not know why there were full length side rails on Resident # 52's bed. 13. The record for Resident # 46 was reviewed on 6/27/12 at 10:05 A.M. Current [DIAGNOSES REDACTED]. During the staff interview on 6/26/12 at 10:00 A.M., LPN # 9 indicated the resident used 1/2 rails when in bed. During observation of the resident's side rails on 6/26/12 at 1:45 P.M., the half rails were noted to be loose on the bed creating a gap greater than 6 inches from the mattress, and the rails themselves had a gap of 6 inches between the bars. 14. The record for Resident # 21 was reviewed on 6/27/12 at 2:35 P.M. Current [DIAGNOSES REDACTED]. During the staff interview with LPN # 9 on 6/26/12 at 10:00 A.M., she indicated side rails were not used for Resident # 21. During an observation of siderails on beds on 6/26/12 at 1:30 P.M., Resident #21's side rails were in the up position. The side rail itself had a 9 inch gap in the rail. 15. The record Resident # 16 was reviewed on 6/27/12 at 2:23 P.M. [DIAGNOSES REDACTED]. During the initial tour on 6/25/12 at 8:30 A.M. the resident's bed was observed to have 1/2 side rails with gaps that measured 7 inches. The side rails were up but the resident was not currently in the bed. The current bed rail safety assessment dated [DATE] indicated the resident used the rails for safety but the safety measures (... if half rails are used, the gap between the rails is not large enough to allow for entrapment) of the assessment was crossed off. 16. The record Resident # 22 was reviewed on 6/26/12 at 2:49 P.M. [DIAGNOSES REDACTED]. During the initial tour on 6/25/12 at 8:30 A.M. the resident's bed was observed to have 1/2 side rails with gaps that measured 7 inches. The side rails were not up and the resident was not currently in the bed. The current bed rail safety assessment dated [DATE] indicated the resident used the rails for safety but the safety measures (... if half rails are used, the gap between the rails is not large enough to allow for entrapment) of the assessment was crossed off. 17. Resident #14's record was reviewed on 6/26/2012 at 3:30 P.M. Resident #14 was admitted on [DATE] and had current [DIAGNOSES REDACTED]. During an observation on 6/26/2012 at 3:20 P.M. Resident #14 was observed in bed with full side rails on both side of the beds. The bed rails were in the up position, loosely attached, and did not fit properly on the bed causing a gap between the bed and side rail. 18. Resident #47's record was reviewed on 6/26/2012 at 9:30 A.M. Resident #47 was originally admitted on [DATE] and had current [DIAGNOSES REDACTED]. Resident # 47 was alert but confused at times. During an interview on 6/26/2012 at 2:15 P.M., LPN #8 indicated Resident #47 did not use side rails. During an observation on 6/26/2012 at 1:25 P.M., Resident #47 was observed in bed with the left side rail raised and the other side of the bed against the wall. The side rail had a middle cap which measured 7.5 inches wide. During an interview on 6/26/2012 at 2:00 P.M., CNA (Certified Nursing Assistant) #14, indicated the rail was supposed to have a cover on it was being washed. During an interview on 6/26/2012 at 2:03 P.M., the Director of Nursing (DON) indicated she assumed when the beds were switched out the old rails were not removed. During an interview on 6/26/2012 at 2:22 P.M. The Administrator stated, "We have new beds. Those old side rails shouldn't even be on the beds. Don't know why they are saving them. We have financed new beds." During an interview on 6/29/12 at 9:45 a.m., the Administrator indicated staff relay concerns by written form. He indicated maintenance requests are put on a form and given to the maintenance director and reviewed with the administrator. The Administrator indicated water temperatures had not been a problem before. The Administrator indicated unsafe side rails had been addressed in 2008 with an 8 month audit performed. The Administrator indicated he was not aware there were problems with the side rails again. Review of a current facility policy titled "Side Rails" provided by the Administrator on 6/29/2012 at 8:10 A.M., indicated it was the policy of the facility to ensure the resident's environment remained free of accident hazards as much as possible. 3.1-13(q)

Based on observation, interview and record review the facility failed to ensure resident safety with the potential for burns from hot water temperatures that exceeded 120 degrees with the potential to effect 46 of 46 residents as indicated by all three halls of the facility had a representation of hot water temperatures greater than 120 degrees Fahrenheit. (#41, #1, #4, #47, #13, #25, #12) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 6/25/12 and began on 6/18/12. The Administrator was notified of the Immediate Jeopardy on 6/25/12. The Immediate Jeopardy was removed on 6/25/12 as confirmed by the mixing valve on the hot water tank was replaced by a professional service. A water temperature policy was submitted by the Administrator 6/26/12 at 10:30 a.m. and indicated water temperatures would be monitored daily and discrepancies must be reported to the Administrator. On 6/26/12 at 12:50 p.m. water temperatures checked in random resident rooms on all three halls were below 120 degrees Fahrenheit. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a level of widespread, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Based on observation, interview and record review the facility failed to ensure resident safety from the potential for entrapment in side rails with side rail gaps measured greater than 4 3/4 inches in 10 resident rooms. (#41, #1, #45, #52, #21, #46, #16, #22, #14, #47) Findings include: 1. The record for Resident #41 was reviewed on 6/26/12 at 8:55 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/18/12 at 12:30 p.m. indicated, "...alert propelling self through facility." During an observation of room safety on 6/25/12 at 10:40 a.m., the hot water from the bathroom spicket in Resident #41's room was turned on. The water temperature was extremely hot with steam rising. The water temperature registered 158 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:25 a.m., the hot water from the bathroom spicket in Resident #41's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 2. The record for Resident #1 was reviewed on 6/26/12 at 8:50 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/25/12 at 5:00 p.m. indicated, "...aox1 (awake and oriented times one) to self restless in w/c (wheelchair) has self release belt cont (continue) to unfasten (sign for with) alarm sounding propelling self throughout unit...." During an observation of room safety on 6/25/12 at 10:40 a.m., the hot water from the bathroom spicket in Resident #1's room was turned on. The water temperature was extremely hot with steam rising. The water temperature registered 158 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:25 a.m., the hot water from the bathroom spicket in Resident #1's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 3. The record for Resident #4 was reviewed on 6/25/12 at 9:10 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/2/12 at 2:00 p.m. indicated, "Resident alert / ox3 (oriented times three), sitting up in bed...non-ambulatory, uses w/c (wheelchair) for mobility, dependent for all ADL's (activities of daily living)/peri-care/transfers...." On 6/25/12 at 10:44 a.m., the hot water from the bathroom spicket in Resident #4's room registered 150 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:28 a.m., the hot water from the bathroom spicket in Resident #4's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 4. The record for Resident #47 was reviewed on 6/26/12 at 9:00 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/2/12 at 2:00 p.m. indicated, "Res. (resident) alert (sign for with) confusion, up daily in w/c (wheelchair), staff propelled...." On 6/25/12 at 10:44 a.m., the hot water from the bathroom spicket in Resident #47's room registered 150 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:28 a.m., the hot water from the bathroom spicket in Resident #47's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 5. The record for Resident #13 was reviewed on 6/26/12 at 9:10 a.m. [DIAGNOSES REDACTED]. A nurses noted dated 6/16/12 at 11:00 a.m. indicated, "Resident Alert (sic) (sign for and) oriented x 2...." The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 used a wheelchair and was independent in locomotion on the unit. On 6/25/12 at 10:46 a.m., the hot water from the bathroom spicket in Resident #13's room registered 130 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:31 a.m., the hot water from the bathroom spicket in Resident #13's room registered 130 degrees Fahrenheit on the facility's non-digital thermometer. 6. The record for Resident #25 was reviewed on 6/26/12 at 9:15 a.m. [DIAGNOSES REDACTED]. A nurses noted dated 6/24/12 at 11:00 p.m. indicated, "Res. (resident) alert, pleasantly confused. Up in w/c (wheelchair) self mobility...." During rounds with Maintenance Manager #1 on 6/25/12 at 11:34 a.m., the hot water from the bathroom spicket in Resident #25's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 7. The record for Resident #12 was reviewed on 6/26/12 at 9:25 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/15/12 at 11:00 p.m. indicated, "Alert to self and name. Up daily in w/c (wheelchair) staff propelled...." During rounds with Maintenance Manager #1 on 6/25/12 at 11:34 a.m., the hot water from the bathroom spicket in Resident #12's room registered 150 degrees Fahrenheit on the facility's non-digital thermometer. 8. On 6/25/12 at 10:42 a.m., the hot water from the sprayer in the beauty shop shampoo sink which is adjacent to the 100 hall way registered 156.7 degrees Fahrenheit with a digital thermometer. During rounds with Maintenance Manager #1 on 6/25/12 at 11:37 a.m., the hot water from the sprayer in the shampoo sink in the beauty shop registered 152 degrees Fahrenheit on the facility's non-digital thermometer. During an interview on 6/25/12 at 10:51 a.m., Maintenance Manager #1 indicated, "It might take a second to find them because I've only been here three weeks," in regards to the water temperature logs requested. On 6/25/12 at 11:21 a.m. the water temperature logs were provided by Maintenance Manager #1, and he indicated the log was recent. A water temperature log entry dated June 18 without a year, indicated, "...NURSES STATION (sic) 125... 203 - 130 206 - 125... 303 129 305 125 304 126 303 130 104 126...." A water temperature log entry dated, "TUE (Tuesday) 19-2012," indicated, "...203 130 206 125... 303 129 305 125 304 125 303 130." A water temperature log entry dated, "(illegible) 20 2012," indicated, "TUB...400 - 130 NURSE STATION 130... 203 135... 303 130 305 125... 308 130 104 126...." A water temperature log entry dated, "Thur (Thursday) 21 2012," indicated, "TUB...400 - 125 NURSE STATION 125... 203 130 206 125... 303 125... 304 129 303 130 104 130... 107 125." The water temperature log lacked documentation for water temperatures for Friday, 6/22/12, Saturday, 6/23/12 or Sunday, 6/24/12. During an interview on 6/25/12 at 11:21 a.m., Maintenance Manager #1 indicated he checked the water temperatures every day or every other day. He indicated the water temperatures should not exceed 120 degrees Fahrenheit. He indicated he had not checked water temperatures today, 6/25/12. He indicated there were four water heaters in the facility. He indicated there was a water heater for the 100 hall, a water heater for the 200 hall, a water heater for the 300 hall and a water heater for the kitchen. He indicated the water gets cooler the farther down the hall from the location of the water heater. During an interview on 6/25/12 at 11:40 a.m., Maintenance Manager #1 indicated he has was not trained on adjusting the mixer valves on the hot water heaters. He indicated the mixing valves were routinely switched out every six months and a work order had been turned in. He indicated the work would be done within the week. When asked how resident safety was ensured, he indicated, "I could probably turn it down." He Indicated he did not receive instruction on the mixer valves and did not know if it would even work. During an interview on 6/25/12 at 11:51 a.m., the Administrator indicated he was not aware of any water temperature problems. He indicated the maintenance manager was to notify him if there were water temperature concerns. He indicated the water temperature concerns would be addressed in the morning meeting and the service company would be notified to evaluate the water heaters. Water temperature policies and a maintenance manager job description were requested. During an interview on 6/25/12 at 4:15 p.m., the Administrator indicated, "Oh, I'm still looking for those," in response to another request for facility policies and a maintenance manager job description. During an interview on 6/26/12 at 9:15 a.m., CNA #2 indicated the water was hot over the weekend. She indicated she mixed the hot water and the cold water. She indicated she did not report the hot water. A Job Description, tiled, "Housekeeping/Maintenance Manager," provided by the Administrator on 6/25/12 at 4:45 p.m. indicated, "...Maintenance Manager is responsible for ensuring that...is clean, orderly, and in a state of good repair, both inside and out, and provides reasonable comfort for all residents...must comply with the standards of the Indiana Administrative Code, Indiana State Department of Health, and any other applicable local, state and federal laws and regulations regarding facility care and maintenance...Reports To: Administrator...." No policies regarding water temperatures were presented by the end of the day at 4:45 p.m. on 6/25/12. On 6/26/12 at 10:54 a.m., Maintenance Manager #1's employee file was reviewed and lacked documentation on training for facility water heaters. On 6/26/12 at 10:30 a.m., an undated facility policy was provided by the Administrator titled, "Water Temperature Monitoring." The policy indicated, "Policy: It is the policy of this facility to assure the water temperatures remain within safe parameters for the safety of the residents and staff...The water temperatures will be monitored daily...should be no warmer than 120 degrees. A Preventative maintenance Log will be kept by the month and reviewed...Any discrepancies must be addressed by the maintenance department and reported to Administration...." 9. The record for Resident #41 was reviewed on 6/26/12 at 8:55 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/18/12 at 12:30 p.m. indicated, "...alert propelling self through facility." A "Bed Rail Safety Assessment" dated 6/6/12 indicated, "All bed rails must be assessed for safety upon initiation of rails and quarterly thereafter. Is resident non ambulatory? (Y with a check mark)ambulatory?...Is resident unaware of safety issues? (Y with a check mark)...Is resident on medications which require increased safety precautions? (Y with a check mark)...Side rails are used for: (Safety with a check mark)...." A large handwritten "X" was marked over the questions regarding safety measures. The safety measures portion indicated, "Bed rails are properly installed according to manufacture's instructions...If half rails are used, the gap between rails is not large enough to allow for entrapment...." During an observation on 6/26/12 at 1:25 p.m., Resident #41's bed was observed with bilateral half side rails up. The side rails had a cloth cover over them; however, the cloth was ripped exposing gaps in the side rails that were 7.5 inches. The resident was not in the bed at the time of the observation. 10. The record for Resident #1 was reviewed on 6/26/12 at 8:50 a.m. [DIAGNOSES REDACTED]. A nurses note dated 6/25/12 at 5:00 p.m. indicated, "...aox1 (awake and oriented times one) to self restless in w/c (wheelchair) has self release belt cont (continue) to unfasten (sign for with) alarm sounding propelling self throughout unit...." A "Bed Rail Safety Assessment" dated 4/17/12 indicted, "All bed rails must be assessed for safety upon initiation of rails and quarterly thereafter. Is resident non ambulatory? (N with a check mark)ambulatory?...Is resident unaware of safety issues? (Y with a check mark)...Is resident on medications which require increased safety precautions? (Y with a check mark)...Side rails are used for: (Safety with a check mark)...." A large handwritten "X" was marked over the questions regarding safety measures. The safety measures portion indicated, "Bed rails are properly installed according to manufacture's instructions...If half rails are used, the gap between rails is not large enough to allow for entrapment...." During an observation on 6/26/12 at 1:25 p.m., Resident #1's bed was observed with bilateral half side rails up. The side rails had a cloth covering over them; however, the cloth was ripped exposing gaps in the side rails that were 7.5 inches. The resident was not in the bed at the time of the observation. 11. The record for Resident #45 was reviewed on 6/26/12 at 3:00 p.m. [DIAGNOSES REDACTED]. A "Bed Rail Safety Assessment" form dated 3/25/12 indicated, "All bed rails must be assessed for safety upon initiation of rails and quarterly thereafter...Is resident non ambulatory? (Y with a check mark)...Is resident unaware of safety issues? (Y with a check mark)...Is resident on medications which require increased safety precautions? (Y with a check mark)...Sire rails are used for: (Safety with a check mark)...." A large handwritten "X" was marked over the questions regarding safety measures. The safety measures portion indicated, "Bed rails are properly installed according to manufacture's instructions...If half rails are used, the gap between rails is not large enough to allow for entrapment...." During an observation on 6/26/12 at 2:50 p.m., Resident #45 was in bed with eyes closed. The bed had four half side rails raised. Two half side rails at the head of the bed on each side and two half side rails at the foot of the bed on each side were raised. The gap between the top half rail and the bottom half rail was 12 inches on each side. During an interview on 6/26/12 at 3:15 p.m., the DoN indicated staff were doing a hall by hall sweep to assess for the needs of side rails. She indicated unsafe rails and rails without medical doctor's orders were going to be removed. During an observation on 6/26/12 at 4:27 p.m., Resident #45's bed had both the upper side rail and the lower side rail on one side of the bed removed. The upper side rail and the lower side rail on the side of the bed near the door still remained and were raised with the 12 inch gap between the rails. During an interview on 6/26/12 at 4:33 p.m., the DoN indicated the rails would be removed, and the resident would be re-assessed for the need to have side rails. 12. Resident # 52's record was reviewed on 6/28/12 at 9:10 A.M. Current [DIAGNOSES REDACTED]. During an interview with LPN # 8, on 6/26/12 at 10:30 A.M., she indicated side rails were not used for Resident # 52. During an observation of side rails on facility beds on 6/26/12 at 1:30 P.M., full length side rails with a gap of 6 inches in the rail were observed on Resident # 52's bed. During an interview with LPN # 8, at that time, she indicated she did not know why there were full length side rails on Resident # 52's bed. 13. The record for Resident # 46 was reviewed on 6/27/12 at 10:05 A.M. Current [DIAGNOSES REDACTED]. During the staff interview on 6/26/12 at 10:00 A.M., LPN # 9 indicated the resident used 1/2 rails when in bed. During observation of the resident's side rails on 6/26/12 at 1:45 P.M., the half rails were noted to be loose on the bed creating a gap greater than 6 inches from the mattress, and the rails themselves had a gap of 6 inches between the bars. 14. The record for Resident # 21 was reviewed on 6/27/12 at 2:35 P.M. Current [DIAGNOSES REDACTED]. During the staff interview with LPN # 9 on 6/26/12 at 10:00 A.M., she indicated side rails were not used for Resident # 21. During an observation of siderails on beds on 6/26/12 at 1:30 P.M., Resident #21's side rails were in the up position. The side rail itself had a 9 inch gap in the rail. 15. The record Resident # 16 was reviewed on 6/27/12 at 2:23 P.M. [DIAGNOSES REDACTED]. During the initial tour on 6/25/12 at 8:30 A.M. the resident's bed was observed to have 1/2 side rails with gaps that measured 7 inches. The side rails were up but the resident was not currently in the bed. The current bed rail safety assessment dated [DATE] indicated the resident used the rails for safety but the safety measures (... if half rails are used, the gap between the rails is not large enough to allow for entrapment) of the assessment was crossed off. 16. The record Resident # 22 was reviewed on 6/26/12 at 2:49 P.M. [DIAGNOSES REDACTED]. During the initial tour on 6/25/12 at 8:30 A.M. the resident's bed was observed to have 1/2 side rails with gaps that measured 7 inches. The side rails were not up and the resident was not currently in the bed. The current bed rail safety assessment dated [DATE] indicated the resident used the rails for safety but the safety measures (... if half rails are used, the gap between the rails is not large enough to allow for entrapment) of the assessment was crossed off. 17. Resident #14's record was reviewed on 6/26/2012 at 3:30 P.M. Resident #14 was admitted on [DATE] and had current [DIAGNOSES REDACTED]. During an observation on 6/26/2012 at 3:20 P.M. Resident #14 was observed in bed with full side rails on both side of the beds. The bed rails were in the up position, loosely attached, and did not fit properly on the bed causing a gap between the bed and side rail. 18. Resident #47's record was reviewed on 6/26/2012 at 9:30 A.M. Resident #47 was originally admitted on [DATE] and had current [DIAGNOSES REDACTED]. Resident # 47 was alert but confused at times. During an interview on 6/26/2012 at 2:15 P.M., LPN #8 indicated Resident #47 did not use side rails. During an observation on 6/26/2012 at 1:25 P.M., Resident #47 was observed in bed with the left side rail raised and the other side of the bed against the wall. The side rail had a middle cap which measured 7.5 inches wide. During an interview on 6/26/2012 at 2:00 P.M., CNA (Certified Nursing Assistant) #14, indicated the rail was supposed to have a cover on it was being washed. During an interview on 6/26/2012 at 2:03 P.M., the Director of Nursing (DON) indicated she assumed when the beds were switched out the old rails were not removed. During an interview on 6/26/2012 at 2:22 P.M. The Administrator stated, "We have new beds. Those old side rails shouldn't even be on the beds. Don't know why they are saving them. We have financed new beds." Review of a current facility policy titled "Side Rails" provided by the Administrator on 6/29/2012 at 8:10 A.M., indicated it was the policy of the facility to ensure the resident's environment remained free of accident hazards as much as possible. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 6/25/12 and began on 6/18/12. The Administrator was notified of the Immediate Jeopardy on 6/25/12. The Immediate Jeopardy was removed on 6/25/12 as confirmed by the mixing valve on the hot water tank was replaced by a professional service. A water temperature policy was submitted by the Administrator 6/26/12 at 10:30 a.m. and indicated water temperatures would be monitored daily and discrepancies must be reported to the Administrator. On 6/26/12 at 12:50 p.m. water temperatures checked in random resident rooms on all three halls were below 120 degrees Fahrenheit. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a level of widespread, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. 3.1-19(r)(2)

Based on record review and interview, the facility failed to ensure a resident with an indwelling catheter (Resident B) was not injured by dislodgement of the catheter. The facility failed to follow a physician's orders [REDACTED]. The accidental removal of the catheter resulted in bleeding and required transfer to an emergency room for treatment. This deficient practice affected 1 of 3 residents reviewed for catheter care in a sample of 11. Findings include: 1. The record of Resident B was reviewed on 1/30/12 at 1:00 p.m. [DIAGNOSES REDACTED]. Nurse's notes indicated: 1/13/12 2:05 p.m., "Res (resident) sent out to...hosp (hospital)...." 1/16/12 4:30 p.m., "Resident returned to facility...Foley cath (indwelling urinary catheter) anchored...." 1/18/12 3:10 p.m., "...M.D. notified by writer requesting urinary leg bag...." 1/20/12 (no time), "Order given for...leg bag for catheter...." 1/28/12 9:00 a.m., "Resident pulled out his Foley catheter with bulb inflated. Has moderate amount of bleeding. Direct pressure held...Emergency 911 notified." 1/28/12 2:00 p.m., "Resident returned from hospital...Foley catheter intact...orders received to leave leg bag on to prevent resident from pulling catheter out...." 1/28/12 8:30 p.m., "...catheter...in place draining bloody red drainage...." A physician's orders [REDACTED]." No health care plan related to use or care of an indwelling urinary catheter was found in the clinical record. During an interview on 1/31/12 at 9:55 a.m., L.P.N. #2 indicated she was the nurse who "regularly" took care of Resident B. She indicated she had called the physician to get an order for [REDACTED]. She indicated she discussed this with the resident's family and all agreed the leg bag was an appropriate intervention to prevent this from happening. When she learned Resident B had pulled out his catheter on 12/28/12, she indicated, "That's terrible. I told them that would happen." During an interview on 1/31/12 at 9:20 a.m., R.N. #1 indicated she was the nurse called to Resident B's room when he was found with his catheter out. She indicated he had a regular gravity catheter bag hanging from his bed. The leg bag was not in use. She indicated "He had a lot of bleeding." In a subsequent interview on 1/31/12 at 9:55 a.m. with the D.O.N. (Director of Nursing) present, R.N. #1 indicated Resident B had the gravity urinary bag in place at the start of her shift and she was unaware Resident B had an order to use the leg bag exclusively. During an interview with the D.O.N on 2/01/12 at 3:00 p.m., she indicated she had no further information or documentation to provide concerning Resident B. This federal tag relates to Complaint IN 637. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure a resident who entered the facility without pressure sores (Resident B) did not develop pressure sores which developed into a Stage IV ulcer, and failed to ensure that resident did not develop additional pressure sores, for 1 of 3 residents reviewed for pressure sores in a sample of 3 and a population of 56. Findings include: The record of Resident B was reviewed on 1/09/12 at 3:20 p.m. [DIAGNOSES REDACTED]. An Initial Minimum Data Set (MDS) assessment, dated 11/01/11, indicated Resident B was moderately cognitively impaired, had an indwelling urinary catheter, was frequently incontinent of bowel, and required staff assistance for all activities of daily living. A "Resident-Data Collection" form, dated 10/25/11, and marked "Admission" indicated Resident B had no pressure sores on admission to the facility. A nurse's note, dated 10/26/11 at 6:30 a.m., included a skin assessment. No pressure sores were noted. "Pressure Wound Risk Assessment" scores, with a score of less than 12 indicating high risk for pressure sores, were: 11/10/11: 10 11/21/11: 7 12/09/11: 11 Nurse's notes for Resident B indicated: 11/4/11 7:00 a.m. (Indicated to be a late entry for 11/3/11) "...open wound found on coccyx .4 x (by) .4 cm ( centimeters) on coccyx...place call to M.D. orders received..." 11/09/11 (No time- indicated to be a late entry) "Skin assessment...has .75 x .75 cm pink wound to coccyx..." 11/23/11 9:00 p.m. "Skin assessment...Pt (patient) has a 1 x 2 cm open red wound on Lt (left) buttocks..." 12/09/11 (No time) "Skin assessment...Lt buttocks near coccyx 4 x 5 cm, pink/red wound (symbol for "with") mod (moderate) amt (amount) of brownish exudate (drainage...) 12/14/11 9:00 p.m. "...low air loss mattress applied to bed today..." 12/19/11 7:00 p.m. "...wound to lt buttocks has black eschar (dry scab) tissue present on 3/4 (three quarters) of wound other portion is red, wound is 5 x 3 cm, .1 in depth. Darken (sic) circumference is 18 x 7.5 cm, appears worsen (sic) since last seen by this nurse on 12/9/11. Now a Stage lll..." 12/21/11 (No time) "Skin assessment...Wound to Lt buttocks now includes coccyx has advanced to a Stage lll...wound center appt (appointment) made...for Jan (January) 4th..." 12/26/11 9:00 p.m. "...notable sediment drsg (dressing) to coccyx..." 12/29/11 (No time) "Skin assessment..Stage lll lt buttocks including coccyx, 6 x 4 cm, larger now, wound is pink in color... darken (sic) circumference 18 x 7.5 cm. Has a mod (moderate) amt of tan exudate, (symbol for "with") a small amt of serous (clear bodily fluid) drainage..." 1/2/12 8:30 p.m. "...has Stage lV coccyx wound..." 1/6/12 10:30 a.m. "Suggested wound vac (wound evacuation device) to wound Dr (Doctor)...no success yet..." A "Skin Conditions" report, dated 11/7/11, indicated: "Date of oldest Stage 2 Pressure ulcer: 11/03/2011...coccyx..." A "Skin Conditions" report, dated 12/29/11, indicated: "Stage ll wound has now advanced to a stage lll...." A "Skin/Wound QI Log" form, dated 11/09/11, indicated "Onset Date...Facility Acquired 11/3/11...Stage ll pressure...coccyx..." A Stage II pressure ulcer is defined by the American Medical Director's Association as "Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough. May also present as an intact or open/ruptured blister." A "Skin/Wound QI Log" form, dated 12/21/11, indicated "Onset Date...Facility Acquired 11/23/11...Advanced to Stage lll...lt buttocks near coccyx..." A Stage III pressure ulcer is defined by the American Medical Director's Association as "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling." A "Skin/Wound QI Log" form, dated 1/04/12, indicated "Onset Date...Facility Acquired 11/23/11...Stage lV...coccyx extending to lt buttocks..." A Stage IV pressure ulcer is defined by the American Medical Director's Association as "Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling." A report from the wound clinic, dated 12/30/11, indicated: "Wound location: Coccyx Wound Type: Pressure Ulcer Date Acquired: 11/1/2011 Status: Not Healed Measurements: 6 x 3 x 0.1 cm..." A physician's orders [REDACTED]." During an interview with the Nursing Unit Manager on 1/10/12 at 4:10 p.m., she indicated that on 11/03/11 Resident B's had the facility's standard foam anti-pressure mattress as available for all residents. A low air loss mattress was not added until 12/14/11. During an interview with the Director of Nursing on 1/10/12 at 3:45 p.m., she indicated that prior to 12/21/11 the Wound Clinic had not been contacted to arrange a consultation for Resident B. During an interview on 1/10/12 at 3:30 p.m., with the facility Wound Nurse, she indicated that between 12/09/11 and 12/19/11, when she entered a nurse's note indicating Resident B's pressure wound had worsened, she had been on vacation. She also indicated that on 1/06/12 she had called the Wound Center and left a message for the wound doctor suggesting a wound evacuation device for Resident B. She indicated she had not received a reply and had not contacted the Wound Clinic again about this matter. This federal tag relates to Complaints IN 566 and IN 887. 3.1-40(a)(1)