Every finding on record at Aperion Care Tolleston Park

Based on record review and interview, the facility failed to prevent an avoidable pressure ulcer for an at-risk dependent resident resulting in the resident developing a facility-acquired stage four (full thickness of the skin) pressure ulcer with infection to the buttocks one month after admission to the facility. (Resident B)The immediate jeopardy began on 5/26/26, when the nursing staff found a malodorous stage four pressure ulcer to the buttocks which tested positive for infection when cultured. The Administrator, RN Corporate Wound Specialist, RN Consultant, Corporate Minimum Data Set (MDS) Nurse, and Director of Nursing (DON) were notified of the immediate jeopardy on 6/10/26 at 3:06 p.m. The immediate jeopardy was removed and the deficient practice corrected on 6/9/26, prior to the start of the survey, and was therefore Past Noncompliance. Finding includes: Resident B's closed record was reviewed on 6/10/26 at 9:54 a.m. The diagnoses included, but were not limited to, Parkinson's disease, stroke, and malignant cancer of the bladder.An admission Braden Scale assessment, dated 4/24/26, indicated a moderate risk for pressure ulcers.The Nursing admission Assessment, dated 4/24/26, indicated the skin was warm to touch, moist, and there were no pressure areas.A Nurse's Note, dated 4/25/26 at 10:10 a.m., indicated a risk for pressure areas. Maximum assistance was required for activities of daily living, the resident was incontinent of bowel and bladder, and redness was observed on the buttocks. Heel floats and an air mattress were in place.There were no further assessments of the redness of the buttocks. An admission Minimum Set Set (MDS) assessment, dated 4/27/26, indicated a moderately intact cognitive status, no impairment of the upper extremities, impairment of the bilateral lower extremities, maximum to dependent assistance required for toileting, bathing and hygiene, and moderate assistance was required for bed mobility. The resident was always incontinent of bowel and bladder, was a risk for pressure ulcers, and had no pressure ulcers/injuries present.A Care Plan, dated 4/27/26, indicated a potential for impaired skin integrity related to impaired mobility and incontinence. The interventions included, changes in the skin status would be reported to the physician.A Care Plan, dated 4/27/26, indicated bowel and bladder incontinence. The interventions included barrier cream was to be used after each incontinent episode, the resident would be checked and changed every two to three hours and as needed and incontinence care would be completed.A Weekly Skin Assessment, dated 5/22/26 at 1:41 p.m., indicated the skin was intact and no concerns were noted.A Nurse's Note, dated 5/26/26 at 9:00 p.m., indicated a pressure wound to the coccyx was observed. The measurement of the wound was 7 centimeters (cm) in length by 9 cm in width and 1.5 cm depth. The wound was draining a tan colored drainage. Treatment orders for the wound were obtained and a wound culture was completed.A Wound Nurse Progress Note, dated 5/27/26 at 12:53 p.m., indicated the coccyx wound measured 3.8 cm in length by 5 cm width with 1.8 cm depth. There was moderate purulent and malodorous drainage. The resident was a high risk for skin breakdown related to poor bed mobility, incontinence, chronic obstructive pulmonary disease and hemiparesis.A Wound Assessment Details Report, dated 5/27/26 at 5:37 a.m. and completed by the Wound Nurse, indicated the area on the coccyx was 30% red and 70% slough (a yellowish, soft, and often stringy material that forms in wounds as a result of dead or dying tissue, protein buildup, and bacterial contamination). The clinical stage was a stage four.The Wound Nurse Practitioner (NP) Progress Note, dated 5/29/26, indicated the wound culture showed multiple bacteria in small quantities and a broad band antibiotic was ordered. There was a moderate amount of serosanguineous drainage with a strong odor from the wound. The wound had 71-80% eschar (a thick, dry layer of dead, necrotic tissue) and a surgical debridement was completed. The post debridement measurements were 3.9 cm length by 3.6 cm width by 2 cm depth.A Nurse's Note, dated 5/29/26 at 11:54 a.m., indicated the Wound NP ordered doxycycline (antibiotic) 100 milligrams (mg) twice a day for seven days. An X-Ray of the sacrum was also ordered to rule out osteomylitis (infection and inflammation of the bone.)The results of the sacrum X-Ray, dated 5/29/26, indicated the resident had been moving and yelling out during the testing due to pain, which resulted in suboptimal x-rays. An MRI was recommended to rule out osteomylitis.A Nurse's Note, dated 6/3/26 at 3:43 p.m., indicated the resident's blood pressure was 88/66 and pulse was 105. The NP ordered IV (intravenous) antibiotics.A Physician's Order, dated 6/3/26, indicated meropenem (antibiotic) 1 gram per IV every eight hours for bacterial infection for seven days.A Nurse's Note, dated 6/3/2026 at 4:24 p.m., indicated an IV was placed in the left hand.A Nurse's Note, dated 6/4/26 at 2:14 a.m., indicated the resident pulled the IV out.A Nurse's Note, dated 6/4/26 at 9:37 a.m., indicagted the resident's blood pressure was 88/58 and pulse was 108 and there were complaints of pain. A physician's order was obtained to transfer the resident to the hospital.A Nurse's Note, dated 6/4/26 at 4:56 p.m., indicated the resident had been admitted to the hospital.An NP progress Note, dated 6/4/26 at 11:45 p.m., indicated the resident had developed worsening sacral wound pain and infection. The wound culture grew moderate Pseudomonas aeruginosa. The antibiotics were changed from doxycycline to ciprofloxacin, then escalated to IV meropenem due to persistent infection and elevated C-reactive protein (CRP, used to detect general inflammation). The IV was pulled out by the resident during the night and staff were unsuccessful with reinsertion. This morning the resident had chills and experienced recurrent hypotension. She was transferred to the hospital Emergency Room.The Hospital History and Physical, dated 6/4/26, indicated the resident was admitted into the hospital with severe sepsis and wound infection.During interviews on 6/10/26 at 1:07 p.m., the Director of Nursing (DON) indicated the staff who had been assigned to the resident were interviewed and had said they either had not seen the area or the resident refused care. She indicated the resident was assessed with a red area on her butttocks on admission and barrier cream after incontinence care was initiated. She was unsure how the pressure area had not been observed by the staff when they were providing incontinence care, bathing, and other care multiple times daily.The past noncompliance immediate jeopardy began on 5/26/26. The immediate jeopardy was removed and the deficient practice corrected by 6/9/26 after the facility implemented a systemic plan that included the following actions:The facility determined a deficiency in their wound assessment program on 5/26/26 and immediately implemented a plan of improvement. An assessment and interventions were initiated for Resident B on 5/26/26. The facility educated 27 of 27 nurses on skin assessments that were to be completed weekly with the CNA and documented in the record. The assessments were to be co-signed by the nurse and the CNA. All skin impairments were to have a Risk Management Form initiated and the Physician and Responsible Party were to be notified. A treatment for the area was to be obtained and initiated. The DON and Wound Nurse were to be notified. The facility educated 57 of 57 CNA's that all skin impairments were to be reported to the nurse immediately and documented in the chart. They were to monitor and inspect the skin during all care provided. A full house skin sweep was conducted to ensure no other resident were affected. A full house audit was completed to ensure all interventions were in place and accurate. Seven Nurses, one QMA, and six CNA's from different shifts were interviewed and all were knowledgeable of the policies and procedures they were educated on. Audits had been completed and were still ongoing to ensure weekly skin assessments were completed timely and accurately and preventative skin interventions were in place. All information would be reviewed and submitted to the facility's Quality Assurance Program.This citation relates to Intake 3033261.410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(1)410 IAC 16.2-3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to shaving, nail care, providing showers, and incontinence care for 6 of 11 residents reviewed for ADLs. (Residents H, E, G, D, F, B)Findings include: 1.During an interview on 2/16/26 at 3:24 p.m., Resident H indicated staff did not set him up to brush his teeth. He also indicated the razors were dull and shaving was very brutal, he would like an electric razor but no one had offered one. On 2/17/26 at 10:30 a.m., the resident was observed in his room and he had a large amount of facial hair. On 2/18/26 at 7:45 a.m. and 12:30 p.m, the resident's facial hair remained and oral care had not been provided. On 2/19/26 at 11:10 a.m., the resident had a large amount of facial hair and he indicated his teeth had not been brushed. At 11:17 a.m., CNA 3 searched the resident's drawers and she was unable to find a toothbrush or toothpaste. She indicated the midnight staff had gotten the resident up and dressed before she arrived to work. She had not completed or set up the resident to provide oral care. The record for the resident was reviewed on 2/19/26 at 2:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease, anxiety disorder, pain right wrist, and insomnia. The 2/7/26 5 Day Medicare Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making. The resident needed partial to moderate assistance with oral hygiene and bathing. A Care Plan, dated 1/31/26, indicated the resident had an ADL (activities of daily living) self-care/mobility performance deficit that could fluctuate with activity throughout the day. Interventions included, but were not limited to, oral hygiene was to be performed in the morning, after meals, and at bedtime. Brush teeth, rinse dentures, cleans gums with a toothette (a sponge on a stick used for oral care), and rinse mouth with wash. Supervision or touching assistance was needed for personal hygiene. Oral hygiene in the CNA task section indicated the resident was provided with oral hygiene 1/30/26 through 2/18/26 except for the days he was hospitalized . The resident was hospitalized [DATE]-[DATE]. Personal hygiene in the CNA task section indicated the resident was provided personal hygiene care 1/30/26 through 2/18/26 except for the days he was hospitalized . The resident was hospitalized [DATE]-[DATE]. There was no documentation the resident refused oral care. During an interview on 2/19/26 at 11:20 a.m., the Assistant Director of Nursing (ADON) was given the information and had no additional information to provide. During an interview on 2/19/26 at 11:55 a.m., the Director of Nursing indicated the facility had an electric razor the resident could have used. She had no additional information to provide. 2. On 2/16/26 at 11:20 a.m., Resident E was observed with food on his clothes, crumbs in his beard, his face was dry with peeling skin, and his hair was greasy. Staff were in the area, however, no one cleaned his face. On 2/18/26 at 12:10 p.m., the resident was seated in a chair in the dining room. He had dried mucus hanging from his nose and his hair remained greasy. At 12:20 p.m., the resident was removed from the dining room and checked for incontinence. When he returned to the dining room, his nose had been cleaned. At 4:15 p.m., the resident was seated in his wheelchair in the dining room. The front of his pants and in between his legs were wet. At 4:20 p.m. CNA 4 indicated she was going to take the resident to the bathroom and change him. When asked when the last time was that she checked or changed him, the CNA indicated it was before lunch and he was dry and she also checked him after lunch which was probably a little after 1:00 p.m. and the resident would not let her check him. This was the next time she had checked him for incontinence. She indicated at that time, she was supposed to check and change residents at least every two hours. On 2/19/26 at 9:19 a.m., the resident was seated in a wheelchair at a table in the dining room. He had food from breakfast on his face and crumbs on his clothes. Staff in the area had not wiped off his face or clothes. At 9:30 a.m., the resident was observed to self propel himself to the window where he liked to sit. At 9:40 a.m., a CNA moved him back to the table. The food crumbs remained on his face. The record for Resident E was reviewed on 2/20/26 at 9:15 a.m. Diagnoses included, but were not limited to, major depressive disorder, schizophrenia, autistic disorder, anxiety disorder, and intellectual disabilities. The 1/16/26 Annual Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident needed supervision with eating, toileting, and personal hygiene. He needed substantial to maximum assistance with toilet transfers. A current Care Plan indicated the resident had an ADL (activities of daily living) self-care/mobility performance deficit that may fluctuate with activity throughout the day. Interventions included, but were not limited to, supervision with eating and substantial to maximum assistance with toileting hygiene. Documentation related to urinary incontinence in the CNA task section indicated documentation was completed at least three times a day and the resident was mostly incontinent. There were some days when the resident was continent. Personal hygiene in the CNA task section had been signed out every shift for the last 14 days. There was no documentation indicating the resident refused care. During an interview on 2/19/26 at 11:20 a.m., the Assistant Director of Nursing (ADON) indicated the resident was supposed to be checked and changed at least every 2 hours. During an interview on 2/19/26 at 12:00 p.m., the Director of Nursing was given the information and had no additional information to provide. 3. On 2/16/26 at 2:55 p.m., Resident G was seated in her wheelchair by the nurse's station. The resident was observed with a large amount of white facial hair on her chin and face. On 2/17/26 at 10:33 a.m., the facial hair remained on the resident's chin. On 2/18/26 at 2:00 p.m. and 3:50 p.m., the facial hair remained on the resident's chin. On 2/19/26 at 9:10 a.m., the resident was observed in bed and the facial hair remained on her chin. The record for Resident G was reviewed on 2/18/26 at 1:30 p.m. Diagnoses included, but were not limited to, Alzheimer's disease and dementia without behavior disturbance. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 12/9/25, indicated the resident was not cognitively intact for daily decision making. The resident needed partial to moderate assistance with personal hygiene. A Care Plan, dated 9/4/25, indicated the resident had an ADL (activities of daily living) self-care/mobility performance deficit that would fluctuate with activity throughout the day. Interventions included, but were not limited to, partial to moderate assistance was required for personal hygiene. Documentation in the Task Section of the record indicated the resident received a bed bath on 1/22 and 2/12/26 and a shower on 1/26, 1/29, 2/5, and 2/9/26. The resident refused bathing on 2/2, 2/16, and 2/18/26. There was no documentation the resident refused personal hygiene between 1/21 and 2/19/26. During an interview on 2/19/26 at 12:00 p.m., the Director of Nursing was given the information and had no additional information to provide. 4. During an interview on 2/16/26 at 11:00 a.m., Resident D was observed with a growth of facial hair and dirty fingernails to the left hand. At the time, the resident indicated it had been several days since he had been shaved and he preferred to be clean shaven.On 2/17/26 at 2:00 p.m., the resident's fingernails remained dirty and he had not been shaved. On 2/18/26 at 12:15 p.m., the resident had been shaved, however, his fingernails remained dirty. During an interview at that time, the resident indicated he received a shave that day. The record for Resident D was reviewed on 2/18/26 at 12:47 p.m. Diagnoses included, but were not limited to, major depressive disorder, psychotic disorder, dementia without behaviors, and anxiety disorder. The 12/24/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident had no behaviors and required substantial to maximum assistance for personal hygiene. A current Care Plan indicated the resident had an ADL (activities of daily living) self-care performance deficit related to rhabdomyolysis (muscle breakdown), gait abnormality, lack of coordination, and cognitive deficit. Interventions included, but were not limited to, substantial to total dependence on staff for personal hygiene. There was no documentation the resident refused personal hygiene between 2/5/26 and 2/18/26. During an interview on 2/19/26 at 11:20 a.m., the Assistant Director of Nursing indicated she cleaned the resident's fingernails the previous afternoon and she shaved him on Tuesday during the late afternoon. 5. On 2/16/26 at 3:58 p.m., Resident F was observed with facial hair on her chin and face and her fingernails were long and jagged.On 2/17/26 at 11:14 a.m., the facial hair remained on the resident's face and chin and her fingernails remained long and jagged. On 2/18/26 at 7:58 a.m., the resident was dressed and propelling her wheelchair. The facial hair remained on her face and chin and her fingernails were jagged. At 12:15 p.m. and 4:10 p.m., the resident's facial hair had not been removed. The record for Resident F was reviewed on 2/18/26 at 8:03 a.m. Diagnoses included, but were not limited to, type 2 diabetes, depression, and vascular dementia. The Annual Minimum Data Set (MDS) assessment, dated 1/23/26, indicated the resident was not cognitively intact for daily decision making and needed substantial to maximum assistance for personal hygiene. A Care Plan, dated 4/23/25, indicated the resident had a ADL (activities of daily living) self-care/mobility performance deficit that would fluctuate throughout the day related to dementia. Interventions indicated the resident required partial to moderate assistance with personal hygiene. There was no care plan indicating the resident refused to be shaved as well as no documentation indicating the resident refused to be shaved. The shower documentation in the Task section of the record indicated the resident had a shower on 1/23, 1/30, and 2/3/26. The resident received a bed bath on 1/20, 1/27, 2/6, 2/10, and 2/13/26. The resident had refused bathing on 2/15/26. During an interview on 2/19/26 at 11:15 a.m., CNA 3 indicated she was able to shave the resident that day.During an interview on 2/19/26 at 11:20 a.m., the Assistant Director of Nursing indicated the resident was shaved that day and had no additional information to provide. 6. The closed record for Resident B was reviewed on 2/17/26 at 2:35 p.m. Diagnoses included, but were not limited to, non-traumatic subarachnoid hemorrhage (bleeding of the brain) and chronic respiratory failure. The resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The 11/24/25 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The resident required substantial to maximum assistance for bathing. A Care Plan, dated 11/22/25, indicated the resident had an ADL (activities of daily living) self-care/mobility performance deficit that would fluctuate throughout the day related to activity intolerance. Interventions included, but were not limited to, adjust provision of ADLs to compensate for resident's changing abilities and the resident required substantial to maximum assistance with bathing. Shower documentation provided by the facility indicated the resident did not receive a shower on 11/24, 12/1, and 12/8/25. The resident received a shower on 12/4 and 12/11/25 and a bed bath on 11/27 and 12/15/25. A Nurse's Note, dated 12/3/25 at 1:54 p.m., indicated the resident had received a shower and her hair was washed. A Nurse's Note, dated 12/7/25 at 8:20 a.m., indicated the resident received patient care from the CNA. During an interview on 2/19/26 at 11:50 a.m., the Director of Nursing was informed the resident did not receive at least two showers a week and she had no additional information to provide. This citation relates to Intake 2705437. 3.1-38(a)(3)(A)3.1-38(a)(3)(C)3.1-38(a)(3)(D)3.1-38(a)(3)(E)

Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty and discolored floor tiles, marred walls and door frames, dusty ceiling vents, and dead insects in light fixtures for 2 of 3 units observed. (South and PCU) Findings include: During the environmental tour with the Environmental Supervisor on 2/24/26 at 1:37 p.m., the following was observed:1. South Unita. In the bathroom of room [ROOM NUMBER], the toilet paper holder was broken and detached from the wall. The bathroom door frame was scratched and marred. One resident resided in the room and used the bathroom. b. The wall behind the head of bed one in room [ROOM NUMBER] was scratched and marred. The floor tile around the base of the toilet was discolored with a white substance. Two residents resided in the room and used the bathroom. c. The floor tile located at the base of the toilet in room [ROOM NUMBER] was discolored with a white substance. Two residents resided in the room and used the bathroom. d. A stained ceiling tile was observed by the window in room [ROOM NUMBER]. The bathroom door frame was scratched and marred. Two residents resided in the room and used the bathroom. 2. PCU a. There were dead insects in the bathroom light fixture of room [ROOM NUMBER] and the ceiling vent was dusty. There were also dead insects in the light fixture of the main room light located on the ceiling. Two residents resided in the room and shared the bathroom. b. The door frames to the room and bathroom of room [ROOM NUMBER] were scratched and marred. The ceiling vent in the bathroom was dusty and the light fixture in the room and bathroom had an accumulation of dead insects. Two residents resided in the room and used the bathroom. c. The door frames to the room and bathroom of room [ROOM NUMBER] were scratched and marred. The ceiling vent in the bathroom was dusty. One resident resided in the room and used the bathroom. d. The bathroom ceiling vent in room [ROOM NUMBER] had an accumulation of dust. Two residents resided in the room and shared the bathroom. e. The bathroom ceiling vent in room [ROOM NUMBER] had an accumulation of dust. One resident resided in the room and used the bathroom. f. The bathroom ceiling vent in room [ROOM NUMBER] had an accumulation of dust. One resident resided in the room and used the bathroom. g. The bathroom ceiling vent in room [ROOM NUMBER] had an accumulation of dust. One resident resided in the room and used the bathroom. During an interview at the time, the Environmental Supervisor indicated all of the above were in need of cleaning and/or repair.3.1-19(f)

Based on record review and interview, the facility failed to ensure a skin assessment was completed following an angiogram for 1 of 1 resident reviewed for change in condition and medications were administered as ordered for 3 of 5 residents reviewed for unnecessary medications. (Residents G, 24, 72, and 96)Findings include: 1. The record for Resident G was reviewed on 2/18/26 at 1:30 p.m. Diagnoses included, but were not limited to, heart failure and peripheral vascular disease. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 12/9/25, indicated the resident was not cognitively intact for daily decision making. A Nurse's Note, dated 12/1/25 at 6:32 p.m., indicated the resident arrived back to the facility from a physician's appointment. The resident was alert and in no distress. The resident was scheduled for a follow up appointment on 12/23/25 at 8:30 a.m. A note from the vein clinic, dated 12/1/25, indicated the resident had an angiogram (a minimally invasive procedure to visualize blood flow and diagnosis blockages or damage) and discharge instructions were given to her. A hand written note on the bottom of the page indicated the resident was to have a right angiogram on 12/23/25. The next documented entry in the nurse's notes was on 12/3/25, and was completed by behavioral health. There was no documented assessment of the area after the angiogram. There was also no documentation related to the resident going to her appointment on 12/23/25. Discharge instructions from the vein clinic on 12/23/25 indicated the resident had a right angiogram. Again, there was no documentation of an assessment to the area after the angiogram. Nurse's Notes, dated 1/4/26 at 4:05 p.m., indicated the resident had an appointment for a left angiogram on 1/21/26 at 10:00 a.m. Nurse's Notes, dated 1/21/26 at 8:45 a.m., indicated the resident exited the facility for her appointment. The resident returned to the facility at 1:39 p.m. There was no documentation of an assessment to the angiogram site after the resident returned. A Weekly Skin Assessment, dated 1/22/26, did not address the angiogram site. During an interview on 2/19/26 at 11:54 a.m., the Director of Nursing indicated she would look into the documentation to see if there was an assessment after the resident returned. During an interview on 2/19/26 at 2:00 p.m., the Nurse Consultant indicated there was no assessment of the resident after all of the angiograms, nor was there documentation on 12/23/25 of when the resident left or returned from the appointment. 2. The record for Resident 72 was reviewed on 2/18/26 at 2:50 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, bipolar type. A Care Plan, updated 4/18/24, indicated the resident used psychotropic medications related to schizoaffective disorder. The interventions included to administer psychotropic medications as ordered. A Physician's Order, dated 11/12/24, indicated Haldol decanoate 100 milligrams per milliliter (mg/ml), inject 100 milligrams (mg) intramuscularly every 28 days. The Medication Administration Record (MAR), dated 11/2025, indicated the Haldol injection was to be given on 11/11/25. The medication was not signed off as given and there were no electronic medication administration (eMAR) notes. The Quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated the resident received antipsychotic medication. The Medication Administration Record (MAR), dated 1/2026, indicated the Haldol injection was to be given on 1/6/26. The medication was not signed off as given and there were no electronic medication administration (eMAR) notes. The Medication Administration Record (MAR), dated 2/2026, indicated the Haldol injection was to be given on 2/3/26. The medication was not signed off as given. An eMAR note, dated 2/3/26 at 1:21 p.m., indicated awaiting pharmacy delivery. During an interview on 2/20/26 at 2:05 p.m., the Director of Nursing indicated the medication had not been documented as given. The Haldol had been delivered from the pharmacy, so she was unsure why it had not been given. 3. The record for Resident 96 was reviewed on 2/18/26 at 12:36 p.m. Diagnoses included, but were not limited to, dependence on renal dialysis and diabetes. A Care Plan, revised on 9/6/24, indicated the resident had diabetes. Interventions included monitoring blood sugar and administering medications as ordered. The Quarterly Minimum Data Set (MDS) assessment, dated 12/8/25, indicated the resident was cognitively intact for daily decision making, and was dependent in ADLs. a. A Physician's Order, dated 2/14/26, indicated Lantus Insulin (long-acting), inject 21 units every day shift. The February Medication Administration Record (MAR) indicated the Lantus Insulin was held on 2/14/26 and 2/15/26. There were no parameters or orders to hold the medication. b. A Physician's Order, dated 2/14/26, indicated Humalog Insulin (short acting) dosage to be given per a sliding scale, three times a day with meals. The Humalog Insulin was not given and no blood sugar was documented for the mornings of 2/18/26 and 2/20/26. During an interview on 2/20/26, the Director of Nursing (DON) indicated the insulin should have been administered as ordered. The resident went to dialysis on 2/18/26 and 2/20/26, but the nurse should have checked his blood sugar and administered the insulin as ordered before he left. 4. The record for Resident 24 was reviewed on 2/18/26 at 3:01 p.m. Diagnoses included, but were not limited to diabetes. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was not cognitively intact for daily decision making, and required supervision assistance with ADLs. a. A Physician's Order, dated 3/26/25, indicated insulin glargine (long acting), inject 65 units at bedtime. There were no parameters for holding the medication. The February 2026 MAR indicated the bedtime insulin was held on 2/4/26, 2/6/26, 2/7/26, and 2/13/26. b. A Physician's Order, dated 1/5/26, indicated insulin lispro (short acting) 25 units each morning, hold if the blood sugar was less than 110. The 2/3/26 morning blood sugar was 104, and the insulin was given. c. A Physician's Order, dated 1/5/26, indicated insulin lispro, 35 units each afternoon, hold if the blood sugar was less than 110. The 2/4/26 afternoon blood sugar was 135, and the insulin was held. The 2/15/26 afternoon blood sugar was 118, and the insulin was held. d. A Physician's Order, dated 1/5/26, indicated insulin lispro, 38 units each evening, hold if the blood sugar was less than 110. A Care Plan, revised 3/27/24, indicated the resident had diabetes. Interventions included and administering diabetes medications as ordered. The 2/2/26 evening blood sugar was 77, and the insulin was given. The 2/4/26 evening blood sugar was 130, and the insulin was held. The 2/8/26 blood sugar was 92, and the insulin was given. The 2/12/26 evening blood sugar was 91, and the insulin was given. The 2/13/26 evening blood sugar was 97, and the insulin was given. The 2/14 evening blood sugar was 82, and the insulin was given. The 2/15/26 evening blood sugar was 124, and the insulin was held. The 2/16/26 afternoon blood sugar was 66, and the insulin was given. During an interview on 2/24/26 at 10:15 a.m., the Director of Nursing was informed of the findings and indicated the nurses would be educated on administering insulin as per order. 3.1-37

Based on observation, record review, and interview, the facility failed to ensure residents were provided with adequate supervision to prevent falls and accident hazards were not present in resident rooms for 2 of 3 residents reviewed for accidents. (Residents B and C)Findings include: 1.The closed record for Resident B was reviewed on 2/17/26 at 2:35 p.m. Diagnoses included, but were not limited to, subarachnoid hemorrhage (bleeding in the brain) and chronic respiratory failure. The resident was admitted to the facility on [DATE], had a hospital admission on [DATE], returned to the facility briefly on 12/18/25, then was readmitted to the hospital on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 11/24/25, indicated the resident was not cognitively intact for daily decision making. She had no history of falls, was dependent on staff for toileting, and was dependent on staff for transfers from the bed to the chair. A Care Plan, dated 11/22/25, indicated the resident was at risk for falls due to incontinence. Interventions included, but were not limited to, anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, the resident needed prompt response to all requests for assistance, and ensure the resident was wearing appropriate footwear when ambulating or mobilizing in her wheelchair. A Fall Occurrence Note, dated 11/27/25 with no time, indicated the resident fell in front of the nursing station. A loud noise was heard and the resident was observed on the ground lying on her right side. Her wheelchair was tipped over and lying next to her. The resident indicated she was leaning forward to straighten her shoes and she tipped over. Interventions implemented were increased supervision and neuro checks were initiated. A Nurse's Note, dated 12/18/25 at 8:50 p.m., indicated staff were called into the resident's room by the CNA because the resident was found on the floor. When asked what happened, the resident indicated she was trying to go sit in her chair, she slid but was not hurt. The resident was assessed with no apparent injury. The Initial Fall Occurrence Note, dated 2/18/25 at 8:15 p.m., indicated the resident had an unwitnessed fall in her bathroom. During an interview on 2/18/26 at 3:26 p.m., the North Unit Manager indicated the resident was left on the toilet by herself and fell to the floor on 12/18/26 while attempting to transfer herself. The resident should not have been left alone on the toilet. 2. During a random observation on 2/17/26 at 11:05 a.m., Resident C was ambulating in his room. His right foot, ankle, and lower leg were visibly swollen. At that time, he indicated he hurt his foot a few days prior when he was trying to fix his broken closet door and it hit his foot. The closet door, visible from the doorway, was out of the track and hanging down, away from the closet. He indicated staff was aware, and he had tests done on his foot, but they did not show anything. He could walk with a cane, but his foot pain was making it difficult for him to walk. On 2/18/26 10:11 a.m. the resident was observed propelling himself in a wheelchair down the hallway with only the left shoe on. At that time, he indicated he could not walk due to the pain in his right foot and ankle, and his shoe wouldn't fit due to the swelling. The closet door remained hanging off. On 2/18/26 at 3:50 PM p.m., the resident was observed walking in hallway with cane, not wearing his right shoe. At that time, he indicated the pain medicine was helping him feel well enough to walk. On 2/19/26 at 3:00 p.m., the closet door was observed and remained hanging off of the track. The resident's record was reviewed on 2/18/26 at 4:56 p.m. The Quarterly Minimum Data Set (MDS) assessment, dated 1/9/26, indicated the resident was cognitively intact for daily decision making, and required supervision assistance with ADLs. In a follow-up note, dated 2/13/26, Nurse Practitioner 1 indicated, . Patient previously reported right foot pain after he states he hurt his foot on closet in room . During an interview on 2/19/26 at 3:48 p.m., Unit Manager 1 indicated the resident had doppler (a test of blood flow) and x-rays of his foot completed, but he did not tell her how it started hurting. She indicated she would have maintenance come fix the closet door. During an interview on 2/24/26 at 10:15 a.m., the Director of Nursing was informed of the findings and offered no additional information. This citation relates to Intake 2705437. 3.1-45(a)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to the storage of urinals and wash basins on 1 of 3 units. (The South Unit) The facility also failed to ensure a catheter port was cleansed prior to administering intravenous (IV) antibiotics for 1 of 1 resident observed for IV medication administration. (Resident 7)Findings include:1.On 2/16/26 at 2:30 p.m., two urinals were observed hanging from the grab bar in the bathroom. A yellow wash basin was observed on the floor underneath the bathroom sink. The urinals and wash basin were not contained. On 2/24/26 at 1:50 p.m., three urinals were observed hanging from the grab bar in the bathroom and the wash basin remained on the floor underneath the bathroom sink. Again, the urinals and wash basin were not contained. Two residents resided in the room and used the bathroom.During an interview on 2/24/26 at 3:45 p.m., the Director of Nursing indicated the urinals and wash basin should have been contained in plastic bags when not in use. 2. On 2/18/26 at 7:39 a.m., LPN 3 was observed administering an intravenous (IV) antibiotic to Resident 7. The LPN donned a gown, gloves, and mask and entered the resident's room. After administering the resident's oral medications, the LPN removed the cap from the resident's PICC (peripherally inserted central catheter) line port and flushed the port with normal saline. The LPN did not cleanse the port with an alcohol wipe prior to attaching the syringe. The port then touched the resident's sheets, and the LPN did not cleanse the port prior to connecting the IV antibiotic tubing. During an interview on 2/18/26 at 4:24 p.m., LPN 3 indicated she thought the orange cap was an alcohol cap, and that was what she used before administrating the saline flush, she indicated she did not wipe the single lumen with an alcohol wipe prior to administrating the IV antibiotic. The current and undated Central Venous Catheter policy, provided by the Director of Nursing on 2/19/26 at 9:19 a.m., indicated the procedure for flushing a catheter was to clean the valve with alcohol allow to dry, flush catheter, remove syringe, cleanse valve with alcohol and insert agent.3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure medications were not left unattended on top of the medication cart during medication administration for 2 of 6 residents observed during medication pass. (Residents 7 and 46)Findings include:1. On 2/18/26 at 3:52 p.m., a punch card containing two pills was observed unattended on top of the medication cart on the PCU Unit. There was no name on the punch card. At 4:03 p.m., the Assistant Director of Nursing and LPN 3 were observed sitting behind the nursing station and the medication was still on top of the medication cart. During an interview on 2/18/26 at 4:24 p.m., LPN 3 indicated she thought the pills were empty, she then pulled them out of the garbage can where she threw them away and indicated there were 2 pills left and they were Aricept (medication to manage dementia). 2. On 2/18/26 at 3:55 p.m., LPN 4 was observed completing a glucometer blood sugar check for Resident 46. The LPN gathered her supplies and entered the resident's room at 3:59 p.m. to wash her hands. She left the resident's insulin pen unattended on top of the medication cart while she washed her hands. She exited the resident's room at 4:00 p.m. and then proceeded to enter the resident's room again and closed the door. The insulin pen was again left on top of the medication cart while the LPN completed the glucometer check. During an interview on 2/18/26 at 4:25 p.m., the Assistant Director of Nursing indicated the insulin should not have been left unattended on top of the medication cart while not in view of the nurse. The current and undated Storage of Medications policy provided by the Director of Nursing on 2/19/26 at 9:19 a.m., indicated medications were stored safely, securely, and properly following manufacture's recommendations.3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure residents with a gastrostomy tube (g-tube, the surgical insertion of a feeding tube) received the appropriate treatment related to administration of the tube feeding for 2 of 2 residents reviewed for tube feedings. (Residents 50 and 133)Findings include:1. On 2/16/26 at 3:09 p.m., Resident 50 was observed lying in bed. The tube feeding, Jevity 1.5 (tube feeding formula), was connected and infusing at 75 milliliters per hour (ml/hr).The resident's record was reviewed on 2/18/26 at 10:33 a.m. Diagnoses included, but were not limited to, gastrostomy, dysphagia, and adult failure to thrive.A Care Plan, updated 11/23/25, indicated the resident had a swallowing problem and required the tube feeding.The 5-Day Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively impaired and received the majority of their nutrition by tube feeding.A Physician's Order, dated 2/4/26, indicated the resident was to receive Jevity 1.5 at 75 milliliters per hour (ml/hr) continuously for 21 hours for a total volume of 1575 milliliters (ml) per day. There were no documented times to turn on or turn off the tube feeding.The Medication Administration Record, dated 2/2026, indicated the tube feeding had been signed off every shift. There were no documented times to turn on or turn off the tube feeding. There was an area to document the amount of tube feeding infused for each shift. Some shift documentation were number of milliliters, some were percentages, and some were yes/no. None of the days added up to the 1575 ml per day the resident was to receive.During an interview on 2/19/26 at 10:47 a.m., the Nurse Consultant indicated there was an issue with how the tube feeding orders had been entered into the computer and they would be updated. 2. On 2/16/26 at 11:52 a.m., Resident 133 was observed lying in bed. The tube feeding, Osmolite 1.5 (tube feeding formula), was connected and infusing at 50 milliliters per hour (ml/hr).The resident's record was reviewed on 2/18/26 at 9:04 a.m. Diagnoses included, but were not limited to, dysphagia. A Care Plan, updated 2/15/26, indicated the resident had a swallowing problem and required the tube feeding.The Physician's Order Summary, dated 2/2026, indicated the resident was to receive Osmolite 1.5 at 50 ml/hr continuously for 21 hours. There were no documented times to turn on or turn off the tube feeding.The Medication Administration Record, dated 2/2026, indicated the tube feeding had been signed off every shift. There were no documented times to turn on or turn off the tube feeding. During an interview on 2/19/26 at 10:47 a.m., the Nurse Consultant indicated there was an issue with how the tube feeding orders had been entered into the computer and they would be updated.A facility policy, received as current from the Nurse Consultant, titled Gastrostomy Tube-Feeding and Care, indicated, .1. Licensed nurse will review physician's order for type of formula, concentration, rate of flow, and method of administration .3.1-44(a)(2)

Based on record review and interview, the facility failed to ensure acceptable parameters of nutrition were maintained related to obtaining a re-weight in a timely manner following a hospitalization for 1 of 4 residents reviewed for nutrition. (Resident H)Finding includes: The record for Resident H was reviewed on 2/19/26 at 2:20 p.m. Diagnoses included, but were not limited to, chronic kidney disease and anemia. The resident was admitted to the facility on [DATE].A Care Plan, dated 2/2/26, indicated the resident had a nutritional problem related to receiving a therapeutic diet and dietary restrictions. Interventions included, but were not limited to, provide and serve diet as ordered. The 2/7/26 5-Day Medicare Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision-making. The resident held food in his mouth, weighed 219 pounds, had a significant weight loss, and received a therapeutic diet.On 1/30/26 the resident weighed 237 pounds.On 2/7/26 the resident weighed 219 pounds. The resident was admitted to the hospital on [DATE] and returned to the facility on 2/7/26. The next documented weight after the hospital return was not until 2/14/26, which was 227 pounds. There was no reweight after the 18 pound weight loss following the hospital stay. There was no documentation the Registered Dietician (RD) was notified of the resident's weight loss after his hospital return. A Physician's Order, dated 2/7/26, indicated the resident was to receive a no added salt diet and was to have weekly weights obtained for four weeks. No supplements had been ordered for the resident since his weight loss and he was not seen by the RD until 2/20/26. During an interview on 2/20/26 at 10:25 a.m., the Director of Nursing indicated the RD was not notified after the resident returned to the facility even though he had a weight loss. The RD would be evaluating the resident today (2/20/26) and the resident was not reweighed after the 18 pound weight difference from the hospital return. The current and revised 10/17/19 Weights policy, provided by the Nurse Consultant on 2/20/26 at 11:59 p.m., indicated a re-weight should be obtained if there was a difference of 5 pounds or greater (loss or gain) since the previous recorded weight. A re-weight should be taken as soon as possible after an unanticipated weight change was noted. An undesired or unanticipated weight gain/loss of 5% in 30 days shall be reported to the physician and RD. 3.1-46(a)

Based on observation, record review, and interview, the facility failed to ensure accurate documentation of pressure ulcers was completed upon admission for 2 of 3 residents reviewed for pressure ulcers. (Residents 2 and 133)Findings include: 1.The record for Resident 2 was reviewed on 2/19/26 at 10:30 a.m. Diagnoses included, but were not limited to, stroke, history of traumatic brain injury, and severe protein calorie malnutrition. The resident was admitted to the facility from another long term care facility on 1/28/26. The admission Minimum Data Set (MDS) assessment, dated 1/31/26, indicated the resident was cognitively intact for daily decision making. The resident had two Stage 3 pressure ulcers (a full thickness skin loss exposing subcutaneous fat, but not muscle, tendon, or bone) that were present on admission. An admission Assessment, dated 1/28/26, indicated the resident had an ace wrap to the bilateral lower extremities. The resident refused a skin assessment. A discharge instruction sheet, dated 1/28/26 from the other long term care facility, indicated the resident's skin was intact, he had no open areas or treatments. Nurse's Notes, dated 1/28/26 at 6:25 p.m., indicated the writer attempted to communicate with resident at that time, the resident continued to be unapproachable, refusing to answer questions, refusing to allow writer to obtain vital signs, and unable to redirect, POA aware. Nurse's Notes, dated 1/29/26 at 2:13 p.m., indicated the resident refused all patient care during the shift. The resident refused to take his medications as well as his breakfast and lunch. The Physician was made aware. Nurse's Notes, dated 1/30/26 at 6:50 a.m., indicated staff attempted to perform a skin assessment related to him being a new admission. The resident refused and denied any skin impairments. The resident was encouraged to allow staff to assess him related to being at risk for skin breakdown due to impairments. The resident verbalized understanding and continued to refuse. The Unit Nurse was made aware and a message was left for the physician. Nurse's Notes, dated 1/30/26 at 11:07 a.m., indicated the resident's skin was assessed and impaired skin was noted to the right buttock measuring 1.1 centimeters (cm) in length by 2 cm in width by 0.1 cm deep with 70% granulation and 30% intact skin. The wound edges were attached and the surrounding skin was intact. Impaired skin was noted to the left buttock measuring 1 cm in length by 0.9 cm in width x 0.1 deep with 100% granulation noted. The wound edges were attached as well as the surrounding skin. Impaired skin to the left shin measured 11 cm in length by 5.5 cm in width by 0.1 cm deep with 70% intact skin and 30% granulation along with moderate, odorless, serous-sanguineous drainage (pink to light red drainage) . The wound edges were attached and the surrounding skin was intact. The resident's physician and guardian were notified. Physician's Orders, dated 1/30/26 and discontinued on 2/2/26, indicated the open areas to the left and right buttocks were to be cleansed with wound cleanser or normal saline, pat dry, and apply hydrocolloid (a wound care dressing) three times weekly and as needed (PRN). Cleanse the open area to the left shin with wound cleanser or normal saline, pat dry, apply calcium alginate (a wound treatment) followed by ABD pad and kerlix dressing three times weekly and PRN as needed. The Wound Rounds notes indicated the left and right buttock pressure areas were identified on 1/30/26 and were classified as a Stage 3. A Care Plan, dated 1/30/26, indicated the resident had pressure ulcers to the right and left buttock related to immobility. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness and complete weekly treatment documentation to include measurements of each area of the skin breakdown's width, length, depth, type of tissue and exudate (drainage). There were no physician orders for the pressure ulcers at the time of admission. During an interview on 2/19/26 at 1:30 p.m., the Wound Nurse Consultant indicated the resident had refused a skin assessment on 1/28, 1/29 and 1/30/26, however, the wound nurse was finally able to assess the resident's skin later on 1/30/26. They documented the wounds were present on admission, however, no one saw his skin or was able to assess his skin on admission. She did not reach out to the sister facility who discharged him to confirm if his skin was intact at the time of discharge. During an interview on 2/19/26 at 2:10 p.m., the Nurse Consultant indicated she pulled the documentation up that was provided at the time of discharge and the resident had refused most of 12/2025 and 1/2026 skin assessments. She had called the facility and asked the nurse who discharged him and she indicated the resident had a large bowel movement right before he was getting ready to be transferred and the CNAs indicated the resident's buttocks were red. During an interview on 2/20/26 at 9:00 a.m., the Wound Nurse indicated she documented the wound on his left and right buttock were present upon admission. She had spoken with his family and they were aware he had the area on his shin. She had no additional information to provide. 2. On 2/20/26 at 9:02 a.m., the Wound Nurse was observed completing Resident 133's wound treatments. There was a red circular nickel-sized area to her right buttock and red circular quarter-sized area to her left buttock. Record review for Resident 133 was completed on 2/18/26 at 9:04 a.m. The resident was admitted to the facility on [DATE]. The 72 hour Admission/readmission Observation, dated 2/14/26, indicated the resident had a skin tear to her left breast. There were no other skin conditions documented. A Progress Note, dated 2/14/26 at 11:00 a.m., indicated the resident was admitted to the facility. She had a skin tear to her left breast and no other skin issues noted. A Care Plan, dated 2/16/26, indicated the resident had pressure ulcers to the right and left buttock related to immobility. A Wound Rounds Assessment, dated 2/16/26, indicated the resident had a stage 3 pressure ulcer to the left buttocks that was present upon admission. It measured 0.4 centimeters (cm) by 0.4 cm by 0.1 cm. A Wound Rounds Assessment, dated 2/16/26, indicated the resident had a stage 3 pressure ulcer to the right buttocks that was present upon admission. It measured 2 cm by 1.5 cm by 0.1 cm. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 2/2026, lacked documentation of any treatments to the right or left buttocks until 2/16/26. During an interview on 2/19/26 at 12:03 p.m., the Director of Nursing indicated the Wound Nurse had documented the wounds as present upon admission because that was her admission assessment and note. During an interview on 2/19/26 at 1:32 p.m., the Wound Care Nurse Consultant indicated the Wound Nurse Practitioner (NP) had come in that day and assessed the resident's wounds. The NP felt the staging of the wounds was incorrect and they were re-staged as stage 2 pressure ulcers. The Wound Nurse's documentation was incorrect. During an interview on 2/20/26 at 8:53 a.m., the Wound Nurse indicated she had first assessed the buttocks wounds on 2/16/26. She had documented the buttocks wounds were present upon admission because she felt the wounds had probably been there upon admission and didn't feel they would have just appeared in the two days from when the resident was admitted until the wound nurse had completed her first assessment. Her documentation was incorrect. A facility policy, received as current from the Director of Nursing, titled Pressure Injury and Skin Condition Assessment, indicated .1. A skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission/readmission .3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse . 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to provide activities to support the psychosocial well-being of cognitively impaired, dependent residents for 1 of 2 residents reviewed for activities. (Resident 8)Finding includes: During a random observation on 2/16/26 at 3:23 p.m., Resident 8 was lying in bed. She was blankly staring at the wall, and did not respond to verbal stimulation. The television was on. No staff was observed interacting with resident. On 2/18/26 at 10:20 a.m., two staff members entered the resident's room, repositioned her, and immediately left the room. At 1:26 p.m., the resident was observed lying in bed, staring blankly. The television was on. At 1:42 p.m., the Activities Director entered the resident's room, spoke to her for 1-2 minutes, and left the room. On 2/19/26 at 10:43 a.m. and 3:06 p.m., the resident was observed lying in bed, staring blankly toward the wall. The television and radio were off. No staff interaction was observed. On 2/20/26 at 9:05 a.m. and 11:02 a.m., the resident was observed lying awake in bed. The television and radio were off. No staff interaction was observed. On 2/23/26 at 10:00 a.m., the resident was observed lying awake in bed. The radio was on. No staff interaction was observed. The record for Resident 8 was reviewed on 2/18/26 at 1:39 p.m. Diagnoses included, but were not limited to, anoxic brain damage, and persistent vegetative state. The Quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident was not cognitively intact, and was dependent in activities of daily living (ADLs). The One-to-One Activities Record, received from the Activities Director on 2/23/26 at 3:00 p.m., indicated the following: On 1/8/26, the AA (activities aide) made sure tv was on; on 1/10/26, the AA played music for the resident, on 1/11/26 the AA played music; on 1/24/26, the AA read the Daily Chronicle to the resident; and on 1/25/26, the AA played music. A Quarterly Activities Review, dated 2/5/26, indicated the resident was to receive one-to-one room visits, and staff would read to her and play music for sensory stimulation. A Care Plan, revised on 8/24/24, indicated the resident had little or no activity involvement related to a brain injury. Interventions included providing one-to-one visits three times per week. During an interview on 2/23/26 at 3:10 p.m., the Activities Director indicated the resident should have been getting one-to-one visits three times a week. They used to have a staff member for one-to-one visits, but she left. 3.1-33(a)

Based on record review and interview, the facility failed to ensure a care plan conference was held quarterly for 1 of 1 resident reviewed for care planning. (Resident 1)Finding includes:During an interview on 2/16/26 1t 11:20 a.m., Resident 1 indicated he was his own responsible party and had not been invited to or participated in any care plan conferences for a while.The record for Resident 1 was reviewed on 2/18/26 at 1:25 p.m. A Care Plan Meeting Progress Note, dated 9/30/25, indicated a care plan conference was held and the resident had attended. The Quarterly Minimum Data Set (MDS) assessment, dated 1/9/26, indicated the resident was moderately cognitively impaired.There was lack of documentation the resident had been invited to any care plan meetings, or any care plan meetings had been held since 9/30/25.During an interview on 2/19/26 at 12:05 p.m., the Nurse Consultant indicated the last care plan conference was completed in September 2025. She was unable to find any further care plan meeting documentation.3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure a comprehensive care plan was in place for pain for a resident receiving opioid (narcotic pain medication) medication for 1 of 31 residents whose care plans were reviewed. (Resident 131)Finding includes:The record for Resident 131 was reviewed on 2/19/26 at 10:07 a.m. Diagnoses included, but were not limited to, polyneuropathy.A Physician's Order, dated 11/9/25 and discontinued on 2/12/26, indicated hydrocodone-acetaminophen 5-325 milligrams (mg) 1 tab twice a day. A Physician's Order, dated 2/13/26, indicated hydrocodone-acetaminophen 5-325mg 1 tab every 6 hours as needed for pain.The Quarterly Minimum Data Set (MDS) assessment, dated 1/15/26, indicated the resident had received scheduled pain medication and had received opioid medication in the past seven days.The Medication Administration Record, dated 2/2026, indicated the resident had received the opioid medication as ordered.There was a lack of any care plan for pain or opioid medication use.During an interview on 2/19/26 at 12:03 p.m., the Director of Nursing was made aware there was no care plan for pain or opioid medication use.During an interview on 2/19/26 at 2:08 p.m., the MDS Consultant indicated there was no care plan in place for pain or opioid use.3.1-35(a)

Based on record review and interview, the facility failed to ensure evidence was provided related to Level 1 and Level 2 PASARR (Pre admission Screening and Annual Resident Review) screening for 1 of 1 resident reviewed for PASARR. (Resident 2)Finding includes:The record for Resident 2 was reviewed on 2/19/26 at 10:30 a.m. Diagnoses included, but were not limited to, post traumatic stress disorder (PTSD) and major depressive disorder. The resident was admitted to the facility on [DATE] from another long term care facility. The admission Minimum Data Set (MDS) assessment, dated 1/31/26, indicated the resident was cognitively intact for daily decision making. The resident had the coded diagnoses of post traumatic stress disorder and depression. A Care Plan, dated 2/6/26, indicated the resident suffered from trauma informed care due to military trauma or exposure. Interventions included, but were not limited to, provide emotional support and psychiatry/psychology services. A Level 1 PASARR (Pre admission Screening and Annual Resident Review), dated 9/16/24, indicated a Level 2 was not required. A new Level 1 at the time of admission was not available for review. During an interview on 2/17/26 at 11:45 a.m., the Social Service Director indicated a new Level 1 and 2 were not completed at the time of admission for the resident. She did not do a new one based on the 9/16/24 Level 1 outcome, however, she was not aware of the resident's current diagnoses of PTSD and major depressive disorder. 3.1-29(a)

Based on observation, record review and interview, the facility failed to maintain a resident's dignity related to wearing a hospital gown during the day for 1 of 3 residents reviewed for dignity. (Resident 35)Finding includes: During random observations on 2/16/26 at 11:13 a.m., 2/18/26 at 10:27 a.m., 2/20/26 at 9:03 a.m., 10:56 a.m., and 2:39 p.m., and 2/24/26 at 10:12 a.m., Resident 35 was observed in his bed, wearing a hospital gown. During interviews on 2/16/26 at 11:13 a.m., 2/20/26 at 2:39 p.m., and 2/24/26 at 10:12 a.m., the resident indicated he did not want to wear a hospital gown, and he had his own clothes in his closet. The resident's record was reviewed on 2/18/26 at 10:48 a.m. The Medicare-5 Day Minimum Data Set (MDS) assessment, dated 2/14/26, indicated the resident was cognitively intact for daily decision making, and was dependent in activities of daily living (ADLs). The resident's record lacked documentation that the resident preferred to wear a hospital gown during the day.During an interview on 2/24/26 at 10:15 a.m., the Director of Nursing was informed of the findings and indicated the Care Plan would be updated to include that the resident may chose to wear a hospital gown during the day at times. 3.1-3(t)

Based on record review and interview, the facility failed to ensure a medical record was complete and accurately documented related to a resident death for 1 of 5 residents reviewed for accidents. (Resident J)Finding includes:Resident J's record was reviewed on 2/20/26 at 2:36 p.m. Diagnoses included, but were not limited to, end stage renal disease.A Death in Facility Minimum Data Set (MDS) entry was completed on 12/11/25.A Progress Note, dated 12/11/25 at 9:39 a.m., indicated the resident had left the facility to go to dialysis. No acute distress noted at this time. There were no further progress notes documented.During an interview on 2/24/26 at 10:25 a.m., the Director of Nursing indicated the resident had gone out to dialysis and coded while there. She had passed away that day and had not returned to the facility. The resident's death had not been documented in the progress notes, but her discharge would have been reflected in the midnight census.This citation relates to Intake 2712287.3.1-50(a)(1)

Based on record review and interview, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident B)Finding includes:An Indiana Department of Health (IDOH) report form, dated 12/19/25 at 9:01 a.m., indicated Resident C had reported to the Administrator that a male entered his room several times during the night and touched his roommate, Resident B, inappropriately. Resident C became very agitated, was evaluated by the Nurse Practitioner, who indicated he was having an acute exacerbation of his mental illness. Investigation included review of staffing and camera footage. The preventive measure taken was sending Resident C to the ER for psychiatric evaluation. The incident follow-up documented that Resident C was admitted to the hospital, and the care plan would be adjusted upon his return to the facility.The facility investigation notes, received as complete from the Administrator on 12/30/25 at 11:20 a.m., indicated the Director of Nursing performed a head-to-toe assessment on Resident B on 12/19/25, and no redness or bruising was observed. In an investigation note dated 12/19/25, the Administrator indicated when he asked Resident B if anyone touched him, he shook his head no, and when he asked if he was ok, he nodded yes. The administrator indicated, . there were no signs of any psychosocial or distress issues with him. The investigation record lacked interviews with other residents and employees.During an interview on 12/30/25 at 1:20 p.m., Resident C indicated he told the Administrator that he observed CNA 1 have oral sex with Resident B, who was unable to speak or take care of himself. Resident C indicated this led to a verbal altercation which resulted in him being sent to the hospital.During an interview on 12/30/25 at 1:47 p.m., QMA 1 indicated Resident B could not communicate-verbal or non-verbally. She indicated she could tell if he was happy or tired, but that was all. On 12/30/25 at 1:50 p.m., Resident B was observed in his wheelchair in the hallway near the nurse's station. He was awake, with his eyes open, but did not respond to verbal stimuli. No verbal or non-verbal engagement was observed. The record for Resident B was reviewed on 12/30/25 at 11:25 a.m. Diagnoses included, but were not limited to, spastic diplegic cerebral palsy, dysphagia, Down syndrome, intellectual disabilities and adult failure to thrive.The Annual Minimum Data Set (MDS) assessment, dated 9/26/25, indicated the resident had severe cognitive impairment, was rarely/never understood, and was dependent in activities of daily living (ADLs).The record for Resident B lacked any documentation about the reported incident on 12/19/25. There was no psychosocial follow-up assessment or notification of family/responsible party of the abuse allegation or investigation. During an interview on 12/30/25 at 3:15 p.m., the Administrator indicated no interviews with staff or other residents were conducted, no further assessments were performed for Resident B, and no family/responsible party was notified of the abuse allegation. A policy titled, Abuse Prevention and Reporting-Indiana, received as current from the Administrator on 12/30/25 at 11:22 a.m., indicated, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of goods and services by staff or mistreatment . This will be done by: . Filing accurate and timely investigative reports . All incidents will be documented, whether or not abuse . was alleged or suspected. Any incident or allegation involving abuse . will result in an investigation. Investigative Procedures: The appointed investigator will, at minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable . Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.This citation relates to Intake 2701897.3.1-28(d)

Based on record review and interview, the facility failed to ensure residents received necessary care and services, related to 72 hour assessments and neurological assessments not completed for a resident with an unwitnessed fall and medication not given as ordered for 1 of 3 residents reviewed for accidents and 1 of 3 residents reviewed for medication administration. (Residents C and G)Findings include:1.Resident C's record was reviewed on 12/15/25 at 3:00 p.m. The diagnoses included, but were not limited to, heart disease, copd, sepsis, depression, dementia, and anxiety.The 11/13/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The Medication Administration Records (MAR), from October and November 2025 indicated the medications were blank and not signed out as being completed on the following days:aspirin: blank on 10/25, 10/29, 11/8, and 11/28/25zoloft: blank on 10/25, 10/28, 11/8, and 11/28/25norco: blank on 11/8, 11/14, and 11/28/25A Physician's Order, dated 12/13/24, indicated to administer Aspirin 81 Milligrams (mg) via PEG-Tube every morning related to atrial fibrillation (abnormal heart rhythm)A Physician's Order, dated 12/13/24, indicated to administer Zoloft 100 Milligrams (mg) via PEG-Tube every morning related to depression.A Physician's Order, dated 7/18/25, indicated to administer Norco (pain medication) 5-325 Milligrams (mg) via PEG-Tube three times a day related to pain.During an interview on 12/16/25 at 12:48 p.m., the Director of Nursing indicated she did not know why the medication was not given on the above dates. She had no further information to provide. 2. Resident G's record was reviewed on 12/16/25 at 12:22 p.m. The diagnoses included, but were not limited to, respiratory failure, COPD, diabetes, kidney disease, dialysis, and dementia.The 9/24/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. Eating, shower/bathing, upper body dressing, and personal hygiene required supervision. Toileting, lower body dressing and chair to bed transfers required partial to moderate assistance.A Nurses' Note, dated 9/15/25 at 6:30 a.m., indicated Resident G had an unwitnessed fall on 9/15/25 at 6:30 a.m., The resident was found lying on his back on the floor. An assessment at the time indicated neurological checks had been initiated and non-skid footwear was placed on the resident.The Neurological Assessment Form was not completed on 9/15/25 at 10:30 p.m., 9/16/25 at 2:30 a.m., and 9/16/25 at 6:30 a.m.The 72-hour post-fall charting ended on 9/16/25 at 7:58 p.m. There were no other follow-up assessments completed.A Care Plan, dated 9/16/25, indicated the resident had an actual fall on 9/15/25. Interventions were to ensure the walkway is free of clutter and determine causative factors.During an interview on 12/17/25 at 12:41p.m., the Director of Nursing indicated the nurse stopped documentation on the neurological form, she must have felt the resident was okay. The 72 hour documentation post fall was not completed past 9/16/25 and should have continued for the full 72 hours. She had no further information to provide.The facility policy titled Neurological Assessment was provided on 9/20/24 at 1:54 p.m. by the Director of Nursing and identified as current. The policy indicated. neuro checks will be completed at the time of physician order, potential head injury or change in condition every 4 hours for 24 hours.This citation relates to Intakes 2651445 and 2693418.3.1-37(a)

Based on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to showers not being completed and documented for 2 of 3 residents reviewed for ADLs. (Residents B and D)Findings include:1.Resident B's record was reviewed on 12/15/25 at 10:00 a.m. The diagnoses included, but were not limited to, spinal cord disease, schizophrenia, gout, difficulty walking, depression, and bipolar disorder.The 8/8/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had impairment on one side of the lower extremity and required substantial/maximum assistance for eating, oral hygiene, and personal hygiene. All other ADLs required dependent care. The resident required substantial/maximum assistance for all transfers.The Care Plan, revised on 9/3/25, indicated the resident had an ADL self-care/mobility performance deficit related to gout. An approach indicated the resident was dependent with shower/bathing self.The record lacked any shower documentation for June, July, and August 2025.During an interview on12/16/25 at 4:13 p.m., the Director of Nursing indicated they use the weekly skin assessments to document showers. However, there was no documentation in the skin assessment that indicated a shower or bed bath was completed. The assessment only documented skin observations. She indicated she would investigate the process and see if there was a clearer way to document showers. No additional information was provided. 2. Resident D's record was reviewed on 12/16/25 at 11:47 a.m. The diagnoses included, but were not limited to, COPD, depression, adult failure to thrive, dementia, cerebral palsy, schizophrenia.The 8/8/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making.The Care Plan, revised on 9/3/25, indicated the resident had an ADL self-care/mobility performance deficit related to cerebral palsy. An approach indicated shower/bathing required substantial/maximum assistance.The Shower Task was reviewed and there were no showers documented from 11/18/25 - 12/13/25.During an interview on 12/16/25 at 4:13 p.m., the Director of Nursing indicated they used the weekly skin assessments to document showers. However, there was no documentation in the skin assessment that indicated a shower or bed bath was completed. The assessment only documented skin observations. She indicated she would investigate the process and see if there was a clearer way to document showers. No additional information was provided.This citation relates to Intake 2693418.3.1-38(a)(3)(B)

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to treatments not completed as ordered by the Physician for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: During an observation on 1/23/25 at 11:08 a.m., the Director of Nursing (DON) completed Resident C's pressure ulcer treatments with the assistance of Unit Manager 1. The DON indicated the pressure ulcer treatment on the coccyx was a duoderm (hydrocolloid dressing) and was to be changed every three days. She indicated the treatment had been completed on 1/22/25. The dressing on the coccyx at the time of the observation was a border gauze dressing with the date of 1/22/25 on the dressing. Resident C's record was reviewed on 1/23/25 at 11:02 a.m. The diagnoses included, but were not limited to, vascular dementia. A Physician's Order, dated 12/15/24, indicated a duoderm dressing was to be applied to the coccyx every three days. The order was discontinued on 1/22/25. A Significant Change Minimum Data Set assessment, dated 12/16/24, indicated a severely impaired cognitive status and unhealed pressure ulcers were present on admission. A Wound Physician's Order, Wound Evaluation and Management Summary, dated 1/17/25, indicated an order for the duoderm dressing every three days to be discontinued and a calcium alginate (dressing to absorb drainage) and border gauze dressing was to be applied daily. A Care Plan, dated 12/20/24, indicated a stage two (partial thickness loss of the dermis) pressure ulcer was present on the the coccyx. The interventions indicated the treatment to the area would be completed as ordered by the Physician. The Treatment Administration Record, dated 1/2025, indicated the duoderm dressing had been applied to the coccyx on 1/20/25 and the order for the calcium alginate dressing was to be started on 1/23/25. A Physician's Order, dated 1/22/25, indicated the pressure ulcer on the coccyx was to be cleansed with wound cleaner, patted dry, and a calcium alginate and dry dressing was to be applied daily. The start date for the treatment was 1/23/25. During an interview on 1/23/25 at 12 p.m., the DON indicated she was unaware orders for the coccyx pressure ulcer treatment had been changed. During an interview on 1/23/15 at 1:09 p.m., the DON indicated the Wound Physician had written a change in treatment orders for the coccyx pressure ulcer in his summary notes on 1/17/25 and the orders had not been transcribed in the resident's record until 1/22/25. During an interview on 1/23/25 at 1:18 p.m., the DON indicated the new treatment for the coccyx pressure ulcer had been completed on 1/22/25. This citation relates to Complaint IN00449958. 3.1-40(a)

Based on observation, record review, and interview, the facility failed to ensure a risk for hazards to residents did not occur related to a resident who was deemed unable to maintain her own smoking materials due to safety, repeatedly keeping her smoking materials on her person without facility intervention, the resident continued to light cigarettes inside the facility, and placed a lit cigarette in the trash can, causing a fire which activated the fire alarm and had to be extinguished. All residents in the facility not residing on the 2 locked, inaccessible units were at risk for fire hazards related to unsafe smoking. (Resident C) The Immediate Jeopardy began on 1/20/22, when the resident placed a lit cigarette in the trash can, causing a fire which activated the fire alarm and had to be extinguished. The facility failed to follow their smoking policy and the resident continued to keep her smoking material and have occurrences of lighting a cigarette inside the building in non-approved smoking areas. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 2/15/22 at 10:39 a.m. The immediate jeopardy was removed on 2/16/22, but noncompliance remained at the lower scope and severity level of no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Finding includes: Resident C was observed on 2/14/22 at 12:15 a.m., in the front lobby, sitting in a wheelchair. She was wearing her winter coat, gloves and hat. She indicated she had just been outside to smoke and she does not turn her cigarettes and lighter in to the staff. She then pointed to her pocket of her coat and indicated her cigarettes and lighter were in her pocket Resident C's record was reviewed on 2/14/22 at 12:35 p.m. The diagnoses included, but were not limited to, [CONDITION(S)] and [CONDITION(S)]. A Quarterly Minimum Data Set, dated dated [DATE], indicated an intact cognitive status, no behaviors, required limited assistance for bed mobility and transfers, and extensive assistance with ambulation and locomotion, and received an anti-anxiety and antidepressant medication the past 7 days. A Care Plan, dated 9/24/21, indicated she was a smoker. The intervention indicated she would be instructed about the smoking risks and hazards and educated on the smoking cessation aids that were available. A Care Plan, dated 12/6/21, indicated she was a smoker and had been assessed as being unsafe to smoke independently, had smoked inside her room and refused to turn in the lighter and cigarettes to the nurse. The interventions included, a smoking schedule would be created as needed and reviewed with the resident, family, and staff. The family would be educated to not provide cigarettes, lighter or matches to the resident. The Nursing Staff would keep the Cigarettes and lighter/matches in a safe area. A Smoking Assessment, dated 12/13/21, indicated she was not able to store smoking materials. The Nursing Progress Notes indicated the following: On 12/5/22 at 11:17 a.m., she was observed sitting in a wheelchair in her room. A cigarette was lit and she was smoking. She was instructed to put the cigarette out and was easily redirected. She was asked by the nurse for the smoking materials and the resident refused to turn them in. The Physician, family, and Nursing Supervisor were informed of the incident. On 12/18/21 at 7:28 p.m., the resident was propelling herself in the wheelchair in the hallway with a lit cigarette, and began to smoke the cigarette by the North Nurses' Station. On 12/18/21 at 8:01 p.m., the nurse was unsuccessful in getting the resident's cigarettes and lighter from the resident. The family was notified and informed the nurse, to do what is needed. A Behavior/Mood Note, dated 1/20/22 at 5:26 p.m., indicated a fire was observed in the trash can, located in the resident's room. The fire alarm had been activated and a full fire event took place due to the resident setting the fire. A Nurse's Progress Note, dated 1/20/22 at 6:21 p.m., indicated the nurse smelled smoke, and observed a flame in the garbage can in the resident's room. The Administrator was informed the resident had set a fire in the garbage can. The Physician was notified and the Resident's family was notified. The resident was sent to the hospital to be evaluated and treated. A Nurse's Progress Note, dated 1/21/22 at 9:20 a.m., indicated she returned to the facility with no new orders. A Nurse's Progress Note, dated 2/11/22 at 9:51 a.m., indicated the resident was smoking in her room. She allowed staff to extinguish the cigarette and she then proceeded to the smoking area. A Nurse's Progress Note, dated 2/15/22 at 3:40 a.m., indicated she attempted to smoke a cigarette in the hallway. She then voluntarily relinquished the lighter and cigarettes to the staff. She was educated on the dangers and safety of smoking in the facility. The Administrator was notified of the incident. A reportable incident, dated 2/3/22 with the follow up on 2/10/22 by the Administrator, indicated the resident had been attempting to smoke in the dining area. There was no documentation in the progress notes of this behavior on 2/3/22. The CNA Task form indicated safety checks every 15 minutes to monitor violations of the smoking agreement and resident safety were to be completed. Random dates were reviewed and the 15 minute checks were completed at the following times: On 1/17/22 they were completed at 9:42 p.m., 9:43 p.m., 9:44 p.m., and 9:45 p.m. On 1/19/22, safety checks were completed at 1:34 a.m., 1:46 a.m., then at 6:50 a.m., 6:51 a.m., then at 2:42 p.m., 2:47 p.m., then at 7:02 p.m. and 7:03 p.m., then at 8:15 p.m. through 10:45 p.m. they were completed every 15 minutes, and none were completed after 10:45 p.m. On 1/20/22, at 7:18 p.m. it was documented the resident was not available and there was not any other documentation for the day. On 1/21/22, the fifteen minute checks were started at 6:45 a.m. then completed at 6:46 a.m. and 6:47 a.m. The next check was at 1:59 p.m., 2 p.m. and 2:01 p.m. The next check was at 8:28 p.m. 8:45 p.m., and then 10:08 p.m. On 2/10/22, the fifteen minute checks were started at 12:59 p.m. and 1:03 p.m. The next check was at 1:34 p.m. 1:36 p.m., and 2:29 p.m. There were no other checks after 2:29 p.m. On 2/11/22, the fifteen minute checks were started at 12:04 p.m., 12:16 p.m., 1:30 p.m., 2 p.m., 2:15 p.m., 2:30 p.m., and 2:45 p.m. The next check was at 7:53 p.m. and 7:54 p.m. There were no more checks completed after 7:54 p.m. During an interview on 2/14/22 at 1:42 p.m., the Administrator indicated the resident's family had been notified and they said they were not bringing the resident's cigarettes and lighters. The resident gave money to others and they would bring them to her. She refused to turn in her smoking material and would not allow staff to look for them. She was placed on 15 minute checks. There was not a fire, LPN 1 was right outside the room and she walked in as the resident was throwing the cigarette in the trash can. It was not reported, there was no fire, and the alarm had not been activated. During an interview on 2/14/22 at 1:50 p.m., LPN 1 indicated there was a fire and it was in the trash can. The fire had activated the fire alarm. The resident was propelling herself in the hallway and she was coming toward LPN 1. There was a smell and the resident's room was entered. LPN 1 indicated she started to walk out of the room and saw orange out of the corner of her eye and saw it was a fire. There were flames coming from the trash can. The fire extinguisher was used to put the fire out. During an interview on 2/15/22 at 1:12 p.m., the Director of Nursing indicated the 15 minute checks were not being completed. A facility smoking policy, dated 11/28/12 and revised on 1/22/19, was provided by the Administrator as current. The policy indicated the facility had the right to enforce a policy prohibiting residents from keeping any smoking materials in their possession for health, safety and security reasons. Smoking privileges would be revoked if there was a pattern of persistent, hazardous behavior. All persons interested in retaining smoking privileges must follow the guidelines set forth in this policy. The immediate jeopardy that began on 1/20/22 was removed on 2/16/22 when the facility had inserviced 77 of the 130 facility staff on the facility smoking safety policy. Staff were interviewed and indicated if the resident was assessed to be unsafe to keep their own smoking materials then the materials would be locked in the Medication Cart or in the Medication Room. Residents who smoked in an unauthorized area would have their materials stored in the Medication Cart or in the Medication Room. The Administrator, Director of Nursing, and Charge Nurse would be notified of the behavior. The Administrator would be notified if the resident refused to turn in the smoking materials. All staff will be inserviced on the safe smoking policy either by phone or prior to working their next shift. All residents who smoke were reassessed for safety and a meeting was held to re-educate on the safe smoking policy of the facility. The non-compliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility still needs to inservice the rest of the staff who work in the facility. The facility will monitor residents who smoke. Smoking safety risk assessment will be completed on admission. Those residents who are at risk for keeping smoking materials will be questioned randomly if they have smoking materials on their persons. Findings of the questioning of residents will be discussed monthly during QAPI meeting with necessary revisions implemented, for six months based on the committee's recommendations. 3.1-45(a)

Based on observation, record review and interview, the facility failed to implement adequate supervision measures to prevent a cognitively impaired resident from exiting the building. The resident left the building unattended around 7:45 p.m. on 11/3/21 wearing pajamas and socks and was overheard knocking on the door he exited from 50 minutes later. The resident was assessed upon his return and transferred to the facility's secure unit. The facility is located within 1 mile of a major interstate and adjacent to a busy 2 lane road. (Resident B) The immediate jeopardy began on 11/3/21 when the resident had exited the facility without supervision or knowledge of facility staff. The resident was able to exit from the North door. The door was not completely closed even though the key pad indicated the lock was engaged. The door did not have an alarm at that time. The resident was overheard knocking on the same door he exited from 50 minutes later. The resident was assessed upon his return and transferred to the facility's secured unit. The Administrator and Director of Nursing were notified of the immediate jeopardy at 3:04 p.m. on 11/16/21. The immediate jeopardy was removed, and the deficient practice corrected on 11/10/21 prior to the start of the survey and was therefore Past Noncompliance. Finding includes: The record for Resident B was reviewed on 11/16/21 at 9:26 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, malignant neoplasm of brain, type 2 diabetes, mild protein-calorie malnutrition, lack of coordination, palliative care, and psychoactive substance abuse. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 9/21/21, indicated the resident was cognitively impaired for daily decision making. The resident had no episodes of wandering and required extensive assistance with one person physical assistance for locomotion on and off of the unit. The elopement risk assessment, dated 9/14/21, indicated the resident was not at risk to elope at the time, placement on the elopement risk protocol was not indicated. The resident had no Care Plan related to wandering based on the Admission MDS and elopement risk assessment. Nurses' Notes, dated 11/3/21 at 8:21 p.m., indicated the CNA came to nursing station and state [sic] resident was knocking on the B wing exit door with no shoes on and leaves all over his body, hands cold, but no apparent injuries to body, resident asked why was he outside, state [sic] he did not know, resident have [sic] been confused since his transfer from south unit, resident unable to find the bathroom, resident would go to closet and urinate or defecate there, poor historian, Administrator called and informed of situation, state [sic] to move resident to BHU [behavior health unit] DON [Director of Nursing] called and informed of situation state [sic] to do urine c&s and sent to lab. Evening supervisor also notified, transferred resident to BHU per wheel chair in good condition. According to www.weather.com, the local temperature was 36 F at 7:45 p.m. on 11/3/21. Interview with the Administrator on 11/16/21 at 9:37 a.m., indicated the resident left the facility around 7:47 p.m. on 11/3/21 and returned on his own approximately 50 minutes later. He was last seen inside the facility at approximately 7:30 p.m. An investigation was initiated and the incident was reported to the Indiana Department of Health (IDOH). The Administrator indicated the resident was observed on the camera exiting the door on the middle hall of the North Unit. The resident was residing in Room 115 at the time which was approximately 10-15 feet from the exit door. The resident was observed pushing an overbed table in the hall. The table bumped against the door and the door opened due to the door not being latched securely and locked. There was no 15 second delay release for the door and/or alarm. There was a keypad on the door to get out, the Administrator indicated the red light on the key pad was on, which should have meant the door was locked. The code to get out was the month and year which all staff knew. The Administrator also indicated she did not feel the resident was actually exit seeking, the door opened when the table hit it. When the resident returned, he was assessed and moved to the secured unit. The resident had no previous elopement attempts. The Administrator indicated she immediately changed the code to the door, management staff received the code to the door, and a sign was posted on the door to no longer use the door as an entrance or exit unless it was an emergency. Observation of the North exit door on 11/16/21 at 9:45 a.m. with the Administrator, indicated there was a key pad lock along the door frame and a magnetic lock in the top right hand corner of the door. The Administrator pushed on the door and the door would not open. When she put the code in on the key pad, the door opened and the alarm also sounded. Staff in the area looked down the hall in response to the alarm. Further interview with the Administrator at 10:16 a.m., indicated staff did not know the resident was missing due to the door did not alarm when it was opened. She indicated the resident knocked on the same door he exited 50 minutes later. She felt he stayed in the same area the whole time he was outside due to his reflection being seen on the outside camera from time to time. As soon as the resident was brought inside, she was notified as well as the resident's Physician and family. He was assessed and moved to the secured unit. A facility wide head count was also completed. Review of facility investigation and elopement timeline, indicated the resident exited the building through the North door. He was gone approximately 50 minutes. He was observed with a dark green sweatshirt, flannel pajama bottoms, and non-skid socks. The resident was assessed by the RN and his vitals were normal including body temperature. He had an elopement risk assessment completed, and he was moved to the facility's secure unit. Family and Physician were notified of the outcome of the investigation. Assessments and care plan updated. The facility checked the North door several times and were unable to open the door without a code. Code changed by facility. Safe Care was contacted on 11/4/21 to determine if the door magnet was faulty and how the resident exited the door. On 11/8/21, Safe Care determined the swing door needed adjustment and small particles of debris needed to be removed from the outside of the door near the door sweep. The door magnet and the keypad were in working order. An alarm system was added to the door per facility request on 11/9/21. Door checks were completed on the North door as well as all doors in the facility until Safe Care made their service call. Daily door checks were also added to the preventive maintenance log. Per the Leadership team, the root cause of the malfunction of the door was determined to be: a staff or resident exited out of the North door, and when the door closed it did not magnetize or latch securely, however, the key pad light had turned red to indicate the door was locked. An elopement policy, provided by the Administrator on 11/17/21 at 10:44 a.m., indicated All personnel are responsible for reporting a cognitively resident [sic] attempting to leave the premises, or suspected of missing, to the Charge Nurse as soon as practical. This includes any resident that did not sign out on pass and/or did not notify a staff member of his or her leaving. The past noncompliance immediate jeopardy began on 11/3/21. The immediate jeopardy was removed and the deficient practice corrected by 11/10/21 after the facility implemented a systemic plan that included the following actions: the resident was transferred to the facility's secured unit and reassessed for elopement, the code to the North door was changed, daily door checks were completed, elopement drills were initiated and risk screenings were started for all residents, all staff were inserviced related to the elopement policy, Safe Care was called to assess the doors and ensure they were in working order, an alarm was added to the North door, and Root Cause analysis was started with the Management team. Photographs and resident information for residents at risk for elopement will be kept at the Nurses' Station and Reception Desk. Staff were interviewed and able to explain the policies and procedures. Binders were located at the Nurses' Desk and Receptionist Desk, which included the other residents who were at risk for elopement. This Federal tag relates to Complaint IN 601. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure each resident was free from accidents related to ensuring a totally dependent resident received a physical two person assist during care which resulted in a fall with a laceration to the upper left eye lid area that required three (3) sutures for 1 of 3 residents reviewed for accidents. (Resident #E) Finding includes: The record for Resident #E was reviewed on 1/28/16 at 11:00 a.m. The resident's [DIAGNOSES REDACTED]. The 6/29/15 Quarterly Minimum Data Set (MDS) assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately impaired for decision making and had some cognitive impairment. The resident was an extensive physical two person assist with transfers and totally dependent with a physical two person assist with personal hygiene and bathing. The resident did not have a history of falls since the last assessment. The current and updated care plan dated 3/7/14 indicated the resident had a history of [REDACTED]. The interventions included, but were not limited to, bed in low position, encourage resident to use handrails or assist devices properly, and if falls occur notify Physician, Director of Nursing (DON), and family. The Nursing Progress Notes dated 7/25/15 at 2:19 p.m., indicated the resident rolled out of bed while receiving an one person physical assist during care. The resident broke her eye glasses and was noted to have a 2.5 (cm) centimeter laceration to her upper left eye lid with a small amount of bleeding. At 2:32 p.m., the resident was sent out to the hospital per Physicians orders for evaluation and treatment. The Fall Investigation Worksheet dated 7/25/15 indicated the resident was on an air mattress while receiving care and rolled out of bed. Continued review of the Nursing Progress notes dated 7/25/15 at 5:35 p.m., indicated the resident returned from the hospital alert and verbally responsive with 3 sutures to her upper left eye lid area. The resident was also noted to have an as needed Tylenol order for pain or discomfort. Interview with the DON on 1/27/16 at 4:37 p.m., indicated the resident had a fall with an injury while receiving one person assisted care. This Federal tag relates to Complaint IN 090. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided for a cognitively impaired male with a history behaviors including, but not limited to, wandering into other resident rooms, exposing himself, and touching staff members inappropriately. The lack of supervision resulted in the resident entering the room of a dependent and cognitively impaired female resident with female resident found on the floor and both residents found unclothed. This resulted in an Immediate Jeopardy. (Residents #E and #H) The Immediate Jeopardy began on 11/21/15 when Resident #H entered a female resident's room and was found to have removed his clothing while sitting next to a cognitively impaired dependent female resident who was lying on the floor on her abdomen and was also disrobed. The Director of Nursing and the facility Administrator were notified of the Immediate Jeopardy on 12/3/15 at 7:05 p.m. The Immediate Jeopardy was removed on 12/5/15, but noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: 1. On 12/2/15 at 10:00 a.m. Resident #E was observed in bed being turned by the CNA. The mattress had bolsters attached. On 12/3/15 at 8:35 a.m. the resident was observed awake in bed. She was laying on a scoop mattress with a mat on the floor on the left side of the resident's bed. The record for Resident #E was reviewed on 12/2/15 at 3:50 p.m. The resident's [DIAGNOSES REDACTED]. Review of the 9/28/15 Minimum Data Set quarterly assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (3). A score of (3) indicated the resident's cognitive patterns were severely impaired. The assessment also indicated the resident required extensive assistance of two staff members for bed mobility and transfers. The assessment indicated the resident was totally dependent on two staff members. The 11/2015 Nursing Progress notes were reviewed. An entry made on 11/21/15 at 10:15 p.m. indicated the RN was summoned to Resident #E's room by the CNA. The resident was found on the floor in a prone (laying on her stomach) position and disrobed with her brief and dressing to the coccyx removed. A Foley catheter was in place and draining amber urine. The resident denied pain and was unable to explain how she got on the floor. The bed was in the lowest position and her call light was in reach. Reddened areas were noted to the left side of her face, left shoulder, arm, wrist, and her left knee. An entry made on 11/21/15 at 11:00 p.m. indicated the resident was sent out to the hospital. A Fall IDT (Interdisciplinary Team) note was entered on 11/24/15. This note indicated the resident was observed on the floor on her left side with her bed in the lowest position. The resident's 11/21/15 Hospital Emergency Department records were reviewed. The records indicated the resident was a female admitted with a history of Multiple Sclerosis, migraine, and dementia who presented to the emergency room from a fall from the bed. The patient had a bruised hand and a small bruise to her face. The patient was oriented to self and was aphasic. The records indicated a review of the the resident's systems listed she denied headaches, dizziness, back or abdominal pain. The Physical Exam indicated the resident appeared well-developed and in no distress. No assessment of her Genital or Urinary system was recorded. The Clinical Impression was listed a fall and concussion with no loss of consciousness. The patient was to be sent back to the nursing facility. A Fall Investigation Worksheet, dated 11/21/15 at 11:00 p.m., indicated the activity at the time of the fall was unknown. The resident was not using any assistive devices. It was an unwitnessed fall. The conclusion of the root cause analysis was that the resident rolled out of bed. The resident was oriented to person, place, and time. There were no physiological or situational factors noted. Hand written statements in regards to the fall investigation: CNA #1's statement, dated 11/21/15 with no time documented, indicated while doing my last round I went into Resident #E's room and saw Resident #H in the room naked sitting in his wheelchair and Resident #E on the floor naked, as well. I then called for a nurse. CNA #3 statement dated 11/21/15 at 10:15 p.m. indicated, RN #1 came and got me and the nurse. We went into Resident #E's room and she was naked on the floor face down. Resident #H was naked in his chair. 2. On 12/3/15 at 8:55 a.m Resident #H was observed in his wheelchair in the main dining room self propelling himself. The record for Resident #H was reviewed on 12/3/15 at 9:15 a.m. The resident's [DIAGNOSES REDACTED]. The 9/19/15 Minimum Data Set significant change assessment indicated the resident's BIMS (Brief Interview for Mental Status) was not completed as the resident was rarely understood. The assessment indicated the resident required extensive assistance of one staff member for bed mobility and transfers and a wheel chair was used for mobility. The resident's current Care Plans were reviewed. A Care Plan initiated on 7/25/15 and revised on 11/30/15 indicated the resident displayed behaviors. The behaviors included, touching staff inappropriately on the breast and buttock, flashing his private parts in the hallways and making sexual comments. He also tried to throw urine on staff and hit staff when upset. The intervention included, but were not limited to, inform resident the behavior was unacceptable and tell him No. Inform the family, obtain a psychological consultation and social service one on one as needed. Staff were to redirect the resident by offering him a snack, cup of coffee, or activity. A Care Plan initiated on 9/17/15 and revised on 11/30/15 indicated, the resident wanders aimlessly and often tried to wander into other residents' rooms. The interventions included, but were not limited to, distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. Staff were to identify patterns of wandering and intervene appropriately. Resident was to be provided activities: toileting, walking, reorientation strategies, such as signs, pictures, and memory boxes. The resident was to be re-educated on the location of his room. A facility psychiatric evaluation completed on 8/3/14 indicated, the history of the present illness was a resident with metabolic [DIAGNOSES REDACTED] (abnormality that affects brain function), Spanish speaking only, who presents with impulsive behaviors, resistance to care, noncompliance with dressings, and public urination in his room. He had very poor comprehension even when spoken to in his native language, he had difficulty understanding or following directions. His poor cognition was related to his metabolic [DIAGNOSES REDACTED] and vascular dementia. Review of the 10/31/15 facility psychiatric visit indicated the reason for the visit was cognitive symptoms, behavior symptoms, confusion, refusing and resisting care or medications, and sexual impulsivity. The impression was the resident was diagnosed with [REDACTED]. The chief complaint was behavioral disturbance (inappropriate with female staff and noncompliant with rules), and senile dementia-mild. A Behavior/Mood Charting form dated 9/7/15 at 5:45 a.m., indicated the resident was exit seeking and observed leaving out the door, buttons to pad not properly functioning and resident noted pushing buttons on pad lock which opened with no difficulty. This occurred in the hallway, family was called and the resident was reassured and redirected. The resident accepted the intervention and was talkative. The resident was directed back into the facility and stated that it was a beautiful day. A Behavior/Mood Charting form, dated 9/14/15 at 10:21 a.m., indicated the resident was verbally aggressive, socially inappropriate, and was resistive to care. The resident was sitting in front of his room preventing staff from entering room. The resident made statements this was his house only. The resident removed objects like roommate's chair and bedside table from the room into the hallway. The interventions tried were 1:1 with social worker and staff, conversation, left alone and reproached and reassurance. The resident was uncooperative and the behavior lasted 30 minutes. The resident's behavior improved. A Behavior/Mood Charting form, dated 9/1/5/15 at 22:58 (10:58 p.m.), indicated the resident was wandering down to the other end of the building trying to urinate in garbage cans and plate lids. The resident was agitated and easily upset. This behavior occurred in the hallway. The resident was offered a snack and redirected. He was uncooperative and the behavior continued for 2 minutes. The resident's behavior improved. A Behavior/Mood Charting form, dated 9/22/14 at 10:06 (8:06 p.m.), indicated the resident was wandering in the hallway. No interventions were provided, the behavior lasted 2 minutes and the behavior improved. A Behavior/Mood Charting form, dated 9/26/15 at 14:27 (2:47 p.m.), indicated the resident was trying to push the bed out of the room. The resident was throwing pieces of the bed and was attempting to hit the CNA. He was agitated and easily upset. He was redirected and had 1:1 with staff. He was uncooperative and the behavior continued. This lasted for 3 minutes and the outcome was unchanged. A Behavior/Mood Charting form, dated 9/30/15 at 6:30 a.m., indicated the resident was wandering, physically aggressive, social inappropriate and resisted care. The resident refused to allow staff to give care. He was agitated and easily upset. This behavior occurred in the hallway. The resident was left alone and re-approached, a phone call was made to family, and he was redirected. He was uncooperative and the behavior continued. This behavior lasted form 1:00 a.m. until 6:30 a.m. The interventions were unsuccessful. A Behavior/Mood Charting form, dated 10/7/15 at 21:20 (9:20 p.m.), indicated the resident was wandering. He was upset and stated his roommate kept yelling at him and told him to get out of the room. He was fearful. The incident happened in the resident's room. The resident was reassured, redirected, reoriented and had 1:1 with staff. He accepted the interventions provided but was still fearful. The behavior lasted most of the shift. The outcome was successful. A Behavior/Mood Charting form, dated 11/9/15 at 18:14 (6:14 p.m.), indicated the resident was socially inappropriate. He said sexually inappropriate comments to the writer. This occurred in the hallway. He was redirected and accepted the intervention. This behavior lasted 3 minutes and the outcome was successful. A Nursing Progress Notes indicated an entry was made on 11/21/15 at 9:39 p.m. The entry indicated the writer was called to Resident #E's room by another Nurse. The resident was observed sitting in a wheel chair completely disrobed and a gown was placed on the resident. The resident was immediately re-directed into the hallway to be taken to his room. The resident was unable to be interviewed due to language barrier. Upon assessment a skin tear was observed to his left anterior lower leg. The resident was resting quietly in bed at this time. Safety was maintained. A Behavior/Mood Charting form, dated 11/27/15 at 14:18 (2:18 p.m.), indicated the resident was attempting to throw urine on the Admissions Coordinator and two CNAs. He had repeated verbalization. This behavior occurred in the hallway. The resident was provided 1:1 with staff. He accepted the intervention provided. The behavior lasted 2 minutes and the outcome was successful. A Behavior/Mood Charting form, dated 11/28/15 at 2:59 a.m., indicated the resident was hitting staff, throwing shows (sic), attempting to enter other residents' rooms. The resident was refusing to cooperate with staff. He had repetitive verbalizations, insomnia, repetitive physical movements, was agitated and easily upset. This behavior occurred in the hallway and lasted one hour. The interventions attempted were 1:1 with staff, conversation, offered food and snack, and a call to the family. The resident was hostile, uncooperative, and the behavior continued. The outcome was unchanged. A Social Service Note, dated 11/30/15 at 14:40 (2:40 p.m.), indicated the writer spoke to the resident in regards to recent behavior. The resident appeared to be in a happy mood, was smiling and flirting. The resident showed no signs of distress or poor mood. The resident stated he did not behave in this manner and his memory was poor. The resident was educated that verbal and physical aggression was not appropriate. A Social Service Note, dated 12/2/15 at 15:38 (3:38 p.m.), indicated the writer, Social Service Director, and the Unit Manager met with the resident and family to discuss the resident's recent behaviors on 11/27 and 11/28. The resident's family indicated he has been redirecting the resident to improve his behavior and to be more gracious toward others. Staff indicated that redirection was being applied by staff when needed. The family asked if the resident's medication could be increased to help with his behaviors. The Social Service Director indicated the resident's doctor would be notified. A Nursing Note, dated 12/3/15 at 20:47 (9:47 p.m.), indicated due to behaviors exhibited by resident toward staff and fell ow residents, MD notified and obtained an order for [REDACTED]. One to one care initiated at 7:10 p.m. When interviewed on 12/3/15 at 9:30 a.m., RN #1 indicated she worked on 11/21/15 and was assigned to care for Resident #E when she was observed on the floor. CNA #1 came out of the resident's room and indicated she was on the floor. The RN indicated the resident was on the floor on her abdomen and could not say how she fell . The RN indicated she and three other CNA's log rolled the resident over and placed her back and into bed using the Hoyer ( a mechanical lifting device) lift. The resident had red areas on her face and left knee with no swelling present. RN #1 also indicated Resident #H was present in the room when they arrived. He was midway in the room, between the two beds. The RN indicated Resident #E resided in the bed by the window and Resident #H was sitting in the wheel chair facing the bathroom. The male resident had no clothing on but then stated I think he had a brief on. Resident #E had no clothing on and her gown was on her right hand but off her shoulder hanging down by her feet and she was on her stomach. Resident #H's clothes were in the room on a night stand folded neatly. The RN indicated they put a gown on Resident #H when they entered the room and he kept saying siesta (sleep) in Spanish and other words in Spanish. The RN indicated she did not recall the names of the CNA's . The RN indicated she asked Resident #E if the other resident had touched her and she said I don't think so and with both of them in that position I didn't know what to think. The RN indicated Resident #H was confused. RN #1 indicated neither of the CNA's reported any physical contact between the two residents. The RN indicated there was another Nurse working on the unit that was taking care of Resident #H though she could not recall her name at this time. When interviewed on 12/3/15 at 10:50 a.m., the Director of Nursing indicated she received a phone call on 11/21/15. She was informed Resident #E was found on the floor in her room, a male resident (Resident #H) was in the room and both resident's were disrobed. The staff reported the resident's face was red. The Director of Nursing indicated RN#1 was assigned to care for Resident #E and the RN had obtained statements from the other staff members who were present. The DON indicated CNA #1 was assigned to care for Resident #E. CNA #1 informed her she was the first person who observed Resident #E on the floor. The CNA had last seen the resident at approximately 9:45 p.m. The resident was found face down on the floor next to her bed and Resident #H was found in his wheel chair next to the resident's bed. The DON indicated no staff members had reported observing any contact between the two residents. The DON indicated RN #1 stated that Resident #H would not have the ability to get up from the floor and into his chair. The DON indicated no visitors were observed in the facility when she arrived and the Administrator reviewed the security cameras and no visitors were observed . The DON further indicated Resident #H had no injuries. She asked RN #1 and CNA #1 if there had been any resident to resident contact with the two residents and they both denied any contact occurred. When interviewed on 12/3/15 at 11:10 a.m., the facility Administrator indicated he received a call on 11/21/15 around 10:15 or 10:20 p.m. related to Resident #E being found on the floor with Resident #H in her room and both residents were undressed. The Administrator indicated he and the DON both came into the facility and the RN on duty had the staff complete written statements. The Administrator indicated he reviewed the security cameras and they showed Resident #H at the Nursing Station at 9:40 p.m. and it looked like staff were pointing towards his room. The camera indicated the resident rolled down the hallway around 9:45 p.m. and into Resident #E's room. He was in Resident #E's room until 10:12 p.m. (27 minutes). The camera showed CNA #1 entered the room at that time. The Administrator indicated the camera showed the CNA's making their rounds during this time. The DON was present during this interview and indicated Resident #H was capable of undressing himself. CNA #1 was interviewed via telephone on 12/3/15 at 12:45 p.m. The CNA indicated she found Resident #E when she was making her rounds. When she got to the resident's room at first she did not see the resident in bed and then saw her on the floor with no clothes on. Resident #H was in the room in his wheel chair with no clothes on. She yelled out for other staff to help her. The CNA indicated Resident #E said OK. The CNA Indicated no body ever reported Resident #H had touched Resident #E. When interviewed on 12/3/15 at 3:20 p.m., LPN #1 indicated she was working on the evening shift the day Resident #E was found on the floor. The LPN indicated she was at the Nursing Station and was called to the resident's room. Resident #E was observed lying face down on the floor. Her brief was not on and was laying around her. Her wound dressing was off. The LPN indicated, Resident #E can usually say yes or no but not appropriately and she kept saying I don't know. There was another resident in the room sitting in his wheelchair and he was disrobed. This resident was Resident #H and his clothes were bunched up on the table and he only had on socks. LPN #1 indicated she removed Resident #H from the room and got him a gown. The resident had a skin tear to his left lower leg. The LPN indicated she had not been aware of any previous contact or sexual behaviors for Resident #H. LPN#1 indicated the resident takes himself in and out of bed and will dress himself if you provide his clothes. The LPN indicated when she came into Resident #E's room the sheets of her bed were on the floor and a pillow was also on the floor. The LPN indicated she thought everyone responded appropriately and a CNA took Resident #H to his room without any problems. The LPN indicated she did not recall seeing any visitors at the time of the incident. CNA #3 was interviewed in on 12/3/15 at 4:45 p.m The CNA indicated she was working the evening shift on the unit Resident #E resided on. The CNA indicated, CNA #1 came out and called for help and LPN #1 and RN#1 and herself went into Resident #E's room. Resident #E was in the room on the floor and was naked. CNA #1 was in the room and was saying she opened Resident #E's door, saw the bed was empty, and looked down and saw Resident #E on the floor with Resident #H in his wheelchair in the room. CNA #3 indicated she then saw Resident #H in his wheelchair facing Resident #E and the resident was bending over in his wheelchair facing Resident #E's waist/ buttock area. The CNA indicated some other staff member pushed Resident #H out of the room and when she left Resident #E's room to get a pad for the Hoyer lift she observed Resident #H going into another resident's room. She told someone to get him. She believed it was a female's room he was going into. CNA #3 indicated when she first entered the room Resident #E was on the floor naked, had no sheets or boots on her. The boots and sheets were on the other side of the bed by the foot of the bed. The CNA indicated she did not see the resident's brief in sight. The CNA indicated the resident's roommate was sleeping. CNA #3 indicated Resident #H had wandered into other resident's room and and he takes his clothes off in the hallway. The CNA indicated the resident would try and grab and rub you. The CNA indicated the resident had reached out at her breast, private parts, and buttock at different times and everyone was aware of his behaviors. Continued interview with CNA #3 indicated she, RN #1, and LPN #1 all entered Resident #E's room together when CNA #1 was in the room. CNA #3 indicated CNA #1 was holding her face and repeating, It's my fault. CNA #3 #1 stated,He was touching her butt. CNA #3 indicated she interpreted this as he was fondling her. The CNA also indicated RN#1 told them to open the Resident #E's leg and noted something whitish dry on her inner thigh and described as like dry white. CNA #3 stated herself, LPN #1 and RN #1 were all present at this time and RN #1 and CNA #1 asked what was that and RN #1 said she did not know and She's got to go the hospital anyway. CNA #3 indicated she had a conversation with LPN #1 the next day and the LPN told her she just wrote what they told me to write. Continued interview with CNA #3 indicated she wrote a statement on the day of the above occurrence. The CNA indicated once she wrote the initial statement no one from the facility asked her any more questions about the day. A written statement from CNA #1 was reviewed. The statement indicated while she was doing her last rounds she entered Resident #E's room and saw Resident #H naked and sitting in his wheel chair and Resident #E was on the floor naked as well. I then called for help. Nothing further was in the written statement. The Immediate Jeopardy began on 11/21/15 and was removed 12/5/15 when the facility assessed residents with behaviors, in-serviced staff on what to do when residents had behaviors and who to report behavioral issues to when they occur in the facility, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy due to continued in-services of staff employees. This Federal tag relates to Complaint IN 012. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure necessary services and treatments were provided related to the lack of assessment and intervention in a timely manner for a resident with pain. The facility also failed to ensure necessary services and treatments were provided related to the lack of assessment and treatment to an open wound on a resident's abdomen for 1 of 3 residents reviewed for non-pressure skin related issues. (Resident #B) Findings include: 1. Resident #B was initially observed on 9/10/14 at 9:30 a.m. She was in her bed moaning, her face was contorted and there were tears on her face. She would open her eyes, but was unable to communicate. Her hands were contracted and she had palm protectors in both hands. LPN #1 indicated she was having pain due to excoriation to her buttocks and it was time to reposition her. She repositioned the resident. She indicated the resident had a prescription for [MEDICATION NAME] (a narcotic pain medication) as needed. She did not receive a scheduled pain medication. At 12:05 p.m., at 9/10/14 another observation was made with LPN #1. The LPN gave the resident her noon medications through the feeding tube. The resident was grimacing and would moan at times. CNA #1 assisted the LPN with pericare and wound care. They indicated the resident had some redness and excoriation to her groin areas. The resident had a small 0.5 centimeter (cm) round open area on her left buttock that was bleeding and a slit-type open area approximately 1 x 0.3 cm under her left abdominal fold that was red and had mild drainage surrounding the wound. There was no dressing on the wound. The resident continued to grimace and moan during care. Interview with the LPN at this time indicated the wound had been there a couple of weeks. They were treating her skin issues with [MEDICATION NAME] lotion (a skin protectant). She further indicated when a new wound was observed, an initial skin sheet was to be completed, and the Wound Nurse would complete weekly assessments of the wound. At 12:25 p.m., the LPN indicated the resident was having pain. She indicated one of the noon medications was [MEDICATION NAME] (a muscle relaxant), and that some of the resident's pain was from her legs and she would wait half an hour to see if the [MEDICATION NAME] relieved the pain. She then removed the dressing to the residents [DEVICE] site, cleansed the area and applied a new dressing. At 12:55 p.m. on 9/10/14 Restorative Aide (RA) #1 removed the palm protectors. When the resident's hands were opened, she yelled out and grimaced. The RA indicated she might be having pain, and he would notify the nurse. He then continued to remove the other palm protector. The resident's record was reviewed on 9/10/14 at 10:00 a.m. The resident's [DIAGNOSES REDACTED]. She had a gastrostomy ([DEVICE]) tube for feeding. The Significant Change Minimum Data Set assessment dated [DATE], indicated the resident was rarely or never understood, and required full care for bed mobility, transfers, and activities of daily living. Review of Nursing Notes indicated the wound was first noted on 8/23/14 at 7:21 a.m., the area was referred to as "mons pubis" in the Nursing Note. Nursing Note dated 8/24/14 at 4:08 a.m. indicated "New order for periguard skin protectant to pubis q (every) shift until open area healed..." A Nursing Note dated 8/25/14 at 2:55 p.m. indicated the order was changed to [MEDICATION NAME] for the mons pubis wound. There was no further documentation in the Nursing Notes related to the mons pubis wound after that. The Weekly Skin Assessment sheets for August and September 2014 were reviewed. None of the assessments involved the wound to the mons pubis area. There was no evidence of documentation indicating an initial skin sheet related to the mons pubis wound. The September 2014 Medication Administration Record [REDACTED]. [MEDICATION NAME] had been given one time in September on 9/9/14. The September 2014 Treatment Administration Record (TAR) was reviewed. The record indicated [MEDICATION NAME] ointment to the right armpit was completed on 9/3/14 and [MEDICATION NAME] to the groin was completed on 9/3/14. There was no treatment in place for the mons pubis wound. The physician's orders [REDACTED]. There was no order for treatment to the mons pubis. The DON indicated the treatment orders were completed on 9/4/13. There were no additional orders for skin related issues. A care plan dated 10/11/13 indicated the resident had potential for pain related to immobility. The goal was, "Will have no signs of pain (restlessness, facial grimacing, guarding of affected area, yelling out, tearfulness) through next review. The interventions included to assess for signs of pain, administer medications as ordered and notify MD if ineffective. A care plan dated 10/3/11 was for pain related to contractures. The goal was to have relief from pain within 1 hour of intervention. Interventions included to medicate as ordered and note effectiveness, document and report non-verbal sign of pain. A care plan for contracture management of hands dated 12/28/13 indicated the resident was to wear palm protectors 3-7 times a week. An updated intervention on 6/23/14 was to apply palm protectors before breakfast and remove after lunch; and inform nurse of signs of pain. Nursing Notes for 9/2014 were reviewed. There was one entry for the month dated 9/9/14 related to the resident crying with pain in her facial expression. There were no other entries. At 1:03 p.m., the resident was observed with the Director of Nursing (DON). Care had been completed and the resident was alone in her room. Her face was contorted and tearful. The DON approached the resident and massaged her arm, "oh honey, don't worry, the nurse is getting your pain medication". The LPN entered and gave her pain medication. Interview with the DON at that time indicated the resident had previously been on scheduled [MEDICATION NAME], but it had made her lethargic. She also indicated the staff was aware they should be assessing for pain. Interview with the Wound Nurse on 9/10/14 at approximately 1:30 p.m., indicated she was not aware of the mons pubis wound. She indicated she would assess the resident at that time. After she assessed the resident, the Wound Nurse indicated the wound had some drainage and the Physician needed to be notified. The policy, Pain Evaluation, dated 3/2102, was received from the DON on 9/10/14 at 3:45 p.m. The policy indicated the purpose was to provide "...optimal comfort through a pain control plan..." The policy further indicated, "Nursing will document any complaints or signs/symptoms of pain in the progress notes". 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide the necessary treatment and services for a skin tear related to a wound dressing not in place as ordered for 1 of 3 residents reviewed for alterations in skin integrity in the sample of 3. (Resident #B) Findings include: On 8/25/14 at 8:35 a.m., Resident #B was observed in bed. Unit Manager #1 and CNA #2 entered the resident's room to complete a skin check.. The CNA and the Unit Manager removed the resident's disposable brief. There was an open area with edges to the resident's lower back area. There was no dressing in place over the area. The area was approximately 0.5 cm x 0.5 cm. The record for Resident #B was reviewed on 8/25/14 at 8:49 a.m. The resident's [DIAGNOSES REDACTED]. The 7/14/14 Minimum Data Set Quarterly Assessment indicated the resident's cognitive patterns were severely impaired. The Assessment also indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) of two staff members for bed mobility and transfers. The Assessment also indicated the resident was totally dependent on one staff member for personal hygiene and bathing. Review of the current Physician orders [REDACTED]. The 8/2014 TAR (Treatment Administration Record) was reviewed. The above ordered treatment was last signed out as completed on 8/23/14. A 7/8/14 Non-Pressure Ulcer Condition report indicated a skin tear was first noted to the resident's lower left lateral back. The area measured 0.5 cm (centimeters) x 0.5 cm x 0.1 cm. The report indicated the wound edges were distinct, the wound bed was 100% red, and a small amount of serous (bloody) drainage was noted. The report also indicated the ordered treatment to the area was to cleanse the area with wound cleanser, pat dry, apply [MEDICATION NAME] AG, and cover with a dry dressing every three days and prn (as needed). The skin tear was last measured and assessed on 8/12/14. The skin tear measured 0.2 cm x 0.3 cm x 0.1 cm, the wound bed had 100% red/pink granulation tissue and no drainage was noted. The ordered treatment was still [MEDICATION NAME] AG every three days. When interviewed on 8/25/14 at 11:44 a.m., LPN #3 indicated she was assigned to care for Resident #B today. The LPN indicated her shift began at 7:00 a.m. LPN #3 indicated the night shift Nurse did not inform her of the resident not having a dressing in place. The LPN also indicated the day shift CNA did not report the resident's dressing not being place this AM. LPN #3 indicated the resident was to have dressing in place as ordered. When interviewed on 8/25/14 at 1:00 p.m., the Director of Nursing indicated the resident should have had dressing in place to the back as ordered by the Physician. This Federal tag relates to Complaint IN 215. 3.1-37(a)

Based on record review and interview the facility failed to ensure the resident's drug regime remained free of unnecessary drugs related to lack of monitoring PT/INR ([MEDICATION NAME]/International Normalized Ratio) laboratory test levels for the use of blood thinners in a timely manner for 1 of 3 residents reviewed for change in condition in the sample of 8. This resulted in a Critical laboratory level requiring the administration of Vitamin K to reverse the effects of the blood thinning medication. (Resident #C) Findings include: The closed record for Resident #C was reviewed on 8/22/13 at 10:50 a.m. The resident's diagnose included, but were not limited to, [MEDICAL CONDITION], malignant neoplasm of the prostate, [MEDICAL CONDITION],urethral strictures, convulsions, [MEDICAL CONDITION], contractures, and [MEDICAL CONDITION] reflux. The resident was admitted to the facility on [DATE]. Review of the 7/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The medication was initially ordered on [DATE]. The [MEDICATION NAME] 5 milligrams was signed out as given at 4:00 p.m. daily 7/1/13 through 7/10/13. The 7/3/13 PT/INR laboratory test results were as follows: 7/03/13 PT-19.2 (Low) INR-1.82 (Low) The 7/10/13 PT/INR laboratory test results were as follow: PT- 46.1 (High) INR- 4.10 (High) The 7/10/13 laboratory test result report indicated the specimen was collected by the Laboratory on 7/10/13 at 6:57 a.m. and the results were faxed to the facility on [DATE] at 11:46 a.m. There was writing on the bottom of the form which noted "hold [MEDICATION NAME] today & tomorrow, repeat PT/INR on Saturday." There was no date, time, or initial/signature next the above writing. The 7/13/13 laboratory test results indicated the PT/INR level were as follows: PT- 62.5 (High) INR- 5.35 (Critical) The 7/13/13 Physician orders [REDACTED]. The 7/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The 7/15/13 laboratory test results indicated the PT/INR level were as follows: PT-18.1 (Low) INR- 1.72 (Low) Review of the 7/2013 Nursing Progress Noted were reviewed. There was no documentation of attempts to notify the Physician of the 7/10/13 PT/INR laboratory test results. An entry made on 7/11/13 at 4:39 p.m., indicated the Physician and Responsible Party were notified of the PT/INR results of PT-46.1 and INR -4.10, the resident's [MEDICATION NAME] was to be held today and tomorrow, and a PT/INR test was to drawn on Saturday July 13, 2013. The 2010 Nursing Spectrum Drug Handbook indicated [MEDICATION NAME] was classified as an anticoagulant drug which could cause major or fatal bleeding. Bleeding was more likely with higher INR (international Normalized Ratio) levels and INR levels should be monitored regularly. The facility policy titled "Physician/Family/Responsible Party Notification For Change in Condition" was reviewed on 8/22/13 at 10:30 a.m. The policy had a revised date of 1/2012. The Director of Nursing provided the policy and identified the policy as current. The policy indicated medical care problems were to be communicated to the attending Physician in a timely, efficient, and effective manner. The policy also indicated the Physician was to be notified of abnormal laboratory test results When interviewed on 8/22/13 at 10:28 a.m., the Nurse Consultant indicated the results of the high PT/INR levels above were faxed to the facility on [DATE]. The Nurse Consultant indicated they were not called the Physician until 7/11/13 and [MEDICATION NAME] was not held until 7/11/13. When interviewed on 8/22/13 at 10:45 a.m., the Nursing Unit Manager indicated the 7/10/13 PT/INR lab results were not followed through on 7/10/13. The Unit Manager indicated if the Physician were called when the results came in 7/10/13 the 4:00 p.m. dose of [MEDICATION NAME] could have been held that day. This federal tag relates to Complaint IN 339. 3.1-48(a)(5)

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being related to a resident sustaining a fracture upon staff attempting to the insert an indwelling Foley catheter for 1 of 3 residents reviewed of Foley catheters in the sample of 6. (Resident #F) (CNA #1) (RN #1) The facility also failed to follow the policy related to care of a port a cath insertion site for 1 of 3 residents reviewed with intravenous insertions in the sample of 6. (Resident #F) The facility also failed to ensure Insulin was administered as ordered for 1 of 3 residents reviewed for Insulin administration in the sample of 6. (Resident #B) Findings include: 1. The record for Resident #F was reviewed on 2/1/13 at 9:10 a.m. The resident's [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] and returned to the facility on [DATE]. The resident was sent to the hospital emergency roiagnom on [DATE]. Review of the 1/24/13 Physician orders indicated there was an order to change the Foley catheter as needed for leakage or dislodgement. Review of the 1/2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This treatment was last signed out as completed on 1/10/13. The treatment was signed at not completed on 1/17/13 as the resident had been sent to the hospital on [DATE]. The treatment was not signed out as completed from 1/23/13 through 1/30/13. The 11/28/12 Minimum Data Set (MDS) quarterly assessment indicated the resident was totally dependent on the assistance of two or more staff members for transfers and bed mobility such as moving to and from a lying position, turning side to side, and positioning her body while in bed. The assessment also indicated the resident displayed impairment in range of motion on both upper extremities and both lower extremities. The assessment also indicated the resident had an indwelling catheter in place. The 1/2013 Nursing Progress Notes were reviewed. An entry made on 1/8/13 at 7:20 p.m. indicated the the resident's Foley catheter was out and the bulb of the catheter tube was inflated. The entry also indicated the resident was assessed and no bleeding was observed in the perineal area. An entry made on 1/8/13 at 10:40 p.m. indicated the Nurse attempted to reinsert the resident's Foley catheter but was unsuccessful. The entry also indicated the Unit Manager and the Director of Nursing were informed and the Director of Nursing informed the Nurse the Foley catheter would be reinserted the next day. An entry made on 1/9/13 at 7:26 a.m. indicated the resident's Foley Catheter had been reinserted, the resident tolerated the procedure well, no signs or symptoms of pain or acute distress or discomfort were observed, and the Foley catheter was intact and draining yellow urine via gravity. An entry made on 1/11/13 at 11:53 p.m. indicated the resident's Foley catheter had been replaced on 1/11/13 and the catheter was draining clear yellow urine. An entry made on 1/30/13 at 4:50 a.m. indicated the Nurse was summoned by the CNA as the resident's urinary catheter (Foley catheter) has been displaced while pericare was being rendered. The entry indicated the Nurse "attempted to replace urinary catheter-in manipulating right lower extremity laterally approx 25 degrees this nurse heard a 'pop'-immediately this nurse maintained right lower erect and without movement-nduring (sic) this occurrence resident did not demonstrate any facial grimacing/moaning..." The entry also indicated the Physician was notified of the change in condition and orders were obtained to send the resident to the hospital emergency room for an evaluation. The next entry was made on 1/30/13 at 4:55 a.m. This entry indicated the ambulance service was called, a voicemail message was left with the resident's family, and the emergency room was called and a report was given to the Charge Nurse. The next entry was made on 1/301/3 at 5:07 a.m. This entry indicated the ambulance service was in the resident's room and the two ambulance attendants transferred the resident from the bed to the cart. This entry also indicated the resident was heard moaning during the transfer. An entry made on 1/31/13 at 3:45 p.m. indicated the Director of Nursing was informed by the hospital staff that the resident's x-ray revealed a comminuted [MEDICAL CONDITION] femur. Hospital reports were reviewed on 2/1/13 at 9:50 a.m. A right femur x-ray was completed on 1/30/13 at 6:40 a.m. The X-ray report indicated there was a comminuted [MEDICAL CONDITION] one third of the right femur, with medial displacement of the fracture fragments with marked osteopenia noted. Further hospital records were obtained at the hospital on [DATE] at 4:00 p.m. The emergency room Physician notes were reviewed. The Physician notes indicated the resident presented to the emergency room from a nursing home for an evaluation of pain and swelling to the right distal thigh and proximal leg which began when the nursing home staff began placing a Foley catheter and the staff felt a popping sensation to the region. The notes also indicated a Review of Symptoms was positive for joint swelling. The Physician's Physical Exam indicated the resident exhibited [MEDICAL CONDITION] and tenderness and right distal thigh proximal leg tenderness with ecchymosis (bruising) and decreased range of motion at the knee joint. The Physician Notes also indicated the the resident's X-rays were consistent with a distal one third femur spiral displaced fracture. The 1/30/13 emergency room Nurses' Notes indicated an entry was made at 6:48 a.m. This entry indicated the resident was observed with a large decubitus ulcer to the coccyx and the resident's port a cath was assessed. The note indicated the needle on the port a cath was bent and the dressing over the port a cath was soiled and dated as changed last on the 22nd of the month. A Orthopedic Surgery Consult Note dated 1/31/13 was also noted in reviewing the resident's hospital records. This Physician consult indicated the resident was admitted on [DATE] and the resident was a nursing home resident who was admitted through the emergency room with a history of an injury to the right femur which occurred prior to admission. The note also indicated the nursing home was apparently attempting to insert a Foley catheter and while supporting the resident's legs they felt a "pop" in the right leg with some deformity. The note also indicated the X-rays confirmed the resident had a "spiral supracondylar [MEDICAL CONDITION] femur with soap separation of the fragments." The Physician's plan indicated the resident was not a surgical candidate and a long leg posterior mold was to be maintained. When interviewed on 2/1/13 at 9:50 a.m., the Director of Nursing indicated she received a telephone call from the Activity Director around 7:00 a.m. on 1/30/13 and the Activity Director reported the CNA (CNA #1) told her that something happened to Resident #F. The Director of Nursing indicated she then told the Activity Director to put the CNA on the phone and she then spoke with the CNA on the phone at this time. The Director of Nursing indicated the CNA reported to her that during pericare the resident's Foley catheter became dislodged and the CNA informed the Nurse and the Nurse came into the room and attempted to put the catheter back in. The Director of Nursing also indicated the CNA was talking a lot and indicated that they were holding the resident's legs and heard a popping sound. The Director of Nursing indicated she then had the CNA give the phone back to the Activity Director and the Activity Director gave the phone to the RN#1 and she spoke with the RN on the phone at that time. The Director of Nursing indicated the RN told her the CNA informed him the resident's Foley catheter was dislodged and the Nurse completed the documentation he was doing, obtained a Foley catheter insertion kit, and entered the resident's room to insert the catheter. The Nurse also indicated he had the resident's right leg and the CNA had the resident's left leg during the attempt. The Director of Nursing indicated she instructed the RN to remain in the facility lobby until she arrived at the facility. She arrived at approximately 7:30 a.m. The Director of Nursing indicated she took the RN into the resident's room and had him reenact the occurrence to show how the staff members were positioned during the procedure. The RN indicated he had his forearm on her thigh and his hands towards the resident's calf. When interviewed further on 2/1/13 at 12:50 p.m. the Director of Nursing indicated when CNA #1 was called on 1/30/13 around 2:30 p.m. or 3:00 p.m.,he was "jabbering all over the place" and made statements indicating the Nurse used "pressure" and asked him to change his story and the Director of Nursing asked the CNA why he had not mentioned this when she had spoken to him on the telephone earlier that morning. The Director of Nursing indicated the CNA stated he told the Activity Director this in the morning. The Director of Nursing indicated she first saw CNA's written statement on 1/30/13 at approximately 2:30 p.m. or 3:30 p.m. When interviewed on 2/1/13 at 1:06 p.m., CNA #1 indicated he was working on 1/30/13 and was assigned to care for Resident #F. The CNA indicated he observed the resident's pad under her was wet and when he started to turn the resident he noticed the resident's catheter was out and he told the Nurse. The CNA indicated he assisted the Nurse in trying to put the catheter in and the Nurse tried several times and then said he thought it was in. The CNA indicated he returned to the resident's room approximately 30 minutes later with the Nurse to replace the catheter. The CNA indicated he was at the foot of the bed and the Nurse instructed him to hold the residents' legs "like this" and showed him. The CNA indicated they heard the "pop" during the second time they were in the resident's room to put a catheter back in. When interviewed on 2/4/13 at 1:15 p.m., RN #1 indicated he was assigned to care for Resident #F on 1/30/13. The RN indicated he worked the night shift. The RN indicated CNA #1 informed him he was providing care to Resident #F and the resident's Foley catheter had become dislodged. The RN indicated he assessed the resident's vital signs and then began to attempt to replace the catheter. The RN indicated the resident was morbidly obese and approximately 60% of her weight was at her 'bottom." The RN indicated it was difficult to visualize the insertion and he spent approximately "1/2 an hour looking to see where the insertion point would be." The RN indicated he normally would lower the head of the bed and elevate the foot of the bed but the CNA informed him the head of the resident's bed could not go all the way down. The RN indicated he elevated the foot of the bed and they brought the resident's torso down in bed so he could visualize the area and that did not work due to the head of the bed being elevated and then he and the CNA moved the resident toward the left side and moving her legs toward the right side of the bed. The RN indicated it was still difficult for him to visualize due to the resident's abdomen protruding down into the area and he had the CNA go over to the side he (the RN) was on and he went over to the side the CNA was on which was her right side. The RN indicated he wanted to show the CNA how he wanted the leg positioned. The RN indicated he lifted her right leg and moved it laterally approximately 15 degrees for adequate visualization and this is when I heard the "pop." When interviewed further at this time, the RN was asked if any attempts had been made to reinsert the Foley catheter that shift prior to the above information he had just provided. RN #1 then indicated he had attempted to insert the Foley catheter prior to the above time. The RN indicated he attempted to insert the catheter earlier and at that time approximately five attempts were made and then on one attempt he felt the catheter was in place, inflated the catheter bulb and hooked the catheter tubing to the drainage bag. RN #1 indicated he went back to check several times and no urine was observed in the bag and he removed the catheter. The RN indicated this was approximately 20 minutes after it was inserted. The RN then indicated this is when he attempted to re insert the Foley catheter and the "pop" was heard with the the second episode of attempting to insert the catheter. The RN indicated he informed the EMS (Emergency Medical Services) the resident needed to be evaluated as she could have sustained a fracture. The RN indicated he thought he also told the hospital emergency room staff in report the same report. During continued interview at this time, the RN indicated there were two other staff Nurses working in the facility on the night shift. The RN indicated the other Nurses were working on the other two units and he did not talk to the other Nurses related to the Foley catheter insertion attempts for the resident. When interviewed on 2/4/13 at 9:05 a.m., the Director of Nursing indicated she was aware Resident #F's Foley catheter has to be replaced on several other episodes as it was observed out by staff. The Director of Nursing indicated staff had reported difficulty inserting the Foley catheter in the past and staff had reported this to the Unit Manager and she would then insert the catheter. The Director of Nursing indicated if multiple attempts were made or staff had difficulty or any trouble they could have called management or the Physician. The facility policy titled "Implanted Venous Access Port Dressing Change" was reviewed on 2/4/13 at 8:55 a.m. The policy was received from the Nurse Consultant and identified as current. The policy was dated as last revised on August 15, 2008. The policy indicated the implanted venous port needle was to be changed at least every 7 days and dressing changes were to be performed at least weekly. When interviewed on 2/4/13 at 2:30 p.m. the Nurse Consultant indicated the residents port a cath care was to be completed every seven days. 2. The record for Resident #B was reviewed on 2/4/13 at 1:00 p.m. The resident's [DIAGNOSES REDACTED]. The 12/2012 Medication Administration Records were reviewed. There was a Physician's order for the resident to receive an subcutaneous injection of 25 units of [MEDICATION NAME] 70/30 insulin three times a day before meals. The Physician's order indicated the insulin injections were to be given at 7:00 a.m., 11:00 a.m., and 4:00 p.m. The 7:00 a.m. doses of the [MEDICATION NAME] 70/30 insulin were coded as being held on 12/14/12 and 12/16/12. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s blood glucose level was 118. The 12/2012 Nursing Progress Notes were reviewed. An entry made on 12/14/12 at 6:08 a.m. indicated the scheduled dose of 25 units of [MEDICATION NAME] 70/30 insulin was held. The entry also indicated the resident's blood sugar level was 112. There was no documentation of the resident displaying any signs of [DIAGNOSES REDACTED] (low blood sugar level) or of the resident voicing any complaints or symptoms. There was no documentation of the Physician being notified or orders given to hold the above scheduled dose of insulin. An entry made on 12/16/12 at 6:02 a.m. indicated the scheduled dose of 25 units of [MEDICATION NAME] 70/30 insulin was held. The entry also indicated the resident's blood sugar level was 118. There was no documentation of the resident displaying any signs of [DIAGNOSES REDACTED] (low blood sugar level) or of the resident voicing any complaints or symptoms. There was no documentation of the Physician being notified or orders given to hold the above scheduled dose of insulin. When interviewed on 2/4/13 at 3:30 p.m., the Director of Nursing indicated the resident had no documented signs of [DIAGNOSES REDACTED] and the Nurse should have administered the insulin as ordered as there were no Physician ordered parameters to hold the insulin on the above dates. This federal tag relates to Complaints IN 956 and IN 512. 3.1-37(a)

Based on record review and interviews, the facility failed to ensure the resident received the necessary treatment and services to treat an urinary tract infection when a resident was exhibiting signs and symptoms of an urinary tract infection for 1 of 3 residents reviewed for urinary tract infections of the 3 who met the criteria for urinary tract infections. Findings include: The closed record was reviewed for Resident #B on 8/18/11 at 8:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE] with an indwelling foley catheter. The 5/26/11 catheterization evaluation indicated the resident had the [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of the laboratory data indicated the first urinalysis obtained was not until 5/23/11. The final culture dated 5/27/11 indicated greater than 100,000 entercoccus faecium. The organism was resistant to [MEDICATION NAME] and [MEDICATION NAME] antibiotics. The organism was susceptible to [MEDICATION NAME] and linezolid antibiotics. Review of Nurses Notes dated 5/25/11, indicated the resident had a [MEDICAL CONDITION] and was sent out to the emergency room at 6:32 a.m. The resident returned to the facility on [DATE], at 3:00 p.m. with Physician orders [REDACTED]. Review of Physician order [REDACTED]. Review of Nurse's Notes dated 5/27/11 indicated the resident's Physician was not made aware of the culture results of the 5/23/11 urinalysis. Review of the laboratory results indicated the next urinalysis obtained was on 6/7/11. The final culture was dated 6/8/11 which indicated 60,000 to 70,000 multiple gram positive organisms. The resident's physician was notified and no new orders were obtained. Nurses notes dated 7/7/11, at 8:09 p.m., indicated the resident's urine was cloudy and yellow in color with slight hematuria (blood in the resident's urine). Review of Physician orders [REDACTED]. The next entry in Nurses Notes for an urine assessment was 7/8/11, at 1:55 a.m., which indicated the urine was yellow and cloudy with no odor or sediment in the tubing. The next entry for an urine assessment was on 7/8/11 at 3:31 p.m., which indicated the urine was yellow with no hematuria noted. The urine sample was in the refrigerator awaiting lab pick up. The next documentation about the resident's urine was not until 7/11/11 at 8:49 p.m., which indicated the urine was yellow with mucous threads noted. Nursing Progress Notes dated 7/17/11, at 9:08 p.m., indicated called to room at 8 p.m. by other staff due to change in level of consciousness, excessive frothy sputum in mouth. Resident found to be postictal (after seizing). Urinary output was decreased. The physician was notified and new orders were obtained to start an intravenous line with D5 .9 normal saline give 200 cubic centimeters (cc) [MEDICATION NAME] then 100 cc an hour thereafter. Urinary output was to be monitored. Another entry in Nursing Progress Notes was on 7/17/11 at 9:36 p.m., which indicated there was no urinary output and the intravenous fluids were infusing without problems. On 7/18/11 at 3:13 a.m. Nursing Progress Notes indicated the resident appeared lethargic and there was some yellow urine observed in the foley bag. On 7/18/11 at 4:30 p.m. Nursing Progress Notes indicated at 9 a.m., resident was lethargic and not responding and had a [MEDICAL CONDITION] which last over 20 minutes. The resident's physician was notified and new orders were obtained to send to the hospital. Review of the laboratory results indicated there were no results for urinalysis that was collected on 7/8/11 and placed in the refrigerator. Interview with South Unit Manager on 8/19/11 at 2:27 p.m., indicated she had called the lab and they indicated they did not receive an urine sample from the facility for Resident #B. Review of Physician orders [REDACTED]. Review of the Medication Record for 6/11 indicated the foley catheter was changed on 6/3/11 and 6/24/11. Review of the 7/11 Medication Record indicated the foley catheter had not been changed from 7/1-7/18/11. Review of a urinalysis that was completed in the hospital on [DATE] indicated greater than 100 white blood cells, 1 plus bacteria, 2 plus blood, 20-50 red blood cells. The final urine culture was dated 7/20/11 which indicated 70-80,000 proteus mirabilis pipercillin and greater than 100,000 multiple gram positive organisms indicating an urinary tract infection. Interview with the South Unit Manager on 8/19/11 at 2:25 p.m., indicated the foley catheter was not changed every two weeks as ordered and was not changed in July 2011. She further indicated the facility only collected two urine samples from 5/11/11 and the one sample collected on 7/8/11 was not sent to the lab. The South Unit Manager also indicated at the time, the resident was sent out to the hospital on [DATE] and did not come back to the facility. 3.1-41(a)(2)

Based on observation, record review and interviews, the facility failed to ensure each resident was free from falls related to functioning wheelchair alarms and sensor alarms for 2 of 3 residents reviewed for accidents of the 5 residents who met the criteria for accidents. This resulted in Resident #H fracturing her humerus after falling. (Resident #H and #J) Findings include: 1. On 8/15/11 at 3:25 p.m., Resident #H was observed lying in bed. While walking up to the resident's bed and sitting in the arm chair next to the bed, there was no evidence a sensor alarm was sounding or turned on by the resident's bed. On 8/16/11 at 2:22 p.m., the resident was out of her room. While walking around her room and around the resident's bed, there was no evidence a sensor alarm was not turned on and functioning. On 8/17/11 at 4:12 p.m., the resident was observed sitting on the side of her bed, while approaching her and standing approximately one foot from her bed, the sensor alarm did not sound. Further observation at that time, indicated the PCU Unit Manager entered the room and turned a switch on the sensor alarm that was located on the wall parallel to the resident's bed. The alarm immediately sounded. CNA #1 was observed to come into the room, she indicated that she did not know what the device was on the wall, and she had no idea what a sensor alarm was. Interview with LPN #1 on 8/17/11 at 4:22 p.m., indicated she had no idea Resident #H used a sensor alarm. Interview with LPN #2 on 8/17/11 at 4:24 p.m., indicated she was the nurse taking care of the Resident #H and she had no idea the resident had a sensor alarm in place. The record for Resident #H was reviewed on 8/17/11 at 8:23 a.m. The resident's [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was alert and oriented with limited assist with transfers, bed mobility, toileting, and locomotion on unit. The resident had a history of [REDACTED]. Review of the Fall Risk assessment dated [DATE], indicated the resident was a low risk for falls. Review of the Fall Risk assessment dated [DATE], indicated she was a high risk for falls with three or more falls in last 3 months. Review of the personal alarm assessment 4/26/11, indicated the resident had previous falls, the resident does try to stand, transfer, and walk alone, and staff have to remind her to use the call light. Review of the personal alarm assessment dated [DATE], indicated the resident has had previous falls, tries to get out bed unsafely, tries to stand, transfer and walk alone. The resident cannot walk to and from the bathroom due to her balance and unsafe gait. The resident does have poor safety awareness and decision making, and requires assistance with toileting and ambulation and often refuses to use the call light for assistance. The current care plan dated 6/7/11, indicated the resident had the potential for falls related to history of falls and an unfamiliar environment. The nursing approaches were for a sensor alarm and a bed and chair alarms. Review of the Nursing Progress Notes dated 5/4/11, at 8 p.m., indicated the resident was found on floor in her room and both bed and chair alarms were in place but not sounding. The resident indicated she had turned them off. Review of the Fall Investigation Worksheet dated 5/4/11, indicated the resident's bed and wheelchair alarms were not sounding and the resident stated, "I turned them off. They irritate me." The interventions put into place at the time of the fall was to provide the resident non-skid safety socks to wear, therapy to evaluate her, and continue with bed and chair alarms. Review of Nursing Progress Notes dated 5/14/11 12:15 p.m., indicated the resident transferred herself from a chair to the wheelchair. The resident was observed sitting on the floor in front of her chair. The resident indicated she slid out of the chair. Review of the Fall Investigation Worksheet dated 5/14/11, indicated the resident's alarm was sounding at the time of the fall. The new interventions at the time of the fall was to place a dycem in the wheelchair. Review of Nursing Progress Notes dated 6/7/11, at 3:30 a.m., indicated nursing staff heard a loud noise and upon entering the room the resident was on the floor. The resident indicated she took the bed alarm apart, got out of bed and ambulated to get a brief out of her closet. The resident had complaints of pain to her right arm at that time. Nursing Progress Notes dated 6/7/11 at 7:30 a.m., indicated the resident refused to get out of bed due to pain in her right arm. The resident's physician was called and new orders were obtained to send the resident to the hospital to get an X-ray. Review of the X-ray results dated 6/7/11, of the right shoulder, indicated the resident had a comminuted fracture of the head of the humerus and the surgical neck with slight impaction. Review of the IDT notes dated 6/7/11, indicated reviewed resident's history of falls. Resident noncompliant with use of alarm to bed. Resident with a history of disconnecting or dismantling alarms. Sensor alarm to be placed in resident room. Care plan updated. Review of Nursing Progress Notes dated 7/7/11 at 6:00 p.m., indicated the resident was found on the floor in room. The resident was observed in front of wheelchair sitting on her buttocks. Review of the Fall Investigation Worksheet dated 7/7/11, indicated the alarms were not sounding. Review of Nursing Progress Notes dated 7/30/11 7:20 p.m., indicated the resident noted to be sitting on the floor in her bathroom. The resident stated she was walking from the toilet to the sink to wash up and put on night clothes. The alarm was sounding. Review of Physician orders [REDACTED]. Interview with the PCU Unit Manager on 8/18/11, at 4:55 p.m., indicated she had not tried any other type alarms or hiding the resident's alarms under the wheelchair or the bed due to her noncompliance. She further indicated the sensor alarm was to be turned on and in place at all times. Interview with the Director of Nursing on 8/19/11 at 11:13 a.m. indicated there was no documentation in the fall investigations report that the resident was wearing her non skid socks at the time of the fall on 6/7/11. She further indicated the bed and chair alarms continued to be an intervention for the resident, even though she was noncompliant with all of the alarms. 2. On 8/17/11, at 4:00 p.m., Resident #J was observed up in a wheelchair. There was a chair alarm noted to the chair, and there was a chair cushion on the bottom of the chair. On 8/17/11 at 4:13 p.m., CNA #1 was observed in the resident's room, at that time, she indicated she placed the resident in the wheelchair that she was currently sitting in. The CNA indicated she had thought this was Resident #J's wheelchair. Further observation at the time, indicated the CNA was asked to stand Resident #J up from the chair. The PCU Unit Manager and CNA #1 then stood the resident up from the wheelchair. The chair alarm did not sound. Further observation indicated the chair alarm was turned off. There was also no dycem noted on top of the cushion or under the cushion in the wheelchair. The record for Resident #J was reviewed 8/17/11 at 3:30 p.m. The resident's [DIAGNOSES REDACTED]. Review of quarterly MDS assessment dated [DATE], indicated the resident was alert and oriented and needed extensive assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use, and personal hygiene. The resident had no falls prior to the last assessment. The current plan of care dated 6/17/11, indicated the resident was at risk for falls. The nursing approaches were to have bed and wheelchair alarm and a dycem to the wheelchair. Review of Physician orders [REDACTED]. Review of Nursing Notes dated 7/27/11, indicated the resident had a fall at 3:30 p.m. The resident was noted on the floor in her room lying on her left side. The resident indicated she was trying to pick up her call light that had fallen to the floor. Interview with the PCU Unit Manager on 8/17/11 at 4:30 p.m., indicated the resident was to have wheelchair alarm and a dycem under her cushion while up in the wheelchair. 3.1-45(a)(2)

Based on record review and interviews, the facility failed to ensure the resident received the necessary treatment and services to treat an urinary tract infection when a resident was exhibiting signs and symptoms of an urinary tract infection for 1 of 3 residents reviewed for urinary tract infections of the 3 who met the criteria for urinary tract infections. Findings include: The closed record was reviewed for Resident #B on 8/18/11 at 8:35 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE] with an indwelling foley catheter. The 5/26/11 catheterization evaluation indicated the resident had the [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of the laboratory data indicated the first urinalysis obtained was not until 5/23/11. The final culture dated 5/27/11 indicated greater than 100,000 entercoccus faecium. The organism was resistant to [MEDICATION NAME] and [MEDICATION NAME] antibiotics. The organism was susceptible to [MEDICATION NAME] and linezolid antibiotics. Review of Nurses Notes dated 5/25/11, indicated the resident had a [MEDICAL CONDITION] and was sent out to the emergency room at 6:32 a.m. The resident returned to the facility on [DATE], at 3:00 p.m. with Physician orders [REDACTED]. Review of Physician order [REDACTED]. Review of Nurse's Notes dated 5/27/11 indicated the resident's Physician was not made aware of the culture results of the 5/23/11 urinalysis. Review of the laboratory results indicated the next urinalysis obtained was on 6/7/11. The final culture was dated 6/8/11 which indicated 60,000 to 70,000 multiple gram positive organisms. The resident's physician was notified and no new orders were obtained. Nurses notes dated 7/7/11, at 8:09 p.m., indicated the resident's urine was cloudy and yellow in color with slight hematuria (blood in the urine). Review of Physician orders [REDACTED]. The next entry in Nurses Notes for an urine assessment was 7/8/11, at 1:55 a.m., which indicated the urine was yellow and cloudy with no odor or sediment in the tubing. The next entry for an urine assessment was on 7/8/11 at 3:31 p.m., which indicated the urine was yellow with no hematuria noted. The urine sample was in the refrigerator awaiting lab pick up. The next documentation about the resident's urine was not until 7/11/11 at 8:49 p.m., which indicated the urine was yellow with mucous threads noted. Nursing Progress Notes dated 7/17/11, at 9:08 p.m., indicated called to room at 8 p.m. by other staff due to change in level of consciousness, excessive frothy sputum in mouth. Resident found to be postictal (after seizing). Urinary output was decreased. The physician was notified and new orders were obtained to start an intravenous line with D5 .9 normal saline give 200 cubic centimeters (cc) [MEDICATION NAME] then 100 cc an hour thereafter. Urinary output was to be monitored. Another entry in Nursing Progress Notes was on 7/17/11 at 9:36 p.m., which indicated there was no urinary output and the intravenous fluids were infusing without problems. On 7/18/11 at 3:13 a.m. Nursing Progress Notes indicated the resident appeared lethargic and there was some yellow urine observed in the foley bag. On 7/18/11 at 4:30 p.m. Nursing Progress Notes indicated at 9 a.m., resident was lethargic and not responding and had a [MEDICAL CONDITION] which last over 20 minutes. The resident's physician was notified and new orders were obtained to send to the hospital. Review of the laboratory results indicated there were no results for urinalysis that was collected on 7/8/11 and placed in the refrigerator. Interview with South Unit Manager on 8/19/11 at 2:27 p.m., indicated she had called the lab and they indicated they did not receive an urine sample from the facility for Resident #B. Review of Physician orders [REDACTED]. Review of the Medication Record for 6/11 indicated the foley catheter was changed on 6/3/11 and 6/24/11. Review of the 7/11 Medication Record indicated the foley catheter had not been changed from 7/1-7/18/11. Review of a urinalysis that was completed in the hospital on [DATE] indicated greater than 100 white blood cells, 1 plus bacteria, 2 plus blood, 20-50 red blood cells. The final urine culture was dated 7/20/11 which indicated 70-80,000 proteus mirabilis pipercillin and greater than 100,000 multiple gram positive organisms indicating an urinary tract infection. Interview with the South Unit Manager on 8/19/11 at 2:25 p.m., indicated the foley catheter was not changed every two weeks as ordered and was not changed in July 2011. She further indicated the facility only collected two urine samples from 5/11/11 and the one sample collected on 7/8/11 was not sent to the lab. The South Unit Manager also indicated at the time, the resident was sent out to the hospital on [DATE] and did not come back to the facility. This federal tag relates to Complaint IN 023. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure two staff assisted a resident to transfer by a mechanical lift. The feficient practice affected 1 of 5 residents reviewed related to falls in a sample of 12. (Resident #C) The resident fell from the lift during transfer, fractured her leg, and was transferred to the hospital for treatment. Findings include: The record for Resident #C was reviewed on 3/8/11 at 12:35 p.m. The resident's [DIAGNOSES REDACTED]. A progress note dated 2/21/11 at 10:33 a.m., indicated fall risk assessment note. A fall risk assessment was completed with a score of 8. This score did not indicated the resident was a high risk for falls. A progress note, dated 2/21/11 at 2:30 p.m., indicated nurses note. The resident was found on the floor in room. The resident was being transferred using Hoyer lift (mechanical lift used to move a resident) and staff stated the Hoyer pad came undone and the resident fell . The resident remained alert and verbally responsive. The resident was unable to move her right arm and right leg. The Hoyer lift was removed from the resident by three staff members, 911 was called and staff remained with the resident. A progress note dated 2/21/11 at 2:30 p.m., indicated fall. The resident fell at 2:30 p.m. Vital signs were temperature 98.8, pulse 95, respirations 24, and blood pressure 167/76. The resident was being transferred by the Hoyer lift to bed by staff and fell . The resident's pupils (eyes) were reactive, neurological check performed due to the resident hitting head on floor. The resident was unable to move right arm and right leg. 911 was called immediately and staff remained with the resident. The resident remained alert and verbally responsive and oriented times three. A change in condition Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was 63 inches tall and 219 pounds she was total dependence, requiring full staff performance every time during entire 7 day period with two plus persons physical assist for transfers. A care plan initiated on 11/15/10, indicated a focus of risk for falls characterized by history of fall/injury, multiple risk factors related to mechanical lift for transfers, staff provide ADL (activities of daily living) care, psychotropic medication usage. The interventions included, but were not limited to, transfer and change positions slowly. Mechanical lift for transfers. A hospital form dated 2/22/11, indicated an admitted for 2/21/11 with a chief complaint, "I was dropped on the floor." History of present illness: The resident "presented to the emergency room with a chief complaint of being dropped to the floor with a Hoyer lift. The patient stated that she was moving from the chair to the bed when the Hoyer lift tilted and she fell , resulting in pain and swelling to the right upper extremity and hip." Investigations: "The chest x-ray was negative. The pelvic x-ray revealed an acute fracture of the right femur." Extremities: "The right upper extremity was swollen and tender to palpation and has limited range of motion. The hip is tender to palpation. Straight leg raising test is only about 10 degrees." Impression: The impression included, but was not limited to, fracture of right femur. Plan on admission included, but was not limited to, Orthopedic consultation will be obtained. A reportable incident provided by the Administrator on 3/9/11 was reviewed on 3/10/11 at 10:30 a.m. The incident dated was 2/21/11 at 2:30 p.m. Staff involved: CNA #1 Description of incident: Resident #C had a fall from mechanical lift. "Type of injury: admitted to hospital with fracture of right femur. Immediate action taken: assessment of resident, sent to emergency room for evaluation." Resident's physician and family notified and internal investigation completed. CNA #1 was sent home. The mechanical lift and sling was removed from operation pending clearance from vendor. "Preventative measures taken: Direct Care staff in-serviced and return demonstration on use of mechanical lifting devices. Maintenance reviewed all lifting devices on date of event to make sure they were working properly. All lifts were found in proper working order. All slings were examined and found to be in proper condition. Lift and sling used on resident were both proper lift and proper sling. Vendor of lift called to report and came to examine the lift used. Lift examined and found to be in proper order and sling in proper order." "Our follow up investigation included interviews with (CNA #1's name), and we do not feel this was substantiated abuse or neglect. The CNA did follow procedure and the lift was functioning properly as was the sling." A teachable moment dated 2/24/11, indicated a subject of Hoyer lift transferring a resident from bed to broda chair. CNA #1 "demonstrated the proper use of Hoyer lift while transferring a totally dependent resident from his bed to the broda. Straps were double check by (CNA #1's name), writer and another CNA to ensure resident's safety." A written interview with CNA #1 was provided with the incident report. CNA #1 indicated "was in the room preparing to provide care to (Resident #C's name) around 2:00 p.m. Before placing the (resident's name) in the lift went to go get additional help." CNA #1 "went to (Resident #C's name) room with the lift. The (resident's name) was in the wheelchair with the lift pad under her. Place lift in front of the resident, opened legs" and placed to side, lowered lift as low as it could go. "Lock latches to lift pad to machine, yanked to listen to click and to be in position. Then went to lift her while holding one grab bar of machine." The lift was going then fell . The resident's body slipped out of lift pad. CNA #1 wrote, on 2/21/11, "I was giving care to (resident's name) I ask QMA #1 for help so I just said I will start to (sic)she come. I hooked the Hoyer pad to the lift. Lifted (resident's name) a little then began to move lift." The "lift pad came apart and she fell . I did not move her I went for help." A written interview provided with the incident from the PCU Unit Manager dated 2/21/11, indicated the Unit Manager was called to the room by QMA #1 that another CNA needed help. The PCU Unit Manager ran to the room and found the resident laying on the floor with other CNA lying by her side. "States resident fell out of the Hoyer lift. Unit manager ran back to the nurses station called 911 et (and) MD (physician)." Unit manager went back to the room and asked the resident what happened. The resident indicated, "She fell off lift states her shoulder hurts and hip. Writer informed staff not to move resident. Resident stated that it was an accident and please don't blame CNA because it wasn't her fault." The Transfer/Position Resident Sling Lift (Maxi Lift) Policy was provided by the Administrator and reviewed on 3/9/11 at 11:10 a.m. The policy indicated, "The lift may be completed by one staff person, however, with the more difficult resident transfer, a second staff person may be required.: The Maxi Lift (mechanical lift) instruction manual was provided by the Administrator and reviewed on 3/9/11 at 11:10 a.m. The manual indicated, can be used by one person. A CNA Assignment Sheet was provided by CNA #2 on 3/10/11 at 10:17 a.m. The sheet indicated Resident #C was total for assist needed and was to use the Hoyer lift. Interview with CNA #2 on 3/10/11 at 10:25 a.m., indicated she had worked for the facility about one year. She indicated Resident #C was a Hoyer lift and a two person transfer. She further indicated she had been oriented by the Assistant Director of Nursing (ADoN) and was trained to use two staff members when using a mechanical lift. Interview with CNA #1 on 3/10/11 at 9:00 a.m., indicated on 2/21/11 at almost 2:00 p.m. she had asked QMA #1 to help her because staff were to use two people during a transfer with the lift. QMA #1 was finishing up with another resident so CNA #1 indicated she went ahead to start with Resident #C. She placed the pad under the resident and heard the clamps snap or click in place and she then started to lift the resident out of her chair. She had moved the resident away from the chair and the clamps came undone and the resident fell . The QMA was not in the room at the time. She further indicated a typical transfer was with two people and she had just started. Interview with CNA #2 on 3/10/11 at 9:22 a.m., indicated anytime a mechanical lift was used other than the sit to stand lift she was always to use two people for the transfer. She indicated she had learned this in her CNA training and during orientation at the facility. Interview with CNA #3 on 3/10/11 at 10:05 a.m., indicated when using a mechanical lift she needs to use someone as spotter. She also indicated there are to be two people when using the mechanical lift. She was taught this in CNA training and in orientation at the facility. Interview with CNA #4 on 3/10/11 at 10:55 a.m., indicated she had just finished transferring the resident with a mechanical lift and her helper had just walked out of the room. She further indicated when using a mechanical lift she was to use two people for the transfer. She learned this in orientation. Interview with the ADoN on 3/10/11 at 10:00 a.m., indicated she does the staff orientation on transfers. At 10:22 a.m. she indicated they like to the staff to have 2 people for mechanical lift transfers. She further indicated they are taught in orientation to use two people when transferring using a mechanical lift. Interview with the PCU Unit Manager on 3/10/11 at 12:30 p.m., indicated when staff transfer using the hoyer lift they like the staff to use two people but the policy does not indicate they have use two people. She prefers her staff to use two people every since the accident with another resident a couple of months ago. She further indicated that this accident happened prior to the fall of Resident #C from the Hoyer lift. She also indicated that there was only one person on the CNA assignment sheet that she had written was a two person transfer and she really needs to update that sheet. Interview with the Administrator on 3/10/11 at 1:15 p.m., indicated the facility policy states the need for only one person during transfers. She also indicated staff were told to use two if they can but that would not always be feasible. She further indicated Resident #C could be transferred by one person that two people were for difficult residents which she was not a difficult resident. She indicated difficult would be residents who shake or have behaviors. She then indicated if the CNA had transferred the resident by herself and there had been a need for two person transfer, she would have terminated the CNA. She also indicated that the MDS for a two persons refers to the person and the lift. Interview with the Administrator, Director of Nursing, and the Nurse Consultant on 3/10/11 at 1:55 p.m., indicated the facility followed their policy and if they go above the policy to use two people during a transfer that would be a good thing. This federal tag relates to Complaint IN 627. This deficiency was cited on 12/28/10. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(2)

Based on interviews and record reviews, the facility failed to supervise and plan interventions to prevent falls for 1 of 3 residents in the sample of 6 who had sustained two falls. Resident: E Findings include: 1. Review of the clinical record of Resident E on 1/24/11 at 1:00 p.m., indicated the [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) and was receiving Two Cal Hn (formula) at 70 ml (milliliters) for 18 hours per day. The resident was currently in the hospital. The quarterly Minimum Data Set Assessment ((MDS) dated [DATE], indicated the resident cognitive status was severely impaired and he required total assistance with all areas of activities of daily living. The resident required the use of a Hoyer life to transfer from the bed to the wheel chair. This MDS indicated the resident had no history of falls. The nurses' notes on 1/25/11 at 9:50 a.m., indicated on 1/11/11 at 2:27 p.m.,"... the resident was noted on the bed laying on his stomach bottom half on the floor. Complete head to toe assessment was done no complaints of pain or discomfort no bruises noted at this time...." On 1/15/11 at 7:50 p.m., the resident was again observed lying on the floor with his upper body under the bed and his feet on the foot rest of the chair. The resident was assessed and transferred to the hospital. Review of the facility's form entitled "Fall Investigation Worksheet" dated 1/11/11, indicated the resident was trying to transfer alone and had sustained an unwitnessed fall. The intervention/recommendations that were put in place at this time were to place the resident in a wheel chair and that he would attend activities. It could not be determined from the report where the resident had been when he fell , the bed or the chair. The "Fall Investigation Worksheet" dated 1/16/11, indicated the resident was not to be left in his room alone in the chair and that a chair alarm was to be put in place. This investigation was completed the day after the resident was admitted to the hospital. In addition, to the chair alarm, a physical therapy and occupational therapy screen and evaluation was to be completed. The fall risk assessment done on 1/11/20 at 2:30 p.m., indicated the resident's score was 10, he had intermittent confusion, 1-2 falls in past 3 months and was chair bound. The fall risk assessment completed after the fall on 1/15/20 at 7:30 p.m. indicated the score was now 12, and the only change was for a physical therapy and occupational therapy screen. Interview on 1/25/20 at 1:40 p.m., with the Administrator indicated the resident was already on the case load for the restorative program after the first fall on 1/11/20 and the therapy screenings were ordered after the second fall on 1/15/20, but never completed because the resident was sent to the hospital. The Administrator indicated the facility had a conference with a family member after the first fall, and it was felt the resident needed to attend more scheduled activities, and this was one of the recommendations after the first fall. The plan of care dated 1/11/11, identified a problem of the resident being at risk for falls with an intervention to encourage resident to participate in activities. This intervention as noted on the plan of care, and was the responsibility of nursing staff and the activities department. Documentation was lacking to indicate what type of interventions would be utilized when regularly scheduled activities were not being done. During an interview with the Director of Nursing (DON) on 1/26/11 at 11:00 a.m., she indicated no other interventions were implemented after the first fall on 1/11/11, only that the resident would attend activities, staff would anticipate resident's needs, and therapy screens were ordered to evaluate or treat. Review on 1/25/11 at 2:00 p.m., of the facility policy dated 8/2009, and provided by the Administrator entitled "Fall Risk and Post Fall Investigation" included but was not limited to: "Any resident scoring a "10" or above on the Fall Risk Assessment form will be placed in the "High Risk for potential falls" category. Complete new Fall Investigation and update existing form and new score. Implementation- interventions to prevent further falls. Update care plan with new intervention. Possible interventions included for bed: Personal Bed alarm, Bed Wedge and Lo bed, for chair: Personal Alarm, Wheel chair wedge (unless has hip fracture) Self-release seat belt." This federal tag relates to Complaints IN 750 and IN 069. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure two staff assisted a resident to transfer by a mechanical lift. The deficient practice affected 1 of 5 residents reviewed related to falls in a sample of 12. (Resident #C) The resident fell from the lift during transfer, fractured her leg, and was transferred to the hospital for treatment. Findings include: The record for Resident #C was reviewed on 3/8/11 at 12:35 p.m. The resident's [DIAGNOSES REDACTED]. A progress note dated 2/21/11 at 10:33 a.m., indicated fall risk assessment note. A fall risk assessment was completed with a score of 8. This score did not indicated the resident was a high risk for falls. A progress note dated 2/21/11 at 2:30 p.m., indicated nurses note. The resident was found on the floor in room. The resident was being transferred using Hoyer lift (mechanical lift used to move a resident) and staff stated the Hoyer pad came undone and the resident fell . The resident remained alert and verbally responsive. The resident was unable to move her right arm and right leg. The Hoyer lift was removed from the resident by three staff members, 911 was called and staff remained with the resident. A progress note, dated 2/21/11 at 2:30 p.m., indicated fall. The resident fell at 2:30 p.m. Vital signs were temperature 98.8, pulse 95, respirations 24, and blood pressure 167/76. The resident was being transferred by the Hoyer lift to bed by staff and fell . The resident's pupils (eyes) were reactive, neurological check performed due to the resident hitting head on floor. The resident was unable to move right arm and right leg. 911 was called immediately and staff remained with the resident. The resident remained alert and verbally responsive and oriented times three. A change in condition Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident was 63 inches tall and 219 pounds she was total dependence, requiring full staff performance every time during entire 7 day period with two plus persons physical assist for transfers. A care plan initiated on 11/15/10, indicated a focus of risk for falls characterized by history of fall/injury, multiple risk factors related to mechanical lift for transfers, staff provide ADL (activities of daily living) care, psychotropic medication usage. The interventions included, but were not limited to, transfer and change positions slowly. Mechanical lift for transfers. A hospital form dated 2/22/11, indicated an admitted for 2/21/11 with a chief complaint, "I was dropped on the floor." History of present illness: The resident "presented to the emergency room with a chief complaint of being dropped to the floor with a Hoyer lift. The patient stated that she was moving from the chair to the bed when the Hoyer lift tilted and she fell , resulting in pain and swelling to the right upper extremity and hip." Investigations: "The chest x-ray was negative. The pelvic x-ray revealed an acute fracture of the right femur." Extremities: "The right upper extremity was swollen and tender to palpation and has limited range of motion. The hip is tender to palpation. Straight leg raising test is only about 10 degrees." Impression: The impression included, but was not limited to, fracture of right femur. Plan on admission included, but was not limited to, Orthopedic consultation will be obtained. A reportable incident provided by the Administrator on 3/9/11 was reviewed on 3/10/11 at 10:30 a.m. The incident dated was 2/21/11 at 2:30 p.m. Staff involved: CNA #1 Description of incident: Resident #C had a fall from mechanical lift. "Type of injury: admitted to hospital with fracture of right femur. Immediate action taken: assessment of resident, sent to emergency room for evaluation." Resident's physician and family notified and internal investigation completed. CNA #1 was sent home. The mechanical lift and sling was removed from operation pending clearance from vendor. "Preventative measures taken: Direct Care staff in-serviced and return demonstration on use of mechanical lifting devices. Maintenance reviewed all lifting devices on date of event to make sure they were working properly. All lifts were found in proper working order. All slings were examined and found to be in proper condition. Lift and sling used on resident were both proper lift and proper sling. Vendor of lift called to report and came to examine the lift used. Lift examined and found to be in proper order and sling in proper order." "Our follow up investigation included interviews with (CNA #1's name), and we do not feel this was substantiated abuse or neglect. The CNA did follow procedure and the lift was functioning properly as was the sling. A teachable moment dated 2/24/11, indicated a subject of Hoyer lift transferring a resident from bed to broda chair. CNA #1 "demonstrated the proper use of Hoyer lift while transferring a totally dependent resident from his bed to the broda. Straps were double check by (CNA #1's name), writer and another CNA to ensure resident's safety." A written interview with CNA #1 was provided with the incident report. CNA #1 indicated "was in the room preparing to provide care to (Resident #C's name) around 2:00 p.m. Before placing the (resident's name) in the lift went to go get additional help." CNA #1 "went to (Resident #C's name) room with the lift. The (resident's name) was in the wheelchair with the lift pad under her. Place lift in front of the resident, opened legs" and placed to side, lowered lift as low as it could go. "Lock latches to lift pad to machine, yanked to listen to click and to be in position. Then went to lift her while holding one grab bar of machine." The lift was going then fell . The resident's body slipped out of lift pad. CNA #1 wrote, on 2/21/11, "I was giving care to (resident's name) I ask QMA #1 for help so I just said I will start to (sic)she come. I hooked the Hoyer pad to the lift. Lifted (resident's name) a little then began to move lift." The "lift pad came apart and she fell . I did not move her I went for help." A written interview provided with the incident from the PCU Unit Manager dated 2/21/11, indicated the Unit Manager was called to the room by QMA #1 that another CNA needed help. The PCU Unit Manager ran to the room and found the resident laying on the floor with other CNA lying by her side. "States resident fell out of the Hoyer lift. Unit manager ran back to the nurses station called 911 et (and) MD (physician)." Unit manager went back to the room and asked the resident what happened. The resident indicated, "She fell off lift states her shoulder hurts and hip. Writer informed staff not to move resident. resident stated that it was an accident and please don't blame CNA because it wasn't her fault." The Transfer/Position Resident Sling Lift (Maxi Lift) Policy was provided by the Administrator and reviewed on 3/9/11 at 11:10 a.m. The policy indicated, "The lift may be completed by one staff person, however, with the more difficult resident transfer, a second staff person may be required.: The Maxi Lift (mechanical lift) instruction manual was provided by the Administrator and reviewed on 3/9/11 at 11:10 a.m. The manual indicated, can be used by one person. A CNA Assignment Sheet was provided by CNA #2 on 3/10/11 at 10:17 a.m. The sheet indicated Resident #C was total for assist needed and was to use the Hoyer lift. Interview with CNA #2 on 3/10/11 at 10:25 a.m., indicated she had worked for the facility about one year. She indicated Resident #C was a Hoyer lift and a two person transfer. She further indicated she had been oriented by the Assistant Director of Nursing (ADoN) and was trained to use two staff members when using a mechanical lift. Interview with CNA #1 on 3/10/11 at 9:00 a.m., indicated on 2/21/11 at almost 2:00 p.m. she had asked QMA #1 to help her because staff were to use two people during a transfer with the lift. QMA #1 was finishing up with another resident so CNA #1 indicated she went ahead to start with Resident #C. She placed the pad under the resident and heard the clamps snap or click in place and she then started to lift the resident out of her chair. She had moved the resident away from the chair and the clamps came undone and the resident fell . The QMA was not in the room at the time. She further indicated a typical transfer was with two people and she had just started. Interview with CNA #2 on 3/10/11 at 9:22 a.m., indicated anytime a mechanical lift was used other than the sit to stand lift she was always to use two people for the transfer. She indicated she had learned this in her CNA training and during orientation at the facility. Interview with CNA #3 on 3/10/11 at 10:05 a.m., indicated when using a mechanical lift she needs to use someone as spotter. She also indicated there are to be two people when using the mechanical lift. She was taught this in CNA training and in orientation at the facility. Interview with CNA #4 on 3/10/11 at 10:55 a.m., indicated she had just finished transferring the resident with a mechanical lift and her helper had just walked out of the room. She further indicated when using a mechanical lift she was to use two people for the transfer. She learned this in orientation. Interview with the ADoN on 3/10/11 at 10:00 a.m., indicated she does the staff orientation on transfers. At 10:22 a.m. she indicated they like to the staff to have 2 people for mechanical lift transfers. She further indicated they are taught in orientation to use two people when transferring using a mechanical lift. Interview with the PCU Unit Manager on 3/10/11 at 12:30 p.m., indicated when staff transfer using the hoyer lift they like the staff to use two people but the policy does not indicate they have use two people. She prefers her staff to use two people ever since the accident with another resident a couple of months ago. She further indicated that this accident happened prior to the fall of Resident #C from the Hoyer lift. She also indicated that there was only one person on the CNA assignment sheet that she had written was a two person transfer and she really needs to update that sheet. Interview with the Administrator on 3/10/11 at 1:15 p.m., indicated the facility policy states the need for only one person during transfers. She also indicated staff were told to use two if they can but that would not always be feasible. She further indicated Resident #C could be transferred by one person that two people were for difficult residents which she was not a difficult resident. She indicated difficult would be residents who shake or have behaviors. She then indicated if the CNA had transferred the resident by herself and there had been a need for two person transfer, she would have terminated the CNA. She also indicated that the MDS for a two persons refers to the person and the lift. Interview with the Administrator, Director of Nursing, and the Nurse Consultant on 3/10/11 at 1:55 p.m., indicated the facility followed their policy and if they go above the policy to use two people during a transfer that would be a good thing. This federal tag relates to Complaints IN 70 and IN 069. This deficiency was cited on 12/28/10. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(2)

Based on observation, interviews and record reviews, the facility failed to ensure 2 of 5 residents with gastrostomy tubes in the sample of 6 received the appropriate treatment and services to prevent dehydration and metabolic abnormalities (Resident E) and failed to ensure the proper elevation of the resident's upper body while receiving enteral feedings,which resulted in the need for pharyngeal suctioning and the onset of abnormal vital signs, resulting in the need to transport the resident to the hospital. (Resident C). Findings: 1. Review of the clinical record of Resident E on 1/24/11 at 1:00 p.m., indicated the [DIAGNOSES REDACTED]. The resident had a gastrostomy tube ([DEVICE]) and was receiving Two Cal Hn (formula) at 70 ml (milliliters) continuously for 18 hours a day. The feeding tube was to be flushed with 30 cc. (cubic centimeters) before and after administrating medications every shift. In addition, the feeding tube was to be flushed with 500 cc. of water every shift. The resident received nothing by mouth. The resident was currently in the hospital. The quarterly Minimum Data Set Assessment ((MDS) dated [DATE], indicated the resident's cognitive status was severely impaired and he required total assistance with all areas of activities of daily living. This MDS indicated the resident had no history of falls. The nurses' notes on 1/25/11 at 9:50 a.m., indicated on 1/11/11 at 2:27 p.m.,"... the resident was noted on the bed laying on his stomach bottom half on the floor. Complete head to toe assessment was done no complaints of pain or discomfort no bruises noted at this time...." On 1/15/11 at 7:50 p.m., the resident was again observed lying on the floor with his upper body under the bed and the his feet on the foot rest of the chair. The resident was assessed and transferred to the hospital. Documentation related to the resident's condition and mental status was lacking in the nurses' notes at the time of discharge. The history and physical from the hospital dated 1/16/11, indicated the resident was admitted because he was showing altered levels of consciousness and was found to be severely hypernatremic (elevated sodium levels) with a sodium level of 169 (reference range 137-145). The chloride level was also high at 121 (reference range 96-108) and the BUN (blood urea nitrogen level) was 55 (reference range 9-20). The resident was aggressively hydrated. Additional notes on 1/22/11, indicated the final [DIAGNOSES REDACTED]. The resident's feeding was changed to [MEDICATION NAME] 1.2 and the sodium level was corrected. A consultation report dated 1/17/11, listed the resident's weight as 134 pounds and the blood pressure at 83/53 (reference range 120/80). This consultation report indicated the impression was [MEDICAL CONDITION] related to fluid dehydration and indicated the feeding he was receiving at the nursing home (2 Cal Hn) may be causing the [MEDICAL CONDITION]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The intake and output sheet provided by the Unit Manager for the month of January indicated no formula or flushes were charted for 1/11/11 on the 11-7 shift and 3-11 shift, on 1/12/11 for the 11-7 and 3-11 shift and on 1/13/11 for the 11-7 and 3-11 shift. There were no outputs listed for these three days. In addition, the outputs that were listed for the 7-3 shifts on 1/11, 1/12 and 1/13/11 indicated only that the resident had voided "2 times." There was no indication if the amounts of output were of small, medium or large amounts. During interview on 1/25/11 at 2:05 p.m., with the Assistant Director of Nursing (ADON), she indicated she was unaware why the intake and output sheet were incomplete, especially the days prior to his fall and hospitalization . During interview on 1/25/11 at 1:30 p.m., the Registered Dietitian indicated she did not have an explanation why this resident, who was receiving tube feedings had become dehydrated and was admitted to the hospital with [REDACTED]. Review of the plan of care on 1/25/11 at 3:00 p.m., identified a problem of at risk for aspiration due to use of a feeding tube, but documentation was lacking to identify any risks of dehydration or electrolyte imbalance. Review of Lippincott's Nursing Reference Facts, dated 1998, indicated [MEDICAL CONDITION] was a deprivation of water and hypertonic tube feedings with inadequate water supplements. The nursing intervention included, but were not limited to: monitor fluid losses and gains. Monitor for changes in behaviors, such as restlessness, disorientation and lethargy. 2. Resident # C's clinical record was reviewed on 1/24/11 at 3:20 p.m. and indicated [DIAGNOSES REDACTED]. Further review of her clinical record indicated she was admitted to the facility with severe contractions to bilateral upper and lower extremities which required splinting. During observation of Resident # C on 1/26/11 at 8:30 a.m., she was observed lying in her bed with her chest positioned flat on the mattress with only her head elevated (bent at the neck) approximately 5-10 degrees. The HOB (head of the bed) was permanently affixed to be elevated at 30 degrees. She had a nasal cannula (used for oxygen administration) in her nares. A large amount of white, frothy substance was observed oozing from her nares and mouth. The substance was seeping down the corners of her mouth and onto her neck and chest. Her feeding tube was attached to her PEG tube and was running at 70 cc's (cubic centimeters) per hour. LPN # 4, who was at the Unit 100 Nurse's Station, was immediately informed of Resident # C's condition and she entered the resident's room with CNA # 5. Together they pulled Resident # C up in the bed so that she would be properly positioned at 30 degrees to prevent aspiration of the feeding. LPN # 4 sent CNA # 5 to obtain a new nasal cannula and some clean wash cloths. LPN # 4 cleaned the white substance from the Resident # C's mouth and nose. Almost immediately, Resident # C began coughing and a large amount of white, frothy mucus oozed from her nose. Her mouth was observed to be full of the substance. Unit Manager, LPN # 6, entered the room at 8:35 a.m. and assisted LPN # 4 with cleaning Resident # C. While LPNs # 4 and # 6 cleaned her, Resident # C was observed silently gagging while attempting to swallow the frothy mucus. Her mouth was observed to, once again, be filled with the white, frothy mucus. She had a look of panic on her face. She was incapable of summoning assistance either vocally or with use of a call light. LPN # 6 assessed Resident # C's vital signs and reported as follows: T (temperature) 99.3 , P (pulse) 100; R (respirations) 18; BP (blood pressure) 120/104 (normal range is: T-98.6; P: 60-100; R: 12-20; BP: 120/80). At 9:00 a.m., LPN # 6 indicated she called the Medical Director to get an order for [REDACTED]. The annual MDS (Minimum Data Set) Assessment, dated 12/27/10, indicated Resident #C's "ability to express ideas and wants" was "rarely or never understood" and her "ability to understand verbal content" was "rarely or never understands." A Resident Care Plan, dated 3/04/10, indicated Resident # C's "Problem: Potential risk of aspiration related to Pe[DEVICE] feeding...Goal: ...Resident will experience no aspiration from reflux of feeding...Intervention: ...Keep HOB (head of bed) elevated AAT (at all times)...." LPN # 6 indicated in an interview on 1/26/11 at 9:15 a.m., she was going to call the physician and have Resident # C sent to the emergency room for the chest x-ray and evaluation. During an interview with LPN # 6 on 1/26/11 at 10:35 a.m., she indicated Resident # C was transported to the hospital around 10:05 a.m. Review of a facility policy titled "[MEDICAL CONDITION] Tube Feeding via Continuous Pump," revised 2/2005, indicated, "...4. Always keep a resident receiving a continuous feeding, in semi-Fowler's (placement of the patient in an inclined position with the upper half of the body raised by elevating the head of the bed) position or higher...." This Federal tag relates to complaint IN 750. 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to perform the necessary suctioning to adequately clear the airway of a medically compromised and totally dependent resident with copious amounts of secretions which resulted in the resident gagging, struggling for breath, and exhibiting a facial expression of panic. The facility also failed to ensure the necessary equipment was available for suctioning and insertion of a Foley catheter. This deficient practice affected 1 of 1 resident receiving suctioning and requiring a Foley catheter in a sample of 6. Resident #C Findings include: 1. Resident #C's clinical record was reviewed on 1/24/11 at 3:20 p.m. and indicated [DIAGNOSES REDACTED]. Further review of her clinical record indicated she was admitted to the facility on [DATE] with severe contractions to bilateral upper and lower extremities which required splinting. During observation of Resident #C on 1/26/11 at 8:30 a.m., she was observed lying in her bed with her chest positioned flat on the mattress with only her head elevated (bent at the neck) approximately 5-10 degrees. The HOB (head of the bed) was permanently affixed to be elevated at 30 degrees. She had a nasal cannula (used for oxygen administration) in her nares (nostrils). A large amount of white, frothy substance was observed oozing from her nares and mouth. The substance was seeping down the corners of her mouth and onto her neck and chest. Her feeding tube was attached to her PEG tube and was running at 70 cc's (cubic centimeters) per hour. LPN #4, who was at the Unit 100 Nurse's Station, was immediately informed of Resident #C's condition, and she entered the resident's room with CNA #5. Together they pulled Resident #C up in the bed so that she would be properly positioned at 30 degrees to prevent a risk for aspiration. LPN #4 sent CNA #5 to obtain a new nasal cannula and some clean wash cloths. LPN #4 cleaned the white substance from Resident #C's mouth and nose. Almost immediately, Resident #C began coughing and a large amount of white, frothy mucus oozed from her nose. Her mouth was observed to be full of the substance. It was indicated to LPN #4 that Resident #C may need to be suctioned. Unit Manager, LPN #6, entered the room at 8:35 a.m. and assisted LPN #4 with cleaning Resident #C. While LPNs #4 and #6 cleaned her, Resident #C was observed silently gagging while attempting to swallow the mucus. Her mouth was observed to, once again, be filled with the white, frothy mucus. She had a look of panic on her face. LPN # 4 returned to the Nurse's Station. It was indicated to LPN # 6 that Resident #C may need to be suctioned in order to clear her airway. LPN # 6 left the room and Resident #C was, again, observed coughing up white, frothy mucus with it oozing from her mouth and both nares. LPN # 6 assessed Resident #C's vital signs and reported as follows: T (temperature) 99.3 , P (pulse) 100; R (respirations) 18; BP (blood pressure) 120/104 (normal range is: T-98.6; P: 60-100; R: 12-20; BP: 120/80). LPN # 6 left the room. A suction machine was observed to be positioned on a bedside stand. It was unplugged and lacked a suction bottle to collect suctioned liquid and a suctioning cannula. LPN # 4, who was still at the 100 Unit Nurse's Station, was queried as to the whereabouts of LPN # 6. LPN # 4 indicated she was in the supply room getting the necessary equipment to suction Resident #C. LPN # 6 re-entered Resident #C's room and attached the suctioning bottle and nasal cannula to the suctioning machine. She determined the machine was not plugged into an outlet when it failed to turn on. LPN # 6 plugged the machine into a wall outlet and began suctioning Resident #C at 8:55 a.m., 25 minutes after she was discovered lying flat with the white substance oozing from her nose and mouth. LPN # 6 left the resident's room again, and at 9:05 a.m., LPN # 6 indicated she called the Medical Director to get an order for [REDACTED]. A physician's orders [REDACTED]." It further indicated the original order was dated 5/19/10. Resident #C was observed at 9:15 a.m. on 1/26/11, with her nasal cannula out of her nares and resting on top of her nose. The white substance was, once again, oozing from her nares. Resident #C was alone in her room with hard splints in place to her hands and arms. She was incapable of summoning assistance either vocally or with use of a call light. LPN # 6 was immediately summoned to her room and suctioned the resident. LPN # 6 indicated in an interview, at the time, she was going to call the physician and have Resident #C sent to the emergency room for the chest x-ray and evaluation. The annual MDS (Minimum Data Set) Assessment, dated 12/27/10, indicated Resident #C's "ability to express ideas and wants was rarely or never understood" and her "ability to understand verbal content" was "rarely or never understands." A Resident Care Plan, updated 5/19/10, indicated Resident #C's "Problem: Potential for ineffective breathing pattern r/t (related to): Requires O2 (oxygen) therapy...Goal: Resident will maintain adequate breathing pattern thru next review...Intervention: ...2. Observe for changes in respiratory rate, pattern, depth and rhythm...5. Observe for s/s (signs/symptoms) of respiratory infection i.e. increased respirations, elevated temp (temperature), marked dyspnea (shortness of breath), color of secretions...suction as needed." During an interview with LPN # 6 on 1/26/11 at 10:35 a.m., she indicated Resident #C was transported to the hospital around 10:05 a.m., and "I had to suction her again before she went out (to the hospital)." A facility policy titled "Oropharyngeal Suctioning," revised 9/2005, indicated, "Purpose: 1. To maintain an unobstructed airway and prevent aspiration of mucus and secretions...4. To prevent pooling of secretions which can lead to infection...Procedure: ...3. Set up the suction machine in the resident's room. Plug it into an electrical outlet...4. Place a conscious resident in a Semi-Fowler's position...." 2. Review of a Nurse's Note, dated 6/18/10 at 4:00 a.m., indicated, "Res. (resident) in bed resting, alert/responsive. Foley cath (catheter) remains out , unable to reinsert @ this time. Res. voiding without difficulty...." A Nurse's Note, dated 6/18/10 at 2:10 p.m., indicated, "Dr. (Name) informed of no supplies for reinsertion of Foley on 6/17/10. MD (Medical Doctor) okay (sic) order to insert 18 Fr (French) Foley today...." A Nurse's Note, dated 6/18/10 at 3:45 p.m., indicated, "Resident's Foley reinserted of 18 Fr 10 cc (cubic centimeters), return of yellow urine noted...." During interview with Unit Manager, LPN # 6, she indicated she could not recall a lack of availability of a Foley catheter for Resident #C. This Federal tag relates to complaint IN 750 and IN 949. 3.1-37(a)