Every finding on record at Aperion Care Vincennes

Based on observation, interview, and record review, the facility failed to ensure ongoing communication was maintained for 1 of 2 resident reviewed for dialysis services. Dialysis communication forms or any other documented dialysis visit notes could not be retrieved by the facility and Director of Nursing was not aware that the dialysis center had changed a resident's prescribed dialysis schedule from three (3) days per week to two (2) days per week. (Resident B)Finding includes:Resident B's record review on 5/26/26 at 1:30 P.M., indicated the resident's diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis.The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/11/26, indicated the resident was cognitively intact and received dialysis services. The care plan included but was not limited to, Resident need dialysis due to renal failure (initiated 11/18/25). Interventions included but were not limited to encourage resident to go to dialysis appointments Monday, Wednesday, and Fridays (initiated 11/18/25). Physician orders included but were not limited to, dialysis treatments three times a week every Monday, Wednesday, and Friday (restarted 5/8/26). Resident B's record contained no dialysis communication forms past the date of 3/202/6. The dialysis communication form on 3/20/26 included instructions for facility staff to monitor fluid intake due to noncompliance with the fluid restriction. Observation on 5/27/26 at 1:25 P.M., Resident B's dialysis communication binder was behind the nurse's station. The binder was empty upon review. Interview on 5/27/26 at 2:00 P.M., LPN 3 indicated dialysis communication forms were used to communicate information such as pre and post dialysis vital signs and any new orders or instructions from the dialysis center. Interview on 5/27/26 at 3:15 P.M., the Facility Administrator indicated the resident's dialysis communication binder had been emptied after the resident passed away on 5/18/26. The Facility Administrator indicated the ambulance service that provided transportation for the resident to and from dialysis also may have had the communication sheets. A handwritten note with dates of dialysis appointments indicated the resident had been scheduled two days per week and often missed dialysis appointments. The Director of Nursing (DON) indicated the dialysis center changed the resident's order from three days per week to two days per week without notifying the facility.On 5/27/26 at 3:38 P.M., the Facility Administrator provided a copy of the dialysis contract, dated 3/9/26 and titled, Nursing Home Dialysis Transfer Agreement. The contract included, .15. Medical Records. Center shall maintain reports of all services rendered by center in accordance with it's usual medical records procedures . Facility shall have the right to photocopy any such reports, records or documents for inclusion in it's own records.On 5/27/26 at 3:58 P.M., the Facility Administrator provided a treatment attendance record from the dialysis center that included scheduled dialysis dates from 3/2/26 through 5/18/26. A noted on the attendance record included, Patient treatments were prescribed two treatments per week on Monday and Friday (morning) .This citation relates to intake 3020811. 410 IAC (Indiana Administrative Code ) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Residents did not receive routine physician prescribed medications due to the medications not being available and new physician prescribed medication was not started timely following a readmission from the hospital. (Resident B, Resident C)Findings include:1. Resident B's record review on 5/26/26 at 1:30 P.M., indicated the resident's diagnoses included, but were not limited to, end stage renal disease, chronic heart failure, cirrhosis of liver, and pneumonia. Physician order's included but were not limited to hydrocodone-acetaminophen 10-325 milligrams (MG) 1 tablet by mouth every 4 hours (started 11/18/25) and amoxicillin 500 MG by mouth two times a day started 5/11/26. The April and May 2026 Medication Administration Records (MAR) indicated the resident did not receive the physician prescribed hydrocodone-acetaminophen 10-325 mg medication order on 4/25/26 at 8:00 A.M., 4:00 P.M., and 8:00 P.M., 4/26/26 at 12:00 A.M., 4/27/26 at 8:00 A.M., 5/1/26 (missed all six administrations), 5/2/26 missed all six administrations, and 5/3/26 at 12:00 A.M. and 4:00 A.M. The order was discontinued on 5/3/26. Nurses progress notes included, but were not limited to:4/25/26 at 4:21 P.M. - Order Administration note regarding hydrocodone-acetaminophen 10-325 milligrams medication - awaiting pharmacy.4/25/26 at 8:10 P.M. - Order Administration note regarding hydrocodone-acetaminophen 10-325 milligrams medication - awaiting pharmacy.4/26/26 at 12:01 A.M. - Order Administration note regarding hydrocodone-acetaminophen 10-325 milligrams medication - awaiting pharmacy.5/1/26 at 1:22 A.M. - Order Administration note regarding hydrocodone-acetaminophen 10-325 milligrams medication - waiting on pharmacy.5/1/26 at 5:05 A.M. - Order Administration note regarding hydrocodone-acetaminophen 10-325 milligrams medication - waiting on pharmacy.5/8/26 at 9:16 P.M. - Resident was readmitted from the hospital this shift. Medications were confirmed. 5/10/26 at 10:35 P.M. - Resident stated that he was to be taking an antibiotic according to the hospital doctor when he was discharged . upon looking into the discharge orders this nurse did not see an order on any of the included pages. Called hospital and was transferred to the physician's line where a message was left for a call back. The nurse on the unit called back and stated that all medication had been faxed to the pharmacy including an antibiotic order.Resident is upset that medication hasn't been given.5/11/26 at 12:34 A.M. - Received original hospital orders and found that the resident is to be on amoxicillin oral capsule 500 MG twice a day for eight days. Hospital Discharge summary, dated [DATE] at 1:30 P.M., included a discharge diagnosis of pneumonia. The hospital course included, Transitioned to oral amoxicillin on discharge . Discharge Medications included, start taking these medications: amoxicillin 500 MG capsule - take 1 capsule (500 mg) by mouth two times daily for eight days. Interview on 5/27/26 at 10:20 A.M., the Director of Nursing (DON) indicated the hospital had originally only sent every other page of Resident B's discharge summary received 5/8/26. The first page of the summary included that the resident should start taking amoxicillin but did not include an order for the mediation with a dosage or frequency. The facility attempted to contact the hospital for clarification. On 5/9/26 a list of medication orders was sent from the hospital, but no order for amoxicillin was included. On 5/10/26 the hospital sent the discharge summary which included the physician's order for amoxicillin. The amoxicillin was started the following day. Interview on 5/27/26 at 2:15 P.M., RN 6 indicated a residents hospital discharge orders should be clarified as soon as possible. Interview on 5/28/26 at 9:55 A.M. the Infection Control Preventionist indicted staff should have documented every attempt to clarify Resident B's antibiotic order from the hospital. 2. Record review on 5/27/26 at 10:30 A.M., indicated Resident C's diagnoses included but were not limited to, polyneuropathy, irritable bowel syndrome, and glaucoma. Physician orders included, but were not limited to pregabalin oral capsule 225 milligrams (MG) two times a day (started 5/1/26), Artificial Tears ophthalmic solution 0.2-0.2-1 % one drop in both eyes four times a day (started 5/1/26), and diphenoxylate-atropine (Lomotil) oral tablet 2.5-0.025 MG one tablet by mouth three times a day (started 5/1/26).May 2026 Medication Administration Records (MAR) indicated the resident did not receive the physician prescribed medications; pregabalin 225 MG two times a day 5/1/26 through 5/4/26, and on 5/6/26, Artificial Tears one drop in both eyes four times a day was not administered 5/1/26 and 5/9/26, and Lomotil 2.5 - 0.025 MG was not administered 5/1/26 through 5/4/26 and on 5/9/26.Nurse's notes included the following:5/2/26 at 11:01A.M. - Order Administration Note - Diphenoxylate-atropine oral tablet 2.5-0.025 MG pending from pharmacy. Not available in the Emergency Drug Kit (EDK). Physician aware.5/2/26 at 5:36 P.M. - Order Administration Note - Pregabalin oral capsule 225 MG pending from pharmacy, not in EDK, physician aware. 5/3/26 at 7:46 A.M. - Order Administration Note - Pregabalin oral capsule 225 MG pending from pharmacy.5/3/26 at 7:46 A.M. - Order Administration Note - Diphenoxylate-atropine oral tablet 2.5-0.025 MG pending from pharmacy.5/4/26 at 7:58 A.M. - Order Administration Note - Diphenoxylate-atropine oral tablet 2.5-0.025 MG pending from pharmacy.5/4/26 at 7:59 A.M. - Order Administration Note - Pregabalin oral capsule 225 MG pending from pharmacy.5/8/26 at 11:36 A.M. - Order Administration Note - Note Artificial Tears Ophthalmic Solution 0.2-0.2-1 % on order. Physician aware. Interview on 5/28/26 at 10:10 A.M. the Director of Nursing (DON) indicated the facility had been in between pharmacies and during the transition period some resident medications were briefly unavailable, and there had been an issue with insurance coverage for medications when a resident returned from a transfer to another facility. On 5/28/26 at 12:22 P.M., the Facility Administrator supplied a copy of the signed pharmacy contract, titled Pharmacy Services Agreement. The contract included, .effective as of the 6th day of March 2026 . 1.2 Delivery Schedule. The pharmacy agrees to deliver to the facility any prescriptions and supplies seven (7) days per week. All medications will be delivered within reasonable times, except for circumstances and conditions beyond its control . This citation relates to intake 3020811.410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on interview and record review, the facility failed to ensure laboratory services were provided for 1 of 3 residents reviewed for quality of care. Labs were not completed per the physician's order. (Resident B)Finding includes:Resident B's record review on 5/26/26 at 1:30 P.M., indicated the resident's diagnoses included, but were not limited to, end stage renal disease, chronic heart failure, cirrhosis of liver, and atrial fibrillation (A-fib). The most recent quarterly minimal data set (MDS) assessment, dated 5/11/26, indicated the resident was cognitively intact and received dialysis services. Physician orders included but were not limited to, Prothrombin Time/ International Normalized Ration - PT/INR (lab test to measure how quickly blood clots) daily for two weeks due to increased results (started 5/13/26). The May 2026 Medication Administration Record / Treatment Administration Record (MAR/TAR) included the PT/INR daily for two weeks order that started on 5/13/26 and indicated the lab test was not completed on 5/15/26, 5/16/26, and 5/17/26. The order was discontinued on 5/18/26. Nurse's notes included but were not limited to the following:5/16/26 at 6:15 P.M. - The lab can't come to facility this weekend to draw resident PT/INR. Physician is aware. 5/17/26 at 7:42 A.M. - The lab can't come out this weekendInterview on 5/27/26 at 10:40 A.M., the Director of Nursing and Facility Administrator indicated the facility's contracted lab service was unrealizable and would only come to the facility once a week to provide lab services. The facility attempted to use a local hospital lab service to complete Resident B's PT/INR lab orders; however the hospital lab staff was unable to come to the facility. On 5/27/26 at 11:03 A.M., the Facility Administrator supplied a copy of an outsourced lab contract, signed and dated 3/20/24. The Laboratory Service Agreement included, This Laboratory Services Agreement . effective as of March 1, 2024 . I. Services. [Lab Company] will travel to Client Locations to draw and/or collect patient specimens for duly ordered tests and will transport the specimens to one of [Lab Company] laboratories for testing all in accordance with the terms of the Laboratory Services Agreement and this Exhibit (or arrange for performance by a duly licensed reference laboratory) . a. Testing ordered on an urgently time sensitive basis (STAT Testing) incurs an additional fee of $30.00 per patient per visit. ST AT Testing is based on the AHA Standard Testing Fee Schedule and is only available for the tests set forth on Schedule I (attached hereto); b. Set-Time Collection fee of $30.00 per requested Set-Time Collection. Set-Time Collection means a request by Facility for one or more patient specimens to be collected at a specific time . STAT Testing Schedule . Hematology & Coagulation . 3. Prothrombin Time (PT/INR) .An interview on 5/27/26 at 2:30 P.M., RN 4 indicated the facility did not have a contract with the hospital lab. This citation relates to intake 3020811. 410 IAC (Indiana Administrative Code) 16.2-3.1-49(a)

Based on interview and record review, the facility failed to ensure clinical records contained bed hold policy, completed transfer/discharge forms, and documentation that a representative of the Office of the State Long-Term Care Ombudsman was notified of transfer/discharge for 7 of 7 residents reviewed for hospitalizations. The clinical records lacked documentation of bed hold, transfer/discharge forms, and notification to Ombudsman for residents reviewed. (Resident 12, Resident D, Resident 4, Resident B, Resident 3, Resident 1, Resident 6)Findings include:1. On 3/19/26 at 12:13 P.M., Resident 12's clinical records were reviewed. Diagnoses included, but were not limited to dementia, severe, with psychotic disturbance, schizoaffective disorder, diabetes mellitus with diabetic polyneuropathy, and emphysema. Resident 12's clinical record indicated she was hospitalized from [DATE] through 10/3/25 and 11/6/25 through 11/11/25 for a psychiatric evaluation. The clinical records lacked a bed hold policy, transfer/discharge form and documentation that the ombudsman was notified for both hospitalizations. 2. On 3/20/26 at 9:37 A.M., Resident D's clinical records were reviewed. His diagnoses included, but were not limited to pneumonia, Type II diabetes mellitus, personal history of traumatic brain injury, tracheostomy status, and gastrostomy status. Resident D's clinical record indicated he was sent to the emergency room on 3/20/26 due to a clogged G-tube (gastrostomy feeding tube) and returned to the facility on 3/20/26. Resident D was admitted to the hospital on [DATE] and remained in the hospital on 3/26/26 for high sodium level and pneumonia with G-tube replacement pending. The clinical records lacked a bed hold policy, transfer/discharge form and documentation that the ombudsman was notified for both hospitalizations. 3. On 3/23/26 at 11:19 A.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. Resident 6 was sent to the emergency room (ER) following falls on the following dates: 10/10/25 11/11/25 1/23/26 Resident 6's clinical record lacked documentation that a bed hold was sent with the resident, given to the resident's representative, or sent to the ombudsman. 4. On 3/19/26 at 10:12 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Resident B was cognitively intact. A Nurse's Note, dated 2/12/26 at 2:05 P.M., indicated Resident left facility via [name of Emergency Medical Service (EMS)] for evaluation. [Name of family] is aware of this. The clinical record lacked any other documentation about the resident being transferred to the hospital for evaluation. The clinical record lacked transfer and discharge forms and a bed hold policy notification. On 3/24/26 at 11:26 A.M., the Ombudsman's office indicated they had not received notification of the transfer. 5. On 3/24/26 at 2:37 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, COPD. Resident 1 was cognitively intact. Nursing notes, dated 1/29/26, indicated the resident was sent to the emergency room (ER) for evaluation and admitted to the hospital. The clinical record lacked a bed hold policy and ombudsman notification. 6. On 3/24/26 at 9:55 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain and malnutrition. Resident 4 was cognitively intact. Transfer 1: A Nurse's Note, dated 2/10/26 at 5:37 P.M., indicated Resident returned from hospital leave at 1337 [1:37 P.M.]. New orders received to start potassium chloride supplement once a day for 5 days. No nausea or vomiting at this time. Resident resting in bed with eyes closed. Family aware of arrival to the facility, will continue to monitor. The clinical record lacked any other documentation about the resident being transferred to the hospital for evaluation. The clinical record lacked transfer and discharge forms and a bed hold policy and ombudsman notification. Transfer 2: A Nurse's Note, dated 2/11/26 at 10:39 A.M., indicated [Name of EMS] here for transport. Report given to ER nurse [name of nurse]. Pt [patient] aware of new orders for transport. The clinical record lacked any other documentation about the resident being transferred to the hospital for evaluation. The clinical record lacked a bed hold policy and ombudsman notification. 7. On 3/19/26 at 2:45 P.M., Resident 3's clinical record was reviewed. Diagnosis included, but was not limited to, hypertension. Resident 3 was sent to the emergency room (ER) on 2/11/26. Resident 3's clinical record lacked documentation that a bed hold was sent with the resident, given to the resident's representative, or sent to the ombudsman. On 3/24/26 at 12:45 P.M., the ombudsman indicated she had not received notification for Resident 12, Resident D, Resident 4, Resident B, Resident 3, Resident 1, and Resident 6's discharges. During an interview on 3/24/26 at 1:28 P.M., the Director of Nursing (DON) indicated a bed hold form should be completed on each discharge. She indicated medical records was behind and the bed holds were not uploaded to the clincial records. During an interview on 3/25/26 at 9:40 A.M., the Social Services Director (SSD) indicated he notified the ombudsman once a month on discharges. On 3/25/26 at 8:54 P.M., the Administrator provided a current Bed Hold and Return to Facility policy, dated 11/28/12 that indicated, .The facility bed hold policy will be given to the resident and/or resident representative as follows: .At the time of a transfer from the facility . During an interview on 3/26/26 at 9:20 A.M., the Administrator indicated they do not have a policy on ombudsman notification, but it was their policy to notify the ombudsman of each discharge. 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)

Based on interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessments for 1 of 1 residents reviewed for hospice, 1 of 5 reviewed for unnecessary medications, 1 of 1 reviewed for medication side effects, and 1 of 1 reviewed for Preadmission Screening and Resident Reviews (PASRR). Residents who received hospice services were marked as not getting them, a resident with a diagnosis of dementia was not identified as having that diagnosis, and a resident's PASRR was not marked on their MDS assessment. (Resident 4, Resident 24, Resident 63, Resident 12)Findings include:1. On 3/19/26 at 12:13 P.M., Resident 12's clinical records were reviewed. Diagnoses included, but were not limited to schizoaffective disorder, depressive type, and dementia, severe, with psychotic disturbance. The most current quarterly Minimum Data Set (MDS) Assessment, dated 2/25/26 indicated Resident 12 had moderate cognitive impairment, required set up (helper sets up or cleans up; resident completes activity) for eating, supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting, mobility and transfer. The MDS indicated Resident 12 did not have a Preadmission Screening and Resident Review (PASRR) with diagnosis. Resident 12's clinical record indicated PASRR Determination was completed on 7/17/23 with an effective date of 7/7/23 for Long Term Approval without Specialized Services. During an interview on 3/24/26 at 12:57 P.M., the Minimum Data Set (MDS) Coordinator indicated Resident 12 did have a PASRR II and should have been marked yes. 2. During an interview on 3/18/26 at 10:40 A.M., Resident 4 indicated he received hospice services. On 3/24/26 at 9:55 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain and malnutrition. The most recent quarterly MDS assessment, dated 3/16/26, indicated Resident 4 was cognitively intact, was dependent on staff for toileting, showering, transfers, and bed mobility, and not receiving hospice services. Physician's Orders included, but were not limited to, the following: admitted to (Hospice Company name) for severe protein calorie malnutrition, ordered 2/26/26 During an interview on 3/24/26 at 11:38 A.M., the MDS Coordinator indicated indicated the question regarding hospice services should have been marked yes but was marked no in error. 3. On 3/20/26 at 10:34 A.M., Resident 24's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent significant change Minimum Data Set (MDS) assessment, dated 3/3/26, indicated no for a diagnosis of dementia. On 3/25/26 at 2:00 P.M., the Director of Nursing (DON) provided a note from the MDS Coordinator that indicated dementia was not marked on Resident 24's 3/3/36 MDS because the resident was not currently taking any medications related to dementia. 4. On 3/25/26 at 10:35 A.M., Resident 63's clinical record was reviewed. The most recent annual Minimum Data Set (MDS) assessment, dated 2/20/26, indicated no hospice. Current physician orders included, but were not limited to: Hospice: admitted to [name of hospice] hospice, dated 11/26/25. On 3/25/26 at 11:39 A.M., the MDS Coordinator indicated hospice should have been marked on Resident 63's 2/20/26 MDS assessment and was not marked due to entry error. At that time, she indicated the Resident Assessment Instrument (RAI) manual was used as a policy for entering MDS assessment information.

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for 4 of 5 residents reviewed for nutrition and hospitalizations, and 1 of 3 residents reviewed for pressure ulcers . Weekly weights were not completed as ordered and medications were not reviewed by the primary care physician when the resident returned from the hospital. (Resident 6, Resident 24, Resident 35, Resident 4, Resident 3)Findings include:1. On 3/19/26 at 2:45 P.M., Resident 3's clinical record was reviewed. Diagnosis included, but was not limited to, anxiety disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 2/27/26, indicated moderate cognitive impairment and a stage 3 pressure ulcer to the right heel and a stage 4 pressure ulcer to the right trochanter (large bony projection on the upper femur). Current physician orders included, but was not limited to: Treatment to the right hip. Cleanse wound with normal saline or wound cleanser. Apply calcium alginate to wound bed and cover with bordered foam dressing every day shift on every Tuesday, Thursday, Saturday, and Sunday, dated 2/21/26 A review of Resident 3's Medication Administration Record (MAR) indicated Resident 3 failed to receive that treatment on the following dates: March 1, 2026 March 14, 2026 March 15, 2025 Treatment to the right hip. Cleanse with normal saline or wound cleanser. Apply wet to moist packing to the wound bed and secure it with a bordered gauze dressing on every day shift on Mondays, Wednesdays, and Fridays, dated 2/20/26 A review of Resident 3's Medication Administration Record (MAR) indicated Resident 3 failed to receive that treatment on March 6, 2026. Treatment to the right outer foot and heel. Cleanse the areas with normal saline or wound cleanser. Apply betadine everyday and night for the wound, dated 2/19/26. A review of Resident 3's Medication Administration Record (MAR) indicated Resident 3 failed to receive that treatment on the following dates: March 1, 2026—dayshift March 6, 2026—dayshift March 14, 2026—dayshift March 15, 2026—dayshift During an interview on 3/24/26 at 1:28 P.M., the Director of Nursing (DON) indicated the MAR should not be left blank. Nursing staff should put a note in indicating that the wound nurse completed the treatment. 2. On 3/23/26 at 11:19 A.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/21/25, indicated a moderate cognitive impairment and a significant weight loss. Current physician orders included, but were not limited to: Weekly weights in the morning every Sunday, dated 2/22/26. An order administration note, dated 3/15/26, indicated Weekly weights . Sheltering in place Resident 6's March Medication Administration Record (MAR) indicated a weekly weight was not completed on 3/15/26 or 3/22/26. 3. 3/23/26 at 9:19 A.M., Resident 24's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. Current physician orders included, but were not limited to: Weight every day shift for baseline weight for 3 days and every day shift every Sunday for weekly, dated 3/2/26. An order administration note, dated 3/15/26, indicated Weekly weights . Sheltering in place Resident 24's March Medication Administration Record (MAR) indicated a weekly weight was not completed on 3/15/26 or 3/22/26. 4. On 3/23/26 at 10:45 A.M., Resident 35's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. Current physician orders included, but were not limited to: Weekly weight every day shift every Sunday, dated 9/21/25. An order administration note, dated 3/15/26, indicated Weekly weights . Sheltering in place Resident 35's March Medication Administration Record (MAR) indicated a weekly weight was not completed on 3/15/26 or 3/22/26. On 3/23/26 at 11:26 A.M., Certified Nurse Aide (CNA) 9 indicated she did not know where the scale was for the A/B Halls where Residents 6, 24, and 35 resided. She indicated it had been moved into the dining room just outside the unit, but was not there when she looked. She indicated she was unsure what the current protocol was for obtaining weights for the residents on the A/B Halls. On 3/25/26 at 9:33 A.M., the Infection Preventionist (IP) indicated typically resident's weekly weights should still be obtained when sheltering in place by donning the resident in a gown and mask to go off of the unit to weigh. She indicated the staff on A/B units required education for obtaining weights when there were residents with COVID on the unit. 5. During an interview on 3/18/26 at 10:40 A.M., Resident 4 was laying in bed with the blinds closed. He had a flat affect, indicated he had a lot of pain, and thought he would be better off dead. On 3/24/26 at 9:55 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified disorder of adult personality, anxiety, depression, chronic pain, panic disorder, gastroparesis, and malnutrition. The most recent quarterly MDS assessment, dated 3/16/26, indicated Resident 4 was cognitively intact, had no behaviors, was dependent on staff for toileting, showering, transfers, and bed mobility, on a pain medication regimen, no non-medication interventions for pain, and received as needed (PRN) pain medication, and not receiving hospice services. A current New Admit Care Plan, last revised on 1/14/26, included, but was not limited to, an intervention for pharmacotherapy including administration and monitoring of side effects of medications, initiated 1/14/26. The emergency room (ER) discharge records, dated 2/17/26, indicated Resident 4 should stop the following medications he had been taking since admission on [DATE] for anxiety, depression, and insomnia upon return: Alprazolam 0.5 milligram (mg) tablet, give one tablet by mouth two times a day for generalized anxiety disorder (given at 6:00 A.M. and 4:00 P.M.) Alprazolam 1 mg tablet, give one tablet by mouth at bedtime for generalized anxiety disorder Lamotrigine 100 mg tablet, give one tablet by mouth at bedtime for depression related to recurrent major depressive disorder Lamotrigine 25 mg tablet, give two tablets by mouth in the morning for depression Sertraline 100 mg tablet, give one and a half tablets by mouth at bedtime for recurrent major depressive disorder Trazodone 50 mg tablet, give one tablet at bedtime for insomnia Progress notes were reviewed after the resident returned 2/17/26 to present and included, but were not limited to, the following behaviors: 2/28/26 7:00 P.M., This evening nurse (while in the hallway) heard resident yelling out for assistance with feeding. Nurse told resident someone would be with him soon. Resident became agitated and yelled back at nurse, it will be cold by then. Nurse attempted interventions to calm resident and provide reassurance his needs would be met. Resident yelled at nurse with false beliefs and stated, you never do anything to help me. Resident agitated and knocked his food from tray table onto the floor proceeding to yell at nurse. Communication interventions unsuccessful. Resident left in a safe manner to calm. On 2/28/26 at 7:04 P.M., Reapproached resident. Resident apologized for his behavior. Behavior ceased. On 3/15/26 at 2:00 P.M., The resident continues on hospice. Resident eats very little. Resident doesn't participate in activities. Resident demeanor very angry and mean to staff. Resident doesn't show signs of nonverbal ques for pain at this time. Resident doesn't like food in facility. Offered several items. Resident refused all. Resident threw breakfast tray into a/c unit in room. staff cleaned and resident called staff derogatory names. This nurse asked resident to stop name-calling and that the staff was attempting to help him. On 3/19/26 at 10:39 A.M., Hospice Note: Resident refusing all medications and treatments. Resident said, I won't take any medications as long as I am here. I want to die. Social worker [NAME] is aware of situation. Nurse will report to hospice. On 3/19/26 at 7:35 P.M., Nurses Note: Nurse received notification that resident called 911. Since nurse arrival, resident has been in an agitated state. Attempted 1:1 intervention with resident. Resident upset and yelling at writer. Pain assessment completed. Resident showing signs and symptoms of pain and has verbal complaints of pain. Upon questioning for presence of pain, resident stated, hell yes I'm in pain, what do you think? Attempted to administer morphine to resident, but resident declined stating he did not want morphine. If I wanted that I would have asked for it! Attempted to administer Percocet crushed in applesauce per MD orders, but resident stated, If that is in applesauce, I don't eat applesauce and I'm not taking that, rinse off the applesauce and I will take it then. Informed resident, that the Percocet tablet had been crushed so that was not possible. Resident demanded to take a whole pain pill without crushing. Administered Percocet 10/325 mg whole without applesauce. Resident tolerated well. No difficulties with swallowing noted. On 3/19/26 at 8:35 P.M., Nurses Note: Checked in on resident at this time. Since administration of narcotic analgesic, resident now resting comfortably with eyes closed. Clear, easy, unlabored respiration pattern noted. Arouses easily. No further distress noted. Resident apologized to writer for his behavior. The clinical record lacked documentation that the discontinued medications were discussed with the Primary Care Physician (PCP) for clarification following the resident's return from the hospital. The most recent Patient Health Questionnaire (PHQ-9) assessment (a standardized, 9 question tool used to diagnose and monitor the severity of depression), dated 3/16/26, indicated the resident scored a 13 (Moderate depression) and sometimes he felt isolated. This was an increase from the previous assessment, dated 1/14/26, where he scored 10 (moderate depression) and never felt isolated. During an interview on 3/25/26 at 2:12 P.M., the Director of Nursing (DON) indicated she was not sure why the medications were discontinued in the ER. We should be reviewing medications every morning when a resident comes back to the hospital. She indicated she would have the PCP review the resident's medications. At that time, she indicated Resident 4 had been very angry about placement in long term care facilities. On 3/25/26 at 4:33 P.M., a current Nurse Job description, dated 5/2/17, was provided by the Administrator and indicated, . complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge . may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times . On 3/25/26 at 8:51 A.M., a current Physician Orders Policy, last revised 1/31/18, was provided by the Administrator and indicated, . Notify the resident's physician (if not the prescribing physician), for verification if applicable. Notify the family/responsible part and the resident of the new orders) . 410 Indiana Administrative Code (IAC) 16.2-3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure that dependent residents were receiving Activities of Daily Living (ADL) services for 3 of 4 residents reviewed for ADLs and 3 of 3 residents in Resident Council. Resident's did not receive showers and oral care. (Resident B, Resident C, Resident D)Findings include:1. On 3/20/26 at 9:37 A.M., Resident D's clinical records were reviewed. His diagnoses included, but were not limited to pneumonia, Type II diabetes mellitus, personal history of traumatic brain injury, tracheostomy status, and gastrostomy status. The most current admission Minimum Data Set (MDS) assessment, dated 1/21/26, indicated Resident D was never or rarely understood and dependent on staff for toileting, bathing, mobility and transfer. Resident D had a tracheostomy, used oxygen, suctioning, a foley catheter, and had a Stage 4 pressure ulcer present on admission. Activities of Daily Living (ADL) care plan, initiated 1/28/26, included, but were not limited to the following interventions: Oral Hygiene: (A.M., PC (after meals), HS (at bedtime): brush teeth, rinse dentures, clean gums with toothette, rinse mouth with wash. My usual performance is dependent, date revised 1/28/26 On 3/26/26 at 10:31 A.M. the Certified Nurse Aide (CNA) Task Form for oral care indicated Resident 12 lacked oral care at the following times: 2/27/26 days 3/1/26 nights 3/3/26 nights 3/4/26 nights 3/5/26 nights 3/6/26 nights 3/8/26 nights 3/11/26 days 3/13/26 days, nights 3/14/26 nights 3/15/26 nights 3/20/26 nights 3/22/26 nights 3/23/26 days, nights 2. During an interview on 3/18/26 at 9:59 A.M., Resident C was observed with greasy hair, white flakes of skin around his scalp, a strong odor of urine, and unshaved. At that time, the resident indicated he was not sure when his last shower was, he preferred to shower, depended on staff for showering and needed staff to help him with mouth care. On 3/19/26 at 12:15 P.M., Resident C was observed in bed. His hair was greasy and he indicated he did not have a shower yesterday and did not get one today. He was not shaved. On 3/20/26 at 1:15 P.M., Resident C was observed in his bed. His hair was greasy, he was unshaved, and had a strong odor of urine. On 3/20/26 at 9:16 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, high blood pressure, stroke, and intellectual disability. The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/6/26, indicated the resident's cognition was moderately impaired, he did not reject care, dependent on staff for toileting, transfers, personal hygiene and showering, and supervision for oral care. A current Activities of Daily Living (ADL) Care Plan, last revised 4/25/25, included interventions indicating the resident was dependent on staff to take a shower/bath/bath at sink/bed bath, Oral Hygiene: (AM, PC [after meals], HS [bedtime]), brush teeth, rinse dentures, clean gums with toothette, rinse mouth with wash. My usual performance is supervision, Personal hygiene (The ability to maintain personal hygiene, including combing hair, shaving, washing/drying face and hands): My usual performance is dependent, all initiated 4/24/25 The Certified Nurse Aide (CNA) task list for the last 90 days was reviewed and indicated the resident should receive a shower on Wednesday and Saturday day shifts but was not given a shower on the following dates: 1/3/26, 1/14/26, 1/31/26, 2/11/26, 2/25/26, 3/4/26, 3/11/26, 3/14/26 The Certified Nurse Aide (CNA) task list for the last 90 days was reviewed and indicated the resident did not receive oral care on the following dates and shifts: 12/26/25 day 12/29/25 day and night 12/30/25 day and night 12/31/25 day 1/4/26 day 1/5/26 day 1/8/26 day 1/9/26 day 1/13/26 day 1/14/26 night 1/19/26 day 1/22/26 day 1/23/26 day 1/26/26 night 1/29/26 night 1/30/26 night 1/31/26 night 2/1/26 day and night 2/2/26 day and night 2/3/26 night 2/4/26 night 2/5/26 night 2/6/26 night 2/7/26 night 2/8/26 night 2/9/26 night 2/10/26 day 2/11/26 day and night 2/13/26 night 2/14/26 day and night 2/15/26 night 2/18/26 night 2/19/26 night 2/22/26 night 2/23/26 night 2/24/26 night 2/25/26 night 2/26/26 night 2/27/26 night 3/1/26 day and night 3/3/26 day 3/4/26 day3/5/26 day and night 3/6/26 day and night 3/7/26 night 3/8/26 night 3/9/26 day and night 3/10/26 night 3/11/26 day and night 3/12/26 night 3/13/26 night 3/14/26 day and night 3/15/26 day and night 3/16/26 day and night 3/18/26 night 3/19/26 day and night 3/20/26 day and night 3/21/26 night 3/22/26 night 3/23/26 day 3. On 3/19/26 at 10:12 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, high blood pressure, chronic obstructive pulmonary disease, congestive heart failure, and a flaccid, neuropathic bladder. The most recent quarterly MDS assessment, dated 12/18/25, indicated Resident B was cognitively intact, had no behaviors or refusals, needed set up assistance from staff for oral care (included cleaning dentures) and personal hygiene, partial to moderate assistance from staff (resident performs over half the effort) for bed mobility, toileting hygiene, and showering, substantial to maximum assistance from staff (staff performs over half the effort) for transfers, and had an indwelling catheter. An Activities of Daily Living (ADL) Care Plan, last revised 2/18/26, included, but was not limited to, interventions for oral hygiene: (AM, PC, HS): brush teeth, rinse dentures, clean gums with toothette, rinse mouth with wash. My usual performance is setup, Shower/Bathe self: I take a shower/bath/bath at sink/bed bath my usual performance is partial, and Personal hygiene: My usual performance is setup, all initiated 9/12/25 The CNA task list for 12/1/25-2/12/26 was reviewed and indicated the resident was not given a shower on the following dates: 12/25/25 12/29/25 1/1/26 1/2/26 (ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time) 1/4/26 (ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time) 1/5/26 (ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time) 1/8/26 (ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time) 1/12/26 1/15/26 1/19/26 (ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time) The CNA task list for 12/1/25-2/12/26 was reviewed and indicated the resident did not receive oral care on the following dates and shifts: 12/2/25 day 12/3/25 day and night 12/4/25 day and night 12/5/25 day 12/5/25 day 12/7/25 day and night 12/8/25 night 12/9/25 day 12/11/25 night 12/12/25 day 12/13/25 day 12/14/25 night 12/15/25 day and night 12/16/25 night 12/17/25 day 12/18/25 day 12/19/25 day 12/20/25 day and night 12/21/25 day and night 12/23/25 day 12/24/25 night 12/25/25 day 12/26/25 day 12/27/25 day 12/28/25 day and night 12/29/25 day and night 12/30/25 day 12/31/25 day 1/1/26 day and night 1/3/26 day 1/5/26 day 1/7/26 day and night 1/8/26 night 1/10/26 day 1/11/26 day 1/12/26 day and night 1/13/26 night 1/15/26 day and night 1/16/26 day 1/17/26 night 1/18/26 night 1/21/26 day and night 1/23/26 night 1/24/26 night 1/25/26 day and night 1/26/26 day 1/27/26 day and night 1/28/26 night 1/29/26 night 1/30/26 day 1/31/26 day 2/1/26 day 2/2/26 day 2/3/26 night 2/4/26 day and night 2/6/26 night 2/7/26 night 2/8/26 night 2/9/26 night 2/11/26 night On 3/19/26 at 10:22 A.M., during the resident council meeting, 3 of 3 residents present indicated they did not get showers when they were supposed to. Sometimes they were told it was because they don't have enough help. During an anonymous interview, it was mentioned oral care and showers were not being performed. During an interview on 3/24/26 at 1:52 P.M., Licensed Practical Nurse (LPN) 7 indicated there was a task for showers on the CNA tasks list and they documented them there. They could also fill out shower forms for the nurses to look at. If a resident refuses, then they should try again, tell the nurse, and the nurse should put in a progress note if the resident refused a shower on shower day. She would try to get resident to shower all of her shift because it was very important for showers to get done. Resident C did not refuse care. CNAs should do oral care in the morning and evening. If it was not documented in the CNA task list, then it was not done. During an interview on 3/25/26 at 10:00 A.M., the Administrator indicated the shower forms were not part of the clinical record. Documentation of showers was inconsistent, some CNAs used shower forms and some document in POC. During an interview on 3/25/26 at 2:12 P.M., the DON indicated when residents get up the CNAs should be offering to set up and do oral care and CNAs on evening shift should be doing it too. Residents should be getting two showers a week at the very least. Refusals should be documented. During an interview on 3/25/26 at 8:57 P.M., the Director of Nursing (DON) indicated showers were scheduled for Resident B on Monday and Thursday nights but residents should have showers at any time they would like. On 3/25/26 at 5:33 P.M., a current CNA job description, dated 5/2/17, was provided by the Administrator and indicated, The CNA is responsible for providing resident care and support in all activities of daily living . provide assistance in personal hygiene by giving bedpans, urinals baths, backrubs, shampoos, and shaves, assisting with travel to the bathroom; helping with showers and baths . On 3/25/26 at 8:55 P.M., a current non dated ADL Policy was provided by the Administrator and indicated, Bathing: washing and drying the body . Grooming: maintaining person hygiene, combing and/or styling hair, brushing teeth, shaving, oral hygiene, safety awareness with nail care, and/or application of deodorant or powder . This citation relates to Intakes 2744744 and 296475. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(b)(1)(2)

Based on observation, interview, and record review, the facility failed to ensure safe medication storage for 1 of 3 hall carts observed. Medication carts were left unlocked and unsupervised, and medications were left unsupervised on the top of a medication cart. (D Hall Medication Cart)Findings include:On 3/19/26 from 12:15 P.M until 12:40 P.M., the D Hall medication cart was observed in the dining room against the wall by the nurses station. At that time, there were residents in the dining room eating lunch. During the continuous observation, five residents walked by the medication cart, as well as two staff members. At 12:40 P.M., Licensed Practical Nurse (LPN) 15 indicated she was going to give insulin to residents, but was asked to assist feeding a resident and forgot about locking the medication cart. At that time, she indicated the medication cart should always be locked. On 3/23/26 at 7:20 A.M., LPN 13 was observed at the D Hall medication cart to prepare medications for Resident 67 that included the following:Protonix 40mg (milligrams)bupropion 150mgacetaminophen 325mg x2clozapine 100mgfamotidine 40mgpropanolol 40mgsucralfate 1gm (gram)The medications were placed from a multi-use medication card into a medication cup, and the medication cards (with medications still in them) were then placed on top of the medication cart. LPN 13 then walked away from the medication cart leaving the medication cards on the medication cart and the medication cart unlocked. At that time, a resident was observed sitting directly in front of the medication cart. LPN 13 walked down the hall and into Resident 67's room to administer the medications. LPN 13 returned to the medication cart at 7:24 A.M. and indicated normally she would not have left the medication cards out. On 3/25/26 at 5:30 P.M., the Administrator provided a current Medication Storage policy, last revised 7/2/19, that indicated Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 410 IAC (Indiana Administrative Code) 16.2-3.1-25(m)

Based on interview and record review, the facility failed to ensure physician orders were followed leading to a discontinuance of an anticonvulsant medication for 1 of 1 residents reviewed for medication side effects. A resident's anticonvulsant medication was discontinued despite a physician's contraindication to discontinue. The physician nor family were notified of the medication discontinuance. (Resident 63)Finding includes:On 3/20/26 at 11:00 A.M., Resident 63's clinical record was reviewed. Diagnosis included, but was not limited to, epilepsy. The most recent annual Minimum Data Set (MDS) assessment, dated 2/20/26, indicated a severe cognitive impairment and use of an antianxiety medication. Routine physician orders for Ativan (an antianxiety/anticonvulsant medication) included the following:Lorazepam 1mg (milligram), 1 tablet every 6 hours related to anxiety disorder, dated 4/10/25 through 2/9/26. Lorazepam 1mg, 1 tablet four times a day for seizures, dated 2/18/26 and current.All other physician orders related to seizure activity included the following as needed (prn) physician orders:Valtoco (an anticonvulsant medication) 5mg nasal liquid 5mg/0.1ml (milliliters), 0.1ml in nostril every 4 hours as needed for seizures, dated 8/21/23 and current.Lorazepam injection solution 4mg/ml, inject 1ml as needed for initial seizure activity, if continued seizure at 10 minutes, give 0.5ml in 10 minute intervals not to exceed 8mg, dated 2/18/26 and current.Lorazepam oral tablet 1mg, give 1 tablet every 2 hours as needed for anxiety, dated 9/14/24 through 2/10/26. Lorazepam oral tablet 1mg, give 1 tablet every 2 hours as needed for anxiety, dated 2/10/26 through 2/18/26. A current seizure care plan, last revised 3/20/25, indicated to administer and monitor for side effects of meds as ordered.During the period from 2/9/26 through 2/18/26 when Resident 63's routine lorazepam was discontinued, Resident 63 experienced a seizure on 2/14/26 and 2/18/26, both required prn lorazepam to be administered. Prior to that, the resident had experienced four seizures in the previous four months.On 3/24/26 at 1:00 P.M., the Administrator provided a pharmacy recommendation for Resident 63. The date of the review was 11/18/25 with a recommendation to reduce the dose of the routine lorazepam. The form included a physician signature, dated 2/9/26, and indicated the dose reduction was contraindicated due to benefits outweighed the risk. The form indicated no need for weening and discontinuation of the medication would likely be harmful to the resident. The form was initialed by the Director of Nursing (DON) on 2/9/26.The order to discontinue Resident 63's lorazepam was put in by the Director of Nursing on 2/9/26 at 5:46 P.M. and indicated pharmacy recommendation as the reason. The physician that discontinued the medication was the psych Nurse Practitioner. Resident 63's clinical record lacked documentation of physician communication regarding the discontinuance of lorazepam on 2/9/26. The clinical record also lacked resident representative notification about the discontinuance of the medication.A nurses note, dated 2/18/26 at 10:43 A.M., indicated review of medication with physician and lorazepam renewed. The renewed routine order for lorazepam was put in at 6:00 P.M. the same day.On 3/18/26 at 11:33 A.M., Resident 63's family member indicated she had not been notified prior to or when the resident's lorazepam had been discontinued on 2/9/26. She indicated if she had been notified, she would not have allowed it as the medication kept her calm and decreased seizure activity. On 3/25/26 at 2:00 P.M., the DON indicated there was an issue with getting pharmacy recommendations signed by the providers. She indicated all pharmacy recommendations were faxed to the providers except for the psych NP as she was in the facility on Thursdays. She indicated Resident 63's pharmacy recommendation from 11/18/25 was not answered until 2/9/26. Hospice would not answer and the facility providers would not do anything. She indicated on 2/9/26, the hospice nurse questioned the nurse about Resident 63's lorazepam orders and told the nurse to discontinue the routine order. The nurse discontinued it, then had questioned if it had been done by mistake and brought to the attention of the DON. She indicated she discussed with the NP and physician as well as the Resident's sister and had the medication renewed. She indicated the hospice nurse had given a verbal order to discontinue the medication, but did not speak with the DON about it. The DON learned about the medication being discontinued later in the day on 2/9/26 when the floor nurse brought it her her attention. The DON was unable to answer why the medication was not renewed for nine days after it had been discontinued. She further indicated when a psychotropic was discontinued, there should have been communication with the NP, provider, and the resident's family.On 3/25/26 at 5:30 P.M., the Administer provided a current Psychotropic Medication- Gradual Dosage Reduction policy, last revised 2/1/18, that indicated Residents who use psychotropic drugs shall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue or reduce the medication . Some medications (e.g., antidepressants, sedative/hypnotics, opioids) require more gradual tapering so as to minimize or prevent withdrawal symptoms or other adverse consequencesOn 3/25/26 at 5:30 P.M., the Administrator provided a current Physician-Family Notification- Change in Condition policy, last revised 11/13/18, that indicated The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is . A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment)410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview, observation, and record review, the facility failed to ensure a plan was in place to control a resident's pain for 1 of 1 resident reviewed for pain management. A resident indicated his pain was not controlled, staff were not giving routine pain medication as ordered, documentation lacked pain characteristics, non pharmacological interventions were not in place, and notification to the Medical Doctor was not consistently documented. Finding includes:During an interview on 3/18/26 at 10:40 A.M., Resident 4 indicated he was having pain that was not controlled and receiving hospice services.On 3/24/26 at 9:55 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified disorder of adult personality, anxiety, depression, chronic pain, panic disorder, gastroparesis, and malnutrition.The most recent quarterly MDS assessment, dated 3/16/26, indicated Resident 4 was cognitively intact, had no behaviors, was dependent on staff for toileting, showering, transfers, and bed mobility, on a pain medication regimen, no pain within the 5 previous days, no non-medication interventions for pain, and received as needed (PRN) pain medication.Physician's Orders included, but were not limited to, the following:Oxycodone/Acetaminophen (Percocet) Oral Tablet 10-325 milligram (MG), Give 1 tablet by mouth every 6 hours as needed for pain, ordered 2/17/26Tylenol 650 MG tablet, Give 1 tablet by mouth every 4 hours as needed for General Discomfort not to exceed 3 grams in 24 hours from all sources, ordered 2/17/26Morphine Sulfate (Concentrate) Oral Solution 20 MG/milliliter (ML), Give 0.5 ml by mouth every 1 hour as needed for Pain/shortness of breath, ordered 2/26/26Fentanyl Pain Patch 72 Hour 50 micrograms (MCG)/ hour (HR), Apply 1 patch transdermally every 72 hours for pain and remove per schedule, ordered 3/1/26 A current Chronic Pain Care Plan, last revised 1/14/26, included, but was not limited to, the following interventions:Administer analgesic medications as ordered by physician, initiated 1/14/26Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, initiated 1/14/26Evaluate the effectiveness of pain interventions. Review for compliance, alleviation of symptoms, dosing schedules, and resident satisfaction with results, impact on functional ability, and impact on cognition, initiated 1/14/26Monitor/record pain characteristics: quality, severity, anatomical location, onset, duration, aggravating factors, and relieving factors, initiated 1/14/26Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. The March 2026 MAR/TAR was reviewed and indicated the resident did not receive the Fentanyl Patch on the following dates:3/4/26-comment to see progress notes 3/7/26-comment to see progress notes3/10/26-comment hold/see nurse notes3/13/26-comment to see progress notes3/16/26-comment to see progress notes 3/19/26-comment hold/see nurse notes3/22/26-comment to see progress notes3/25/26-comment to see progress notesThe resident was not receiving any medication routinely for his pain. His documented pain levels ranged from 5-10. There was no documentation of pain characteristics or non pharmacological interventions tried. Progress notes were from 2/28/26 to 3/24/26 were reviewed and indicated:On 2/28/26 at 8:37 P.M., Hospice Note: Hospice nurse in to see resident this evening. New Medical Doctor (MD) orders received. Begin Fentanyl 50mcg transdermal patch every 72 hours. Resident aware.On 2/28/26 at 10:43 P.M., Nurses Note: Noted on chart, resident has allergy to Fentanyl. Hospice contacted for a return call.On 2/28/26 at 11:23 P.M., Nurses Note: Received call from Hospice Nurse concerning Fentanyl allergy concern. Per Hospice Nurse, and his hospital chart, it is not a true allergy. It did not involve anaphylaxis, only itching. Fentanyl to continue.On 3/4/26 at 8:38 A.M., Administration Note: Fentanyl Patch 72 Hour 50 MCG/HR Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Resident has an allergy to fentanyl.On 3/7/26 at 7:43 A.M., Administration Note: Fentanyl Patch 72 Hour 50 MCG/HR, Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Pending pharmacy.On 3/10/26 at 7:44 A.M., Administration Note: Fentanyl Patch 72 Hour 50 MCG/HR, Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Patch unavailable at this time. Medication on order, provider aware.On 3/10/26 at 11:02 A.M., Nurses Note: Attempted to obtain Fentanyl patch from the Med bank. Unable to obtain patch from bank due to needing a new script. Hospice nurse notified.On 3/13/26 at 8:56 A.M., Administration Note: Fentanyl Patch 72 Hour 50 MCG/HR, Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Pending script.On 3/16/26 at 7:17 A.M., Administration Note: Fentanyl Patch 72 Hour 50 MCG/HR, Apply 1 patch transdermally every 72 hours for pain and remove per schedule. No comment was added as to why the resident did not receive the medication as ordered.On 3/19/26 at 9:11 A.M., Administration Note: Fentanyl Patch 72 Hour 50 MCG/HR, Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Out of patches. Nurse will call.On 3/19/26 at 10:39 A.M., Hospice Note: Resident refusing all medications and treatments. Resident said, I won't take any medications as long as I am here. I want to die. Social worker is aware of situation. Nurse will report to hospice.On 3/19/26 at 7:35 P.M., Nurses Note: Nurse received notification that resident called 911. Since nurse arrival, resident has been in an agitated state. Attempted 1:1 intervention with resident. Resident upset and yelling at writer. Pain assessment completed. Resident showing signs and symptoms of pain and has verbal complaints of pain. Upon questioning for presence of pain, resident stated, hell yes I'm in pain, what do you think? Attempted to administer morphine to resident, but resident declined stating he did not want morphine. If I wanted that I would have asked for it! Attempted to administer Percocet crushed in applesauce per MD orders, but resident stated, If that is in applesauce, I don't eat applesauce and I'm not taking that, rinse off the applesauce and I will take it then. Informed resident, that the Percocet tablet had been crushed so that was not possible. Resident demanded to take a whole pain pill without crushing. Administered Percocet 10/325 mg whole without applesauce. Resident tolerated well. No difficulties with swallowing noted.On 3/19/26 at 8:35 P.M., Nurses Note: Checked in on resident at this time. Since administration of narcotic analgesic, resident now resting comfortably with eyes closed. Clear, easy, unlabored respiration pattern noted. Arouses easily. No further distress noted. Resident apologized to writer for his behavior.On 3/22/26 at 7:25 A.M., Administration Note: Fentanyl Patch 72 Hour 50 MCG/HR, Apply 1 patch transdermally every 72 hours for pain and remove per schedule. There was no comment about the reason the resident did not receive the Fentanyl patch.The documentation of pain characteristics, MD notification, or non pharmacological interventions tried were not consistently documented. During an 3/24/26 at 10:44 A.M., Licensed Practical Nurse (LPN) 7 indicated the resident was not on Fentanyl patches but she was not sure why. She indicated he was on PRN medications but nothing routine for pain. They only give him pain medication if he asks for it since it is PRN. He complains usually about pain in his hips and low back area from the way they have him lay. He will sometimes refuse to lay a different way and/or wiggle himself around to get more comfortable but they try to keep him off the wound on his sacrum. He rated the pain as 4 out of 10 when she gave him oxycodone at 10:00 A.M that morning.During an interview on 3/24/26 at 1:24 P.M., a hospice aide taking care of Resident 4 was at the nurse's desk. She indicated he complained of pain all over, all the time. LPN 7 indicated that he didn't like taking the morphine usually but was not sure why. The hospice aideDuring an interview on 3/25/26 at 2:12 P.M., the Director of Nursing (DON) indicated they do have communication issues with hospice companies and the facility. There was really no process for communication here. She was unaware that the resident was not taking the Fentanyl Patch as ordered and/or why. She was not sure if the hospice MD or the Primary Care Physician had been notified about it or the resident's continued complaints of daily pain status. She was unable to provide documentation of pain talks with the resident, but indicated the resident has multiple complaints about the facility and the care he was receiving. On 3/25/26 at 8:50 P.M., a current Pain Assessment Policy, last revised 7/6/18, was provided by the Administrator and indicated, Purpose: To establish guidelines for appropriate assessment and intervention to manage pain. To respect and support the resident's right to optimal pain management. To measure and document the effectiveness of the plan using objective an subjective assessment criteria. Responsibility: licensed nurse . prior to administration of PRN pain medications, non-pharmacological interventions will be attempted if patient is responsive and willing . input and suggestions will be considered by the interdisciplinary team and, as appropriate, addressed on the plan of care. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure accurate documentation in resident clinical records for 2 of 2 records reviewed. A resident that was in the hospital had a progress note with vital signs documented in the clinical record. A resident had a shower documented when it was not given. (Resident D, Resident C)Findings include:1. On 3/20/26 at 9:37 A.M., Resident D's clinical records were reviewed. His diagnoses included, but were not limited to pneumonia, Type II diabetes mellitus, personal history of traumatic brain injury, tracheostomy status, and gastrostomy status. The most current admission Minimum Data Set, dated [DATE], indicated Resident D was never or rarely understood and dependent on staff for toileting, bathing, mobility and transfer. Resident D had a tracheostomy, used oxygen, suctioning, a foley catheter, and had a Stage 4 pressure ulcer present on admission. Nurses Notes: 3/24/2026 1:55 P.M.Note Text: This nurse phoned ER (Emergency Room) for update. Resident being admitted d/t (due to) high sodium level and pneumonia with g-tube (gastrostomy feeding tube) replacement pending. Son notified. 3/25/2026 3:53 A.M. Orders - Administration NoteNote Text: In hospital 3/26/2026 12:44A.M. Skilled EvaluationVitals: T (temperature) 97.6 - 3/26/2026 12:45 A.M. Route: Forehead (non-contact)BP (blood pressure) 121/71 - 3/26/2026 12:45A.M. Position: Lying l (left)/armP (pulse) 71 - 3/26/2026 12:45 A.M. Pulse Type: RegularCharacter: Normal.R (respirations) 16 - 3/26/2026 12:45 A.M.O2(oxygen) 97 % -3/26/2026 12:45 A.M. Method: Trach. Urine clear yellow in color. No urinary complaints.Urinary catheter intact. Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. 3/26/26 12:41A.M. INFECTION/ ANTIBIOTIC CHARTINGINFECTION TYPE: Type of infection: Other (specify below) Bronchitis Lungs.INTERVENTIONS: [NAME] is receiving oral antibiotic. Dressing to IV site intact, no signs/symptoms of infection .Resident suctioned .EVALUATION/NOTIFICATIONS: Condition is stable, no distress noted . 3/26/2026 at 10:43 A.M. Resident remains in hospital with pneumonia per staff. Resident D's clinical record contained nurse's notes with vital signs dated 3/26/26. 2. On 3/20/26 at 9:16 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, high blood pressure, stroke, and intellectual disability. The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/6/26, indicated the resident's cognition was moderately impaired, he did not reject care, dependent on staff for toileting, transfers, and showering. A current Activities of Daily Living (ADL) Care Plan, last revised 4/25/25, included an intervention indicating the resident was dependent on staff to take a shower/bath/bath at sink/bed bath. The Certified Nurse Aide (CNA) task list for the last 30 days was reviewed and indicated the resident was showered on 3/18/26 at 9:29 A.M. During an interview on 3/18/26 at 9:59 A.M., Resident C was observed with greasy hair, white flakes of skin around his scalp, a strong odor of urine, and unshaved. At that time, the resident indicated he was not sure when his last shower was, he preferred to shower, and depended on staff for showering. During an interview on 3/24/26 at 1:52 P.M., Licensed Practical Nurse (LPN) 7 indicated there was a CNA task related to showers for each resident. The CNA was to document when they gave a shower. They could also fill out a shower form for the nurse to look at if a resident refused or had any skin concerns. Those forms were put in the Director of Nursing (DON) box. She indicated tasks should only be documented as completed when they were done. During an interview on 3/25/26 at 10:00 A.M., the Administrator indicated the shower forms in the DON's office were not part of the resident's clinical record. Some CNAs used the shower forms and some document in CNA task list so the documentation process was not consistent. On 3/25/26 at 5:33 P.M., a current CNA job description, dated 5/2/17, was provided by the Administrator and indicated, . Document actions by completing forms, reports, logs, and records . Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements . 410 Indiana Administrative Code (IAC) 16.2-3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure hospice communication and documentation was occurring between the facility and the hospice company for 1 of 1 residents reviewed for hospice. The clinical record lacked hospice communication. (Resident 4)Finding includes:During an interview on 3/18/26 at 10:40 A.M., Resident 4 indicated he was receiving hospice services.On 3/24/26 at 9:55 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified disorder of adult personality, anxiety, depression, chronic pain, panic disorder, gastroparesis, and malnutrition.The most recent quarterly MDS assessment, dated 3/16/26, indicated Resident 4 was cognitively intact, had no behaviors, was dependent on staff for toileting, showering, transfers, and bed mobility, on a pain medication regimen, no non-medication interventions for pain, and received as needed (PRN) pain medication, and not receiving hospice services.Physician's Orders included, but were not limited to, the following:admitted to (Hospice Company name) for severe protein calorie malnutrition, ordered 2/26/26A current Hospice Care Plan, last revised 2/27/26, included an intervention to maintain good communication with Hospice, initiated 2/27/26During an interview on 3/24/26 at 1:43 P.M., Licensed Practical Nurse (LPN) 13 indicated staff can call hospice at any time. The resident's nurse and hospice staff speak verbally when they are here. The facility kept a binder at the nurse's station, but they were not used or updated. Nurses were to document generic hospice notes in progress notes every shift, but the notes from the hospice staff were not kept anywhere that she was aware of.During an interview on 3/25/26 at 2:12 P.M., the Director of Nursing (DON) indicated it would be nice if they had some sort of communication with hospice companies in the form of a note. The facility had never done communication that way. They have problems with hospice not giving them orders, issues getting things signed, sometimes the facility would send something to the hospice office and they wouldn't get it, and hospice would come in and do something and not let nursing staff know. Sometimes the Social Services Director (SSD) would call the hospice representative if needed.On 3/24/26 at 7:08 P.M., a current (Name of Hospice Company) contract was provided by the Administrator and indicated, . Hospice and Facility shall communicate with one another regularly and as needed, via phone, fax, email, and/or in person, for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day . On 3/25/26 at 8:53 P.M., a current Hospice Services Policy, last revised 11/17/17, was provided by the Administrator and indicated, . 3. Hospice service provider will provide services in accordance with a signed agreement with the facility that meets all requirements for state and federal hospice care and in accordance with the governing body policy regarding agreements . 5. Hospice service will conduct assessments and develop a hospice plan of care which will be integrated with the resident's overall plan of care and maintained in the medical record or other location with the interdisciplinary care plan. 6. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available for all interdisciplinary staff to access .

Based on interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter received care to prevent a urinary tract infection for 1 of 1 resident's reviewed for urinary catheters. A resident did not receive routine catheter care and was hospitalized for a Catheter Associated Urinary Tract Infection (CAUTI). (Resident B) Finding includes:On 3/19/26 at 10:12 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, high blood pressure, chronic obstructive pulmonary disease, congestive heart failure, and a flaccid, neuropathic bladder.The most recent quarterly MDS assessment, dated 12/18/25, indicated Resident B was cognitively intact, had no behaviors or refusals, needed set up assistance from staff for oral care (included cleaning dentures) and personal hygiene, partial to moderate assistance from staff (resident performs over half the effort) for bed mobility, toileting hygiene, and showering, substantial to maximum assistance from staff (staff performs over half the effort) for transfers, and had an indwelling catheter. Physician's orders included, but were not limited to,Foley catheter care every shift as needed, every shift, ordered 10/28/25 An Indwelling (urinary) Catheter Care Plan, last revised 2/18/26, included, but were not limited to, Monitor for signs and symptoms of discomfort on urination and frequency and monitor/document for pain/discomfort due to catheter, last revised 9/29/25. The Certified Nurse Aide (CNA) task list from 12/1/25-2/12/26 was reviewed and indicated catheter care was not performed on the following dates and shifts:12/2/25 night12/3/25 day and night12/4/25 day and night12/5/25 night12/6/25 night12/7/25 day and night12/8/25 day and night12/11/25 day and night12/12/25 night12/13/25 night12/14/25 night12/15/25 day and night12/16/25 night12/17/25 night12/18/25 day and night12/19/25 night12/20/25 day and night12/21/25 day and night12/23/25 night12/24/25 night12/25/25 night12/26/25 night12/27/25 night12/28/25 day and night12/29/25 day and night12/30/25 night12/31/25 night1/1/26 day and night1/2/26 night1/6/26 night1/7/26 day1/8/26 day1/9/26 night1/10/26 night1/11/26 night1/12/26 day1/13/26 day1/14/25 night1/15/25 day and night1/17/26 day1/18/26 day1/20/26 night1/21/26 day1/23/26 night1/24/26 night1/25/26 day and night1/26/26 day1/27/26 day and night1/28/26 night1/29/26 night1/31/26 day2/1/26 day2/3/26 night2/4/26 day2/5/26 day2/6/26 night2/7/26 night2/8/26 night2/10/26 day A Nurse's note, dated 2/12/26 at 2:05 P.M., indicated Resident B left the facility via (Name of Emergency Medical Services) for evaluation. On 3/20/26 at 11:19 A.M., hospital records were reviewed and indicated Resident B was admitted to the hospital 2/12/26 with sepsis and a catheter associated UTI. During an anonymous interview, it was mentioned that catheter care was not being performed. During an interview on 3/24/26 at 1:45 P.M., Licensed Practical Nurse (LPN) 7 indicated there was a task on the CNA tasks list for catheter care (included emptying the urine from the bag and wiping down the tubing) and the CNAs should do the catheter care and document when they did it there. There were two shifts, day and night shift. Catheter care should be done each shift and as needed. If it was not documented, then it was not done. If the resident refused, the aide should tell the nurse and the nurse should attempt. If still refused then there should be a progress note put in. The nurse documented in the Treatment Administration Record (TAR) about catheter care (meaning no kinks in tubing and patency), but they rarely do the routine catheter care. During an interview on 3/25/26 at 2:12 P.M., the Director of Nursing (DON) indicated she expected catheter care to be done per order, every shift, (night and day). Documentation was put into the electronic health record (EHR). CNAs document under tasks and the nurse in Medication Administration Record (MAR)/TAR. On 3/25/26 at 5:35 P.M., a current Urinary Catheter Care/UTI prevention Policy, last revised 2/14/19, was provided by the Administrator and indicated, Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter . catheter drainage bags will be emptied one time on each shift or as needed . Routine hygiene [e.g. cleansing of the meatal surface during daily bathing or showering] is appropriate. Encrustations on the foley catheter should be removed from the meatus outward with clean wash cloth, rinsed with clean water on an as needed bases . Proper catheter use and care reduces the risk of UTIs and minimizes their nosocomial transmission . This citation relates to Intake 2744744.410 IAC (Indiana Administrative Code) 16.2 -3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the past 3 years of state survey results were readily available to visitors, residents, and other individuals without them having to ask to review them for 2 of 2 days reviewed for the survey period.Finding includes:On 3/18/26 at 10:00 A.M., the survey binder was unable to be located. On 3/19/26 at 10:31 A.M., during the resident council meeting, residents indicated they did not know where the state survey binder was located.During an interview on 3/19/26 at 10:34 A.M., the Receptionist indicated she did not know where the survey binder was located.During an observation on 3/19/26 at 11:00 A.M., the survey binder was viewed and lacked survey results for the last 3 years.During an interview on 3/24/26 at 10:48 A.M., the Administrator indicated she updated the survey binder and only placed annual surveys in the binder. Complaint surveys were not to be placed in the binder. At that time, she indicated the past 3 years of survey results should have been in the binder.During an interview on 3/26/26 at 9:20 A.M., the Administrator indicated it is their policy to follow state regulations for the survey binder.410 IAC (Indiana Administrative Code) 16.2-3.1-3(b)(1)

Based on observation, interview and record review, the facility failed to ensure the posted nurse staffing form was posted on all entrances of the facility for 8 of 8 days reviewed for the survey. (3/17/26, 3/18/26, 3/19/26, 3/20/26, 3/23/26, 3/24/26, 3/25/26, 3/26/26).Findings include:During an observation on 3/17/2026 at 9:25 A.M., the posted nurse staffing form was observed on the wall when you enter the first set of doors to go into the building with the main office. The entrances to get into hall A, B, C, D, G, H, and I lacked a posted nurse staffing form.The same was observed on 3/18/26 through 3/26/26.During an interview on 3/20/26 at 1:43 P.M., the MDS coordinator indicated visitors enter through all of the entrances. During an interview on 3/26/26 at 9:39 A.M., the Scheduler indicated the posted nurse staffing was only posted by the main office and the time clock.On 3/25/26 at 8:56 P.M., the Administrator provided the state regulation as a policy and indicated it was their policy to follow the regulation.

Based on interview and record review, the facility failed to ensure residents received end of life care for 2 of 3 residents reviewed for hospice care. A collaborative plan of care was not established for residents who received hospice services and routine assessments, and physician orders were not completed. (Resident B, Resident C)1. During record review on 10/20/25 at 1:15 P.M., Resident B's diagnoses included but were not limited to chronic kidney disease and malignant cancer. Resident B's most recent Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident had not received hospice services. Resident B's physician orders included Lorazepam 0.5 milligrams (mg) one tablet every three hours as needed for anxiety (started 10/6/25 at 8:00 P.M.) and morphine sulfate solution 20 milligrams/milliliter (mg/ml) give 0.5 ml every hour as needed for pain or shortness of breath (started 10/6/25 at 7:49 P.M.), and oxygen at 2 liters per nasal cannula continuously to keep saturation level above 90% every shift for shortness of breath (started 10/7/25). All routine medications had been discontinued.Resident B's nurse's progress notes included, but were not limited to:9/29/25 at 8:50 P.M. - Resident was sent to the hospital.10/6/25 at 2:10 P.M. - Resident admitted back to the facility from the hospital. Resident to be admitted to hospice. Spouse with the resident at bedside. Hospice was notified of the arrival. 10/7/25 at 6:00 A.M. - Resident nonresponsive. No pulse, no respirations. Death verified with a Registered Nurse (RN). Hospice notified.Resident B's Hospice Visit Note Report dated 10/6/25 indicated Hospice services arrived at the facility at 5:44 P.M. and completed assessments at 6:46 P.M. Resident B's pain was rated at a 2 on a scale of 0-10 (0 being no pain and 10 being the worst pain), and the resident's oxygen level was 97 % on 2 liters of oxygen. A visit narrative indicated the resident had a terminal diagnosis of prostate cancer and wished to pass comfortably. Resident B was minimally responsive. The resident depends on the caregiver for all activities of daily living (ADLs). Hospice interventions included: 1. Instruct patient/caregiver(s) how to monitor pain using an appropriate pain scale 2. Instruct administration and side effects of pain medications. 11. Assess signs/ symptoms of death and dying. The Visit Note Report indicated the in-facility visit concluded on 10/6/25 at 6:52 A.M.Resident B's documented vital signs indicated the resident's last documented oxygen saturation levels were assessed at the facility on 10/6/25 at 5:08 P.M. at 95% and 10/6/25 at 6:57 at 87% on room air. Resident B's record contained no further documented assessments of pain, discomfort, restlessness, or oxygen saturation. A Braden Scale observation was completed 10/6/25 at 8:32 P.M., and a Fall Risk Assessment was completed at 8:34 P.M. Resident B's Medication Administration Record indicated that no as-needed medications were administered between the time of readmission on [DATE] and the time of death of 10/7/25. During an interview on 10/21/25 at 11:05 A.M, RN 4 indicated a resident on hospice with orders for as-needed medications every one to two hours should be assessed for comfort every 30 minutes to one hour, and that routine observations and assessments should be documented in the resident's record. 2. During record review on 10/21/25 at 10:30 A.M., Resident C's diagnoses included but were not limited to large B-cell lymphoma lymph nodes of multiple sites. Resident C's most recent MDS dated [DATE] indicated the resident was not receiving hospice care. Resident C's physician orders included, but were not limited to, pain assessments every shift (started 9/9/25), Admit to hospice (started 9/17/25), supplemental oxygen at 2 liters per minute as needed for dyspnea/anxiety every shift (started 9/18/25), Lorazepam 0.5 mg every two hours as needed for anxiety/restlessness (started 9/18/25), morphine sulfate concentrate solution 20 mg/ml every 1 hour as needed for shortness of breath/pain (started 9/18/25)Resident C's facility care plan did not include a plan of care regarding hospice services.Resident C's nurse's notes included, but were not limited to the following: 10/6/25 at 4:55 P.M. - Morphine sulfate concentrate administered related to stomach pain.10/6/25 at 11:48 P.M. - Morphine sulfate concentrated administered was effective. Resident sleeping.10/7/25 at 7:20 A.M. - Residents' respirations ceased, no apical pulse auscultated. Resident C's medication administration record/ treatment administration record (MAR/TAR) for October 2025 indicated the resident's oxygen level was not assessed every shift as ordered during the day or night shift of 10/6/25 through 10/7/25. During an interview on 10/22 at 11:25 A.M., RN 6 indicated following the administration of a PRN pain medication, nursing staff should reassess a resident within an hour to monitor if the medication was effective. RN 6 indicated that a resident requiring hospice services should be assessed and monitored more frequently. On 10/21/25 at 2:30 P.M., RN 8 supplied a facility policy titled Hospice Services, dated 11/18/2012. The policy included, .The facility will provide hospice services either directly or through arrangements with a qualified service provider. 17. All treatments and services are documented in accordance with the facility's medical record policies and nursing procedures.This citation relates to intakes 2641662 and 2639734. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from accident hazards for 1 of 3 residents reviewed for accidents. Staff provided hot water to a resident without monitoring or checking the temperature of the water. The resident spilled the hot water which resulted in second-degree burns to the resident's abdomen, left hip, and lower back. This deficient practice resulted from a failure to follow the facility's procedure for serving hot beverages and contributed the development of second-degree burns that required routine treatment and the resident pain rated at a 5 on a scale of 0 - 10 (zero indicating no pain and 10 indicating the most pain). (Resident C)Finding includes: During a review of Facility Reported Incidents (FRIs) on 9/17/25 at 1:50 P.M., an incident dated 9/13/25 at 10:01 P.M. indicated Resident C had requested that CNA 4 heat a cup of water. CNA 4 placed the heated water on a bedside table, and Resident C spilled the water onto herself when raising her head of bed. Resident C received second-degree burns to her abdomen and back. During an observation and interview on 9/17/25 at 2:50 P.M., Resident C was sitting up in a Broda wheelchair in her room. Resident C indicated that she recently sustained second-degree burns from a spilled hot water after staff had brought her boiling hot water that had been warmed in a microwave. The resident indicated she often liked to make instant coffee in the evening. Resident C provided images of the burn wounds that included 3 separate reddened areas with what appeared to be a peeling off of the outer layer of skin. During record review on 9/17/25 at 3:00 P.M., 2/26/25 at 11:15 A.M., Resident C's diagnoses included, but were not limited to, spastic paraplegia, demyelinating disease of the central nervous system, hypertrophic osteoarthropathy, cerebellar ataxia, lack of coordination, and muscle spasm.Resident C's most recent Annual Minimum Data Set (MDS) assessment, dated 9/2/25, indicated the resident had no cognitive impairment, had lower extremity impairment to both sides, and required setup assistance for eating.Resident C's care plan included, but was not limited to, Activity of Daily Living (ADL) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughoutthe day due to limited mobility, limited Range of Motion (ROM), and musculoskeletal impairment (initiated 3/07/2025). Interventions included but were not limited to set up assistance for eating (revised 6/16/25). Resident C's physician orders included, but were not limited to: Silver sulfadiazine external cream 1%, apply to trunk and lower back topically two times a day for burns (started 9/14/25) and treatment to hip, abdomen and left flank, gently cleanse areas with normal saline, apply Silvadene, cover with non-adherent dressing and secure with rolled gauze every day shift for burn and as needed if soiled or dislodged (started 9/18/25). Resident C's progress notes included, but were not limited to:9/14/25 at 2:30 P.M. - Follow-up assessment of burn - Burn areas continue to be red with large blisters noted to the abdomen, under both breasts, lower back, and left outer thigh. Silvadene treatment applied. 9/15/25 at 6:33 A.M. - CNAs reported a skin issue to the nurse. Resident C stated that the night shift CNA had been asked to heat up a cup of water for the resident to make instant coffee in her room. The resident states that the CNA told her she had heated the cup of water for two and a half minutes. The resident raised the head of the bed with her remote control, and the cup of hot water was knocked over and spilled on the resident's torso and traveled to her back. Skin was red, and blisters were noted forming. The physician was notified, and orders were received to send to the hospital. The area was draped with a cool compress.9/15/25 at 9:57 A.M. - Blistering present at burn site. Some blisters open. Resident C's wound assessments included, but were not limited to the following:9/15/2025 1:24 PM - abdomen, facility acquired burn, partial thickness, wound tissue intact skin 20%, pale pink or red epithelial 20%, bright pink or red 60%, pain rated at 5 on scaled 0 - 10 (0 being no pain and 10 being the most pain), wound measurement 34 cm (centimeters) x 10 cm x 0.10 cm (L x W x D).9/15/2025 1:28 PM - left side lower back, facility-acquired burn, partial thickness, wound tissue intact skin 15%, pale pink non-granulating 15%, bright pink or red 70%, pain rated at 5 on scale 0 - 10, wound measurement 19 cm x 12 cm x 0.10 cm.9/16/25 at 7:19 A.M. - Left trochanter (hip), facility-acquired burn, partial thickness, wound tissue 100% bright pink or red, pain rated at 4 on scale 0 - 10, wound measurement 15 cm x 8 cm x 0.10 cm.During an interview on 9/18/25 at 10:55 A.M., the Director of Nursing (DON) indicated that staff should monitor the temperature of heated liquids that are served to residents and that there was no documentation or indication that the temperature of the water served to Resident C was monitored. The DON indicated education was provided to staff regarding water/drinking temperatures, thermometers were provided near microwaves, and signage to remind staff to monitor temperatures had been added in the dining areas near microwaves. On 9/18/25 at 11:06 A.M., the Facility Administrator supplied a facility policy titled Precautions for Handling Hot Beverages, dated 2020. The policy included, Staff will monitor, serve, and hold hot beverages in a safe manner to prevent potential burns. 1. The temperature for brewing and serving hot beverages will be based on the manufacturer's recommendations for the beverage equipment utilized in the community. Although the recommended settings for proper brewing may vary based on equipment, it is recommended that the temperature of the equipment be set at the lowest possible temperature for adequate brewing, anticipated to be in the range of 160 - 170 degrees Fahrenheit. The serving temperature should be approximately 10 - 15 degrees less than the brewing temperature . 4. Additional precautions may be implemented: a. Assessing and identifying those individuals served who are at high risk for burning themselves with hot beverages. b. ensuring staff monitor the identified high-risk resident(s) during meal times and/or when hot beverages are served . The deficient practice was corrected on 9/15/25 after the facility implemented a systemic plan that included the following actions: an action plan included in-service review of policy for heating or reheating food and beverages, use of microwave with staff and residents, and ongoing monitoring of the use of thermometers on each unit when reheating food and beverages. This citation relates to intake 2605036.3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 1 of 3 resident units observed and 1 of 2 dining rooms observed. Resident areas had missing paint on the walls, missing cove base, plywood covering a window, and a dark decolorization to dining room vaulted ceiling. (C/D halls, room [ROOM NUMBER], room [ROOM NUMBER] and C/D dining room)Finding includes:During an observation on 9/17/25 at 11:35 A.M., Resident room [ROOM NUMBER] was missing paint from the wall under the window, around the air conditioning unit, and behind the bed. The cove base behind the resident bed was missing from the wall. An observation on 9/17/25 at 11:38 A.M., Resident room [ROOM NUMBER] had a piece of plywood completely covering 1 of 2 windows in the room. An observation on 9/17/25 at 11:40 A.M., a shared restroom door near the nurse's station on the C/D hall unit had a protective door covering that had peeled away from the door, approximately 5 inches from the top right corner, approximately halfway up the door. An observation on 9/23/25 at 12:08 P.M., the C/D unit dining room contained an activity area with a television and dividing half wall. Approximately 80 % of the paint had peeled off the wall. The vaulted ceiling had a black discoloration near the top of the ceiling. An observation on 9/23/25 at 12:14 P.M., Resident room [ROOM NUMBER] was missing paint from the wall under the window, around the air conditioning unit, and behind the bed. The cove base behind the resident bed was missing from the wall. During an interview on 9/23/25 at 1:00 P.M., the maintenance director indicated that when residents move out of their room, the room is then repaired and renovated. The maintenance director indicated that he had been at the facility for approximately four weeks and the facility was soon hiring an assistant maintenance personnel. The window in room [ROOM NUMBER] had been broken by a lawnmower, and the facility was waiting on a repair window, and an outside source was scheduled to be at the facility the following day to bid on the work for the dining room. Facility maintenance could not complete the larger projects and required outside sources to make those repairs. On 9/23/25 1:30 P.M., The Facility Administrator supplied an undated facility policy titled Environmental Services Policy. The policy included, Purpose: To ensure that the facility is designed, equipped, and maintained in accordance with all governing rules and regulations and standards . It is the policy of the facility that it is constructed, equipped, and maintained to carry out the function of all services and to protect the health and safety of residents, personnel, public, and in compliance with all applicable Federal, State, and Local regulations.This citation relates to intakes 2603099, 2600442, and 2596108. 3.1-19(a)(4)

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment was maintained in accordance with professional standards for food services safety during 1 of 1 kitchen observations. Containers of food were stored on the dry food storage room floor and on the walk-in freezer floor, and a buildup of dust and debris was observed over the cookstove hood, on the ceiling in and around the vents above the dishwashing area, on top of the dishwasher, and along the base of the walls and floor. Finding includes:1. During an observation on 7/30/25 at 11:45 A.M., the facility kitchen' cookstove hood had a buildup of dust, the ceiling contained a buildup of dust in and around vents above the dishwashing area, the top of the dishwasher had a buildup of dust and debris, and dust and debris was built up along the base of the walls in the dishwashing area. During an interview on 7/31/25 at 1:00 P.M., Culinary Aide (CA) 4 indicated the kitchen staff had not been completing a daily cleaning task checklist and was unaware of where to find a cleaning task checklist. 2. During an observation on 7/30/25 at 11:55 A.M., the dry food storage room contained one (1) box of frosted flakes, a flat of canned beans, a box of canned sliced apples, a box of bagged sugar, and two (2) boxes of pudding cups on the floor. A walk-in freezer contained a box of dinner rolls stored on the floor. During an interview on 7/30/25 at 11:55 A.M., CA 4 indicated that the kitchen was short staffed. During an interview on 7/30/25 at 12:00 P.M., CA 4 indicated the food delivery truck's most recent delivery was two days prior (7/28/25). During an interview on 7/31/25 at 12:55 P.M., the Dietary Manager (DM) indicated there are areas of the kitchen that need cleaned and that food should be stored up off the floor. On 7/31/25 at 1:05 P.M., the Facility Administrator supplied facility policies titled, Food Storage (Dry, Refrigerated, and Frozen) dated, 2020 and Sanitation of Dining and Food Service Areas, dated 2020. The Food Storage (Dry, Refrigerated, and Frozen) policy included, Food shall be stored on shelves in a clean, dry area free from contaminants . (1) e. Store deliveries as soon as they have been inspected . (3) c. Store dry food on shelves . six inches off the floor to allow for proper sanitation . The Sanitation of Dining and Food Service Areas policy included, The Dining Services staff will uphold sanitation of the dining areas according to a thorough, written schedule.This citation relates to complaints 2568057 and 2572931. 3.1-21(l)(2)3.1-21(l)(3)

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to prevent and promote healing of facility acquired pressure injuries for 3 of 8 residents reviewed for pressure ulcers. Specific care plans were not developed, physician orders and other interventions not followed, and assessments were not completed thoroughly or accurately. This deficient practice resulted in facility acquired unstageable, Stage 3, and Stage 4 pressure ulcers. (Resident 20, Resident 7, Resident 25) Findings include: 1. On 2/5/25 at 11:05 A.M., Resident 20 was observed by the nurses' station sitting in a wheelchair. The resident was wearing slip on shoes on both feet. The left foot was wrapped with a gauze wrap and dated 2/4/25. On 2/6/25 at 2:31 P.M., Resident 20's clinical record was reviewed. Diagnosis included, but were not limited to, heart failure, diabetes mellitus, and dementia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/16/25, indicated no cognitive impairment and no behaviors. Resident 20 had two unstageable facility acquired pressure ulcers. (National Pressure Ulcer Advisory Panel defines an unstageable pressure ulcer as full thickness tissue loss in which the base of the ulcer is covered by slough (tan, brown or yellow) and /or eschar (tan, brown or black) in the wound bed.) Current physician orders included, but were not limited to: Treatment to Left Plantar Medial Heel: Cleanse with normal saline solution or Wound Wash, pat dry, apply calcium alginate to wound bed, cover with ABD pad, heel foam protector, and wrap with Kerlix (gauze wrap), secure with tape. Daily and as needed, dated 2/2/25. Treatment to Coccyx: Cleanse with normal saline solution, pat dry, apply collagen powder to open area, then insert calcium alginate, cover with Optifoam 4x4 dressing daily and as needed, dated 12/31/24. Float heels while resident in bed. Resident to wear pressure off loading boots every shift, dated 12/12/24. A current pressure ulcer care plan indicated an unstageable to the left medial heel as well as an unstageable to the coccyx, last revised 1/17/25. Interventions included, but were not limited to, follow physician orders for skin care and treatments, off load wound and float heels in bed every shift, treatments as ordered, and wound physician to manage wound care. Resident 20's clinical record lacked a separate care plan in place for the left medial heel pressure ulcer and the coccyx pressure ulcer. From November 2024 through February 2025, Resident 20's clinical record included the following assessments of pressure injuries: Coccyx 11/19/24 A wound nurse assessment indicated an unstageable coccyx pressure ulcer was identified that measured 1.5cm (centimeters) x 1cm x 0cm. An order was received 11/20/24 that indicated clean the coccyx with normal saline, apply calcium alginate, and cover with a foam dressing daily and as needed. The progress notes lacked documentation that the wound physician was notified of a coccyx pressure area and did not document on the area until 1/15/25. The wound physician note at that time indicated an unstageable coccyx pressure ulcer that measured 1cm x .5cm x .3cm. The coccyx wound lacked an assessment from 12/17/24 through 12/31/24. 12/31/24 The coccyx treatment order was changed to cleanse with normal saline, apply collagen powder to open area, insert calcium alginate, and cover with Optifoam 4x4 dressing. 1/7/25 A wound nurse assessment form indicated resident refused will assess tomorrow. The next wound nurse assessment was documented on 1/14/25. 1/22/25 A wound physician note indicated an unstageable coccyx pressure ulcer that measured 1cm x .5cm x .3cm. The wound physician indicated to continue the dressing treatment plan for calcium alginate and cover with foam border dressing daily. That order was not current and was not placed into Resident 20's clinical record. Resident 20's weekly skin assessments from 11/2024 through 2/2025 indicated the following assessment dates that lacked documentation of the coccyx: 11/21/24, 11/28/24, 12/5/24, 12/12/24, 12/14/24, 12/27/24, 1/3/25, 1/10/25, 1/31/25, and 2/7/25 Resident 20's Treatment Administration Record (TAR) from 11/2024 through 2/2025 indicated the following days a coccyx treatment was not completed and lacked an explanation: 11/20/24, 12/13/24, 12/19/24 On 2/11/25 at 10:40 A.M., the wound nurse was observed to change Resident 20's coccyx dressing. The area on the coccyx measured 2cm x 1cm x 0cm and was bright red on the inside with distinct edges. The area surrounding the wound was pink. When the old dressing was removed, red, pink, and brown drainage was observed on the inside of the dressing. The wound nurse cleansed the wound with normal saline, and applied collagen powder to the inside of the wound using a cotton tip applicator. A small square of calcium alginate was placed over the wound, and a large sacral dressing with a border was placed on top. The dressing was not dated or initialed. At that time, it was not the wound physician's recommendation to add collagen powder to the wound. Left Heel 11/5/24 A wound nurse assessment indicated a facility acquired unstageable left heel pressure ulcer. The form indicated the area had been identified on 1/3/24. The wound currently measured 2cm x 1.5cm x unknown. Wound nurse assessments completed on the following dates identified the left heel pressure as unstageable: 11/11/24, 11/19/24, 11/26/24, 12/3/24, 12/10/24, 12/17/24, 12/24/24, 1/7/25, 1/14/25, 1/21/25, 1/29/25, 2/4/25 11/8/24 A wound physician note indicated a Stage 3 pressure ulcer (National Pressure Ulcer Advisory Panel defines Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury) to the left plantar medial heel that measured 3cm x 2cm x 0.1cm. The wound physician indicated to continue a treatment of calcium alginate, collagen powder, an ABD pad, and gauze roll. Wound physician assessments completed on the following dates identified the left heel pressure as Stage 3: 11/13/24, 11/20/24, 11/26/24, 12/4/24, 12/11/24, 12/18/24, 12/26/24, 1/8/25, 1/15/25, 1/22/25, 1/29/25, 2/5/25 11/16/24 Received new physician's order for the left heel to cleanse with normal saline, apply collagen powder and calcium alginate, and cover with Kerlix (gauze wrap). The order did not include an ABD pad as per the wound physician's recommendations. The ABD pad was not added to the order until 11/21/24 (5 days later). 12/12/24 Received new physician's order for the left heel to cleanse with normal saline, apply collagen powder and calcium alginate, then place an ABD pad, heel foam protector, and wrap with Kerlix daily and as needed. The most current wound physician recommendation did not include a heel foam protector. 1/29/25 The wound physician indicated to discontinue the collagen powder. The order was changed in the clinical record on 2/2/25 (4 days later). 2/5/25 The wound physician indicated to add collagen powder to the treatment plan. The new order was not placed in the resident's clinical record. Resident 20's weekly skin assessments from 11/2024 through 2/2025 indicated the following assessment dates that lacked documentation of the left heel: 11/21/24, 12/14/24, 12/19/24, 1/3/25, 1/10/25, 1/31/25 Resident 20's Treatment Administration Record (TAR) from 11/2024 through 2/2025 indicated the following days a left heel treatment was not completed with no explanation: 11/7/24, 11/8/24, 11/10/24, 11/11/24, 11/19/24, 11/20/24, 11/21/24, 11/22/24, 12/12/24, 12/13/24, 12/19/24, 2/2/25 On 2/11/25 at 10:40 A.M., the wound nurse was observed to change Resident 20's left heel dressing. The area on the left heel measured 2.5cm x 4cm and was pink on the inside. The surrounding area was pink and yellow, with dark red and black areas and non-distinct edges. When the old dressing was removed, brown drainage was observed on the inside of the dressing. The wound nurse cleansed the wound with normal saline, applied a single layer of calcium alginate, and placed an ABD pad over it. The area was then covered with a foam heel protector and the foot wrapped with a Kerlix. The dressing was not dated or initialed. At that time, collagen powder was not placed on the wound as recommended by the wound physician as it was not entered into the resident's current physician orders in the clinical record after the most recent recommendation. 2. On 2/6/25 at 2:43 P.M., Resident 7's clinical record was reviewed. Diagnosis included, but were not limited to, hemiplegia following a stroke effecting the right side, dementia, anxiety, and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 12/16/24, indicated severe cognitive impairment and no behaviors. Resident 7 required substantial to maximal assistance (staff assists with more than half the effort) and was totally dependent with bathing. Resident 7 had one facility acquired unstageable pressure ulcer. Current physician orders included, but were not limited to: Treatment for the left buttock: Cleanse area with normal saline, pat dry, apply [NAME]/Castor Oil twice a day and as needed, dated 12/31/24. A current pressure ulcer to the left buttock care plan, revised 2/4/25, was initiated 12/2/24 and included, but was not limited to, the following interventions: Treatments as ordered, dated 12/2/24. From November 2024 through February 2025, Resident 7's clinical record included the following assessments of a left buttock pressure injury: 11/17/24 A weekly skin assessment indicated a new skin concern. Resident had a newly identified Stage 2 pressure ulcer on the left buttock (National Pressure Ulcer Advisory Panel defines a Stage 2 pressure ulcer as a partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose [fat] is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) and indicated a care plan was initiated. The care plan was initiated on 12/2/24 (15 days later). The assessment lacked measurements, color, or other condition or appearance of the wound. 11/26/24 A wound physician note indicated a Moisture Associated Skin Damage (MASD) area to the left buttock that measured 2cm x 1cm x .1cm. At that time, the wound physician indicated to add [NAME]/Castor Oil as a left buttock treatment. The order was not placed in the resident's clinical record until 12/5/24 (9 days later). 12/11/24 A wound physician note indicated an unstageable pressure injury to the left buttock that measured 4cm x .8cm x .1cm. At that time, the wound physician indicated to discontinue the [NAME]/Castor Oil and add Leptospermum Honey and a gauze island with border dressing daily. The new order was placed into the clinical record 12/12/24, but the [NAME]/Castor Oil was not discontinued until 12/31/24. On 12/19/24, the physician's order to apply leptospermum honey to the left buttock was discontinued. A new physician's order was received to cleanse the left buttock with normal saline, pat dry, apply Medi honey, then gauze Optifoam with border daily and as needed. The order received was not the current recommendation of the wound physician. 12/30/24 the wound physician indicated to change the Leptospermum Honey (which was not the current order in the clinical record, only their own most recent recommendation) to [NAME]/Castor Oil and discontinue the foam with border. The clinical record was updated with the new order the next day, 12/31/24. Wound nurse assessments completed on the following dates identified the left buttock pressure as Stage 2: 12/17/24, 12/24/24, 1/6/25, 1/13/25, 1/20/25, 1/27/25, 2/3/25 Wound physician assessments completed on the following dates identified the left buttock pressure as unstageable: 12/18/24, 12/26/24, 12/30/24, 1/8/15 1/15/25 A wound physician note indicated the unstageable pressure injury to the left buttock had resolved. The clinical record lacked clarification that the left buttock pressure area had been healed, and lacked documentation to the wound physician about the wound remaining. Resident 7's weekly skin assessments from 11/2024 through 2/2025 indicated the following assessment dates that lacked documentation of the left buttock: 11/20/24, 11/27/24, 12/4/24, 12/19/24, 1/2/25, 1/10/25, 1/15/25, 1/17/25, 1/18/25, 1/19/25, 1/24/25, 1/31/25, 2/5/25, 2/7/25 Resident 7's Treatment Administration Record (TAR) from 11/2024 through 2/2025 indicated the following days a left buttock treatment was not completed with no explanation: 12/13/24 evening shift, 12/18/24 evening shift, 12/19/24 evening shift, 12/21/24 evening shift, 2/3/25 evening shift On 2/10/25 at 10:33 A.M., the wound nurse was observed to enter Resident 7's room with supplies to change a dressing to her buttock. The resident indicated she was not feeling well, and pain was ten out of ten. The wound nurse indicated the resident had been given pain medication an hour prior, would not be doing the dressing change at that time, and left the room. 3. On 2/6/25 at 2:49 P.M., Resident 25's clinical record was reviewed. Diagnosis included, but were not limited to, paraplegia, anxiety, and depression. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/8/25, indicated no cognitive impairment and no behaviors. Resident 25 was dependent on staff with toileting, bed mobility, transfers, and bathing. The resident had one facility acquired Stage 4 pressure ulcer. (National Pressure Ulcer Advisory Panel defines Stage 4 Pressure Injury as full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole [rolled edges], undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury). Current physician orders included, but were not limited to: Treatment to left/right buttocks: Cleanse with soap and water, pat dry, then apply barrier cream twice a day and as needed every day and evening for wound, dated 12/20/24. [NAME]/Castor Oil ointment, apply to left buttocks every day and evening shift for wound care. Cleanse with soap and water and pat dry before applying. Twice a day and as needed, dated 12/5/24. A current pressure ulcer care plan included both the left buttock and right trochanter (hip), revised 2/4/25 and initiated 4/23/24. Interventions included, but were not limited to, wound physician follows wound care, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage). From November 2024 through February 2025, Resident 7's clinical record included the following assessments of a left buttock pressure injury: 11/1/24 A wound nurse assessment indicated a facility acquired left buttock Deep Tissue Pressure Injury (DTI), identified on 4/23/24. The wound measured 5.5cm x 4.5cm x 0cm. 11/8/24 A wound physician assessment indicated a Stage 4 left buttock pressure ulcer that measured 6cm x 3.6cm x .1cm. At that time, the wound physician indicated to continue [NAME]/Castor Oil twice a day. At that time, the current order was for a daily treatment. The order wasn't changed to twice a day until 11/21/24 (13 days later). 2/5/25 A wound physician assessment indicated a Stage 4 left buttock pressure ulcer that measured 4.2cm x 2.6cm x .1cm. At that time, the wound physician indicated to discontinue [NAME]/Castor Oil and add Leptospermum Honey with a gauze island with border once a day. The new order was not placed into the resident's clinical record. Resident 25's weekly skin assessments from 11/2024 through 2/2025 indicated the following assessment dates that lacked documentation of the left buttock: 11/25/24, 12/9/24, 12/31/24, 1/7/25, 1/14/25, 1/20/25, 2/3/25 Resident 25's TAR indicated the following dates from November 2024 through February 2025 the treatment for the left buttock was not completed: 11/4/24 evening shift, 11/11/24 evening shift, 11/19/24 day shift, 11/28/24 day shift, 12/3/24 evening shift, 12/13/24 evening shift, 12/18/24 evening shift, 12/19/24 evening shift, 12/21/24 evening shift On 2/10/25 at 10:40 A.M., the wound nurse was observed to prepare to change Resident 25's left buttock dressing. Upon observing him from the hallway, Resident 25 was sitting in a wheelchair, out of the bed. The wound nurse sighed and indicated that since the staff had already assisted the resident to get up, it would be too much trouble to get him back to bed, and she would be unable to do the dressing at that time. On 2/13/24 at 10:12 A.M., the wound nurse indicated she made weekly rounds with the wound physician. If she was not in the building, the floor nurse would usually do it. She indicated the orders in the resident's clinical record should be the most recent orders from the wound physician, as those orders were placed into the clinical record either the day of the assessment or the following day. She indicated the wound physician will sometimes give a verbal order or change the dressing in the middle of a dressing change, but that order should be what was current in the clinical records. She indicated she was unsure why her assessments indicated different staging and measurements than the wound physician and could be because they differ in how they measure wounds. She further indicated weekly skin assessments were entered by the floor nurses, should include something to address current wounds, and all the nurses had been inserviced how to fill them out. She indicated the floor nurses were also responsible for daily treatments and would expect them to be carried out as ordered. She indicated although she was not the one that currently entered care plans, there should have been a separate care plan for each wound unless it required the same interventions. On 2/12/25 at 11:26 A.M., the Administrator provided a current Wound Nurse description, dated 3/23/17, that indicated The Wound Nurse is responsible for providing primary skin care to residents under the medical direction and supervisor of the residents' attending physician, the Director of Nursing, or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders . Examine the resident and his/her records and charts, and discriminate between normal and abnormal findings, in order to recognize when to refer the resident to a physician for evaluation, supervision, or directions . Provide assessment and diagnostic services to residents. Perform an assessment evaluation using techniques including observation, inspection, and palpation . Implement and maintain established policies and procedures relative to skin care treatments. On 2/11/25 at 3:30 P.M., the Administrator provided a current Skin Condition Assessment and Monitoring Pressure and Non-Pressure policy, dated 6/8/18, that indicated Pressure and other ulcers . will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record . residents identified will have a weekly skin assessment by a licensed nurse . at the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes . dressings which are applied to pressure ulcers, skin tears, wounds, lesions, or incisions shall include the date of the licensed nurse who performed the procedure . the licensed nurse is responsible for notifying the attending physician, Director of Nursing and legal representative of any suspected wound infection . a licensed nurse shall observe condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. 3.1-40(a)

Based on observation, interview, and record review, the facility failed to ensure supervision to prevent multiple falls, resulting in a fall with a fracture to left clavicle (shoulder), for 1 of 3 residents reviewed for falls. (Resident H) Findings include: On 4/11/22 at 8:40 A.M., the Unit Manager indicated Resident H had recently fallen. The clinical record of Resident H was reviewed on 4/11/22 at 4:15 P.M. Diagnoses included, but were not limited to Congenital Disorder. A care plan, initially dated 9/25/20, indicated a problem of, Falls, potential for r/t [related to] muscle weakness, lack of coordination, difficulty walking, and abnormal gait. The Interventions included: 1/01/22 Educated not to get up without using the call light first for assist. 3/03/22 Keep wheel chair locked at bedside. 4/02/22 Residents bed to be in the lowest position at all times. 3/27/22 Clutter removed from room and from path to bathroom, resident continues to be non-compliant with asking for assist with transfers or toileting. 4/9/22 re-educated resident on importance of calling for assist with transfers to prevent further injuries. Nurses notes included the following notations: 1/1/22 at 5:25 P.M.: Resident had a unwitness [sic] fall at 1620 [4:20 P.M.]. CNA was walking out of another residents room and found resident on the floor, resident stated to her that she hit her head on the floor .Resident was educated not to get up without using the call light first so that she could have help, she stated that she understood A quarterly Minimum Data Set (MDS) assessment, dated 2/12/22, indicated Resident H had a moderately impaired memory problem, required limited assistance of one staff for transfer and walking, and extensive assistance of one staff for toilet use. A test for balance during transitions and walking indicated, Not steady, only able to stabilize with human assistance. The resident had fallen 2 or more times since the previous assessment. Nurses notes continued: 3/3/22 at 6:08 P.M.: Resident had a fall this shift. It was witnessed by therapy. Resident did hit her head on the floor .Resident was educated that she need to call for help before getting up 3/4/22 at 1:33 A.M.: Have reminded pt. [patient] several X's [times] to ask staff for assistance with her transfers but remains non-compliant. 3/27/22 at 9:30 P.M.: Resident's room mate was yelling for 'help', this nurse entered room and resident was attempting to get up off the floor, this nurse assisted resident up and resident ambulated to bath room, no injuries noted, resident denied pain. Fall was witnessed by roommate who stated she didn't hit her head on anything .Will continue to monitor. 4/2/22 at 11:20 P.M.: Resident came up to Nurses' station, in w/c [wheelchair] and stated she had fallen and her shoulder hurts Has approx. quarter size red area on top of Lt [left]. shoulder ROM [range of motion] is painful The resident was transferred to the emergency roiagnom on [DATE] at 4:50 A.M. and diagnosed with a left broken clavicle (shoulder). Nurses notes continued: 4/3/22 at 10:18 P.M.: Will e [sic] in low bed at all times and assist as needed. 4/7/22 at 7:45 P.M.: Resident came to this nurse to tell me that she had fallen in her bathroom of her room. She stated that she had picked herself up and put herself back in her chair .Gait remained baseline. This nurse assisted her to her bed and found no new skin areas. Call light et [and] beverages within reach. Educated resident on importance of using call light before getting out of bed if assistance is needed 4/9/22 at 8:30 P.M.: Resident wheeled herself to nurses station and told this nurse that she had fallen while transferring herself from bed to wheel chair. Resident reported that she hit her head on nightstand. Resident was assessed and small red hematoma [raised bruise] noted on right side of head .Re-educated resident on importance of asking for assist with transfers to prevent further injuries, resident agreed that she needs to ask for assist but continues to be non compliant. Will continue neuro checks per policy and monitor closely. 4/9/22 at 10:00 P.M.: Resident resting quietly in bed, easily aroused for neuro checks, hematoma on right side of head continues to be tender to touch . denies pain other than right side of head tenderness, left arm remains in sling from previous clavicle fracture. Reminded to call for assist as needed, call light and fluids in reach. No fall assessments were found in the clinical record. On 4/12/22 at 11:30 A.M., Resident H was observed sitting in a wheelchair in her room. There were no non-skid strips in the room. There was no signage reminding the resident to ask for assistance. On 4/12/22 at 2:00 P.M. the Administrator and DON indicated the resident had been cleared by therapy to assist self out of bed or transfer self from chair, also that if w/c was removed from bedside the resident would attempt to walk independently. They acknowledged the resident had been instructed by nursing to ask for assistance and instructed by therapy to assist self. On 4/12/22 at 2:45 P.M., the DON provided the current facility policy, Fall Management, dated November 2014. The policy included: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review On 4/12/22 at 3:05 P.M., the DON indicated she could not find any fall assessments for Resident H. This Federal tag relates to Complaint IN 584. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure supervision to prevent falls, resulting in a fall with a head laceration requiring sutures; and failed to ensure supervision to prevent a resident from eloping, for 3 of 5 residents reviewed for supervision, in a sample of 6. Resident A, Resident E, and Resident C Findings include: 1. The closed clinical record of Resident A was reviewed on 6/15/16 at 1:40 P.M. [DIAGNOSES REDACTED]. Documentation indicated the resident resided on the Alzheimer's Care Unit. Nurse's Notes included the following notations: 3/2/16 at 4:30 P.M.: Resident was up in w/c (wheelchair) this nurse just put shoes back on resident and this nurse turned to get sock off table resident pulled self out of chair by grabbing on to table et (and) slid out of w/c A Minimum Data Set (MDS) assessment, dated 3/15/16, indicated Resident A was unable to complete a brief interview for mental status, had a short- term and long-term memory problem, and was severely impaired in cognitive skills for daily decision making. The MDS assessment indicated Resident A required extensive assistance of one staff for bed mobility and transfer, and did not ambulate. A test for balance during transitions and waling indicated, Not steady, only able to stabilize with staff assistance while moving from a seated to standing position, and surface-to-surface transfer. The resident had fallen since the previous assessment. A Care Plan, dated 4/30/14 and updated with a goal of 7/28/16, indicated, Potential for Falls related to: unaware of limitations, weakness, dementia with behaviors. History of falls. The Interventions included: Alarms as ordered. Dycem to wheelchair. Encourage resident to be compliant with limitations and to ask for assistance as needed. Evaluate all falls for cause and attempt to prevent further falls, innitiate (sic) appropriate interventions Nurse's Notes included the following notations: 4/2/16 at 8:30 A.M.: Resident asleep in bed till this time in shift, upon arising, this nurse noted deep purple bruise (4 x 8 cm) to (right) temporal (head) area. Resident states she fell - but doesn't recall when .Will monitor. 4/4/16 at 7:45 P.M.: Resident alert and cooperative. She was sitting in dining room peacefully. Environmental aid (sic) walked to front of hallway to redirect another resident and this nurse heard a large crash. After investigation it was noted this resident had fallen out of wheelchair onto ground in dining room. This resident was noted to be laying on left side with head laying on ground. She is able to move all extremities .Upon body assessment a hematoma (raised bruise) was noted to left temporal lobe .Resident placed in bed and alarms were turned on. Call bell within reach 4/7/16 at 9:15 P.M.: Resident was checked on to find her sitting on floor/mat in room. resident was attempting to sit on edge of bed and slid to ground 4/14/16 at 5:00 P.M.: Resident was (up) in w/c earlier pulling self up by the handrails on wall, CNAs put resident in regular chair (with) alarm resident rocking in chair leaned to the left and tipped chair over CNA's (sic) broke resident's fall she would not hit head. Resident received bruise to the (left) side of neck shoulder area 4/28/16 at 6:45 P.M.: .CNA called for this nurse. This nurse ran back the hall (sic) to find resident laying on right side unresponsive with eyes shut legs slightly bent with right arm under left arm bent and head touching floor. Wheelchair was pulled away from table. Under head blood was noted .asked other nurse to call 911 .attempted sternum rub on resident several times as well as attempting to say resident's name several times .EMT was en route. 4/28/16 at 7:00 P.M.: EMT arrived .to hospital. 4/28/16 at 3:00 P.M. Back charting - Resident was restless this nurse took resident on a walk outside. Resident was in wheelchair .brought resident back inside. Resident began to scream .assisted CNA to laying resident down in bed .Resident began to yell and then attempted to get out of bed. This nurse assisted CNA to place resident in wheelchair .Resident was then set at table on 1:1 with CNA so she could eat a snack and have a drink. 4/28/16 at 6:30 P.M. Back charting. Resident sitting at table in wheelchair with head looking down (appears to be resting). (No) c/o (complaints of) pain/discomfort noted. 4/28/16 at 7:15 P.M.: Once resident was on way to hospital this nurse obtained witness accounts from both CNA's (sic). (CNA # 1) stated resident was sitting to her direct right. CNA heard alarm sound 1 time. CNA turned around at same time residents (sic) head hit the floor. CNA stated wheelchair was locked in position at table. As CNA moved wheelchair backwards she yelled for this nurse. This nurse then approached seen (sic) (dining room) to assess resident 4/29/16 (sic) at 9:00 P.M.: This nurse called (name of hospital) ER to check on condition of resident. ER nurse stated bleeding was from arterial tare (sic). No abrasion to head noted .Resident had 2 sutures placed in artery and bleeding subsided .She was admitted for observation. An emergency room note, dated 4/28/16, indicated, Chief Complaint: Fall .Apparently she has one-on-one assistance at the nursing home and has some dementia. Today she was up and got away from the staff and fell on to the right frontal area of her head .There is some bleeding at the right frontal area with a puncture type laceration .the area of bleeding was addressed with two nylon sutures A hospital history and physical, dated 4/28/16, indicated, Chief Complaint: Forehead/scalp hematoma secondary to a fall. History of Present Illness: .She was sent to the emergency roiagnom on this occasion because of a large forehead/scalp injury from a fall .The ER physician put 2 sutures to stop the bleeding .the family claims that she is now less responsive .The patient is only responsive to painful stimuli .Assessment and Plan: 1. Acute [DIAGNOSES REDACTED]/unresponsiveness and large right frontoparietal forehead/scalp hematoma secondary to a fall On 6/15/16 at 2:30 P.M. during an interview with CNA # 1, she indicated she was agency staff, but that she frequently worked on Resident A's unit. She indicated Resident A liked to lunge out of her chair. She indicated on 4/28/16 Resident A had been agitated, and she had brought her up to the dining area. She indicated she stood up and was opening snacks for everyone, when Resident A fell sideways out of her chair. She indicated she thought that she was within an arm's length of the resident. On 6/15/16 at 2:45 P.M., during an interview with LPN # 1, she indicated she was agency staff. She indicated she did not usually work that particular unit. She indicated she was working on 4/28/16, and Resident A had increased agitation. LPN # 1 indicated she did not know how the accident happened, because she had put the resident on 1:1 monitoring because she was so agitated. LPN # 1 indicated she was at the nursing station when CNA # 1 yelled out for her. She indicated she did not hear an alarm, but that the CNA told her it had sounded. 2. On 6/15/16 at 10:15 A.M., during the initial tour of the Alzheimer's Care Unit, the Director of Nursing (DON) indicated Resident E had recently fallen. The clinical record of Resident E was reviewed on 6/16/16 at 9:20 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 4/19/16, indicated Resident E was unable to complete a brief interview for mental status, had a short-term and long-term memory problem, and was severely impaired in cognitive skills for daily decision making. The MDS assessment indicated the resident required extensive assistance of one staff for bed mobility and transfer, and extensive assistance of two+ staff for ambulation. A test for balance during transitions and walking indicated Not steady, only able to stabilize with staff assistance while moving from a seated to standing position, walking, turning around, and surface-to-surface transfer. The resident had fallen since the previous assessment. A care plan, dated 5/10/12 and updated to a goal of 6/20/16, indicated, The resident has a potential for falls r/t (related to) history of falls, decreased vision, dementia, psychotropic meds. The Interventions included, The resident needs a safe environment .Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .4-24 A (assist) x 2 (with) ambulation. An additional care plan, undated, indicated, At risk for physical injury from falls related to: Unsteady ambulation, Use of high risk medication. The Interventions included: Assist of (two) for transfers. 6/15/16 (Change) to A x 1. Bed alarm. 5-14-16 Place in high traffic area Nurse's Notes included the following notations: 4/24/16 at 3:45 A.M.: Res (resident) fell to floor on bottom while being walked by CNA to BR (bathroom), (no) injury, denies pain, will continue to monitor. 4/27/16 at 1:00 A.M.: Has gotten out of bed by self x 2 to go to BR. Bed alarm on (and) functioning. Assisted to BR (one) person. Gait unsteady (with) (decreased) balance. No complaints. 4/27/16 at 12:30 P.M.: Res cont q (every) 15 min staff checks - Res frequently self transfers. Res gait unsteady .Res enc to use call bell or ask for staff assist 5/14/16 at 11:00 A.M.: Resident was in room alarm sounding .entered room resident trying to stand up wanting to make bed lost balance fell backward et (and) hit head on chair resident was assessed by nurse .Intervention to place in high traffic area 5/22/16 at 10:00 P.M.: Res alarm sounded. Staff responded. Res found lying on side (with) head near tray stand. Approx 10 ml blood on floor and back of head. Cleansed site (with) saline. Sm (small) abrasion approx 2 cm x 1 cm 6/4/16 at 5:00 P.M.: .Staff asked family to please stay (with) resident due to high risk of falls. This writer was told to hire more people. I explained resident falls often and to pls (sic) not leave unattended. Wife again said his needs are high hire more help. Res frequently is redirected due to self transferring. Res cued for needs and wants by staff. 6/10/16 at 4:35 A.M.: This nurse checked resident at 0430 (4:30 A.M.), resident in bed et alarm on. At 0435 resident was on bathroom floor laying on (right) side (with) blood coming from (right) hand, alarm had been shut off .Skin tear on (right) knuckle had re-opened, skin tear noted on (right) pinky, (right) ring finger, et (right) middle finger 6/11/16 at 7:30 P.M.: .Assist of (two) (with) ambulation .resident attempted several times to get up on his own alarm sounding 6/15/16 at 3:40 A.M.: Res alarm sounding. CNA responded to alarm to find res on floor. Res hit head and L (left) elbow. Res tore his alarm up in process of getting up out of bed .Placed res on Q 2 (hour) toileting schedule 6/15/16, untimed: Clarification - Res on Q 1 (hour) toileting schedule .to be evaluated for UTI (urinary tract infection) 6/16/16 at 1:30 A.M.: .large dark purple bruise noticed on (right) arm above elbow .Res. alarm on and working. Res. was reminded to call for help when getting up On 6/16/16 at 9:40 A.M., CNA # 2 and CNA # 3 indicated they were going to ambulate Resident E to the bathroom. CNA # 3 indicated Resident E was a two person assist. Using a gait belt, CNA # 2 and CNA # 3 ambulated the resident. The resident did not verbalize, and gait was slow and unsteady. A dark purple bruise was observed on the resident's right hip. CNA # 3 indicated, He fell early yesterday. On 6/16/16 at 9:55 A.M., the Unit Manager indicated staff had found a large bruise on Resident E's right arm following the resident's fall. The resident was observed to have a large dark purple bruise on his right upper inner arm. The Unit Manager indicated it was measured at 24 cm x 20 cm. She indicated, The resident probably tried to break his fall with that arm. On 6/16/16 at 2:15 P.M., the DON provided the current facility policy on Fall Management, revised November 2014. The policy included: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls A Plan of Care is developed and implemented .with ongoing review 3. The closed clinical record of Resident C was reviewed on 6/16/16 at 11:30 A.M. [DIAGNOSES REDACTED]. Documentation indicated the resident resided on the Alzheimer's Care Unit. A hospital note, dated 4/12/16, indicated, .While a patient (at nursing facility) he was exit seeking, restless, anxious, demanding .Even so much as crawled out a window and facility and the police saw him walking down the road .Judgment: Impaired, Insight: Impaired .Poor cognitive and physical ability An Elopement Risk Assessment, dated 4/14/16, indicated, Is the resident cognitively impaired with poor decision mating skills (i.e. intermittent confusion or disorientation) No. Does the resident have a [DIAGNOSES REDACTED].? Yes. Does the resident ambulate independently? Yes. Does the resident have a history of elopement .Yes. Does the resident have a history of leaving the facility without the need for supervision? Yes. Has the resident verbally expressed the desire to go home .? Yes .Resident is at risk for elopement related to: (left blank). Nurse's Notes included the following notations: 4/27/16 at 6:30 P.M.: Res became abruptly upset and demanded to leave. Res stated he will start breaking windows out unless he leaves .Res was telling staff repeatedly he will leave sometime tonight 5/1/16 at 2:00 P.M.: Res wants to go home, wants to know who or what he has to see or do to get out of here .Close supervision continues. 5/3/16 at 10:05 P.M.: .Resident continues to talk about leaving and how he needs to do it, conversation helpful for short period of time. Cont (with) close supervision A quarterly MDS assessment, dated 5/4/16, indicated the resident scored a 11 out of 15 for cognition, with 15 indicating no memory impairment. The resident required supervision and set up help only with bed mobility, transfer, and ambulation. A test for balance during transitions and walking indicated, Not steady, but able to stabilize without staff assistance while moving from a seated to standing position, walking, and surface-to-surface transfer. The resident had fallen since the previous assessment. Nurse's Notes included the following notations: 5/15/16 at 3:00 P.M.: Res frequently exit seeking this shift. Res was observed carrying (two) door knobs from cabinets in hand. Res was holding them to window. Res was observed at a different time evaluating/examining another resident window. Res redirected 5/19/16 at 11:30 P.M.: Resident pleasant wanting to leave states all he needs is screwdriver will figure out some way to get out 5/28/16 at 11:30 A.M.: (Late Entry) 06:30 CNA entered residents (sic) room to assist him .CNA went et opened curtains et noted there was a knife wedged in the top of the window near the window lock .Resident denied having the knife or using it on the window when asked about it .Cont (with) 15 min checks for resident safety 6/8/16 at 10:40 P.M.: .Expresses the need to leave the facility really wants to leave will find a way. Resident was in (another resident room) had his cane up by window pushing on the screws resident redirected to dining room A Social Service Note, dated 6/9/16 and untimed, indicated, Nurse (name) informed social worker res was in (another resident's room) trying to open window with cane .Social worker (name) informed maintence (sic) Res was attempted (sic) to open window in (another resident's room) by using his cane to pry window block off .Maintence (sic) fixed (and) checked window .Spoke to staff about resident wandering in rooms and educated them on elopement prevention. Res. remains on 15 min checks. Nurse's Notes continued: 6/10/16 at 3:45 P.M.: Resident was finishing up (with) activities in dining area et was going back to room activity assistant walked (with) resident to his room 6/10/16 at 4:00 P.M.: This Nurse went to resident's room to do his 15 minute check et resident was not in his room. This nurse also checked bathroom but was unable to locate resident .All staff members began checking each room on both units to locate resident .1615 (4:15 P.M.) Resident was located on (nearby apartment complex) grounds by staff et transported back to facility 6/10/16 at 10:00 P.M.: When res located @ 1615 he was wearing long-sleeve flannel shirt, sweat pants, socks et shoes. Res had his cane et a bag of personal belongings. A hospital emergency room note, dated 6/10/16, indicated, .Pt (patient) has been in the nursing home for awhile .He does not like the nrg (sic) home .Today he climbed out the window and escaped .he tells me this is the 2nd time he has done this A hospital history and physical, dated 6/10/16, indicated, .Apparently, the patient attempted to climb out of the window of his nursing home x 2 prior to reporting to the emergency department According to weather reports for the facility's location, the temperature on 6/10/16 at 4:00 P.M. was 92 degrees. On 6/16/16 at 9:45 A.M., during an interview with the Unit Manager, she indicated that following the resident's previous elopement attempt, a wooden block was screwed to the each window top. She indicated the room where the resident exited the window was across the hall and two rooms down from the resident's room. A wooden block, approximately 2 inches x 2 inches was screwed to the top of the window frame. The Unit Manager indicated, We think he pried the wooden block off with his cane. The window exited to the facility parking lot. The Unit Manager indicated the resident apparently went around the side of the building, and was found on the grass by a nearby apartment complex. The Unit Manager indicated she felt like the resident had probably been working on it for awhile, referring to the wood block. On 6/16/16 at 2:15 P.M., the DON provided the current facility policy on Elopement Prevention, Identification, and Management, dated 6/10/16. The policy included: It is the policy of this facility to ensure that each resident receives adequate supervision and assistive devices to prevent elopements and that all personnel will report and investigate all reports of missing residents This Federal tag relates to Complaint IN 582. 3.1-45(a)(2)

Based on interview and record review, the facility failed to adhere to the facility's policy regarding a resident's low blood sugar, resulting in the resident's fall with a [MEDICAL CONDITION], for 1 of 3 residents reviewed for diabetic care, in a sample of 14. Resident H Findings include: On 2/7/16 at 4:40 P.M., during the initial tour of the locked Alzheimer's Unit, LPN # 1 indicated Resident H had recently fallen. The clinical record of Resident H was reviewed on 2/7/16 at 6:45 P.M. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 1/12/16, indicated Resident H scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated Resident H required limited assistance of one person for walking in the room and corridor. A test for balance indicated Not steady, but able to stabilize without staff assistance while moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. A Physician order [REDACTED]. An additional physician's orders [REDACTED]. Nurses Notes included the following notations: 1/23/16 at 7:45 A.M.: Res in A hall BR (bathroom). This nurse heard loud crash, upon entering res was lying on back (with) blood coming from back of head. Res was awake but not responding to this nurse, accu (check) 47 mg/dl .2 deep lacerations to back of head noted (with) mod (moderate) active bleeding .prepared for transfer to (name of hospital) ER A hospital ER note, dated 1/23/16, indicated, (Resident H) .who fell , struck his head on a can that was in his room and when he hit the trash can, had no loss of consciousness .Exact circumstances are uncertain. Apparently his blood sugar was low and this may have contributed to his fall .He had two lacerations occipital (head) area, oozing of blood .Six skin staples were placed with good wound approximation .Impression: 1. [MEDICATION NAME] head injury 2. Scalp laceration Nurses Notes continued: 1/23/16 at 11:10 A.M.: Res back to facility, 6 staples noted to lacerations 1/23/16 at 7:35 A.M. Late entry: Res accu (check) 27 mg/dl, rechecked et (and) was 33 mg/dl, res asymptomatic (sic), sitting at dining room table eating breakfast, O.J. given to resident, extra sugar given to res cereal et O.J. et at 0745 (7:45 A.M.) Res had fall in BR. A Care Plan, initially dated 5/10/12 and updated 10/30/15, indicated, The resident has Diabetes Mellitus. The Interventions included: Diabetes medication as ordered by the doctor .Monitor/document/report to MD PRN (as needed) s/sx (signs/symptoms) of [DIAGNOSES REDACTED] On 2/8/16 at 2:55 P.M., the Director of Nursing provided the current facility policy Hypo/hyperglycemic Protocol, undated. The policy indicated: Upon admission, MD must be notified of our facility protocol and an order should be written to 'follow facility hypo/hyperglycemic protocol.' The MD must be asked the parameters that he wishes to be called. For example, if BS (blood sugar) is below 60 or above 350, the Physician should be notified. This must also be included on the order .1. If BS is <60 and resident is conscious and has no swallowing difficulties: give 4 oz orange juice with granulated sugar by mouth followed by peanut butter and crackers .Report results to MD and any reasons that BS could be fluctuating .Request orders for the next scheduled does of insulin. Repeat accucheck in 15-30 minutes The DON indicated at that time that the nurse had not followed the facility protocol regarding a low blood sugar, and the low blood sugar was probably what caused the resident to fall. This Federal tag relates to Complaint IN 171 and Complaint IN 350. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls; utilized alarms in place of supervision; and did not respond to alarms in a timely manner, resulting in falls with lacerations, for 4 of 4 residents reviewed for falls; and failed to provide supervision to prevent an elopement, for 1 of 3 residents reviewed for elopement (Resident F), in a sample of 14. Residents C, F, G, H, and P Findings include: 1. On 2/7/15 at 4:40 P.M., during the initial tour of the locked Alzheimer's Unit, Resident P was observed sitting in a wheelchair in the hallway. Bruising was observed around both eyes. LPN # 1 indicated at that time that Resident P had fallen recently. The clinical record of Resident P was reviewed on 2/8/16 at 10:45 A.M. [DIAGNOSES REDACTED]. A Care Plan, initially dated 4/30/14 and updated 1/22/16, indicated, Potential for Falls related to: unaware of limitations, weakness, dementia with behaviors. History of falls. The Interventions included: Alarms as ordered. Encourage resident to be compliant with limitations and to ask for assistance as needed. Evaluate all falls for cause and attempt to prevent further falls. Keep call light in reach and encourage resident to use it to ask for assistance. Pull alarm at all times. 1-22-16 Keep in high traffic areas. A Nurses Note, dated 11/20/15 at 4:45 P.M., indicated, Resident was in A wing dining room sitting in chair pull alarm attached to back of chair another resident was pulling on alarm in (sic) pulled resident out of chair and onto floor A Nurses Note, dated 12/16/15 at 2:15 P.M., indicated, Res (resident) slid out of chair et (and) fell to floor hitting buttocks on floor .New order received for dycem to chair to prevent sliding. A quarterly Minimum Data Set (MDS) assessment, dated 12/24/15, indicated Resident P had a short-term and long-term memory problem and was severely impaired in cognitive skills for daily decision making. The MDS assessment indicated Resident P required extensive assistance of one person for bed mobility and transfer, and did not ambulate. A test for balance indicated Not steady, only able to stabilize with staff assistance while moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. The MDS assessment indicated the resident had fallen since the prior assessment. Nurses Notes included the following notations: 1/15/16 at 7:15 P.M.: Resident was in w/c (wheelchair) alarm et dycem (sic). Another resident pushing resident holding onto rail tried to stand up et resident slipped out of w/c 1/19/16 at 10:15 P.M.: .Neuro (checks) continue from resident falling out of bed today An Incident Report, dated 1/19/16, indicated, Time of Incident: 1100 (11:00 A.M.) .Res in bed to rest before lunch et rolled out of low bed to floor scraping forehead on heater 1/20/16 at 2:00 P.M.: .Pressure alarm on at all times. Closely monitored d/t (due to) (decreased) safety awareness. 1/22/16 at 7:40 P.M.: Resident in hallway on floor. Lying Rt (right) side .Resident had tried to stand up (with) railing but not strong enough. fell on Rt side of head. Has open area (and) bruising on Rt forehead. Rt eye is black (and) blue swollen shut .she is stiff, no c/o (complaints of) pain other than face hurting. Also has a cut below Rt eye. Has laceration on Rt hand by thumb Documentation did not indicate if an alarm was sounding. The resident was transferred to the emergency roiagnom on [DATE] at 8:45 P.M., and returned to the facility at 11:45 P.M. A Nurses Note, dated 1/22/16 at 11:45 P.M., indicated, Res (resident) returned from (name of hospital) .No broken bones noted .has steri strips on right side of forehead and under right eye. Res. has a long contusion to right eye that is deep purple A Nurses Note, dated 1/23/16 at 2:00 P.M., indicated, .PRN (as needed) for c/o (complaints of) facial et back pain. Res (up) (with) max (maximum) assist of (one) staff member, requires max assist of (one) .Bruising to (left) side of face noted (with) 2 small lacerations which are steri stripped, ice to face x 2 this shift d/t swelling of (right) eye. Alarm on at all x's (times). Close supervision required d/t poor safety awareness 2. On 2/7/16 at 4:40 P.M., during the initial tour of the locked Alzheimer's Unit, Resident G was observed sitting in a chair in the dining room. Bruising was observed around her left eye. LPN # 1 indicated Resident G had recently fallen. The clinical record of Resident G was reviewed on 2/7/16 at 6:30 P.M. [DIAGNOSES REDACTED]. A Care Plan, initially dated 6/9/15 and updated 1/23/16, indicated, Potential for Falls related to: resistive to care, psychotropic med use .unaware of safety and limitations. The Interventions included: Encourage resident to be compliant with limitations and to ask for assistance as needed. Keep call light in reach and encourage resident to use it to ask for assistance. 1-10-16 Pull alarm @ all x's. (Up) (with) A (assist) x 1. 1-8-16 Separate res when trying to hold on to other res. An admission Minimum Data Set (MDS) assessment, dated 10/14/15, indicated Resident G had a short-term and long-term memory problem and was severely impaired in cognitive skills for daily decision making. The MDS assessment indicated Resident G required limited assistance of one person for bed mobility and transfer, and supervision of one person for walking in the room and corridor. A test for balance indicated Not steady, but able to stabilize without staff assistance while moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. Nurses Notes included the following notations: 12/5/15 at 2:35 P.M.: Around 1230 resident was observed walking in hallway during dinner time bumped into the foodcart (sic) (and) fell to floor onto her knees 1/8/16 at 3:40 P.M.: Pt (patient) fell @ 1515 (3:15 P.M.) pt was holding onto another pt shirt following him he turned quickly (and) pt went to floor on bottom .did not hit her head 1/10/16 at 10:30 A.M.: Res was sitting in dining room et got (up) from chair, upon rising res lost balance et fell backward et hit head on arm of chair. Res has 4 cm (centimeter) laceration to back of head .Laceration bled for short period of time .Will cont neuro checks et monitor closely. A quarterly MDS assessment, dated 1/20/16, indicated Resident G had a short-term and long-term memory problem and was severely impaired in cognitive skills for daily decision making. The MDS assessment indicated Resident G required limited assistance of one person for bed mobility and transfer, and walking in the room and corridor. A test for balance indicated Not steady, only able to stabilize with staff assistance while moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. Nurses Notes continued: 1/23/16 at 2:45 P.M.: Res in chair, bent over to do something to shoe et tumbled head first out of chair, hit (left) forehead on floor, ice applied 3. On 2/7/16 at 4:40 P.M., during the initial tour of the locked Alzheimer's Unit, LPN # 1 indicated Resident H had recently fallen. The clinical record of Resident H was reviewed on 2/7/16 at 6:45 P.M. [DIAGNOSES REDACTED]. An annual MDS assessment, dated 1/12/16, indicated Resident H scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated Resident H required limited assistance of one person for walking in the room and corridor. A test for balance indicated Not steady, but able to stabilize without staff assistance while moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. A physician's orders [REDACTED]. Nurses Notes included the following notations: 1/23/16 at 7;45 A.M.: Res in A hall BR (bathroom). This nurse heard loud crash, upon entering res was lying on back (with) blood coming from back of head. Res was awake but not responding to this nurse, accu (check) 47 mg/dl .2 deep lacerations to back of head noted (with) mod (moderate) active bleeding .prepared for transfer to (name of hospital) ER A hospital ER note, dated 1/23/16, indicated, .who fell , struck his head on a can that was in his room and when he hit the trash can, had no loss of consciousness .Exact circumstances are uncertain. Apparently his blood sugar was low and this may have contributed to his fall .He had two lacerations occipital (head) area, oozing of blood .Six skin staples were placed with good wound approximation .Impression: 1. Blunt head injury 2. Scalp laceration Nurses Notes continued: 1/23/16 at 11:10 A.M.: Res back to facility, 6 staples noted to lacerations 1/24/16 at 6:00 P.M.: Resident was found on floor between bathroom et room of another resident. Resident was lying on back hit his head bleeding noted to small laceration left side of head ice applied .Son (name) aware stated 'now what happened . will monitor, gait very slow et unsteady. 1/23/16 at 7:35 A.M. Late entry: Res accu (check) 27 mg/dl, rechecked et was 33 mg/dl, res assymptomatic (sic), sitting at dining room table eating breakfast, O.J. given to resident, extra sugar given to res cereal et O.J. et at 0745 (7:45 A.M.) Res had fall in BR. A Care Plan, initially dated 5/10/12 and updated 1/23/16, indicated, The resident has potential for falls r/t history of falls, decreased vision, dementia, psychotropic meds. The Interventions included: Anticipate and meet the resident's needs. Ensure that the resident is wearing appropriate footwear 5/10/12. (Up) (with) (assist) x (one) for transfers/ambulation r/t weakness. 4. On 2/7/16 at 5:15 P.M., Resident C was observed sitting at a table in the dining area of the Alzheimer's Unit. The clinical record of Resident C was reviewed on 2/7/16 at 6:10 P.M. [DIAGNOSES REDACTED]. An annual MDS assessment, dated 9/23/15, indicated Resident C had a short-term and long-term memory problem and was severely impaired in cognitive skills for daily decision making. The MDS assessment indicated Resident C required extensive assistance of one person for bed mobility, and walking in the room and corridor. The resident required limited assistance of one person for transfer. A test for balance indicated Not steady, only able to stabilize with staff assistance while moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer. The MDS assessment indicated the resident had fallen twice since the last assessment. Nurses Notes included the following notations: 11/10/15 at 1:30 P.M.: Res alarm sounded, CNA entered room et res slid from chair to knees .pull alarm applied as intervention to alert staff earlier that res is getting (up) 12/3/15 at 8:15 P.M.: Resident in recliner in sitting room when upon entering the room resident stated 'another resident pulled her out of her chair.' Resident was on her buttocks alarm in place. No signs of hitting head 12/13/15 at 9:00 P.M.: Resident stood up sounding alarm in sitting room. CNA (name) wittnessed (sic) before able to get to her. Resident tried to sit down missing chair landing on buttocks .Will cont to monitor. 12/24/15 at 7:30 P.M.: This nurse was assisting another resident when heard resident's alarm sound this nurse seen resident up walking when resident tried to get back to sit in her chair she fell on floor landing on her bottom. This nurse was not able to get to resident before she fell .Will cont to monitor. 1/5/16 at 3:15 A.M.: Heard alarm sounding et found resident sitting on floor (with) back against door .Will cont to monitor. A Care Plan, dated 12/5/13 and updated 1/5/16, indicated, The resident has potential for falls or/t Parkinson's, dementia, unaware of safety The Interventions included: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. 1/5/14 High traffic areas only .Pressure alarm @ all times 2/4/15. Dycem to chairs. 11-10-15 Pull alarm when (up) in chair. 12-3-15 Keep in high traffic area. 12-13-15 Offer position (change) several x's per shift On 2/8/16 at 11:05 A.M., during an interview with the Alzheimer Unit Manager, she indicated she was aware that there had been several falls on her unit. She indicated she did not schedule the staff for her unit. The Unit Manager indicated, We need 3 CNAs and 1 additional nurse besides me on day shift, 3 CNAs and 2 nurses on evening shift, and 2 CNAs and 1 nurse on night shift. The Unit Manager indicated the staff was not currently scheduled at that ratio. The Unit Manager indicated it was especially difficult on her unit, because most of the residents required 1 on 1 attention. The Unit Manager indicated she was trying to get the Environmental aides to do activities with the residents after supper, to assist in decreasing the falls and behaviors. The Unit Manager indicated she also wished she had a more consistent staff, which she felt like would help the residents. On 2/10/16 at 10:45 A.M., the Director of Nursing (DON) provided the current facility policy on Managing Falls and Fall Risk, revised August 2006. The policy included: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .If falling recurs despite initial interventions, staff will implement additional or different interventions 5. On 2/7/16 at 4:40 P.M., during the initial tour of the locked Alzheimer's Unit, LPN # 2 indicated Resident F had exited the facility unattended. The clinical record of Resident F was reviewed on 2/8/16 at 10:20 A.M. [DIAGNOSES REDACTED]. An Elopement Risk Assessment, dated 10/12/15, indicated, Is the resident cognitively impaired with poor decision making skills? Yes. Does the resident have a [DIAGNOSES REDACTED].? Yes. Does the resident ambulate independently .? Yes . Does the resident wander aimlessly? Yes. Does the resident express a desire to go home? Yes Is the resident cognitively impaired and has been observed standing at the exit door waiting for someone to let them out? Yes. Total Score 14. A score of 5 or more is considered to be at risk for elopement. An annual Minimum Data Set (MDS) assessment, dated 11/21/15, indicated Resident F scored a 6 out of 15 for cognition, and required limited assistance of one person to walk in his room and corridor. Nurses Notes included the following notations: 12/5/15 at 2:30 P.M.: Around 1200 (12:00 P.M.) Resident was exit seeking set off alarm for door to unit doors of facility, nurse was able to stop him from leaving facility .Insisted he was leaving 'going home.' .Will cont to monitor. 1/11/16 at 12:00 P.M.: Res. (resident) alert et (and) verbal (with) confusion. Asks to go home often - easily redirected 1/13/16 at 9:45 P.M.: Resident has been up and down about this day wanting to leave going from side to side pushing on doors 1/14/16 at 11:40 P.M.: Resident wanting to leave cursing at staff, pushing on doors, swings arms trying to hit staff et saying .'let me out of here' 1/15/16 at 11:50 P.M.: Resident wanting to leave pacing the floor going from side to side door to door (sic) wanting to leave 1/22/16 at 9:30 A.M.: Attempted to exit fire door. Alarm sounded et res stopped from exiting through door. Res then ambulated down other hall et attempted to exit. Alarm sounded. Res stopped from trying to get door opened. Res redirected. 1/30/16 at 6:20 P.M.: Noted Res. had been restless - ambulating around the unit as res does this daily. Requires supervision - due to exit seeking through the eve. CNA on duty was in a room (with) a resident who was trying to get (up) alone - CNA not familiar (with) the unit - didn't recognize resident was doing out, didn't recognize the alarm - Nurse off unit to BR (bathroom) - Resident went to the road. A Care Plan, dated 12/16/13 and updated for a target date of 2/19/16, indicated, The resident is an elopement risk/wanderer AEB (as evidenced by) Impaired safety awareness . The Interventions included: Disguise exits: stop sign at back door with alarm. Identify pattern of wandering .Monitor location, encourage resident to walk and participate in activity area/day room. Provide structured activities A Care Plan, dated 3/19/14 and updated for a target date on 2/19/16, indicated, The resident has a behavior problem r/t (related to) elopement. Resident paces up and down looking for his car, brother, and wife. Sometimes will stand by the exit door. He lives on the locked unit. Dementia, with agitation. The Interventions included: Anticipate and meet the resident's needs .Keep resident away from the exit doors. Monitor behavior episodes and attempt to determine underlying cause .Resident will walk around the units with staff to help calm down. Take to recliner or room to relax. On 2/8/16 at 10:35 A.M., during an interview with the Alzheimer's Unit Manager, she indicated the previous exit door would open and alarm if someone pressed on it for 15 seconds. The Unit Manager indicated the CNA who was working the evening of 1/30/16 didn't know what the alarm was, and the other staff member was off of the floor. The CNA went to find another staff member to ask them what the alarm meant. The Unit Manager indicated the resident walked to the intersection of a county road outside of the facility, and a passer-by stopped and called the facility. The Unit Manager indicated all staff had since been trained on what the door alarms sound like and to respond immediately to the alarms. According to a weather history data site, the temperature on 1/30/16 at 5:53 P.M. was 48 degrees. On 2/9/16 at 4:15 P.M., the Administrator provided an Incident form sent to the Indiana State Department of Health. The Incident included: Follow up added - 2/4/16 Investigation revealed the following. (Resident F), who resides on the secured Alzheimer's unit, exited the building at the end of A hall and walked in a straight line to a 4-way intersections (sic) at approximately 6:10 pm. The door alarm sounded .A passerby had stopped and was engaging (Resident F) with conversation and called the number on the sign by the intersection to inform staff there might be a resident in the road .Staff signed a 'Door Alarm Response' paper that describes what to do when a door alarm goes off .Staff were taken to the exit doors and were made aware of the sound of the alarm when the bars are being pushed and when the doors open .(Resident F's) Behavior Management plan for exit seeking was updated with interventions that were specific to him On 2/10/16 at 10:20 A.M., the Administrator provided the current facility policy, Elopement Prevention, Identification and Management, undated. The policy included: It is the policy of this facility to ensure that each resident receives adequate supervision and assistive devices to prevent elopements .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or necessary supervision to do so .Prevention of Elopements .The resident's care plan is to be updated to ensure wandering and potential for elopement interventions are included .The facility will perform door alarm testing .for alarm function and staff response to the alarms . The Elopement Prevention and Management Summary indicated: .Try to prevent any elopement before it happens. Try to divert any attempt to leave as nicely as possible. Get help if necessary. Go to any exit door alarm immediately and exit that door to try to find out where the resident went This Federal tag relates to Complaint IN 171 and Complaint IN 350. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented and care plans updated regarding skin breakdown; failed to update the physician of a pressure ulcer; failed to assess pressure ulcers at least weekly; failed to document and assess the reopening of an ulcer; failed to perform treatments as ordered, and failed to arrange transportation to a wound clinic for pressure ulcer care. This resulted in a Stage 3 pressure area on the resident's coccyx, and the redevelopment of a resident's back pressure ulcer, without a documented assessment or treatment order (Resident D), and the increase in size of a resident's Stage 4 pressure area (Resident B). This affected 2 of 4 residents reviewed with pressure areas, in a sample of 11. Resident D and B Findings include: 1. On 1/4/16 at 9:25 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident D had open areas to her coccyx and buttocks. The clinical record of Resident D was reviewed on 1/5/16 at 11:15 A.M. A care plan, initially dated 2/24/15 and with a goal target date of 8/2/15, indicated: Focus: Skin breakdown, potential for related to: decreased mobility, weakness and Peripheral [MEDICAL CONDITION] which has affected resident's BLE's (bilateral lower extremities) and is progressing. Resident requires assistance from staff for all transfers .Interventions: Notify family/physician of any new areas of skin breakdown .Treatments as ordered A care plan regarding current skin breakdown was not found in the clinical record. A Minimum Data Set (MDS) assessment, dated 10/27/15, indicated Resident D was moderately impaired in cognitive skills for daily decision-making, required extensive assistance of two+ staff for bed mobility and transfer, and had no pressure ulcers. A physician's orders [REDACTED]. Apply Stimulen Powder to wound bed. Cover (with) foam dressing QD (every day) et (and) prn (as needed) x 2 weeks then re-eval (re-evaluate). Nurse's Notes did not document the area on the Resident's back. Nurse's Notes included the following notations: 11/11/15 at 3:00 P.M.: This nurse went to (change) drsg (dressing) on back, when this nurse observed open areas on buttocks. Coccyx open area measures 1.2 x .4, Stage II. (Right) buttock open area measuring 4 cm x 1.5. (Left) buttock there are 3 separate (sic) small areas measuring .5 x .7, .5 x .5, et (and) .4 x .1. Hydrogel applied to all et covered (with) foam drsgs 11/19/15 at 2:30 P.M.: N.O. (new order) rec'd (sic) to dc (discontinue) all prev. (previous) wound tx (treatment) to coccyx and buttocks. N.O rec'd .Will continue to monitor. 12/26/15 untimed: Tx done to bilat (bilateral) buttocks/coccyx areas. Appears to be healing well Documentation indicated the 12/26/15 note was the most recent notation in the Nurse's Notes. A Physician's note, dated 12/30/15, indicated, D/C current tx: Begin - Apply hydrogel impregnated gauze to area on coccyx. Apply hydrogel paste to areas on buttocks. Cover (with) [MEDICATION NAME] sacral. D/C when healed. (Change) daily. On 1/5/16 at 10:00 A.M., a skin assessment was requested. RN # 1 assisted the resident to turn. A dressing was observed over the coccyx/buttocks area. When RN # 1 removed the dressing, the buttocks area appeared red and excoriated. An open ulcer, with a yellowish center, was observed on the coccyx. 2 superficial areas were observed on the right buttocks area. On 1/5/16 at 12:10 P.M., skin assessment documentation was requested. RN # 1 indicated she was the staff who was to complete the documentation, but it's probably not up to date. RN # 1 indicated she tried to measure the pressure ulcers weekly, but did not always transfer the information onto the correct forms. RN # 1 provided Resident D's Weekly Pressure Ulcer records at that time. The Weekly Pressure Ulcer records indicated the following: Description of Stages: Stage 1: Intact skin with non-blancheable redness .Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough .Stage 3: Full thickness loss .Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed .Unstageable: Slough and/or eschar (black tissue): Known but not stageable due to coverage of wound bed by slough and/or eschar Date of Onset: Left blank. Site/Location: coccyx. Date 11/11, Stage II. Size in cm (Length x Width) 1.2 x .4. Exudate (drainage) Scant. Wound bed pink, Surrounding skin color pink .Preventive Measures/Progress: Turned q (every) 2 hours. Pressure Relieving Interventions, cushions et mattress. Is resident experiencing pain related to wound? Yes. Date: 11/19, Stage II. Size 1 x 0.5, Depth <0.1 .Tx (changed) Documentation regarding the coccyx pressure ulcer after 11/19/15 was not found. Date of onset: 11-10-15. Site/Location: mid center back. Date 11/10, Stage III. Size 1 x 0.3, Depth 0.1, Exudate scant, Wound bed yellow, Surrounding skin color pink .Response to Treatment/Comments: Stimulen powder (with) foam dressing daily Date 11/19, Stage II, Size 1 x 0.5, Depth <0.1, Exudate Scant .Wound Bed pink Documentation regarding the back pressure ulcer after 11/19/15 was not found. Date of onset: Left blank. Site/Location: Right buttock. Date 11/11, Stage (Left blank). Size 4 x 1.5, Depth (none), Exudate bleeding, Wound bed yellow, Surrounding skin color pink .Response to Treatment/Comments: Hydrogel et foam change daily et PRN Documentation regarding the right buttock pressure ulcer after 11/11/15 was not found. Documentation regarding the left buttock pressure ulcers was not found. On 1/5/16 at 2:50 P.M., another skin assessment was requested. LPN #1 indicated he was unsure if the resident had an area on her back. LPN # 1 and LPN # 2 assisted the resident. An undated duoderm dressing was observed on the resident's lower mid back. LPN # 1 removed the dressing, and a pressure area was observed, with bleeding from the area . LPN # 2 indicated at that time that she would check the resident's treatment record to determine what treatment the resident would receive. The resident's treatment record, dated January 2016, was observed at that time to have no treatment listed for the resident's back open area. LPN # 2 indicated she was aware of the resident having a treatment order for her back the previous month. On 1/5/16 at 3:05 P.M., during an interview with the DON, she indicated she was unaware the resident had an open area on her back. She indicated the area had healed on 12/23/15, and must have reopened. She indicated RN # 1 was responsible for completing the pressure ulcer assessments weekly She indicated the most recent measurements she had received, dated 12/29/15, included: Coccyx: 2 x 1.5 x .2, Right buttock, 1 x 0.5 x .1, and Right buttock, 2 x 2. On 1/6/16 at 1:30 P.M., an additional skin assessment was requested. LPN # 1 assisted the resident, and measured the resident's back pressure ulcer as 1.5 x .3 x <.1 cm. The wound bed was red, without surrounding redness. LPN # 1 indicated he had only been working on that unit for approximately 2 weeks, and was unsure of the etiology of the area. 2. The closed clinical record of Resident B was reviewed on 1/4/16 at 1:30 P.M. [DIAGNOSES REDACTED]. An admission MDS assessment, dated 10/1/15, indicated the resident had a short term and long term memory problem, and was totally dependent on two + staff for bed mobility and transfer. The MDS assessment indicated the resident had 2 unhealed pressure ulcers. A care plan, dated 9/24/15 and with a goal target date of 12/23/15, indicated: Focus, Resident has skin impairment - Admit with chronic decubitus (sic) ulcers to bilateral heels and coccyx areas. Resident does see wound care clinic and (name of physician) for treatment plan to these areas. Interventions: Administer treatments as ordered. Assist with appts (appointments) to wound care clinic (name) as ordered .Use (name) for transfer to (name) wound ctr (center). Wound Care Center notes, dated 11/19/15, indicated, .Wound measurements: Left ischial tuberosity - 2.9 x 2.0 x 0.7, Right heel - 5.0 x 3.2 x 0.3. Wound Care Center notes, dated 12/3/15, indicated, .11-19-15 (Culture and Sensitivity) (positive) Proteus Mirabilis. 1) Nursing bandage change to Right heel Stage 4 pressure ulcer .daily (and) prn. 2) Left ischial tuberosity Stage 4 pressure ulcer .daily (and) prn. Follow up appt. [DATE]. Measurements: Left ischial tuberosity:- 4 x 3.2 x 0.6, Right heel - 7.2 x 4.7 x 0.3. [MEDICATION NAME] (an antibiotic) .x 14 days addition! Wound Care Center notes, dated 12/10/15, indicated, (Left) ischial tuberosity - irrigate wound (with) 20 cc NS (normal saline), skin prep peri wound, barrier cream peri, algidex ag wet gauze, foam q (every) day .(Right) heel stage 4 pressure - irrigate (with) 20 cc NS, barrier cream peri, algidex ag wet gauze, ABD pad, roll gauze q day .Measurements: (Left) ischial - 5.0 x 2.5 x 0.5, (Right) heel - 4.0 x 5.0 x 0.2. F/U (follow up) appt. [DATE]th @ 3:00 pm. Nurse's Notes, dated 12/12/15 at 3:00 P.M., indicated, Treatment done. The next notation in the Nurse's Notes, dated 12/22/15 at 1:15 P.M., indicated the resident was transferred to another facility. Nurse's Notes did not document the resident attended an appointment on 12/17/15. A Medication Administration Record [REDACTED]. The remaining dates were not initialed as completed. On 1/5/16 at 10:30 A.M., during an interview with the DON and Administrator, the DON indicated Resident B did not go to the Wound Care Center on 12/17/15. The DON indicated no staff had set up an appointment with the ambulance service, and another service was contacted but refused to transport the resident due to payment concerns. The DON indicated as far as she knew, the resident did not go to her wound care center appointment after 12/17 and was discharged on [DATE]. On 1/5/16 at 11:40 A.M., during an interview with the responsible family member for Resident B, she indicated she had visited the resident on 12/13/15, and the resident's dressings were dated 12/11/15. The family member indicated nursing staff had informed her they couldn't get everything done. The family member indicated the resident was unable to go to her wound care appointment on 12/17/15, due to the facility not setting up transportation. She indicated the appointment was not rescheduled on 12/18 or 12/19, and she decided to transfer the resident on 12/22/15. On 1/5/16 at 3:05 P.M., during an interview with the DON, she indicated the unit manager was to have filled out weekly pressure ulcer assessments for Resident B, but that they probably were not done. She indicated she did not have any documentation of weekly pressure ulcer assessments for Resident B. On 1/5/16 at 3:45 P.M., the DON provided the current facility policy on Pressure Ulcer monitoring, dated 3/09. The policy included: Purpose: To record on a weekly basis (at a minimum) a complete pressure ulcer description, the response to treatment, and notification of family, doctor, and dietary .Complete this form WEEKLY on every resident with an identified Stage I, II, III, IV, or unstageable pressure ulcer On 1/6/16 at 11:30 A.M., the DON provided the current facility policy on Skin Management, dated November 2014. The policy included: Residents admitted with skin impairments will have: Appropriate interventions implemented to promote healing. A physician's orders [REDACTED].In addition, the following forms are completed and placed with the resident's Treatment Record: .Weekly Pressure Ulcer Record .Wounds are tracked as acquired (developed in-house or admitted with) and are assessed and documented on the Weekly Pressure Ulcer Record .A physician's orders [REDACTED].The Nurse will assure treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner .Pressure ulcers are measured and staged weekly This Federal tag relates to Complaint IN 119. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure care was provided, in that, cognitively impaired, dependent residents admitted without skin impairment developed skin impairment (Resident 109, Resident #182) for 2 of 4 residents reviewed who met the criteria. This deficient practice resulted in Resident #109 experiencing two (2) unstageable wounds to the right heel. Findings include: 1. On 6/29/15 at 8:35 A.M., Resident #109 was observed in the bed on his right side. The right heel was observed, at that time, to have a blue boot on and to be in contact with the surface of the bed. The left heel (medial side) was observed at that time to be in contact with the surface of the bed. A white boot was lying next to his left foot and both heels were not floated. During an interview on 6/29/15 at 8:45 A.M., CNA #6 indicated she had turned and repositioned Resident #109 at 8:30 A.M., and that CNA #6 would turn and reposition Resident #109 again at 10:30 A.M. On 6/29/15 at 9:40 A.M., Resident #109 was observed in bed on his right side. The right heel was observed, at that time, to have a blue boot on and to be in contact with the surface of the bed. The left heel (medial side) was observed, at that time, to be in contact surface of the bed. A white boot was lying next to his foot and both heels were not floated. On 6/29/15 at 10:10 A.M., during an observation of a dressing change, Resident #109 was observed in bed on his right side. The right heel was observed, at that time, to have a blue boot on and to be in contact with the surface of the bed. The left heel (medial side) was observed, at that time, to be in contact with the surface of the bed. A white boot was lying next to Resident #109's foot and both heels were not floated. At that time, LPN #12 indicated the boot should have been on his foot, but the two Velcro straps were missing and could not be secured in place. LPN #12 said, We don't have an abundance of boots here. They are hard to come by. LPN #12 then cleaned and applied sure prep (skin protectant) to a red, non-blanchable area the size of a quarter on the lateral side of left heel, at which time LPN #12 indicated that the area was discovered Friday. LPN #12 then noticed a new unblanchable red area, the size of a nickel, on the medial side of the left heel. The right heel was removed from the boot and two unstageable pressure areas were cleaned and sure prep was applied. At that time, LPN #12 indicated the large, purple pressure area was discovered first, and that a week later the purple area on the inner heel was discovered. LPN #12 indicated Resident #109 had experienced a decline recently and had started developing pressure ulcers. LPN #12 stated, He just doesn't want to get out of bed anymore. LPN #12 exited the room without floating Resident #109's heels or repositioning Resident #109. On 6/29/15 at 11:03 A.M., Resident #109 was observed in bed on his right side. On 6/29/15 at 12:10 P.M., Resident #109 was observed in bed on his right side. On 6/29/15 at 12:28 P.M., CNA #6 was in Resident #109's room and indicated she had just repositioned Resident #109 on his left side. CNA #6 further indicated, she had entered the room to assist Resident #109's roommate when Resident #109 asked her to turn him in bed. The clinical record of Resident #109 was reviewed on 6/26/15 at 9:30 A.M. The clinical record indicated Resident #109 was admitted to the facility on [DATE] with no skin impairment to the right heel and [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #109 was at risk for the development of a pressure ulcer, experienced mild cognitive impairment, and required the assistance of one staff for bed mobility. The last completed Quarterly Nursing assessment dated [DATE] indicated Resident #109 was at risk for the development of a pressure ulcer and had no skin impairment to the right or left heel at that time. A Care Plan dated 12/2/11 indicated, .The resident has potential for impaired skin.r/t (related to).history of skin breakdown.Interventions.The resident needs assistance to turn/reposition at least every 2 hours.Pressure relieving/reducing bed.Administer treatments as ordered.Educate resident.as to causes of skin breakdown.importance of frequent repositioning.6/15/15 sure prep bilat (bilateral heels).heel protectors while in bed float heels. The last update to the care plan prior to 6/15/15 was an update on 1/31/14. The physician's orders [REDACTED]. The CNA assignment sheet dated 5/13/15 was provided by UM #1 and reviewed on 6/25/15 at 10:00 A.M., and it read as follows: .turn and reposition.yes.float heels. A Nurse's note dated 6/1/15 at 1600 (4:00 P.M.) read as follows: .Res (resident) requiring the assistance of 2 for transfers. A Nurse's note dated 6/15/15 at (time not documented) read as follows: .R (right) heel with 2 x 2 soft dark purple UTD (unable to determine) nonblanchable area. tender to touch. N.O. (new orders) Sure Prep q (every) shift and float heels at all times while in bed. A Nutritional Therapy Quarterly Progress note dated 6/22/15 indicated Resident # 109's skin was intact. No supplements were ordered. A WEEKLY PRESSURE ULCER RECORD for the right heel dated 6/15/15 indicated Resident #109 experienced a pressure ulcer to the right heel. The assessment further indicated, un-stageable.non-removable dressing, slough/eschar, suspected deep tissue injury in evolution.dark purple.soft nonblanching.length.2 (two centimeters).width.2 (two centimeters).PREVENTIVE MEASURES.Turned every 2 hours.Pressure Relieving Interventions float heels.6/17/15 heel protectors; Sure prep. The Nutritional/Hydration Status was not completed on the form. A WEEKLY PRESSURE ULCER RECORD dated 6/26/15, (eleven days later) indicated the unstageable pressure area to the right heel had increased in size to 3 cm in length to 3 cm in width. A description of the wounds' appearance was not recorded. A WEEKLY PRESSURE ULCER RECORD for the inner right heel dated 6/26/15 indicated Resident #109 experienced a pressure ulcer to the inner right heel. The assessment further indicated, RISK FACTORS/CAUSE.decline in cond (condition).un-stageable.non-removable dressing, slough/eschar, suspected deep tissue injury in evolution.length.2 (two centimeters).width.1 cm.Sure prep, foam heel protectors, float heels.PREVENTIVE MEASURES.Turned q (every) 2 hours.Air mattress. A description of the wounds' appearance was not recorded. A WEEKLY PRESSURE ULCER RECORD for the inner left heel dated 6/29/15 indicated Resident #109 experienced a pressure ulcer to the inner left heel. The assessment further indicated, .stage 1.intact skin with non-blanchable redness of a localized area usually over a bony prominence.length.2 (two centimeters).width.1 cm. pink soft non-blanchable to left heel.heel protectors, air mattress, float heels. Documentation was lacking for the pressure area located on the left lateral (outer) aspect of the heel which was observed on 6/29/15 at 10:10 A.M. dressing change. A Medication Administration Record [REDACTED].M. An order dated 6/15/15 read as follows: float heels while in bed Documentation was lacking that Resident #109's heels were floated for 13 of the 14 nights during the 7:00 P.M. to 7:00 A.M. shift. An order dated 6/17/15 read as follows: sure prep bilat (bilateral) heels q (every) shift. Documentation was lacking Resident #109's sure prep had been applied to his heels for 9 of the 12 nights on the 7:00 P.M. to 7:00 A.M. shift. An order dated 6/17/15 read as follows: heel protectors while in bed Documentation was lacking that Resident #109's heel protector had been applied to his heels for 9 of the 12 nights for the 7:00 P.M. to 7:00 A.M. shift. During an interview with the UM#1, at the time of the MAR indicated [REDACTED]. During an interview on 6/29/15 at 3:15 P.M., the Unit Manager for C and D halls (UM #1) indicated she was unaware of and could provide no documentation that Resident #109 had a pressure ulcer on the outer left heel. UM #1 indicated on 6/1/15 Resident #109 had experienced a decline. UM#1 further indicated, Resident #109 was at risk to develop a pressure ulcer prior to his decline, but that Resident #109 was at a higher risk to develop a pressure area once he started the decline and did not want to get out of bed. UM #1 indicated no quarterly nursing assessment for determining Resident #109's Braden Scale (scale to determine risk for developing pressure ulcers) had been completed since 10/2014. UM #1 further indicated a new skin risk assessment and revision to the care plan should have been completed when the decline was noticed. UM #1 said, an order for [REDACTED]. During an interview on 6/29/15 at 11:35 A.M., PT#1 indicated Resident #109 was totally dependent for care and could not reposition himself in the bed. PT #1 further indicated Resident #109 was especially weak on his right side. During an interview on 6/30/15 at 4:05 P.M., LPN #12 indicated she was not sure if UM #1 knew about the pressure area on Resident #109's left outer heel. LPN #12 said, It happened on the day we found the two stage 2 pressure ulcers on Resident #109's upper back. There was a lot going on that day, but we have been treating it with sure prep. The Policy and Procedure for Skin Management provided by the Director of Nursing on 6/30/15 at 12:00 P.M. indicated, .Following admission, the Braden Scale - For Predicting Pressure Sore Risk will be completed quarterly, annually, and with a significant change of status.following forms are completed.Weekly Pressure Record.A Care Plan.history of skin impairment or actual impairment.Wounds are tracked as acquired and are assessed and documented on the Weekly Pressure Ulcer Record.Licensed Nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record.A Registered Dietician will assess all residents identified with skin impairments for nutritional status in a timely manner.Pressure ulcers are measured and staged weekly in accordance with the Practice Guidelines. 2. Resident #182 was observed on 6/24/15 at 4:15 P.M., Resident #182 was observed to have bruising around both eyes and a healing laceration to his forehead. At that time during an interview he indicated he had fallen forward from his recliner after falling asleep. He further indicated he had to lean forward and to his side to get off of his sore buttock. Resident #182 was observed on 6/26/15 at 11:14 A.M., Resident #182 was observed sitting in a motorized wheel chair. Resident #182 was observed to be scooted toward the front edge of the wheel chair seat and lean forward while grimacing. At that time during an interview Resident #182 indicated he did this because his buttocks was sore and had been for a long time. He further indicated his family was getting him a cushion to place in his chair and/or recliner but it had not come in yet. On 6/26/15 at 11:22 A.M., Resident #182's skin was observed with Licensed Practical Nurse #2. Resident #182 was observed to have no open areas on his buttock and/or thigh. The clinical record for Resident #182 was reviewed on 6/26/15 at 10:24 A.M., [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] indicated Resident #182 experienced moderate cognitive impairment. A care plan for potential skin impairment was initiated on 10/21/14 it included, but was not limited to, The resident needs, monitoring, reminding and/or assistance to turn and reposition at least every 2 hours, pressure reducing mattress on bed/chair, administer treatment as ordered, follow facility policies protocols for the prevention/treatment of [REDACTED]. A care plan for skin impairment initiated 2/17/15 indicated resident #182 experienced chronic excoriation, to his buttock, and scrotum. Interventions included, but were not limited to, turn and reposition every two hour. A care plan for resident #182 preference to sleep in a recliner was initiated on 10/22/14 it included, but was not limited to, honor residents preference to sleep in recliner, observe for restful nights sleep, keep pressure reducing cushion in chair. A care plan for potential for pain was initiated on 10/21/14. The interventions include, but were not limited to, anticipate the need for pain relief and respond immediately to any complaints, evaluate effectiveness of pain interventions, Observe for and report signs and symptoms of pain to the nurse and report unresolved pain to the medical doctor. On 6/29/15 at 2:50 P.M., Resident #182 was observed in his recliner with Certified Nursing Assistant #5. At that time Resident #182 was observed to not have a cushion to his chair. CNA #5 indicated they did not know if Resident #182 should have a cushion in his chair. Resident #182 indicated his buttock was still very sore. On 6/29/15 at 3:10 P.M., Resident #182's skin was observed with during care with CNA #5 and CNA #19. Resident #182 was observed to have a pencil eraser sized open area on his lower right buttock/thigh area. LPN #2 was notified and assessed the area. During an interview with LPN #2 she indicated Resident #182 had had a cushion in his recliner but it had been taken out due to Resident #182 voicing complaints of sweating. She indicated his family had ordered him a new cushion but was unaware of when it would be received. She indicated she was not aware of another cushion being offered but would ask the therapy department. The clinical record was reviewed. No documentation could be provided, to indicate resident #182 had refused use of a cushion. During an interview on 6/29/15 at 3:05 P.M., Physical therapy assistant #10 indicated Resident #182 had been seen by therapy periodically in the past. She provided documentation that Resident #182 had received a ROHO (type of pressure relief cushion) cushion for his recliner on 1/17/15 and indicated she did not know when the cushion was removed. On 6/30/15 at 3:10 P.M., A Weekly Pressure Ulcer Record dated 6/29/15, it indicated Resident #182 had a Stage 2 wound to his right lower buttock and/or upper thigh area measuring 0.5 x 0.4 x 0.1 centimeters with pain present at the wound. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure effective services were provided to prevent accidents, in that, care was not provided as ordered by the physician (Resident #19), effective interventions were not implemented and/or supervision was not provided (Resident # 8, #74, #182, #137) for 5 of 7 residents who met the criteria for review of accidents. This deficient practice resulted in Resident #10 experiencing a left ankle fracture, Resident #8 experiencing a left arm fracture, Resident #74 experiencing a right ankle fracture. Findings include: 1. Resident #10 was observed on 6/24/15 at 10:30 A.M., sitting in a wheelchair in her room watching television in no apparent distress. The clinical record of Resident #10 was reviewed on 6/26/15 at 9:43 A.M. The record indicated the [DIAGNOSES REDACTED]. The most recent annual MDS (Minimum Data Set) assessment dated indicated Resident #10 experienced no cognitive impairment and required the extensive assist of two staff for transfers. The most recent quarterly MDS assessment dated [DATE] indicated Resident #10 experienced minimal cognitive impairment and required the extensive assist of two staff for transfers. The March 2015 physician's orders [REDACTED]. A Care Plan dated 10/14/14 for Fall Risk Potential for Injury. included, but was not limited to, an intervention of .stand up lift for transfers. The Plan of Care lacked any documentation related to the number of staff required for transfers. A Quarterly Nursing assessment dated [DATE] indicated Resident #10 required the use of an assistive device for all transfers. The assessment lacked any documentation related to number of staff required for transfers. A Nursing note dated 4/14/15 at 9:00 A.M. indicated, .Unit Manager talked to pt. about the incident that occurred Sunday (4/12/15) (with) stand up lift et (and) pt L (left) foot was hurt. pt stated there was only (one) person that assisted her back to bed et she tried to tell her foot was under the pedistal (sic) . An untimed Interdisciplinary Team Progress note dated 4/14/15 indicated, .happened 4/12/15 2100 (9:00 P.M.) Pt was being transferred to bed per stand up lift via 1 person that is assist of 2. L foot with shoes on got caught under the pedistal (sic).Intervention inservice staff on use of stand up lift and pt needs assist of 2 @ (at) all times. A Radiology report dated 4/13/15 at 3:12 P.M. indicated, .Impression: Acute fracture lateral margin of the talus (ankle). The Policy and Procedure for Lifting provided by the DON (Director of Nursing) on 6/26/15 at 11:30 A.M. indicated, .Transfer Activity is performed by nursing personnel based upon the Resident's needs. The Policy and Procedure for Lifting provided by the DON on 6/26/15 at 2:00 P.M. indicated, .Using a Portable Machine Level of Responsibility.2. To promote comfort and to maintain body alignment while the resident is being moved. During an interview, at that time, the DON indicated Resident #10 should have been transferred with the required amount of staff. 2. On 06/25/15 at 9:30 A.M., Resident #8 was observed in a TV lounge sitting in a wheelchair with a cast on the left upper extremity. During an interview 6/25/15 at 10:06 A.M., UM #10 indicated Resident #8 experienced a fall on 6/16/15 and received a fractured left arm. The clinical record of Resident #8 was reviewed on 6/29/15 at 9:30 A.M. The record indicated Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] indicated Resident #8 was a high risk to experience a fall. A Care Plan dated 1/31/15 for Potential for Falls related to.psychotropic med use, confusion. with interventions of, assist with toileting every two hours and as needed, encourage resident to be compliant with limitations and to ask for assistance as needed, ensure proper footwear, evaluate all falls for cause and attempt to prevent further falls, innitiate (sic), keep call-light in reach and encourage resident to use it to ask for assistance, notify family and physician of all falls, PT (Physical Therapy/OT (Occupational Therapy) to evaluate and treat as needed, place Dycem (name of anti-slip device) in w/c (wheel chair) The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #8 experienced minimal cognitive impairment, required the limited assist of one staff for transfers and/or walking, had no history of falls prior to admission and/or had experienced 1 fall since admission to the facility. A Quarterly MDS assessment dated [DATE] indicated Resident #8 experienced moderate cognitive impairment, required the limited assist of one staff for transfers and/or walking, and had experienced no further falls. Fall #1: A Nursing note dated 4/4/15 at 9:15 P.M., indicated Resident #8 experienced a fall from a bed side commode. The note lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #2: A Nursing note dated 4/5/15 at 2:30 P.M., indicated, Resident #8 experienced a fall from a wheelchair. The note lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #3: A Nursing note dated 4/12/15 at 2:10 P.M., indicated Resident #8 experienced a fall from a wheelchair. The note lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #4: A Nursing note dated 4/26/15 at 3:05 P.M., indicated Resident #8 experienced a fall. The note lacked any documentation related to the resident's location at the time of the fall. The note further lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #5: A Nursing note dated 5/7/15 at 10:15 P.M., indicated Resident #8 experienced a fall from the bed and received a bruise to the left hip. The note lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #6: A Nursing note dated 5/15/15 at 3:30 P.M., indicated Resident #8 experienced a fall while independently ambulating with a walker. The note lacked any documentation adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #7: A Nursing note dated 5/15/15 at 10:00 P.M., indicated Resident #8 experienced an unwitnessed fall in the hallway, a non-functioning bed alarm was observed on the bed and/or an immediate intervention of new alarm was initiated to ensure the safety of Resident #8. During an interview on 6/29/15 at 11:50 A.M., UM #10 indicated no documentation could be provided to indicate when the bed alarm was initiated. Fall #8: A Nursing note dated 5/18/15 at 3:00 P.M., indicated Resident #8 experienced a fall from a chair in the dining room. The note lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #9: A Nursing note dated 5/21/15 at 8:00 P.M., indicated Resident #8 experienced a fall from a chair in the dining room. The note lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new. immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #10: A Nursing note dated 5/29/15 at 2:50 P.M., indicated Resident #8 experienced a fall from a chair in the dining room. The note lacked any documentation related to safety equipment in use, adequate supervision was provided, and/or a new. immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. Fall #11: A Nursing note dated 5/30/15 at 9:00 A.M., indicated Resident #8 experienced a fall from a sit to stand lift. The note lacked any documentation related to the safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. The most recent Quarterly MDS assessment dated [DATE] indicated Resident #8 experienced moderate cognitive impairment, required the limited assist of one staff for transfers and/or walking, and had experienced 3 additional falls since the previous quarterly assessment. A Fall Risk assessment dated [DATE] indicated Resident #8 was at a high risk to experience a fall. Fall #12 A Nursing note dated 6/16/15 at 10:00 P.M., indicated Resident #8 experienced a fall from a chair and fell on left arm.noted indentation to left arm above wrist. The note lacked any documentation to related safety equipment in use, adequate supervision was provided, and/or a new, immediate, and/or effective intervention was initiated to ensure the safety of Resident #8. A Care Plan for Falls dated 5/30/15 lacked any documentation a new, immediate, and/or effective intervention was initiated after each fall and/or adequate supervision was provided at the time of the falls on 4/4/15, 4/5/15, 4/12/15, 4/26/15, 5/7/15, 5/15/15 (two falls), 5/18/15, 5/21/15, 5/29/15, 5/30/15, 6/16/15. An X-ray report dated 6/16/15 at 11:59 P.M. indicated, .Impression: Displaced impaction fracture of the distal radius (large bone in the forearm). Ulnar styloid (area the secondary bone in the forearm) fracture is also seen. During an interview on 6/29/15 at 12:15 P.M., UM #10 indicated no documentation could be provided to indicate new, immediate, and/or effective interventions were initiated after each fall and/or adequate supervision was provided to prevent the 12 falls between 4/4/15 and 6/16/15. UM #10 further indicated, at that time, she was not aware new, immediate, and/or effective interventions to ensure the safety of Resident #8 should have been implemented after each fall. UM #10 then indicated, Resident #8 should have received adequate supervision and/or been re-assessed after each fall to prevent further falls. 3. On 6/26/15 at 9:32 A.M., Resident # 74 was observed on secured unit A asleep in a recliner with a black boot device on his right foot. No distress or behaviors were noted. On 6/25/15 at 2:50 P.M., Resident #74's clinical record was reviewed. [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. His quarterly Minimum Data Set assessment ((MDS) dated [DATE], indicated a severe cognitive impairment and the limited assistance of 1 staff for transfers, bed mobility, and ambulation in room and corridor. A MDS annual assessment dated [DATE], indicated a severe cognition impairment and independence in transfers and bed mobility. The assistance of 1 staff had been needed for ambulating in room and corridor. Resident #74's current fall care plan had been initiated on 11/9/13, and addressed the problem of, The resident has potential for falls r/t (related to) Unaware of safety needs and history of heart block with pacemaker placement. Goal was The resident will be free of falls through the review date. Interventions included but were not limited to, reminder sign (4/27/15), pull tab alarm in bed and a motion detector by bed (4/29/15), discontinue tab alarm and start pressure alarm when in bed (6/1/15), and last intervention dated 6/10/15 was to use of a pressure alarm at all times. On 6/29/14 at 4:09 P.M., Nurse Manager #10 of the A and B unit of the secured units of the facility was interviewed in regard to Resident #74's (who resided in the A unit) falls. The following nursing notes were reviewed with Resident #74's Nurse Manager at that time: Nursing note dated 4/27/15 at 12:15 A.M., indicated,Resident was walking up hallway from room and fell against door hitting back of head. Large knot and laceration noted to back of head. Large amt (amount) of blood present pressure dsg (dressing) applied to back of head and cool cloths applied. Nursing note dated 4/27/15 at 12:30 A.M., indicated, Dr. (physician's name) on call for Dr. ( physician's name) notified of fall MN (new)/O(order) rec'vd (received) to send to ER (emergency room ) for eval (evaluation). Weekend Manager notified of fall. Agree c (with) Dr. to send to ER. Nursing Note 4/27/15 at 3:00 A.M., indicated, Report rec'd (received) from (hospital name) ER. CT Scan of head was negative. Res (resident) ambulatory, 3 staples to back of head. Res to be returned to facility. During interview with the Nurse Manager #10 at that time (6/29/15 at 4:09 P.M.) she indicated before the 4/27/15 fall, Resident #74 had been up ad lib with his walker with a pressure alarm on at night. Nurse Manager #10 also indicated the resident had been walking in the hall and hit his head. The intervention after the fall had been a reminder sign to call for assistance with transfers. Nursing notes dated 4/29/15 at 9:30 P.M., indicated, Res.(resident) alarm sounding in room. Responded-found Res lying on floor beside bed. States he is not sure why he was getting up. Nurse Manager #10 indicated at that time the alarm had sounded and the resident was found on the floor. Nurse Manager #10 indicated a motion sensor alarm and a pull tab alarm in bed was initiated after the 4/29/15 fall and the pressure alarm when in bed was then discontinued. Nursing note dated 5/29/15 at 10:45 P.M., indicated, 'Resident was attempting to get out of bed. Got tangled in blankets slid to floor. Nurse Manager #10 indicated at that time, after the 5/29/15 fall the resident's tab alarm was discontinued due to the resident taking it off and a pressure alarm was again initiated in bed. Nursing note dated 6/9/15 at 11:45 P.M., indicated, CNA called for this nurse to come to room 4. Res (resident) was on floor. Res. alarm was in place c (with) alarm box in drawer of bedside table. Alarm was not sounding. Upon assessment of res noted two reddened areas on back et (and) res c/o (complaint) pain to R (right) ankle/foot. Noted edema but no discoloration. Nursing note dated 6/10/15 at 3:00 A.M., indicated, Call received from (name of staff) @ (hospital name) ER to update on res condition. Res (resident) fractured R(right) ankle, OCL(orthopedic casting lab splint) cast in place. Non- weight bearing. Interview with Nurse Manager #10 at that time indicated, Resident 74's alarm should not have been in the drawer. The Nurse Manager also indicated she thought the resident had turned off his alarm. She indicated the intervention after the fall had been to discontinue the low bed. She indicated the resident now needed the assistance of 2 for transfers and was non weight bearing. Nursing note dated 6/15/15 at 8:00 A.M., indicated, This nurse was in med (medication) room when the CNA came and said resident was on the floor. When I got down to the room, the resident was laying on his right side. Resident stated that he was not having any pain. V/S (vital signs) were obtained. Resident was helped up off the floor et placed in chair c (with) alarm. Et at approximately 0815 (8:15 A.M.) the CNA again comes to me et said the resident is once again on the floor, when I arrived to the room the resident was again on his right side and sustained (zero) injuries. Nurse Manager #10 indicated after the 6/15/15 fall, a recliner was used for the resident due to the resident frequently asked to go to bed and can't remember he can't walk. The Nurse Manager indicated the recliner as an intervention had not been added to the care plan yet. Nursing notes dated 6/17/15 at 6:30 P.M., indicated, Resident sitting in dayroom in recliner this nurse walked in et resident slid off bottom of recliner, alarm behind head buttocks et legs on floor assisted back to chair c (with) help of staff no injuries noted. Nurse Manger #10 indicated after the 6/17/15 fall, the pressure alarm was added for all times not just in bed. Nursing notes dated 6/28/15 at 7:15 A.M., indicated, Summoned to res. (resident) room by CNA Res. was down on his knees next to his bed. 0 (zero) c/o (complaint) pain/disc. (discomfort) @ this time voiced by res. ROM (range of motion) WNL (within normal limits) 0 (zero) injuries. Nurse Manager #10 indicated she had added a pull tab alarm at all times after the 6/28/15 fall. She also indicated she was going to get the resident up early around 7:00 A.M., so he wouldn't be so restless. On 6/29/15 at 4:38 P.M., Nurse Manager #10 was made aware of the problem of a lack of supervision in regard to preventing falls for Resident #74. Nurse Manager #10 agreed there had been a lack of supervision to prevent Resident #74's falls. 4. Resident #182 was observed on 6/24/15 at 4:15 P.M., Resident #182 was observed to have bruising around both eyes and a healing laceration to his forehead. At that time, during an interview he indicated he had fallen forward from his recliner after falling asleep. He further indicated he had to lean forward and to his side to get off of his sore buttock. During this observation no pull tab alarm, no Dycem (a no slip surface) and no mat to floor in front of recliner was observed. Resident #182 was observed on 6/26/15 at 11:14 A.M., Resident #182 was observed to be scooted toward the front edge of the wheel chair and lean forward while grimacing. At that time, during an interview Resident #182 indicated he did this because his buttock was sore and had been for a long time. He further indicated his family was getting him a cushion to place in his chair and/or recliner but it had not come in yet. During this observation no pull tab alarm, no Dycem (a no slip surface) and no mat to floor was observed in place. On 6/26/15 at 2:50 P.M., Resident #182 was observed in his recliner with CNA #5 at that time, Resident #182 did not have a cushion to his chair, no tab alarm in place and no mat to the floor. During an interview with CNA #5 they indicated they were unaware of what interventions for safety were to be in place for Resident #182. A mat was observed folded up behind a bedside commode in the room. The clinical record for Resident #182 was reviewed on 6/26/15 at 10:24 A.M., [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] indicated Resident #182 experienced moderate cognitive impairment. The nurses notes were reviewed and included, but were not limited to, 2/19/15 at 0125 (1:25 A.M.) CNA responded to call light upon entering room -(sic) found resident flat on face on floor. The note indicated Resident #182 had bit his tongue, and sustained multiple bruises, abrasions and hematomas. Resident #182 was sent to the emergency room for evaluation and upon return a pull tab alarm was added as an intervention. An Interdisciplinary Team (IDT) Progress note dated 2/19/15 at 11:00 A.M., was reviewed and included, but was not limited to, while sitting upright resident he fell asleep et (and) fell out of chair. A pull tab alarm was added as an intervention. A nurse note dated 3/8/15 at 8:35 A.M. included, but was not limited to, This nurse heard yelling from down the hall. This nurse proceeds down the hallway to find res. (resident) on floor. Resident #182 received no injuries from this fall. An IDT progress note dated 3/9/15 at 10:00 A.M., included, Resident yelling out from room for help nurse entered room to find res (resident) lying on right side.Res. was assisted back into recliner. Dycem placed to seat et (and) Res. educated to ask staff for assist into wheel chair for offloading from buttocks. A nurses note dated 6/22/15 at 2230 (11:30 P.M.) was reviewed it included, but was not limited to, .CNA's made this nurse aware Res on floor in room face down and has blood pooling by nose.,.Has laceration on forehead 1.5 centimeters (cm) x (by) 3 cm . Under L (left) eye 1 cm x 3 cm laceration., Res 0 (no) acute stress. Res stated he fell asleep and fell out of chair. Resident #182 was sent to the hospital for evaluation and returned with stitches to both lacerations. No immediate interventions related to the safety of resident #182 were listed in the nurse ' s notes. A fall care plan initiated 10/21/14 was reviewed, interventions included, but were not limited to, .Evaluate all falls for cause and attempt to prevent further falls, innitiate (sic) appropriate interventions,. PT/OT (physical therapy and ocupational therapy) evaluate and treat as needed.,. (2/19/15) pull tab alarm to recliner @ (at) all x's (times) initiated.,.(3/19/15) apply Velcro to recliner, provide res (resident) education re: not scooting to end of recliner which then (sic) then causes pt. (patient) to slide out of recliner. During an interview with UM #9 on 6/30/15 at 3:30 P.M., she indicated Resident #182 should have a mat in front of his recliner, a pull tab alarm and dycem to the recliner. 5. During a random observation on 6/29/15 at 3:00 P.M. through 3:10 P.M., Resident #137 was observed in the Unit A dining room, sitting in chair within the confines of a stand up lift. During the random observation, AA (Activity Assistant) #10 was observed at a neighboring table, conducting an activity and nursing staff were observed to not be in the dining room. During an interview, at that time, AA #10 indicated NA (Nursing Assistant) #11 placed Resident #137 in the stand up lift and left the dining room. During an interview on 6/29/15 at 3:10 P.M., NA #11 indicated Resident #137 had been left unattended within the confines of the lift to help another staff member for about 3 minutes. During an interview on 6/29/15 at 3:13 P.M., CNA #12 indicated residents should never be left unattended after being placed in a lift. During an interview on 6/29/15 at 3:15 P.M., the UM #1 indicated Resident #137 should not have been left unattended in the dining room after being placed in a lift. The Policy and Procedure for Fall Management provided by the DON (Director of Nursing) on 6/30/15 at 10:30 A.M. indicated, .All residents will be assessed.for significant change.The IDT (Interdisciplinary Team) modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care plan will be .revised as indicated.Each facility is responsible for implementing individualized interventions related to/for each resident's fall risk. The Policy and Procedure for Lifting: Using a Portable Machine provided by the DON on 6/30/15 at 12:45 P.M., lacked any documentation related to the use of a stand up lift. During an interview on 6/30/15 at 11:00 A.M. the DON indicated no specific policy for fall prevention could be provided, but it was the usual practice of the facility to provide adequate supervision to prevent falls. 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify the physician and family of an open area, failed to document the appearance of the open area and obtain treatment for [REDACTED]. Resident C Findings include: 1. The closed clinical record of Resident C was reviewed on 2/2/15 at 10:10 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Nursing Assessment, dated 12/23/14 and untimed, indicated: "Feet, diabetic, Pedal pulses present...Orientation: Alert to Person, Confused...General Skin Condition: Bruises..." An anatomical drawing did not indicate any open areas on the resident's feet. Nurse's Notes, dated 12/23/14 and untimed, indicated, "Resident arrived...Skin pale dry in General lower extremities swollen lightly moist reddish purple pedal pulses present...Unable to bear wt (weight) on (right) side. Alert to self (with) confusion. Will continue to monitor." A Nursing Care Plan, dated 12/23/14, indicated: "Skin breakdown, potential for related to: decline in mobility, thin fragile skin...Interventions: Notify family/physician of any new areas of skin breakdown, Pressure relief on bed/chair as ordered, Treatments as ordered, Turn and reposition every two hours and as needed." Nurses Notes, dated 12/24/14 at 6:00 A.M., indicated, "...Resident alert (with) periods of confusion...Immobilizer intact to Rt (right) leg as ordered. Has +2 [MEDICAL CONDITION] (swelling) to BLE (bilateral lower extremities) et (and) BLE dark pink in color. Able to move toes freely. Pedal pulses (present) - legs warm to touch. Bilat legs elevated...." A Minimum Data Set (MDS) assessment, dated 12/29/14, indicated the resident had a short-term and long-term memory problem, and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident had no pressure ulcers or other wounds of the feet. An Occupational Therapy note, dated 12/31/14, indicated, "Pt (patient) noted to have discharge from open area on L (left) heel; nursing notified and bandage applied." A Physical Therapy note, dated 12/31/14, indicated, "Notified nrsg (sic) of open area on L heel...." Nurse's Notes, dated 12/31/14 and untimed, indicated, "Dr. called due to congestion. N.O. (new order) Keflex (antibiotic)...." Documentation regarding the open area, notification of the physician of the open area, a care plan or treatment of [REDACTED]. A Medication Administration Record, [REDACTED]. A "Weekly Body Assessment," dated 1/1/15, indicated, "(No) new areas." Nurse's Notes included the following notations: 1/2/15 at 10:30 P.M.: "...Alert (with) confusion. Transfers (with) assist of (two)...Remains on A/B (antibiotic) therapy for URI (upper respiratory infection)...." 1/4/15 at 6:00 A.M.: "...Cont. on ABT (antibiotic) for URI...RLE (right lower extremity) immobilizer in place...Refused any food or fluid offered...Will continue to monitor resp. (respiratory) status et encourage oral intake et to take meds." 1/5/15 at 3:00 P.M.: MD notified of pt. (change) of condition; BLE redness/swelling. Pt refusing to eat/drink...New order received (sic) to send to (hospital) for eval (evaluation)...." A facility "MD Report," dated 1/5/15, indicated, "Issue to be addressed by MD: Top of Left great toe black. Bilateral feet et (and) legs red, looks like [MEDICAL CONDITION]. Resident also not eating well." The resident was transferred to the hospital on [DATE] at 3:15 P.M. A hospital Emergency Department record, dated 1/5/15 at 3:58 P.M., indicated, "Nursing Assessment: Skin/Soft Tissue: Decubitus ulcer noted over Bilateral heels have area of breakdown. Note that on the left heel the area on the heel is dark black color, is approx (sic) 4 cm (centimeters) x 2 cm with no open area. He also has a pea sized dark black area on the left great toe that is not open. Note that on the right heel, he has the same dark black area that is approx 5 cm x 2 cm and it does have an open area that is draining serosanguineous drainage. He come (sic) to ER with a 4x4 bandage over the open area to contain the drainage...Chief Complaint: Decreased appetite, BLE redness...Per nursing home report, patient had decreased to no appetite since he has been a resident there which was two weeks ago...Patient is confused and cannot answer questions...BLE are reddened with slight [MEDICAL CONDITION]. Pulses are positive. Note decubitus on bilateral heels...Primary Diagnosis: [REDACTED]. A hospital History and Physical, dated 1/6/15, indicated, "...Skin: Warm and dry. There is some bright red [DIAGNOSES REDACTED] (redness) from below the knees bilaterally. There is an open ulcer on the right heel...The left heel is black and the left first toe is black on the tip. Pulses are not palpable in either foot for my exam. There is slow capillary refill of the left foot...." A hospital Discharge Summary, dated 1/12/15, indicated, "Discharge Diagnoses: [REDACTED]. 2. Bilateral heel decubitus ulcers with dry gangrene. 3. [MEDICAL CONDITION].Hospital Course:...nursing home patient with multiple medical problems...He was sent to theER on this occasion because of increased redness and swelling of both lower leg (sic) and black eschar like ulcer on both heels...There was also mild to moderate bilateral [MEDICAL CONDITION] on arterial Doppler exam...." On 2/2/15 at 2:10 P.M., during interview with Physical Therapist Assistant (PTA) # 1, she indicated she wrote the Physical Therapy note on 12/31/14. She indicated when she and the Occupational Therapist went to get Resident C out of bed, they noticed drainage on the sheet from his heel area. She indicated she did not actually look at the area, but that she notified the nurse. PTA # 1 indicated the nurse came in and put a dressing on the resident's heel. On 2/2/15 at 3:00 P.M., during interview with the Director of Nursing (DON), she indicated she was unable to find additional information regarding the resident's skin condition prior to his 1/5/15 hospitalization . 2. On 2/3/15 at 10:45 A.M., the DON provided the current facility policy "Patients at risk for Pressure Ulcers," dated 11/09. The policy included: "All residents will be assessed on admission and routinely thereafter for skin breakdown. Prevention will be identified and implemented to prevent the development of pressure wounds...Head to Toe Assessments, Purpose: Is to be able to assess the patient's skin more freq (sic) for changes and start preventive, protective as well as supportive measures...Any Abnormalities found should be placed on the appropriate skin recorded (sic)...Skin Condition Weekly Progress Report...If a nurse should find any skin alterations...they are responsible for completing a skin record at that time...The recommendations and or changes will be reported to the residents (sic) attending physician timely...." This Federal tag relates to Complaint IN 390. 3.1-37(a)

A. Based on observation, interview, and record review, the facility failed to ensure effective safety interventions and/or supervision were provided, in that, effective interventions were not implemented to prevent further falls, for a resident identified as having cognitive impairment with intermittent confusion and the resident experienced 3 falls for 1 of 4 residents who met the criteria for review of falls. This deficient practice resulted in the resident experiencing a hip fracture. (Resident #100) B. Based on observation, interview, and record review, the facility failed to ensure supervision was provided during meal time, in that, 2 residents who required aspiration precautions were not monitored during a meal for 1 of 4 residents in the A unit dining room during 1 of 2 meal observations (Resident # 135) and for 1 of 6 residents in the C/D unit dining room during 1 of 2 meal observations. (Resident #168) Findings include: A. During an interview on 05/07/14 at 2:37 P.M., Resident #100 was observed lying in bed and stated, "...I broke my leg here and had surgery..." The clinical record of Resident #100 was reviewed on 05/13/14 at 3:00 P.M. The record indicated Resident #100 was admitted on [DATE] with [DIAGNOSES REDACTED]. The record further indicated Resident #100 had experienced multiple falls after admission to the facility. The Admission MDS (Minimum Data Set Assessment) dated 03/31/14 indicated Resident #100 experienced mild cognitive impairment, limited range of motion to one side of the body, and required assistance with balance during walking. The assessment further indicated Resident #100 had experienced a fall with injury since admission to the facility. The Physician's admission orders [REDACTED]" and lacked any orders related to safety devices. The Admission Nursing assessment dated [DATE] indicated Resident #100 required 1 (one) person assist with ambulation and included a handwritten notation, "slightly flaccid CVA right side". The form further indicated Resident #100 was alert and oriented to person, place, time and experienced confusion during the assessment. A Fall Risk assessment dated [DATE] indicated Resident #100 experienced a balance problem while standing and walking, decreased muscular coordination, problems walking through doorway, jerking/unstable making turns, required assistive device and was a high risk to experience a fall. The Plan of Care lacked any documentation related to a care plan for prevention of falls and/or safety precautions before 03/26/14. A Nurse's note dated 03/25/14 at 11:30 (A.M./P.M. not specified) indicated Resident #100 was admitted to the facility and lacked any documentation safety interventions were implemented to ensure the safety of Resident #100. Fall #1: A Nurse's note dated 03/26/14 at 0400 (4:00 A.M.) indicated, "CNA entered room noted res (resident) on floor...several skin tears noted to bilateral arms...Res stated, 'I came out of bathroom and just went down..." The note lacked any documentation related to safety equipment or an immediate intervention being initiated to ensure the safety of Resident #100. A Fall Risk assessment dated [DATE] indicated Resident #100 was not at a high risk to experience a fall. A Rehab (Rehabilitation) Screen dated 03/26/14 indicated Resident #100 experienced a decline in cognition and "decrease in safety and problem solving..." A Care Plan for Potential for Falls initiated on 03/26/14 identified the following interventions were initiated: "..Assist with toileting every two hours and as needed, education about calling for assist with transfers and reminder sign placed in room, encourage resident to be compliant with limitations and to ask for assistance as needed, ensure proper footwear, evaluate all falls for cause and attempt to prevent further falls, innitiate (sic) appropriate interventions, keep call-light in reach and encourage resident to use it to ask for assistance, notify family and physician all falls...PT/OT (Physical Therapy/Occupational Therapy) to evaluate and treat as needed..." An undated, untimed IDT (Interdisciplinary Team) Progress Note indicated, "On 03/26/14 at 0400 during routine rounds, Res was found lying on floor near bathroom. When questioned stated she was going to the bathroom et (and) did not use call light which was in place. Stated she hit her forehead on the floor...Sustained skin tear...to left hand outer aspect...LFA (left forearm) inner aspect...right hand...Has pull tab alarm that res was carrying when she fell . Educated about using call light for assist to prevent fall. Verbalized understanding. Reminder sign to call for help before getting up placed in room." A Nurse's note dated 04/02/14 at 1430 (2:30 P.M. indicated, "...A/O (Alert and oriented)...with some confusion. Occasionally tries to get up without assist..." A Nurse's note dated 04/02/14 at 2245 (10:45 P.M.) indicated, "Res. up in bathroom by herself, alarm was in bed. Res. stated she took it off. Educated Res. about alarm and safety..." A Nurse's note dated 04/07/14 at 10:25 A.M. indicated, "A/O...with periods of confusion..." A Nurse's note dated 04/07/14 at 1400 (2:00 P.M.) indicated, "Res. re-educated on safely transfering (sic) expresses understanding..." A Nurse's note dated 04/18/14 at 1915 (7:15 P.M.) indicated, "Res walking around in room unassisted. Alarm was turned off by resident by her own admission...Res bent down and turned alarm back on. This nurse...encouraged to res to use call light for assistance et not to turn off alarms but res c/t's (continues) to be non-compliant with alarms..." An MDS worksheet dated 04/22/14 indicated Resident #100 experienced moderate cognitive impairment Fall #2: A Nurse's note dated 04/26/14 at 0700 (7:00 A.M.) indicated, "Res. self transferred (sic) to BR (bathroom) ended on floor in Rm (room) Unable to move without pain..." A Nurse's note dated 04/26/14 at 10:30 (A.M./P.M. not specified) indicated, "Res admitted (to hospital) with fractured right hip." A Nurse note dated 04/26/14 at 1800 (6:00 P.M.) indicated, "Late Entry for 04/25/14 at 1700 (5:00 P.M.) Spoke with resident about safety alarm. Stated, 'I know I need help. I sure don't want to fall.' Assured this nurse that she would con't (continue with safety precautions et always use call light. Alarm removed..." An X-ray report dated 04/26/14 indicated, "..mildly angulated intertrochanter (head of femur) fracture..." A Care Plan for Potential for Falls dated 04/26/14 indicated a new intervention of, "pressure pad alarm at all times for safety..." was initiated. An undated, untimed IDT Progress Note indicated, "On 04/26/14 at 0700, staff heard a loud noise coming from resident's room. Found resident lying on right on floor near closet...d/t (due to) recent compliance with safety alarm being reported, alarm was removed et remained compliant with using call light for assist...Dtr (daughter) notified...agreed with reporting nurse that res fully understood the safety need to use call light..." A Fall Risk assessment dated [DATE] indicated Resident #100 experienced intermittent confusion and was a high risk to fall. A Nurse's note dated 04/29/14 at 1630 (4:30 P.M.) indicated, "Res. returned to facility ...had right hip fx (fracture)...alert et pleasantly confused..." A Fall Risk assessment dated [DATE] indicated Resident #100 was a high risk to fall. A Rehab Screen dated 04/30/14 indicated Resident #100 experienced a decline in cognition and "...cognitive decline reported..." A Nurse's note dated 05/01/14 at 1545 (3:45 P.M.) indicated, "...Alert with periods of confusion.." Fall #3: The Nurse's notes from 05/01/14 at 1545 through 05/03/14 at 1945 (7:45 P.M.) lacked any documentation Resident #100 experienced a fall. A Physician's Telephone Order dated 05/03/14 at 1500 (3:00 P.M.) indicated, "Send to ER (emergency room ) for eval (evaluation)...fall.." A Nurse's note dated 05/03/14 at 1945 indicated, "Res returned to facility from (name of hospital)..." A Fall Risk assessment dated [DATE] indicated Resident #100 was a high risk to fall. An undated, untimed IDT Progress Note indicated, "On 05/03/14 at 1500 (3:00 P.M.) nurse summoned to room by CNA who found res on floor on knees beside bed...recently fell in this facility d/t noncompliance using call light et fractured...hip...stated she was trying to walk from recliner to the other side of the room to answer the telephone. Call light noted to be clipped to recliner...stated she understood what the call light was for. Noted that pressure pad alarm was switched off. Investigation proved that she pulls alarm, clipped on the back of recliner by the cord toward her to turn off. When questioned about this stated, 'I don't remember.' Pull tab alarm added. Spoke with res about being moved to a room closer to the nurse's station..." A Care Plan for Potential for falls dated 05/03/14 indicated a new intervention of, "Alarms out of reach..." was initiated. A Nurse's note dated 05/05/14 at 1630 (4:30 P.M.) indicated, "Conts (continues to get up unassisted et turns off alarms. Res states she doesn't remember she had call light et that she doesn't know how to use it..." A Nurse's note dated 05/05/14 at 1810 (6:10 P.M.) indicated, "Went to res room et found pressure alarm off again..." An untimed Nurse's note dated 05/06/14 indicated, "...room change..." The Nurse's notes from 05/06/14 through 05/13/14 indicated Resident #100 continued to experience episodes of confusion, but had not disabled the safety equipment and experienced no further falls. A Care Plan for "impaired cognitive r/t (related to) short term memory loss" dated 05/07/14 included, but was not limited to, "The resident needs supervisions (sic) with all decision making..." During an interview on 05/13/14 at 3:00 P.M., UM (Unit Manager) #1 indicated a fall risk assessment was not done before removing the alarms on 04/25/14 and supervision and/or new interventions were not provided to Resident #100 after the alarm was removed on 04/25/14. UM #1 further indicated at that time, Resident #100's room was located at the far end of the hall from 03/25/14 through 05/06/14 and staff couldn't get to her in time. UM #1 then indicated, Resident #100 experienced no further falls after the resident's room was located closer to the nursing station and the staff was better able to supervise the resident. During an interview on 05/14/14 at 12:45 P.M., the DON (Director of Nursing) indicated Resident #100 was identified as a high risk to fall upon admission to the facility, but no documentation could be provided to indicate safety interventions were implemented before the fall on 03/26/14. The DON further indicated, at that time, Resident #100 experienced intermittent confusion from 03/25/14 through 04/26/14 and only resident education and reminders were initiated after each occurrence of Resident #100 successfully disabling the alarms and/or each attempt to transfer independently. A Policy and Procedure for Fall Protocol provided by the DON on 05/14/14 at 12:45 P.M. indicated, "It is the policy of this facility to attempt to prevent injuries to any resident...2. Those resident identified, as high risk will be placed on High Risk Fall Protocol...5. Any resident that has fallen and or made attempt to transfer self with out (sic) assistance will have fall risk Interventions put into place immediately at the time of the fall or attempt..." B. 1. On 5/7/14 at 12:34 P.M., dining in the A unit day room was observed. CNA #2 was observed to set a lunch tray on a bedside table located adjacent to the table where Resident #135 was sitting. CNA #2 than exited the day room, and entered a resident room across the hall and shut the door, remaining in the room until 12:45 P.M. During the time CNA #2 was not present, Resident #135 was observed to stand up, reach across the dining room table and grab food off of the tray with her hands and start to eat. On 5/8/14 at 11:44 A.M., during an interview with Unit Manager #5 (UM #5) she indicated, the A unit day room contained residents who needed less distraction during meals. She indicated that the residents in that dining room would normally be supervised but they had to prioritize the needs of all residents on the unit. She indicated one of the residents (Resident #135) was at risk for aspiration. The Speech Language Pathologist (SLP #4) was interviewed on 5/8/14 at 2:32 P.M. She indicated resident #135 was considered at risk for aspiration on 5/7/14 and had been evaluated 3/24/14 due to a cognitive decline and difficulty with expulsion of chewed foods. The medical record for Resident #135 was reviewed on 5/8/14 at 2:20 P.M., [DIAGNOSES REDACTED]. A Speech Therapist Progress & Discharge Summary dated 4/10/14 indicated Resident #135 remained at risk for aspiration and required staff cueing and/or supervision. The physician's orders [REDACTED]. The care plans were reviewed and included risk for nutritional problems related to Parkinsonism, dementia, confusion initiated 9/20/12 revised 4/15/14. The interventions included aspiration precautions and monitor, document, report to medical doctor as needed any signs of dysphasia (chocking, coughing, and drooling) On 5/8/14 at 12:30 P.M., UM#5 provided a policy dated 5/8/14. It included, "... THE FOLLOWING RESIDENTS WHO REQUIRE SPECIAL ATTENTION AND MAY OR MAY NOT BE ASPIRATION PRECAUTIONS WILL SIT IN THE DAY ROOM...., ...AT ALL TIMES A STAFF MEMBER WILL BE IN ATTENDANCE TO ASSIST WITH FEEDING AND MONITORING. THE STAFF MEMBER WILL REMAIN FOR THE DURATION OF THE MEAL AND NOT LEAVE THE RESIDENTS UNATTENDED..." 2. On 5/14/14 at 8:31 A.M., no staff was observed in C & D dining room. Six residents (Residents #75, 168, 102, 10, 4, and 167) were observed sitting at dining room tables finishing their breakfast. On 5/14/14 at 8:33 A.M., CNA #14 entered the dining room and assisted Resident #4 out of the dining room. On 5/14/14 at 8:34 A.M., no staff was observed in the C& D dining room. Resident's #75, 168, 102, 10, and 167 remained at the dining room tables with their meal trays eating at intervals. Resident #168 continued to finish eating his breakfast at 8:35 A.M. On 5/14/14 at 8:36 A.M., CNAs # 6, 7, and 9 entered the C & D dining room to assist residents. On 5/14/14 at 8:38 A.M., CNA #6 was interviewed at that time regarding residents who were at risk for aspiration. She indicated at that time that Resident #168 was at risk for aspiration. His 5/14/14 breakfast tray sheet on the table by his plate indicated, "...ASP. (aspiration) PRECAUTION/THIN LIQS (liquids) LCS Mech Soft (low concentrated sweets mechanical soft diet..." CNA #6 also indicated staff was to supervise residents in the dining room who were at risk for aspiration. She indicated she had left the dining room due to a female resident needing to toilet. She indicated when she had left the dining room to assist the female resident other staff had been present in the dining room to supervise residents eating. On 5/14/14 at 8:50 A.M., the Director of Nursing (DON) was interviewed regarding supervision in the dining room of residents at risk for aspiration precautions. She indicated residents at risk for aspiration in the dining room needed staff supervision. She indicated usually nurses were also present in the dining room to supervise at meal times. On 5/14/14 at 9:07 A.M., Resident #168's clinical record was reviewed. His [DIAGNOSES REDACTED]. His current May 2014 physician orders [REDACTED]. His current care plan with an initiated date of 12/15/13, and a target date of 6/20/14, addressed the problem of "Potential for alteration in nutrition..." Interventions included but were not limited to, "...Aspiration precautions per facility policy..." On 5/14/14 at 9:34 A.M., the DON provided a facility policy (dated 2010) entitled, "Policy and Procedure Subject: Aspiration Precautions/Dysphagia Protocol..." The policy included but was not limited to, "...8. The nursing staff shall provide the appropriate amount of mealtime supervision per recommendation of the SLP (Speech Language Pathologist)..." On 5/14/14 at 3:45 P.M., Speech Therapist (ST) #1, provided a speech therapy discharge note for Resident #168, dated 2/24/14. The discharge note included but was not limited to, "...Pt (patient) presently on mechanical soft diet with thin liquids. Pt requires set up and cues for feeding..." During an interview at that time ST #1 indicated that Resident #168 continued to need supervision at meal times and remained at risk for aspiration. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure supervision was provided to a cognitively impaired resident at risk for falls while sitting on the commode, resulting in a fall and left hip fracture, for 1 of 6 residents reviewed for falls, in a sample of 6. Resident A Findings include: 1. On 10/26/12 at 10:00 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident A had fallen and obtained a fracture. The DON indicated the resident had periods of confusion. On 10/26/12 at 11:30 A.M., Resident A was observed lying in bed. Bruising was observed on the left forehead area. The clinical record of Resident A was reviewed on 10/26/12 at 1:50 P.M. [DIAGNOSES REDACTED]. A Care Plan, dated 6/14/11 and updated 7/21/12, indicated: "Problem, Fall risk, Potential for Injury: Related to: Unsteady gait, Cognitive deficits, Weakness, Use of psychotropic medications, Impaired mobility, Balance problem, CVA with left sided weakness... As evidenced by: History of falls, Unable to ambulate, Unable to transfer without assistance...May be up with assist times two, gait belt, pivot transfer...." A Nursing Assessment, dated 8/15/12, indicated, "...Non ambulatory, (Left) side paralysis d/t (due to) CVA...Functional Status, 2 person assist...Paralysis...Communication/Mood/Behavior, garbled speech, Alert to person...Bedrail Safety Assessment...Does resident have difficulty with balance or poor trunk control? (Yes)...Fall Risk Assessment...Disoriented x 3 at all times, Chair bound - requires assist with elimination, Not able to perform gait/balance test...Total score 10 ("A score of 10 or more represents high risk for falls")." A Minimum Data Set (MDS) assessment, dated 8/19/12, indicated the resident scored a 5 out of 15 for mental status, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for transfer and toilet use, and did not ambulate. A test for balance while moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer indicated "Not steady, only able to stabilize with staff assistance." Nurse's Notes included the following notations: 10/11/12 at 6:45 P.M.: "CNA calling me to Rs (resident) room. I find Rs (resident) lying on her abdomen on floor by BSC (bedside commode)...denies pain, hip Fx (fracture) assessment neg (negative), purple bruise (with) lump noted to (left) forehead, slight abrasion to (right) knee...Neuro (checks) initiated, ROM (range of motion) same as before fall, LOC (level of consciousness) (no change)...ice pack applied to (left) forehead." 10/12/12 at 3:00 A.M.: In bed, awake, (no) c/o pain/discomfort." 10/12/12 at 9:00 A.M.: Res. (resident) now beginning to c/o generalized LLE (left lower extremity) pain. (Nothing) specific just states 'hurts.' Upon assmnt (sic) (no) internal/external rotation noted to the LLE...Bump remains to Lt (left) side of forehead...(Pts (patient's) LLE has hx (history) of being effected (secondary to) CVA). Pt usually rings her call light when needs (assist) off BSC- pt. simply stated 'forgot to ring my call light.' Informed CNAs to not leave res. unattended on BSC. Will have chg nurse to notify (physician) to obtain X-rays to R/O (rule out) any Fx's...." 10/12/12 at 9:05 A.M.: "Call out to (physician) spoke...about incident et (and) Res c/o pain LLE. Awaiting return call from MD." 10/12/12 at 10:35 A.M.: "Received (sic) call from MD to send res to ER for Xray of Lt hip, Lt pelvic, et Left Femur..." The resident was transferred to the hospital on [DATE] at 11:05 A.M. A Nurses Note, dated 10/12/12 at 4:00 P.M., indicated, "Received call from hospital nurse states res will be admitted D/T (due to) Fx of Lt hip et they will be doing surgery...." On 10/26/12 at 2:30 P.M., during interview with Unit Manager # 1, she indicated staff always pinned the call light to the resident's shirt, and she would ring when she was done using the commode, due to she requested privacy. Unit Manager # 1 indicated the resident told the staff that she forgot to use the call light and she fell off of the commode. On 10/29/12 at 3:15 P.M., during interview with CNA # 1, she indicated she and another CNA helped Resident A get on the commode on 10/11/12. CNA # 1 indicated the other CNA left to give a shower, and she went down the hall and "came right back." CNA # 1 indicated, "I guess she (Resident A) fell off." CNA # 1 indicated she was new to the facility, and thought it was okay to leave the resident by herself with her call light. 2. On 10/30/12 at 10:45 A.M., the Director of Nursing provided the current facility policy on "Accidents prevention," dated 2006. The policy included: "...Adequate supervision and assistance devices to prevent accidents. The facility identifies residents who may be at risk for accidents and/or falls...Assessments and care plans are used to develop and implement procedures to prevent accidents. This is especially significant when the resident has...cognitive loss, dementia...." This federal tag relates to Complaint IN 308. 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure a resident at risk for dehydration received the recommended amount of fluids daily, resulting in hospitalization for dehydration, for 1 of 3 residents reviewed for fluid intake, in a sample of 3. Resident A Findings include: 1. The clinical record of Resident A was reviewed on 9/10/12 at 11:20 A.M. [DIAGNOSES REDACTED]. A care plan, dated 6/29/12, indicated a problem of "At risk for dehydration Related to: Daily use of diuretic. New to facility. Dx (diagnosis): Alzheimers." Interventions included: "Observe for poor skin turgor, concentrated urine, dry skin...lethargy... Encourage fluids...Keep MD informed of changes in resident condition...." Physician orders, dated 7/2/12, indicated, "[MEDICATION NAME] (diuretic) 40 mg, Take (1) tablet by mouth once daily [MEDICAL CONDITION](hypertension)." A Dietary Manager note, dated 7/9/12, indicated, "Res. (resident) receives a Regular diet as ordered. Res. is offered 1560 cc fluids dly (daily) (with) meals...." An admission Minimum Data Set (MDS) assessment, dated 7/11/12, indicated the resident scored a 4 out of 15 for mental status, with 15 indicating no memory impairment. The MDS assessment indicated the resident was independent with set-up help only for eating. A Nutrition Risk Assessment, dated 7/11/12 and signed by the Registered Dietician, indicated the resident required 2568 cc total fluids daily. Nurse's Notes included the following notations: 9/1/12 at 9:45 P.M.: "Pt. (patient) alert but confused...Tray set (up) per staff in D.R. (dining room). Tried to encourage him to eat but would not eat much...stated he wasn't hungry...tried to get him to eat a snack later but took only 1/2 of pudding et (and) milk...." 9/3/12 at 9:15 A.M.: "Res alert (with) confusion...Appetite good @ breakfast...Will cont to monitor." 9/4/12 at 9:30 P.M.: "...Fed per staff 90% of meal et took 240 cc...." 9/5/12 at 10:00 A.M.: "Res. appears to be very tired. I fed him breakfast. He ate an egg (and) 1/2 piece of toast. Refuses all his 0700 (7:00 A.M.) meds (medications)...Will cont. to monitor." 9/6/12 at 1:30 P.M.: "Res. @ lunch table (with) family. Family c/o (complains of) Res 'unresponsive' et breathing heavily...Family states want resident sent to E.R." The resident was transferred to the emergency roiagnom on [DATE] at 1:45 P.M. A hospital emergency room note, dated 9/6/12, indicated, "...he is very, very lethargic...Physical Exam:...dry mucous membranes...He had a laboratory workup (sic)...His comprehensive metabolic profile was impressive with a BUN of 46 (6-20 normal limits) and creatinine 1.45 (.50-1.20 normal limits), those are up for him. Sodium 156 (136-145 normal limits)... chloride 122 (96-106 normal limits)...I think it will take a couple of days to sort all of this out and give him fluids and get his electrolytes straightened out. Assessment: 1. Lethargy, dehydration, electrolyte imbalance with severe [MEDICAL CONDITION] (high sodium level)...." A hospital history and physical, dated 9/6/12, indicated, "...He was evaluated in the emergency room and found to have significant electrolyte disturbance and dehydration...Impression: Dehydration with [MEDICAL CONDITION]." On 9/11/12 at 10:20 A.M., the meal consumption record of Resident A was reviewed. The record indicated the resident received the following daily fluids: 9/1/12: 1080 cc 9/2/12: 1380 cc 9/3/12: 1060 cc 9/4/12: 540 cc 9/5/12: 540 cc 9/6/12: 120 cc On 9/11/12 at 11:50 A.M., during interview with the Administrator and Director of Nursing (DON), the DON indicated residents residing on the Alzheimer's unit have frequent activities which provide additional fluids, and she would think that the residents usually consume enough fluids. On 9/11/12 at 2:25 P.M., the Director of Nursing provided the current facility policy on "Hydration Management Process," undated. The policy included: "Appropriate fluid balance will be maintained for all Residents. Residents will be assessed and monitored for inadequate fluid intake...Nursing, Activities and other appropriate staff will be inserviced on the hydration needs for the elderly...Specific interventions will be communicated to care givers responsible for the delivery of care...Fluids intake sheets will be reviewed by designated care giver and referred to RD (Registered Dietician) as appropriate...." This federal tag relates to Complaint IN 141. 3.1-46(b)

Based on interview and record review, the facility failed to ensure a resident who was having frequent loose stools and was being treated for [REDACTED]. Resident C Findings include: The closed clinical record of Resident C was reviewed on 1/3/11 at 12:40 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Nursing Assessment, dated 10/8/10, indicated the resident was cognitively impaired with poor decision making skills, was incontinent of bowel and bladder, and was independent with eating. The resident was hospitalized from [DATE] to 10/16/10 with the [DIAGNOSES REDACTED]." A "Nutrition Risk Assessment," dated 10/18/10, indicated the recommended total fluid intake was "2154 cc" daily. A physician's orders [REDACTED]." The resident was transferred to the hospital on [DATE] and returned the same day with the [DIAGNOSES REDACTED]." Nurse's Notes included the following notations: 12/17/10 at 2:00 A.M.: "...confused to place et (and) time...Continues on [MEDICATION NAME] (an antibiotic) for UTI...." 12/17/10 at 6:00 P.M.: "Remains confused. Total care (with) all ADL's (activities of daily living). Had loose stools x 2...." 12/19/10 at 1:30 P.M.: "Res (resident) had ls (loose) stool x 2...Incontinent of B/B (bowel and bladder)... (name of physician) aware of ls stool (with) N.O. (new order)...." A physician's orders [REDACTED]. [MEDICATION NAME] 250 mg...(three times daily) x 7d for GI distress." A physician's orders [REDACTED]." Nurse's Notes continued: 12/23/10 at 10:00 A.M.: "...has had (no) loose stools today yet...fluids enc (encouraged) et taken in water well (sic). Incont of B/B...Chem 8 (lab) reported to (physician) (with) N.O." A physician's orders [REDACTED]." 12/23/10 at 1:30 P.M.: "Res very lethargic @ this x - had (no) ls stool until staff went to get res (up)...CNA reports had to feed res lunch she was unable to feed herself - notified (physician) of (change) in condition (with) N.O. to send to ER...." 12/23/10 at 5:00 P.M.: "(Hospital) phoned et res admitted (with) DHD (dehydration)." A "BM Monitoring" form, dated December 2010, indicated the following stools: 12/16, 2 medium loose; 12/17, 5 extra large loose and 2 medium loose; 12/18, 2 medium loose and 1 medium watery; 12/19, 2 medium loose, 1 medium watery, and 1 extra large watery; 12/20, 3 large loose +; 12/21, 3 large loose; 12/22, 2 large loose, 1 medium loose, 3 extra large loose. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received [MEDICATION NAME] one time on 12/23/10 (untimed). Resident C's intake and output record, dated December 2010, indicated the following 24 hour fluid intake: 12/16, 480 cc; 12/17, 1440 cc; 12/18, 1980 cc; 12/19, 1630 cc; 12/20, 600 cc; 12/21, 600 cc; 12/22, 1840 cc. A Plan of Care, dated 12/19/10, indicated a problem of "Fluid Volume Deficit related to Inadequate fluid intake, Diarrhea Intermittent, 12-19-10 [MEDICATION NAME] as ordered, [MEDICATION NAME] as ordered, 12-21-10 [MEDICATION NAME] as ordered. Clear liquid diet as needed, Increase (water) intake, 12-19-10 [MEDICATION NAME] adm. - loose stools stopped. 12-23-10 Despite efforts to (increase) fluids (which pt (patient) had been taking in) admitted to (hospital) - Dx (diagnosis) dehydration...." The Interventions included, "Monitor for poor skin turgor, concentrated urine, dry skin...diarrhea, lethargy...Monitor fluid intake and output every shift. Encourage fluids as ordered 12-19 Res fed...." A Plan of Care regarding hydration status was not observed in the clinical record prior to 12/19/10. The hospital clinical record of Resident C was reviewed on 1/4/11 at 9:45 A.M. An emergency room Nurse's Note, dated 12/23/10 at 2:45 P.M., indicated, "...diarrhea x 1 week. Has had (increased) lethargy. Upon arrival incontinent of BM...not oriented. Skin turgor poor...." An emergency room Note, dated 12/23/10, indicated, "...she had a history of [REDACTED]." On 1/4/11 at 12:30 P.M., during an interview with LPN # 1, she indicated she was the normal day shift nurse taking care of Resident C. LPN # 1 indicated the resident did not have any loose stools for her, but had heard she did for other staff. On 1/4/11 at 12:45 P.M., during an interview with the Director of Nursing (DN), she indicated nursing would be unaware of the required fluid intake recommended by the dietician unless a diet communication would be sent to nursing. The DN indicated she did not know why nursing would not have given the resident the medication ordered for diarrhea, but that the facility had recently changed the way BMs were documented. This federal tag relates to Complaint IN 086. 3.1-46(b)