Every finding on record at Avon Health & Rehabilitation Center

Based on observations and interviews, the facility failed to ensure medications and topical gels were labeled and stored appropriately in medication carts and failed to ensure expired medications were not stored on medication carts or in the medication storage room refrigerator. This deficient practice had the potential to affect 60 of 60 residents residing on 100, 300, and 400 halls (Residents 128, 127, 74, 26, 132, 75, and 80). Findings include:On 2/23/26 at 10:00 a.m. the 100-hall medication cart was reviewed with Licensed Practical Nurse (LPN) 5. The findings were as follows: 1. Resident 128 had an Incruse Ellipta (a once-daily, long-acting inhaler) 62.5 micrograms (mcg) that had no open date. LPN 5 wrote a date of 2/22 on the bag indicating she had opened it on the 22nd but forgot to put a date on it. 2. Resident 127 had Arnicare topical gel (a homeopathic topical gel used to temporarily relieve muscle pain) that was stored in the same drawer and next to oral medications. On 2/23/26 at 10:30 a.m. 300-hall medication cart was reviewed with Registered Nurse (RN) 6. The findings were as follows: 1. Resident 74 had a Trelegy (a once-daily, combination prescription inhaler) dated 1/10.2. Resident 74 had an albuterol inhaler (a rapid-acting inhaler) dated 1/10.3. Resident 26 had an albuterol inhaler dated 1/10.4. Resident 132 had Diclofenac topical gel (a nonsteroidal anti-inflammatory drug (NSAID) applied topically to relieve joint pain) stored in the same drawer and next to oral medications.5. A bottle of Over the Counter (OTC) vitamin D3 with a written label on the bottle, but the label had been rubbed off so much it was unreadable. On 2/23/26 at 11:00 a.m. the 400-hall medication cart was reviewed with LPN 7. The findings are as follows: 1. Resident 75 had a bottle of Memantine Hydrochloride (a prescription NMDA receptor antagonist used to treat moderate to severe dementia) that had no pharmacy label on it. LPN 7 indicated she believed it had originally come in a box with a pharmacy label on it, but the box must have gotten thrown away at some point. She indicated they had written the resident's nickname on the lid of the bottle, but there should be a pharmacy label on the bottle. 2. There were several OTC medications, vitamin D3 5000 units (u), vitamin B12 1000mcg, align probiotic, aspirin 81mg and Centrum women's multi-vitamin all that had only AM or PM written on them. There were no labels and no Resident name. LPN 7 indicated the medications were Resident 80's, and that the am and pm indicated when the medications were to be given. LPN 7 indicated the resident's family wrote the AM and PM on the bottles. On 2/23/26 at 11:30 a.m. the 400-hall medication storage refrigerator was reviewed with LPN 7. The findings are as follows: 1. There was a loose vial of Tubersol (A diagnostic tool used to detect tuberculosis infection. It is administered via intradermal injection, with results read 48-72 hours later) that was open and did not have an open date on it. On 2/23/26 at 12:28 p.m. a copy of a current facility policy titled, Medication Storage, dated 11/1/23 was provided. That policy indicated, .3. External products:.drugs for external use are stored separately from internal.8.the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for.outdated.deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Medications policy. On 2/23/26 at 12:28 p.m. a copy of a current facility guideline titled, Product Expiration Dates, dated 5/2023 was provided. That guideline indicated albuterol inhalers expired one week after opening if they were stored outside of the foil package and Ellipta's including Trelegy and Incrusa, expired 42 days after they were opened. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-25(j), 16.2-3.1-25 (m), and 3.1-25(n).

Based on record review and interview, the facility failed to reconcile a resident's medications upon discharge for 1 of 3 residents reviewed (Resident 125).Findings include:On 2/23/26 at 10:05 a.m., a record review was completed for Resident 125. She had the following diagnoses which included but were not limited to muscle weakness, cerebral infarction (stroke), aphasia (difficulty speaking), major depressive disorder, and osteoporosis.Resident 125 discharged from the facility with family on 1/27/26 at 4:08 p.m.During an interview with the Director of Nursing (DON) on 2/23/26 at 1:32 p.m., she indicated the resident was discharged in a rush and her medications were gathered and sent with her.Resident 125's record lacked documentation of medication reconciliation when the resident discharged on 1/27/26.According to Resident 125's physician orders indicated medications that should have been reconciled included: Alendronate (used for arthritis) 70 mg (milligrams), atorvastatin (for high cholesterol) 80 mg, cholecalciferol (a supplement) 50 mcg, famotidine (for the stomach) 20 mg, miraLAX (for constipation) 17 gm (grams), mirtazapine (for depression) 30 mg, potassium chloride 10 meq (milliequivalent), prenatal (a supplement) 27-1mg, thiamine (a supplement) 100 mg, Eliquis (a blood thinner) 2.5 mg, Keppra (for seizures) 100mg/ml (milliliter), protonix (for the stomach) 40 mg, and lactulose (used for constipation) 10gm/30 ml.A policy titled, Drug Disposition, revised on 7/24, was provided by the DON on 2/23/26 at 11:20 a.m. It indicated, Discontinued, outdated, or deteriorated medication shall not be maintained or used in the facility. Medications shall be disposed of in compliance with federal, state, and local laws.

Based on observation, interview, and record review, the facility failed to develop and provide the resident and/or family representative with a copy of the resident's baseline care plan and physician orders within 48 hours of admission for 3 of 4 resident reviewed (Residents 123, 125, and 52). Findings include:1. On 2/20/26 at 12:08 p.m., a record review was completed on Resident 123. He had the following diagnoses which included, but were not limited to, muscle weakness, myocardial infarction (heart attack), history of falling, arthritis, and essential hypertension. Resident 123 had an admission assessment completed on 1/15/25 at 6:40 p.m. The care plan section of the assessment was left blank. On 1/20/26 at 12:00 a.m., a Living Well Meeting was conducted for Resident 123. It indicated Resident 123's daughter was present, but the document lacked a signature indicating she received a copy of the care plan and physician orders. 2. On 2/23/26 at 10:05 a.m., a record review was completed for Resident 125. She had the following diagnoses which included, but were not limited to, muscle weakness, cerebral infarction (stroke), aphasia (difficulty speaking), major depressive disorder, and osteoporosis. Resident 125 had an admission assessment completed on 12/29/25 at 8:00 p.m. The care plan section of the assessment addressed only her fall potential. On 1/17/26 at 1:54 p.m., a Living Well Meeting was conducted for Resident 125. It indicated a phone call was held with the daughter. The section was left blank, indicating the daughter did not receive a copy of the care plan and physician orders. On 2/24/26 at 11:03 a.m., the Director of Nursing (DON) indicated they used the Living Well assessment for the baseline care plans. 3. On 2/19/26 at 11:00 a.m., Resident 52 was initially observed. She was seated in a wheelchair in her room and waited for lunch to be delivered. She indicated she was a new resident and there for rehabilitation (rehab) after a fall at home and surgery at the hospital. She felt weak and was afraid of falling again. On 2/20/26 at 10:27 a.m., Resident 52's call light was observed illuminated and blinking. Housekeeper 3 stopped an unidentified passing Certified Nursing Aide (CNA) and indicated Resident 52 had been waiting a while and needed to use the bathroom, she was afraid she was going to have an accident. The CNA indicated an apology, and that she was the only CNA for the hall at that time and would go to Resident 52 next. On 2/20/26 at 10:35 a.m., the CNA entered Resident 52's room to assist her to the toilet. On 2/23/26 at 10:53 a.m., Resident 52's record was reviewed. She was admitted on the Friday evening of 2/6/26 and resided on the rehab hall. She was admitted for the need for assistance with personal care and rehabilitation following a fall at home which resulted in a fracture that required surgical intervention at the hospital. She had additional diagnoses which included, but were not limited to, a history of falling, and stroke. A nursing admission assessment, dated 2/6/26, the baseline care plan section of the assessment was left blank. She had a fall risk assessment, dated 2/6/26, which indicated she was at risk for falls. A care plan for her risk of falls was not implemented with interventions the following Monday, 2/9/26. On 2/24/25 at 11:15 a.m., the DON provided a copy of the policy titled, Baseline Care Plan, dated 11/1/23. It indicated, .The baseline care plan will be developed within 48 hours of a resident's admission .A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

Based on record review and interview, the facility failed to follow physician's orders regarding the parameters of blood pressure medications for 2 of 5 residents reviewed for unnecessary medications (Residents 7 and 9) and daily weights for 2 of 5 residents reviewed for unnecessary medications (Residents 126 and 70). Findings include: 1. Resident 7's record was reviewed on 2/20/26 at 11:55 a.m. Diagnoses on the resident's profile included, but were not limited to, essential primary hypertension (high blood pressure) and chronic diastolic congestive heart failure (left side of the heart becomes thick and leads to fluid build-up in the body). A physician's order, dated 8/13/25, indicated hydralazine (blood pressure medication) 25 milligrams (mg) by mouth three times daily for hypertension, hold if systolic blood pressure (top number of blood pressure) was less than 110, and notify the physician if the medication needed to be held. A physician's order, dated 11/27/25, indicated isosorbide (dilates blood vessels) extended release (ER) 30 mg by mouth once daily for hypertension, hold if systolic blood pressure was less than 110 or diastolic blood pressure (bottom number of blood pressure) was less than 60. A physician's order, dated 11/27/25, indicated losartan (blood pressure medication) 100 mg by mouth once daily for hypertension, hold if systolic blood pressure was less than 110 or diastolic blood pressure was less than 60. A physician's order, dated 11/26/25, spironolactone (blood pressure medication) 25 mg by mouth once daily for heart failure, hold if systolic blood pressure was less than 110 or diastolic blood pressure was less than 60. A Medication Administration Record (MAR), dated December 2025, indicated the resident's diastolic blood pressure was less than 60 on 12/1/25, 12/2/25, and 12/15/25, at the time of the administration of the isosorbide, losartan, and spironolactone. The MAR lacked documentation the isosorbide, losartan, or spironolactone were held, or the physician was notified of the resident's blood pressure. A MAR, dated January 2026, indicated the resident's systolic blood pressure was less than 110, on 1/1/26 at bedtime, on 1/4/26 in the evening, and on 1/5/26 in the morning, at the times of the scheduled hydralazine administrations. The MAR lacked documentation the hydralazine was held, or the physician was notified of the resident's blood pressure. The resident's systolic blood pressure was less than 110 on 1/5/26 in the morning, and the resident's diastolic blood pressure was less than 60, on 1/11/26, 1/14/26, 1/15/26, and 1/23/26, in the morning at the time of the scheduled isosorbide, losartan, and spironolactone administrations. The MAR lacked documentation the isosorbide, losartan, or spironolactone were held, or the physician was notified of the resident's blood pressure. A MAR, dated February 2026, indicated the resident's systolic blood pressure was less than 110, on 2/14/26 in the morning, and the resident's diastolic blood pressure was less than 60, on 2/3/26, 2/4/26, 2/11/26, and 2/20/26, in the morning, at the time of the scheduled isosorbide, losartan, and spironolactone administrations. The MAR lacked documentation the isosorbide, losartan, or spironolactone were held, or the physician was notified of the resident's blood pressure. Progress notes, dated December 2025, January 2026, and February 2026, lacked documentation the blood pressure medications were held as ordered by the physician or the physician was notified when the resident's blood pressures were outside of the parameters. A care plan, goal target dated 5/13/26, indicated the resident had essential primary hypertension of unknown origin. Interventions included, but were not limited to, check the resident's blood pressure as ordered by the physician, observe for patterns, and administer blood pressure medications as ordered by the physician. During an interview, on 2/23/26 at 9:38 a.m., the Director of Nursing (DON) indicated blood pressure medications should have been held as ordered by the physician, according to the parameters. There had been an issue with the staff not holding the medications at times, and they were working on it. 2. On 2/24/26 at 11:24 a.m., a record review was completed for Resident 9. He has the following diagnoses which included but were not limited to hypertension and heart disease. Resident 9 had an order, dated 12/8/25, for metoprolol succinate extended release (ER) (a medication used to treat high blood pressure) 50 mg one time daily for hypertension. Hold for systolic blood pressure less than 95 or a pulse less than 60. On 2/9/26 Resident 9's blood pressure was 92/56 and his pulse was 72. The February MAR indicated the nurse administered his metoprolol and did not hold it as ordered. Resident 9 had a care plan, dated 11/29/24, indicating he had hypertension of unknown origin. The goal indicated his blood pressure would be managed to a range with his care plan interventions. An intervention indicated he would take his blood pressure medications as ordered. On 2/23/26 at 12:45 p.m., during an interview with the DON she indicated the facility was performing a quality assurance performance improvement plan (QAPI) for parameters for compliance. She indicated the nurse practitioner prescribed a lot of parameters and they were trying to decrease the number of orders. 3. On 2/24/26 at 11:32 a.m., a record review was completed for Resident 126. He had the following diagnoses which included, but were not limited to, muscle weakness, respiratory failure, and congestive heart failure (CHF). Resident 126 had an order, dated 12/14/25, for daily weights on day shift for heart failure, notify the physician of weight gain of more than 2 pounds in one day or 5 pounds in a week. The January MAR indicated between 1/4/26 and 1/5/26 he had a weight gain of 2.6 pounds. Resident 126's record lacked documentation the physician was not notified. The February MAR indicated between 2/1/26 and 2/2/26 he had a weight gain of 3.4 pounds. Resident 126's record lacked documentation the physician was not notified. The February MAR indicated between 2/5/26 and 2/6/26 he had a weight gain of 3.4 pounds. Resident 126's record lacked documentation the physician was not notified. Resident 126 had a care plan, dated 12/3/25, indicating he had heart failure as evidenced by shortness of breath. The goal was for resident to allow himself to be weighed as the physician ordered. An intervention indicated he would be monitored for shortness of breath, edema (swelling), periorbital (eye) edema, sacral (back) edema, dry cough, distended neck veins, weight gain, crackles and wheezes in lungs. 4. On 2/23/26 at 9:47 a.m., Resident 70's record was reviewed. He was a long-term care resident with diagnosis which included, but was not limited to, congestive heart failure (CHF). He had a current physician's order, dated 12/30/25, for daily weights related to CHF. A nutrition progress note, dated 1/12/26 at 2:19 p.m., indicated Resident 70 triggered for a 5% weight gain since December, a 7.5% weight loss since October, and a 10% weight loss since September. Resident's weight fluctuated due to diagnosis of heart failure and recent illnesses. On 1/13/26 he was re-started on a daily diuretic, Torsemide 20 milligrams a day, for CHF and bilateral lower edema. A nursing progress note, dated 1/15/26 at 10:17 p.m., indicated he continued on his diuretic and edema was still noted in his bilateral lower extremities. Resident 70's daily weights were noted missing on the following dates: January 8, 12, 16, 17, 21, and 30; and February 3, 5, 6, 9, 12, 13, 17, and 21, 2026. The policy titled, Following Physician Orders/Parameters, dated 5/2018 and revised 4/2024, indicated, .To administer resident care in a safe and effective manner and following physician orders and ordered parameters.All licensed healthcare providers shall consult the resident's medical orders for the appropriate physician/clinician order prior to administering or performing a resident procedure.check MAR/TAR for physician/clinician order.Licensed healthcare personnel will consult and follow the physician/clinician order when performing any resident procedures.Note any contraindications the resident may have prior to performing a procedure.Check for vitals signs, other tests to be done as prescribed by resident's physician/clinician.evaluate resident for appropriate or accurate response to orders.Notification of Physician/Clinician will be made with resident refusals of physicians order. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-37(a).

Based on interview and record review, the facility failed to ensure a Hoyer lift (mechanical lift) transfer was completed safely to prevent falls for 1 of 2 residents reviewed for accidents (Resident 4). The deficient practice was corrected by 2/13/26 prior to the start of the survey and was therefore past noncompliance. Findings include:During an interview, on 2/19/26 at 10:40 a.m., Resident 4 indicated he was dropped out of the Hoyer lift when a bolt came off, and he fell. Resident 4's record was reviewed on 2/23/26 at 12:44 p.m. Diagnoses on the resident's profile included, but were not limited to, acquired absence of left leg, below the knee. A progress note, dated 2/3/26 at 9:30 a.m., indicated the writer was alerted to an emergency in the resident's room and arrived to find the resident on the floor. The staff assisted the resident back to bed. A progress note, dated 2/3/26 at 10:47 a.m., indicated there were new orders for x-rays related to the resident's fall. A situation, background, assessment, recommendation (SBAR) note, dated 2/3/26 at 12:44 p.m., indicated the resident complained of pain after being observed on the floor between the mechanical lift wheelbase. The nurse practitioner (NP) ordered x-rays of the lumbar and thoracic area (lower back). A progress note, dated 2/3/26 at 6:26 p.m., indicated the resident had x-rays performed after the fall, but they were unable to be read due to poor imaging related to the resident's anatomy. The resident no longer complained of pain, the physician and NP were consulted, and agreed further imaging would be ordered if necessary. An interdisciplinary team (IDT) note, dated 2/4/26 at 12:04 p.m., indicated a staff member assisted the resident with transferring, and the resident fell to the floor. The staff member utilized the mechanical lift for the transfer, the equipment malfunctioned, and the resident fell. The root cause was the resident was being transferred with a staff member present, and the equipment malfunctioned. The intervention was to remove the equipment from the resident's room. A care plan, goal target dated 5/3/26, indicated the resident required assistance with activities of daily living (ADLs) due to the left below the knee amputation. Interventions included, but were not limited to, the resident required the assistance of two staff members and the Hoyer lift for transfers. On 2/24/26 at 11:12 a.m., the Director of Nursing (DON) indicated the facility investigated the resident's fall from the Hoyer lift and provided the investigation file. The investigation file included the following information. -A document titled, Suspension Form-Internal Investigation, dated 2/3/26, indicated Certified Nurse Aide (CNA) 4 was suspended pending the investigation into the resident's fall. CNA 4 transferred the resident utilizing a Hoyer lift without a second staff member for assistance. The investigation included awaiting x-ray results and staff interviews. The employee's conduct included, Employee did not follow policy on utilizing two people for Hoyer lift transfer. This is a violation.from the employee handbook. The corrective action plan indicated, Ensure that you are utilizing a second person for all Hoyer lift transfers. -An undated written statement from CNA 4 indicated, At around 9 am [sic] on 2/3/26 I was going into [resident's room number] to get [resident's name] up and in his chair. I looked down the hall and didn't see another employee so I made the choice to perform the hoyer transfer by myself. I got the weight hoyer from [hall number], the set up the hoyer to lift him. I held him over the bed for a few seconds to get his weight, then proceeded to move the hoyer to his chair. The hoyer moved fine and I got it in place, put the breaks [sic] on, and started to turn him to line him up with the chair when the hoyer broke. He fell straight down. I went to the hall and got a nurse, she took pictures of the broken hoyer, asked if the resident was in pain and where. She then got 3 more people to lift him back into bed. -A CNA job specific orientation checklist indicated CNA 4 was trained on using a Hoyer lift on 12/30/25. -A statement from the DON, dated 2/3/26, indicated, On 2/3/26, I was notified of an incident involving a Hoyer lift during a resident transfer. An investigation was immediately initiated. HFA [Health Facility Administrator], Maintenance, and the writer assessed the equipment and determined that the lift had malfunctioned during use. It appears that a bolt snapped during the transfer, resulting in mechanical failure. The resident was lowered to the floor during the incident. Upon review of the circumstances surrounding the transfer, it was identified that the transfer was not completed in accordance with facility policy for mechanical lift use. The involved staff member was interviewed and acknowledged understanding of the facility's Safe Resident Handling/Transfers policy. The employee has been suspended pending further investigation. -A maintenance logbook documented monthly lift checks, from February 2025 to February 2026. -A statement from the Administrator, dated 2/3/26, indicated, On February 3rd, I met with the Director of Plant Operations to address the reported malfunction involving the Hoyer lift in question. During our discussion, he confirmed that the device had been quarantined, fully inspected, and fixed to return to working condition and put back on the floor. He also provided documentation showing completed and passed audits for the facility's Hoyer lifts for the prior 3 months. The Regional Director of Property Management conducted an onsite investigation to assess the circumstances surrounding the reported malfunction. During the visit, a comprehensive inspection was performed on all mechanical lifts within the facility to verify their operational integrity and ensure that all equipment met safety and compliance standards. This review included evaluating maintenance practices, confirming documentation of recent inspections, and identifying any areas requiring corrective action. -A teachable moment, dated 2/3/26, was signed by the maintenance staff. The teachable moment indicated, .Upon reviewing the incident, it was noted that the missing lock nut on the sling attachment was not identified during the regular inspections. While issues like this can sometimes be difficult to detect, it is important that our inspection forms and procedures allow for clear, consistent documentation and close attention to all critical parts of the equipment, such as bolts, nuts, and sling attachments. -The Hoyer lift manufacturer's guidance for cleaning and maintenance, dated 1/13/25, indicated functional checks should be periodically performed, at least once a year, including checks of the control of mechanical parts such as hooks, pins, and screws. During an interview, on 2/24/26 at 10:11 a.m., the DON indicated a bolt came out of the hydraulic arm of the Hoyer lift during the resident's transfer, and the Hoyer lift broke. When the bolt came out, the resident fell down. The staff member was alone performing the Hoyer lift transfer, which was not consistent with the facility's policy. Two people actively participating in the transfer were required per their facility policy for Hoyer lift transfers. On 2/24/26 at 10:46 a.m., the DON provided a document titled, Safe Resident Handling/Transfers, dated 2/28/24. The policy indicated, .Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and promote a safe, secure and comfortable experience for the resident.Compliance Guidelines.6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly.8. Two staff members must be utilized when transferring residents with a mechanical lift. The deficient practice was corrected by 2/13/26 after the facility implemented a systemic plan that included the following actions: immediate assessment by the charge nurse of the effected resident for follow-up care, transfer status audit for all residents completed by 2/6/26, staff members who provided assistance to residents with mechanical lift transfers received education on proper mechanical lift use completed prior to their next scheduled shift, ongoing maintenance processes updated and implemented by 2/13/26, and a Quality Assurance and Performance Improvement (QAPI) plan implemented with the completion of an audit tool for scaled ongoing monitoring. The plan was fully implemented by 2/13/26. This deficiency reflects State Findings cited in accordance with 410 Indiana Administrative Code (IAC) 16.2-3.1-45(a)(2).

Based on record review and interviews, the facility failed to complete a new level of care Pre-admission screening and resident review (PASARR) for a resident when she had a diagnosis of psychosis added to her history for 1 of 1 resident reviewed (Resident 63). Findings include: On 1/22/25 at 12:22 p.m., a record review was completed for Resident 63. She had the following diagnoses which included but was not limited to hypertension, type 2 diabetes mellitus, generalized anxiety, and delusional disorders. She had a level 1 PASARR in her medical record. It did not include the diagnosis of delusional disorders. On 1/22/25 at 2:30 p.m., during an interview, the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) indicated delusional disorders were on her list of diagnoses, therefore, he coded delusional disorders. On 1/23/25 at 9:30 a.m., the Director of Nursing (DON) indicated a new level of care was being completed for Resident 63 and she would provide the results. On 1/27/25 at 12:10 p.m., the DON provided a copy of Resident 63, new level of care dated 1/24/25, and it indicated to refer for a level 2 PASARR on site. A policy titled, Level I and Level II process was provided by the DON on 1/27/25 at 2:38 p.m. It indicated .Social Service Director will notify refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition to the state mental health authority or the state intellectual authority. Documentation will be made in the progress notes

Based on observation, interview, and record review, the facility failed to ensure a comprehensive resident centered care plan related to advanced directives was revised to reflect the wants and needs of a resident for 1 of 1 resident reviewed for advanced directives. (Resident 32) Findings include: On 1/21/25 at 10:21 a.m., Resident 32 was observed as she sat up in her bed. The Resident was in enhanced barrier precautions for her urostomy (an opening in the abdomen to allow urine to pass through) and gastrointestinal tube (Gtube), and she indicated she had recently tested positive for flu A. A urine drainage bag was observed as it hung on the side of the Residents bed frame covered with a dignity cover. Clear yellow urine was observed in the tubing and no dependent loops were noted. On 1/23/25 at 1:35 p.m., Resident 32's medical record was reviewed. She was a long-term care resident whose diagnoses included but were not limited to, post left wrist flap closure surgery, osteomyelitis (an infection of the bone that causes inflammation and damage to the bone tissue) of the hand and Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Resident 32 had an active care plan, dated 5/17/23, for a Do Not Resuscitate (DNR) code status. Resident 32 had an active order, dated 12/13/24, for a full code status. On 1/24/25 at 10:06 a.m., the Director of Nursing (DON) provided documentation of the original DNR care plan and the updated Full Code care plan. She indicated that the DNR care plan was wrong and should have been a Full Code status care plan. On 1/28/25 at 10:50 a.m., the DON provided a copy of a current facility policy titled, Comprehensive Care Plans, dated 9/18/24. The policy indicated .Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the care plan , .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment 3.1-35(c)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 70) who required the use of a suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen, just above the pubic bone) received treatment and services to prevent the potential for urinary tract infections (UTI) for 1 of 3 residents reviewed for catheters. Findings include: On 1/21/25 at 10:55 a.m., Resident 70 was observed in his room on the secured memory care unit. He was reclined in his bed and spoke out loud to anyone he saw. He repeatedly asked staff that passed by his room, where his watch was, and was told that it was, being cleaned. His voice was raised, but he did not yell, as he continued to ask about his watch, and what he should do. An unidentified staff member who passed by his room indicated, he always does this, he just gets so anxious about one thing after the other, sometimes its his watch, other times the catheter leg bag and he wants the water off his leg. On 1/27/25 at 12:39 p.m., Resident 70's medical record was reviewed. He was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, unspecified dementia (a degenerative brain disease which affects memory and cognitive function), anxiety and benign prostatic hyperplasia (BPH - a condition where the prostate gland, located at the base of the bladder in men, enlarges) with lower urinary tract symptoms (LUTS -symptoms that affect urination and can occur with BPH). There was an initial catheter assessment, dated 3/11/24, and a quarterly assessment, dated 5/27/24, but the record lacked further quarterly assessments. A urology physician's order, dated 12/16/24, indicated his catheter should be changed every 4 to 6 weeks. At the time of the initial record review, the facility's physician order list lacked a physician order with these specific instructions. An admission physician order, dated 3/11/24, indicated Resident 70's urine output should be recorded every shift. Resident 70's March 2024 Medication/Treatment Administration Records (MAR/TAR) was reviewed and revealed there was no output recorded for the following shifts: 3/17/24 night shift, 3/22/24 evening shift, 3/27/24 day shift and 3/31/24 night shift. A nursing progress note, dated 3/15/24 at 12:50 a.m., indicated, hematuria [blood in the urine] continues, daughter aware. The record lacked documentation the physician had been notified. A nursing progress note, dated 3/19/24 at 8:59 p.m., indicated Resident 70 emptied the catheter bag but did not recall how much was in it. The record lacked notification the physician was notified. A nursing progress note, dated 3/20/24 at 7:52 p.m., indicated Resident 70 emptied his catheter bag into the toilet, but an amount of output was not recorded. A nursing progress note, dated 3/28/24 at 8:14 p.m., indicated Resident 70 emptied his bag and the output was not recorded. Resident 70's April 2024 MAR/TAR was reviewed and revealed no output was recorded for the following shifts: 4/9/24 night shift, 4/12/24 evening shift, 4/21/24 night shift and 4/25/24 day shift. A nursing progress note, dated 4/14/24 at 8:46 p.m., indicated hematuria was still noted in his catheter drainage bag, but lacked documentation of physician notification. A nursing progress note, dated 4/18/24 at 9:17 p.m., indicated Resident 70 emptied his bag and no output was recorded. A nursing progress note, dated 4/22/24 at 8:49 p.m., indicated Resident 70 emptied his bag and no output was recorded. A nursing progress note, dated 4/26/24 at 9:45 p.m., indicated Resident 70's urine output was unable to be obtained because the bag was leaking and was replaced. The record lacked documentation the physician was notified. A nursing progress note, dated 4/29/24 at 8:41 p.m., indicated Resident 70 emptied his bag and no output was recorded. Resident 70's May 2024 MAR/TAR was reviewed and revealed no output was recorded for the following shifts: 5/1/24 day shift, 5/8/24 evening shift, 5/16/24 day shift, 5/17/24 day shift, and 5/20/24 day shift. A nursing progress note, dated 5/1/24 at 10:32 p.m., indicated Resident 70 emptied his bag and no output was recorded. A nursing progress note, dated 5/2/24 at 4:45 a.m., indicated no measurable output was obtained because Resident 70 emptied his own bag. A nursing progress not, dated 5/9/24 at 9:27 p.m., indicated his bag leaked but lacked documentation the physician was notified. The record lacked documentation of Interdisciplinary team (IDT) follow up and/or interventions to address Resident 70's behaviors of emptying his bag and not being able to recall the amounts. A change of condition progress note, dated 5/22/24 at 8:13 p.m., indicated Resident 70 had a fever of 100.6 degrees Fahrenheit. A nursing progress note, dated 5/22/24 at 9:19 p.m., indicated Resident 70 was sent to the hospital for catheter dysfunction, fever, and elevated blood pressure. A corresponding hospital summary, dated 5/22/24, indicated Resident 70 was admitted and had blood infection, UTI, and acute kidney injury. Resident 70 had a compressive care plan which was initiated on 3/13/24 which indicated, Resident 70 used a suprapubic catheter due to his obstructive uropathy. Interventions for this plan of care included: Change catheter system when clinically indicated or ordered, I will have extra fluids offered with medications, I will receive fluid of my choice with meals, I will receive teaching on how to care for my catheter and personal hygiene needs, proper positioning of the drainage bag, I will report and you will observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen, My catheter will be flushed as ordered and my treatment will be completed as ordered. The care plan lacked revision to address Resident 70's behavior of emptying his bag without letting staff know when, or how much. The care plan lacked revision of Resident 70's catheter specifications. The care plan lacked revision and specification of his urologist instructions and/or contact information, scheduled and/or as needed visits. On 1/28/24 at 10: 50 a.m., the Director of Nursing (DON) provided a copy of current facility policy titled, Suprapubic Catheterization, reviewed 9/3/24. The policy indicated, Suprapubic catheters will be changed in accordance with current standards of practice to minimize risk for bacterial contamination or failed insertions .the care and maintenance of suprapubic catheters shall be in accordance with physician orders. The orders shall specify the type and size of catheter, and frequency of catheter changes On 1/28/24 at 10: 50 a.m., the DON provided a copy of current facility policy titled, Bowel and Bladder Incontinence Management, revised 5/2022. The policy indicated, . to ensure that a resident is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection . a resident requiring a catheter will have a catheter evaluation . completed at the time of admission, new order for catheter, and quarterly . On 1/28/24 at 10: 50 a.m., the DON provided a copy of current facility policy titled, Comprehensive Care Plans, reviewed 9/18/24. The policy indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . the care planning process will include an assessment of the resident's strengths and needs . resident specific interventions that reflect the resident's needs and preferences . the physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods of refusal of treatment and services and document such attempts in the clinical record 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to adequately implement care planned interventions, provide activities, and ensure proper dementia care was provided for a resident in the memory care unit who was in isolation for flu A for 1 of 3 residents reviewed for activities on dementia care (Resident 72). Findings include: On 1/23/25 at 10:15 a.m., Resident 72 was observed as she left her room to head to the common area. Resident 72 was on contact (a set of precautions that prevent the spread of disease by touching a resident or objects in their room.) and droplet (a set of precautions used to prevent the spread of respiratory infections from a resident to others.) precautions for flu A. Certified Nursing Assistant (CNA) 125 was observed as she redirected the Resident back to her room. CNA 125 came up to Resident 72 and told her she needed to go back to her room because she was sick. Resident 72 indicated she was not sick, and CNA 125 indicated she may not feel sick, but she was. Resident 72 was assisted by CNA 125 back to her room where CNA 125 was observed as she helped settle Resident 72 for approximately 2 minutes. During an interview on 1/23/25 at 10:20 a.m., CNA 125 indicated Resident 72 had tried to come out of her room several times that day. CNA 125 indicated staff did not normally do anything special or different to engage or redirect residents who were in isolation. She indicated the activities staff usually did not go into the isolation rooms, but now that Resident 72 was feeling a little better the activity staff might go in there and do a one-on-one activity. On 1/23/25 at 10:24 a.m., 5 unknown staff members were observed talking amongst themselves at the nurse's station. On 1/27/25 at 11:41 a.m., Resident 72's record was reviewed. She was a long-term care resident who resided in the memory care unit. Her diagnoses included but were not limited to Cerebral infarction (stroke), history of falling, and influenza A. She had a comprehensive care plan, dated 7/26/22, which indicated Resident 72 should be offered snacks, drinks and conversation. She had a comprehensive care plan dated 7/26/22 which indicated, Staff should provide Resident 72 with 1 on 1 conversation and attention and should offer the resident diversional activities when voicing a desire to leave. She had a comprehensive care plan, dated 9/16/22, which indicated staff will give Resident 72 an activity of her choice if she wandered. She had a comprehensive care plan, dated 12/28/23, which indicated Resident 72 enjoyed interacting with her peers and staff. A fall Interdisciplinary Team (IDT) note, dated 2/19/24, indicated Resident 72 had a fall on 2/18/24 where she was found on the floor near her bathroom door. The intervention indicated the Resident will be toileted on the last round of night shift. A fall progress note, dated 3/2/24, indicated Resident 72 was found on the floor by the hallway. The immediate intervention indicated the Resident will participate in a toileting program. A fall progress note, dated 4/8/24, indicated, Resident 72 was found by an unknown CNA as she sat on the floor in the doorway to the resident's bathroom. The immediate intervention indicated staff will assist Resident 72 to the bathroom prior to lunch. A fall progress note, dated 7/15/24, indicated Resident 72 lost her balance in the dining room and fell , she had nonskid socks on, but they were twisted on her feet. A progress note, dated 1/19/25 at 9:00 a.m. indicated Resident 72 tested positive for flu A. A progress note, dated 1/19/25 at 11:27 a.m., indicated Resident 72 was placed in contact and droplet isolation. A fall progress note, dated 1/24/25, indicated at 12:25 a.m. Resident 72 was found on the floor at the foot of her roommate's bed. The immediate intervention indicated the resident would have her call light in reach at all times. A fall progress note, dated 1/24/25, indicated at 3:20 a.m. Resident 72 was found face down on the floor next to her bed. The intervention indicated the resident will have frequent checks throughout the night. Resident 72's activity logs were reviewed. Between the dates of 1/1/25 and 1/17/25 it was charted that Resident 72 was provided with an activity 18 times. On 1/19/25 Resident 72 was put in isolation for flu A until 1/27/25. Between the dates of 1/19/25 and 1/27/25 it was charted that Resident 72 was provided with an activity 4 times and it was charted that the resident was unavailable 5 times. During an interview on 1/27/25 at 1:45 p.m., the Activity Director indicated memory care activity participation fluctuates depending on the level each resident wass at on any given day. She indicated even when a resident was in isolation, they should still be able to receive one-on-one activities and visits with activity staff and other staff. On 1/28/25 at 2:30 p.m., the Director of Nursing (DON) provided a copy of a current facility policy titled, Resident Self Determination and Participation (Activities), dated 1/9/24. The policy indicated, .c. The right to interact with members of the community and participate in community activities both inside and outside of the facility On 1/28/25 at 2:30 p.m., the Director of Nursing (DON) provided a copy of a current facility policy titled, Dementia Care, dated 3/5/24. The policy indicated, .5. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being On 1/28/25 at 2:30 p.m., the Director of Nursing (DON) provided a copy of a current facility policy titled, Activities, dated 1/9/24. The policy indicated, .8. Activities will include individual, small and large group activities as well as: .g. In-room activities ., .9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: .f. Residents who excessively seek attention from staff and/or peers . 3.1-37

Based on observation, interview, and record review, the facility failed to manage a resident's medication regimen for unnecessary medications in the absence of a specific condition or behaviors in the medical record for 1 of 3 residents reviewed (Resident 265). Findings include: On 1/27/25 at 10:30 a.m., a record review was completed for Resident 265. She had the following diagnoses which included but were not limited to dementia with other behavioral disturbances, encounter for palliative care, and insomnia. Resident 265 had orders for the following medications. Trazodone (an antidepressant that is used to treat insomnia) 100 milligrams (mg) at bedtime, melatonin (a supplement used to treat insomnia) 12 mg at bedtime, quetiapine (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 100 mg at bedtime, hydrocodone-acetaminophen (It contains an opioid pain reliever (hydrocodone) and a non-opioid pain reliever (acetaminophen) 7.5/325 mg two times daily, and gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 300 mg two times daily. On 1/9/25 the pharmacist recommended adding a diagnosis for the use of quetiapine. The diagnosis in use was behaviors. The diagnosis was updated to psychosis. She was not seen by psychiatry prior to adding the diagnosis. The resident's medical record lacked documentation of behaviors associated with the use of quetiapine. On 1/21/25 at 10:30 a.m., observed Resident 265 lying in bed with her eyes closed. She did not respond when spoken to. On 1/27/25 at 12:45 p.m., during an interview with the son, he indicated that hospice had her on the medications and he did not know what the quetiapine was used for. He indicated he visited her on 1/26/25 and she appeared to be sleepy. On 1/27/25 at 1:00 p.m., during an interview with the Director of Nursing (DON), she indicated Resident 265 entered the facility on the medications and it was not time for a gradual dose reduction for Resident 265. She indicated there was no consent for antipsychotic usage in the medical record because they do not do consent to treat for antipsychotic medications. On 1/27/25 at 1:14 p.m. during an interview with the hospice nurse, he indicated resident medications were reviewed and her gabapentin was reduced. He indicated she had been on quetiapine for a long time, long before hospice began treating her. He was unsure of why she was on the medication. On 1/28/25 at 10:38 a.m., phoned Resident 265's physician to inquire about quetiapine usage and did not receive a return call. A policy titled Gradual Dose Reduction of Psychotropic Drugs was provided by the DON on 1/27/25 at 2:38 p.m. It indicated, .The timeframes and duration of attempts to taper any medication shall depend on factors including the coexisting medication regimen, the underlying causes of the symptoms, individual risk factors, and pharmacologic characteristics of the medication . 3.1-48(b)

Based on record review and interview, the facility failed to accurately code the MDS (Minimum Data Set) with appropriate PASRR (Preadmission Screening and Resident Review) Level 2 information for 2 of 3 residents reviewed (Resident 17 and 68). Findings include: a.) A comprehensive record review was completed on 11/14/23 at 11:32 a.m. Resident 17 had the following diagnoses which included but were not limited to schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), auditory hallucinations, and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). Resident 17 had a level 2 related to her diagnoses which gave instructions to properly code her mental health status on the MDS. The MDS, dated [DATE], lacked documentation of the level 2 assessment. b.) A comprehensive record review was completed on 11/16/23 at 10:12 a.m. Resident 68 had the following diagnoses which included but were not limited to TBI (traumatic brain injury), dementia, and psychotic disorder. Resident 68 had a level 2 related to his diagnoses which gave instructions to properly code his mental health status on the MDS. The MDS, dated [DATE], lacked documentation of the level 2 assessment. During an interview with the DCS (Director of Clinical Services) on 11/20/23 at 12:15 a.m., she indicated the MDS department follow the RAI (Resident Assessment Instrument) manual for accuracy of assessments.

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 112) was observed for adverse effects related to the use of an opiate medication, and failed to set parameters to ensure nursing staff were provided clear instructions on when to administer a medication and which medication was appropriate to address varying levels of pain for 1 of 5 residents reviewed for unnecessary medications. Finding include: On 11/15/23 at 10:00 a.m., a comprehensive record review was completed for Resident 112. She had the following diagnoses but were not limited to malignant neoplasm of the brain (abnormal masses of tissue that grow in the brain due to excessive overgrowth of brain cells), osteoarthritis, asthma, generalized anxiety disorder, hallucinations, delusional disorder, and malignant neoplasm of the lower lobe, unspecified bronchus, or lobe (cancer). Resident 112's physician's orders included but were not limited to the following as needed (PRN) pain medication. a. Dilaudid oral liquid 1mg/ml (hydromorphone) give 1.5ml by mouth every 2 hours as needed for pain or shortness of breath. Do not give within 1 hour of scheduled dose. b. Norco oral tablet 10/325mg (hydrocodone-acetaminophen) give 1 tablet by mouth every 4 hours as needed for pain not to exceed 4,000 mg of Tylenol in a day from all sources. c. Norco oral tablet 10/325mg (hydrocodone-acetaminophen) give 2 tablets by mouth every 4 hours as needed for pain not to exceed 4,000 mg of Tylenol in a day from all sources. d. Percocet oral tablet 10-325mg (oxycodone with acetaminophen) give 1 tablet by mouth every 4 hours for moderate pain not to exceed 4,000 mg of Tylenol in a day from all sources. On 11/16/23 at 1:17 p.m. Hospice RN 19 was interviewed. He indicated nurses should assess the resident prior to administering medications for pain. There were no parameters on the as needed pain medications. He indicated through the nurse's assessment she should be able to make that determination. He would call the facility with new orders for the as needed medications. On 11/16/23 at 1:23 p.m. LPN 17 was interviewed. She indicated Resident 112 always wanted 2 Norco tablets. LPN 17 indicated she knew what the resident wanted. The order for Percocet was added when Norco was unavailable. The Percocet was never discontinued when the Norco became available. A policy titled, Unnecessary Medications, was provided by the Director of Clinical Services (DCS) on 11/17/23 at 10:32 a.m., it indicated, .Proper medication selection and prescribing (including dose, duration, and type of medication(s) may help stabilize or improve a resident's outcome, quality of life and functional capacity. Any medication or combination of medications-or the use of a medication without adequate monitoring may increase the risk of a broad range of adverse consequences such as medication interactions, depression, confusion, immobility, falls, hip fractures, and death. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used a. In excessive dose (including duplicate drug therapy); or b. For excessive duration; c. Without adequate monitoring; or d. Without adequate indications for its use; or e. In the presence of adverse consequences which indicate the dose should be reduced or discontinued, or f. Any combinations of the reasons stated . 3.1-48(a) 3.1-48(l) 3.1-48(6)

Based on observation, interview, and record review, the facility failed to ensure the Memory Care (MC) residents received warm food during lunch services for 25 of 25 MC residents during 1 of 3 lunch observations. Findings include: On 11/13/23 at 11:53 a.m., Certified Nursing Aide (CNA) 15 indicated the MC residents were receiving glazed pork cutlet, cheesy potatoes, and green beans for lunch. The glazed pork cutlets were observed to be in a portable steam table. The green beans and cheesy potatoes were observed in stainless steel hotel pans on the second shelf. On 11/13/23 at 11:54 a.m., CNA 13 indicated the cheesy potatoes and green beans did not have a heating device below them to keep them warm during serving. On 11/13/23 at 12:03 p.m., CNAs 15 and 13 finished serving lunch, with the residents needing assistance with eating being served last. At the same time, Cook 14 entered the MC dining room to check the temperature of the food. Cook 14 indicated the food left the kitchen at the temperature of 165 Fahrenheit (F) or higher. The cheesy potatoes were 79 F and the green beans were 113 F. She indicated the food temperatures were too low for the food to be served to residents. The glazed pork cutlets were 136 F. She indicated she usually put all the food in the portable steam table, but was in a hurry today and did not do it, and it was her fault the food temperatures were served too low. On 11/13/23 at 12:09 p.m., the residents as the last table served were unable to communicate whether the did not like the food being too cold. It was observed that the residents did not eat their food well. On 11/14/23 at 11:29 a.m., after all the residents were served, the Dietary Director (DD) indicated the chicken noodles were at 168 F and the broccoli at 197 F. On 11/15/23 at 11:10 a.m., an observation of portable steamer being used for MC lunch foods: country fried steak, mashed potatoes, and stewed tomatoes. [NAME] bread and coconut bars were also served. The residents who needed assistance with eating were served first. A policy titled, Food Temperature Monitoring, dated 5/16/23, was provided by the Director of Nursing (DON), on 11/15/23 at 10:33 a.m. A review of the policy, indicated, .Proper food handling techniques, per regulatory requirements, are used in the preparation and serving of food 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff washed their hand appropriate while assisting Memory Care (MC) resident with eating for 2 of 3 lunch observations (Resident 50, 52, 60, 76, and 111). Findings include: On 11/13/23 at 11:31 a.m., Certified Nursing Aide (CNA) 15 was observed serving the MC residents food, CNA 13 was providing it to the residents, and the MC Director (MCD) followed behind and cut-up the resident's food as needed. On 11/13/23 from 12:11 to 12:19 p.m., CNA 15 was observed to assist several MC resident with eating but did not wash her hands between touching the resident, their wheelchair, or their utensils before moving onto the next resident. a. She touched Resident 111's spoon, then touched Resident 60's spoon in her vanilla pudding dessert. b. She assisted Resident 111 with eating by holding his spoon with cheesy potatoes. Then, touching the arm rest of an Resident 60's wheelchair and then assisting her with eating. On 11/13/23 from 12:14 to 12:19 p.m., CNA 13 was observed to assist two MC residents with eating. She assisted Resident 60 by providing a bite of food, then offered Resident 52 a bite of food, and back to Resident 60 to offer a bite of food. She did not sanitize or wash her hands between residents. Resident 52 was visually impaired with blindness. On 11/15/23 at 11:09 a.m., the resident that required assistance with eating were served first. Five resident were observed not eating. The lunch included country fried steak, mashed potatoes, bread, stewed tomatoes, and a coconut bar. On 11/15/23 at 11:15 a.m., CNA 19 was observed standing and leaning her body over the lunch table to assist Resident 52 with opening her barbeque container on the other side of the table. She leaned over Resident 50's and Resident 76's food, while they were sitting at the table waiting for assistance with eating. She did not do hand hygiene and assisted Resident 50 with a bite of food and a drink. Then, she walked away from the table to get milk for Resident 60. She did not do hand hygiene and provided Resident 50 with a bite of food. On 11/15/23 at 11:18 a.m., Activity Assistant 12 was observed to touch Resident 52's sleeve and manual guiding her hand to her drink. She did not do hand hygiene and touched the silverware of Resident 111. She came back to Resident 52's table and touched her sleeve again to manually guide her to the chicken nuggets on her plate. She was overheard saying to an aide, Resident 52 can only see shadows. She did no hand hygiene and at 11:30 a.m., she touched Resident 60's plate, did no hand hygiene afterward, and assisted Resident 52 with a bite of her coconut bar. On 11/15/23 at 11:19 a.m., CNA 19 went back to assist the residents will eating. First, she assisted Resident 76, she touched her plate to turn it. Then, provided 2 bites of food to Resident 50. She did not do hand hygiene between residents. On 11/15/23 at 11:31 a.m., CNA 19 was observed to scratch her back, she did not do hand hygiene, then returned to assisting residents with eating. On 11/15/23 at 11:40 a.m., CNA 15 was observed touching Resident 60's silverware to try and get her to eat more food. Without using hand hygiene between residents, at 11:43, she started assisting Resident 76 with eating her dessert. On 11/15/23 at 11:49 a.m., CNA 15 was observed touching Resident 60's wheelchair handles to move her closer to the table. She did not do any hand hygiene and started assisting Resident 52 with eating for dessert. On 11/15/23 at 11:44 a.m., CNA 19 was assisting Resident 111 with bites of food. She put her hands in her lap, then continued with assisting him with lunch by offering bites of food again. On 11/13/23 at 12:23 p.m., CNA 15 indicated she was trained to wash her hands between resident when assisting them with eating. On 11/15/23 at 11:55 a.m., Licensed Practical Nurse (LPN) 11 indicated the MC staff should have been performing hand hygiene between residents when assisting residents with eating and would educate the staff accordingly. A current policy, titled, Meal Service to Dining Rooms or Resident Rooms, dated 3/2020, was provided by the Director of Nursing (DON), on 11/15/23 at 1:29 p.m. A review of the policy indicated, .Dining service to residents will be provided in an efficient manner, using standard sanitary procedures and providing residents with the assistance and attention they need to enjoy their meals 3.1-21(i)(2) 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure transdermal medication patches (a method of drug delivery in which an adhesive patch provides a pre-prescribed dose of medication that is absorbed through the skin and into the bloodstream) were removed per physician's order for 1 of 11 residents reviewed for nursing services (Resident B). Finding includes: Resident B's record was reviewed on 8/15/23 at 11:47 a.m. The profile indicated the resident's diagnoses included but were not limited to Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A Medicare 5-day Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 8/6/23, indicated the resident had no cognitive deficit and a documented issue had been found during a drug regimen review. A care plan, dated 6/16/23, indicated the resident had increased secretions. Interventions included, but were not limited to, the resident's medicated patch would be applied as ordered. A physician's order, dated 6/23/23, indicated Scopolamine (a medication used for the management of drooling in disabled patients) transdermal patch 72-hour, 1 milligram (mg) every 3 days. Apply 1 mg transdermal every 72 hours for increased secretions Remove old patch before applying new one. Review of the resident's July 2023 medication administration record (MAR) indicated the medication had been discontinued on 8/1/23. The MAR lacked documentation of the patch having been administered on 7/11/23. All other dates indicated the patch had been administered as ordered. A Change of Condition document, dated 7/29/23 at 7:00 p.m., indicated the resident experienced altered mental status (a change in mental function), increased confusion, and general weakness. The resident had trouble feeding himself and was putting his spoon in the air instead of in his food. The physician was contacted and gave orders for a complete blood count (CBC) with differential (a blood test which measures the total number and each type of white blood cells in the body), a comprehensive metabolic panel (CMP-a blood test that measures 14 different substances in the blood), and urine sample to be sent to the lab, the next day. The physician also ordered to monitor the resident's vital signs, every shift, for 72 hours. The resident's daughter was present in the facility during the symptoms and requested the resident be sent out to the hospital. The physician agreed and gave the order to send the resident to the hospital. 911 was contacted and the resident was transferred to the hospital. A progress note, dated 7/29/23 at 7:00 p.m., indicated the resident had been transferred to the hospital via 911 ambulance. The daughter was at the facility and followed the ambulance to the hospital. An emergency room physician's progress note, dated 7/29/23 at 10:08 p.m., indicated the resident had presented to the emergency room with altered mental status. The resident had 2 scopolamine patches on upon arrival. A hospital admitting note history and physical document, dated 7/29/23 at 11:15 p.m., indicated the resident would be admitted to the hospital, as an inpatient, for management of altered mental status. A hospital provider discharge note, dated 8/2/23 at 5:11 p.m., indicated the resident's hospital diagnoses included, but were not limited to, acute metabolic encephalopathy from polypharmacy (results from an acute [sudden onset] dysfunction of the brain due to different physical and chemical process disturbances including medications). On 8/17/23 at 10:32 a.m., the Director of Clinical Services (DCS) provided investigation documentation and indicated they were the documents compiled during the facility's investigation of the incident. The documents included, but were not limited to, the following: a) An undated investigation summary. The summary indicated the facility had begun their investigation after hospital records had been received on 7/31/23, which indicated that 2 scopolamine patches had been found on the resident in the emergency room . The facility had reached out to the hospital to clarify the appearance of the patches (date of placement, initials, type of patch) but the patches found on the resident had been disposed of. The box of the resident's patches was identified in the medication cart. 5 patches of 10 remained in the box. All 5 patches had been signed out by the nursing staff. Nursing staff were interviewed, and all stated the old patches had been removed once the new one was placed. The investigation had been completed on 7/31/23, and the resident' son was notified. b) A grievance form, dated 8/7/23, indicated the resident's power of attorney (POA-an individual who acts on the behalf of a resident) had filed a grievance on 8/7/23, questioning the resident's recent hospitalization and order history of his scopolamine patches. The grievance resolution indicated the facility's nurses and qualified medication aides (QMAs) had been educated on the proper procedures for transdermal patches. The form indicated the Assistant Director of Clinical Services (ADCS) had spoken to the POA, who voiced understanding. During a telephone interview, on 8/17/23 at 9:29 a.m., the consultant pharmacist indicated the typical side effects of scopolamine overdose would be drowsiness, dryness of the mouth and eyes, and confusion. The symptoms often mimic the signs of a urinary tract infection (UTI). The medication in the patches were slow release to minimize the concern over side effects. The patches would be placed every 3 days. Typically, at the end of the 3 days, there is no medication left in the patch. He had not been made aware that a resident had been found with 2 patches in place. Anytime a new order for any patches were made, they would always include removal of the old patch when the new patch is placed. During an interview, on 8/17/23 at 9:38 a.m., the DCS indicated there had been a medication error investigation involving a resident who was taken to emergency room due to extreme confusion. At the emergency room , they found and removed 2 scopolamine patches from the resident. The facility investigated the incident but could not confirm that the patches had been put on at the facility and that, even if they had, there was not any medication left in the old patch which could cause the extreme confusion. Review of the hospital documentation could only confirm that 2 patches were found but could not confirm that the 2 patches were the cause of the resident's confusion. They also were ruling out a UTI at the hospital. During an interview, on 8/17/23 at 10:06 a.m., Resident B indicated about 2 months ago he began to experience overactive drooling. He told the nurses and they spoke with his doctor and got him scopolamine patches. He received 1 patch placed behind his ear every 3 days. A couple weeks ago, the nurse came in to place another patch on him. At that time, he felt behind his left ear and told the nurse he thought he felt the old patch back there. He believed that the nurse just put another patch next to the old patch. He shortly afterwards began to feel off and told his friend, who is a retired pharmacist about it. His friend indicated to him that it was not a good situation to have 2 patches on at the same time. After that, he doesn't remember too much. He believed that was on a Sunday and he didn't remember much until the following Tuesday, when he realized he was in the hospital. He preferred not to mention the nurses name who failed to remove the old patch prior to placing the new one on him. On 8/17/23 at 10:32 a.m., the DCS provided a document, with a revision dated of 7/16, titled, Transdermal Patch Procedure, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure resident does not receive more than the prescribed dosage of medication .All other transdermal patches: .3. The nurse/QMA .will document the removal of the old patch when the documentation of the new patch being placed is documented in the eMAR (electronic medication administration record) On 8/17/23 at 11:48 a.m., the DCS provided a document, with a revision date of 10/19, titled, Following Medication Physician Orders/Parameters, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To administer medications in a safe and effective manner and following physician orders .Procedures: .D .1) Check MAR/TAR (treatment administration record) for order The deficient practice was corrected by 8/1/23, prior to the start of the survey and was therefore Past Noncompliance. Prior to the start of the survey, the facility implemented a plan which included staff education, transdermal medication administration audits, and ongoing monitoring was put in place. This Federal finding relates to Complaints IN00414436 and IN00414657. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 7 of 13 residents randomly observed for call light placement (Residents D, F, H, L, M, P, and Q). Findings include: 1. During an initial pool interview on 6/19/23 at 10:45 a.m., Resident D was observed lying in bed watching television, her call light button was on her right side down between the bed and mattress out of sight of the resident. Resident D requested assistance with her the call light button as she could not find it. Resident D's record was reviewed on 6/20/23 at 8:42 a.m. Diagnoses on Resident D's profile included, but were not limited to, hemiplegia (paralysis) affecting the right side. A current care plan for Resident D indicated the resident was at risk for falls related to weakness. The goal was for the resident interventions to minimize the risk for falls resulting in serious injury. Interventions included to be assisted back to bed upon request and to have personal items that were used frequently within reach. 2. During the initial pool tour, on 6/19/23 at 10:57 a.m., Resident F was observed lying in bed, eyes closed, legs slowly moving under the covers. The resident's call light was hanging down between the side rail and mattress out of sight and reach of resident. Registered Nurse (RN) 7 indicated the resident was primarily dependent on others, could not transfer independently, and did not always use the call light. Resident F's record was reviewed on 6/20/23 at 8:52 a.m. Diagnoses on Resident F's profile included, but were not limited to, history of falling. A quarterly risk evaluation, dated 4/7/23, a score of 8.0 indicated moderate fall risk. A significant change Minimum Data Set (MDS) assessment, completed on 6/8/23, assessed the resident as having the ability to make herself understood and to understand others. Staff were unable to complete the Brief Interview for Mental Status (BIMS) assessment. Resident F required extensive assistance of 2 or more persons physical assist for bed mobility, total assistance of 2 or more persons physical assist for transfers, and the resident's mobility devices included a wheelchair. A current care plan for Resident F indicated at risk for falls related to weakness. The goal was for the resident interventions to minimize the risk for falls resulting in serious injury. Interventions included bolsters on the bed to remind resident of bed boundaries, personal items within reach, and assistive devices to be kept within reach. 3. During the initial pool tour, on 6/19/23 at 11:07 a.m., RN 10 was observed to enter Resident H's room to take her blood pressure. The resident was lying on her left side facing the window, her call light was hanging behind her from the bed rail on the right side of the bed, out of sight and reach of the resident. Resident H's record was reviewed on 6/20/23 at 9:04 a.m. Diagnoses on Resident H's profile included, but were not limited to, Alzheimer's disease, and repeated falls. A quarterly risk evaluation, dated 5/19/23, a score of 13.0 indicated moderate fall risk. An annual MDS assessment, completed on 5/17/23, assessed the resident as having the ability to make herself understood and to understand others. A BIMS score of 1 out of 15 indicated severe cognitive impairment. Resident H required extensive assistance of 2 or more persons physical assist for bed mobility and transfers. Resident H's mobility devices included a wheelchair. Resident H had one fall since prior assessment without injury. A current care plan for Resident H, indicated at risk for falls related to a history of falls, impaired cognition, and impaired mobility. The goal was for the resident interventions to minimize the risk for falls resulting in serious injury. Interventions included bolsters on the bed to remind resident of bed boundaries, keep personal items used frequently within reach, and encourage to use call light when needing assistance prior to transfers. 4. During the initial pool tour, on 6/19/23 at 11:19 a.m., Resident L was observed lying in bed with eyes closed, television on, call light laying on the bottom bed frame under the top of the bed, out of sight and reach of the resident. Licensed Practical Nurse (LPN) 6 indicated the resident required stand by assistance for transfers. LPN 6 indicated the resident required 2 person assist for transfers and did not routinely use her call light to call for assistance. Resident L's record was reviewed on 6/20/23 at 9:15 a.m. Diagnoses on Resident L's profile included, but were not limited to dementia, and history of falling. A quarterly risk evaluation, dated 5/28/23, a score of 15.0 indicated high fall risk. An annual MDS assessment, completed on 5/25/23, assessed the resident as having the ability to make herself understood and to understand others. BIMS score of 3 out of 15 indicated severe cognitive impairment. Resident L required extensive assistance of two or more persons physical assist for bed mobility and transfers. Mobility devices included a wheelchair. A current care plan for Resident L, indicated at risk for falls related to dementia. The goal was for the resident interventions to minimize the risk for falls resulting in serious injury. Interventions included personal items that were used frequently within reach, and assistive devices to be kept within reach. 5. During the initial pool tour, on 6/19/23 at 11:24 a.m., Resident M was observed lying in bed propped with a pillow facing left towards the doorway, call light observed tethered to the bottom of the side rail on the right side of the bed out of sight and reach of the resident. The resident was alert and talkative and indicated if she needed assistance she would use her call button. Resident M's record was reviewed on 6/20/23 at 9:30 a.m. Diagnoses on Resident M's profile included, but were not limited to, generalized anxiety disorder, and history of falling. A quarterly risk evaluation, dated 5/15/23, indicated a score of 9.0 which was a moderate fall risk. An annual MDS assessment, completed on 4/12/23, assessed the resident as having the ability to make herself understood and to understand others. A BIMS score of 5 out of 15 indicated severe cognitive impairment. Resident M required extensive assistance of one person physical assist for bed mobility, and locomotion in the room, extensive assistance of 2 or more persons physical assist for transfers, and mobility devices included a walker. A current care plan for Resident M indicated at risk for falls related to impaired mobility. The goal was for the resident interventions to minimize the risk for falls resulting in serious injury. Interventions included to be assisted back to bed upon request and to have personal items that were used frequently within reach. 6. During the initial pool tour, on 6/19/23 at 11:34 a.m., Resident P was overheard yelling help me. Resident P was observed propped in bed looking out the door, call light observed out of sight on the bedrail on left side of bed. Qualified Medication Aide (QMA) 14 and an unidentified aide were observed to walk by the resident room conversing about personal subjects and did not respond to the resident. LPN 12 indicated the resident was declining quickly and required staff assistance for bed mobility and transfers. On 6/20/23 at 7:52 a.m., the resident's call light was observed hanging down from the top of right handrail past bottom of rail out of sight and reach of resident. Resident P's record was reviewed on 6/20/23 at 9:45 a.m. Diagnoses on Resident P's profiled included, but were not limited to, dementia. A quarterly risk evaluation, dated 5/25/23, indicated a score of 11.0 which was a moderate fall risk. An annual MDS assessment, completed on 4/7/23, assessed the resident as having the ability to make himself understood and to understand others. A BIMS score of 11 out of 15 indicated moderate cognitive impairment. Resident P required an extensive assistance of one person physical assist for bed mobility, locomotion in the room and corridor. The resident required an extensive assistance of 2 or more persons physical assist for transfers. Mobility devices included a wheelchair. A care plan for Resident P, indicated at risk for falls related to impaired mobility and impaired cognition. The goal was for the resident interventions to minimize the risk for falls resulting in serious injury. Interventions included to have personal items that were used frequently within reach and to educate to use the call light prior to attempting to transfer. 7. During the initial pool tour, on 6/19/23 at 11:38 a.m., Resident Q was observed lying in bed propped on her left side facing the door. The call light was observed laying on the floor below the right side of the bed. The resident was alert and talkative and indicated if she needed assistance from staff, she pushed her call button but always had a hard time finding it. LPN 12 indicated the resident required a Hoyer lift for transfers. On 6/20/23 at 7:41 a.m., the resident was observed having her bed adjusted by an unidentified aide setting the resident up for breakfast, the call light was tucked behind the right side of the pillow behind the resident's head, out of sight and reach of the resident. On 6/20/23 at 10:18 a.m., observation of the resident propped in bed, the call light continued to be tucked behind the right side of the pillow behind the resident's head, out of sight and reach of the resident. Resident Q's record was reviewed on 6/20/23 at 9:48 a.m. Diagnoses on Resident Q's profile included but were not limited to history of falling. A quarterly risk evaluation, dated 4/4/23, indicated a score of 14.0 which indicated moderate fall risk. A quarterly MDS assessment, completed on 4/6/23, assessed the resident as having the ability to make herself understood and to understand others. A BIMS score of 11 out of 15 indicated moderately impaired cognition. Resident Q required an extensive assistance of 2 or more persons physical assist for bed mobility and transfers. Mobility devices included a wheelchair and walker. A current care plan for Resident Q indicated the resident was at risk for falls related to weakness. The goal was for the resident interventions to minimize the risk for falls resulting in serious injury. Interventions included to have personal items that were used frequently within reach and to have assistive devices kept within reach. During an interview on 6/20/23 at 10:24 a.m., the Assistant Director of Nursing (ADON) indicated, there was a nurse and/or QMA on each hallway. All staff no matter the department should have made sure call lights were in reach when leaving a resident room, ultimately it fell on the nurse covering the hallway to make sure call lights were in place. Upon rounds the prior day, management staff had observed call lights not being in place. On 6/20/23 at 10:40 a.m., the ADON provided a Resident Call System policy, revised 10/22, and indicated the policy was the one currently being used by the facility. The policy indicated, Purpose: The facility must be adequately equipped to allow residents to call for staff assistance though a communication system which relays the call directly to a staff member or a centralized staff work area .The call light should be within reach of the resident whether in bed, sitting in a chair in their room, in the toilet and bathing area. The intent of this requirement is that residents, when in their rooms, toilet, and bathing areas, have a means of directly contacting caregivers 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure management and oversight of a confused resident resulting in elopement of 1 of 4 residents reviewed for wandering and exit seeking behaviors (Resident B). Using the reasonable person concept, it is likely that this would lead to mental anguish including anger, distrust, and chronic or recurrent fear and anxiety. Findings include: An Indiana State Department of Health Survey Report System report, dated 10/6/22 at 6:01 a.m., indicated Resident B was found in the employee parking lot. Resident assessed by Nurse Practitioner, noted to possibly have delirium related to hospitalization , surgery, and anesthesia. On 1/18/23 at 9:10 a.m., observation of the staff service hallway located midway down the 500 hallway. The door providing access onto the service hallway equipped with a keypad lock was observed to be ajar and visitor was able to access the hallway. A regional maintenance worker indicated the door was not closing properly and would be looked at. The first exit door on the left in the service hallway that provided direct access to the generator and back employee parking lot was observed to have a keypad lock. Housekeeper 13 indicated the keypad lock had recently been installed on that exit door to the parking lot. On 1/18/23 at 9:29 a.m., a second observation of the door providing access to the 500 hallway service hallway observed to be standing ajar. Observation of 2 unidentified staff members going through the door from service hallway, lag time for the door to close and secure was approximately 15 - 30 seconds. The regional maintenance worker indicated he and a crew had entered the facility on Monday 1/16/23 to provide general maintenance to resident rooms and noticed at that time the service doorway was not closing properly, and he had made the facility aware. On 1/18/23 at 9:40 a.m., together with Certified Nursing Assistants (CNAs) 7 and 9, the Assistant Director of Clinical Services (ADCS) was observed exiting the service hallway then walking down the 500 hallway towards the nurses' station. The door opening onto the service hallway was observed to not close completely or latch. On 1/18/23 at 9:50 a.m., contracted construction worker 17 was observed on a ladder at the entry of the employee service hallway. He indicated positive air pressure was the cause of the door not closing or not closing timely and locking. The first exit door on the left in the service hallway facing the employee parking lot and generator had not been locked or had an audible alarm until he had recently installed the keypad lock and alarm over the door. Before the door could be opened just by pushing the bar on the door. Accessing that door could have set off an alarm at the nurse's station, but he was not sure. Contracted construction workers 17 and 18 demonstrated opening the exit door and an alarm sounding in the nurse's station with the button lighting up on the panel. Contracted construction worker 18 demonstrated how to reset the alarm button, then demonstrated how by pushing any button on the alarm panel, the alarms could be silenced on any access doorway to include the door in question on the service hallway. Contracted construction worker 17 indicated the service door from the 500 hallway now had a keypad but no alarm, so anyone could access the service hallway with the code and no alarm would sound. The ADCS indicated this was most likely due to frequent staff traffic in and out. Resident B's record was reviewed on 1/17/23 at 11:37 a.m. Diagnoses on Resident B's profile included, but were not limited to, surgical aftercare, mitral valve disorders, atrial fibrillation (rapid and irregular heart beating), hypertension (high blood pressure), muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, need for assistance with personal care, and cognitive communication deficit (difficulty with thinking and how someone uses language). A physician's order, dated 10/5/22, indicated strict sternal precautions (i.e., don't push or reach out with both arms) for 6 weeks. A physician's order, dated 10/5/22, indicated may go out on leave of absence (LOA) with responsible party and meds. An admission assessment, dated 10/5/22 at 5:21 p.m., indicated Resident B was alert to person, lethargic and questioning, his mood passive and comprehensive slow. The resident ambulated independently with no assistive devices and had no fall history. An initial care plan addressed potential for bleeding, pressure ulcers and falls. There was no documentation that addressed potential for elopement. A Quarterly Risk Evaluations, dated 10/5/22, indicated a score of 8 and moderate risk for falls. The resident had the ability to move about the facility independently and demonstrated poor judgement/impaired safety awareness. No history of wandering. An intra-facility transfer form, dated 10/6/22, indicated resident relocated from the skilled unit to the secured memory care unit. The move was necessary for the welfare of the resident or other persons. Responsible party waived the 48 hour notice and relocation planning conference. The resident record lacked documentation the resident was moved back out of the secured memory care unit to his original room on the skilled unit. A late entry notes by Nurse Practitioner (NP) 20, created on 10/11/22 at 12:50 a.m., effective 10/6/22 at 12:50 a.m., indicated the resident was admitted to the facility secondary to deficits in mobility and activities of daily living (ADL's). Nursing notes that the patient was found outside the building wandering earlier today and had had episodes of increased confusion and agitation. Family notes that the patient did have delirium after surgery without much improvement. Patient continued to have confusion at this facility and was found wandering outside and at times could be agitated. Family stated that they did not want the patient in the dementia unit. Accommodations were made so that the family could stay with the patient 24 hours a day in a private rehab room. A late entry nurse's note by the Assistance Director of Clinical Services (ADCS) created on 10/6/22 at 12:40 p.m., effective 10/6/22 at 7:00 a.m., indicated she was notified by nursing staff at 6:09 a.m. Resident B had been found by staff in the employee parking lot at shift change. Resident was brought in by staff and placed on secure memory care unit for breakfast until he could be assessed for proper placement. ADCS was informed the resident had been at the nurse's station at approximately 5:00 a.m. and was redirected back to his room. Family stated there had been a change in the resident's mentation from the previous day. They did not want to send resident out for evaluation and felt that it was probably from all the changes. Family requested the resident move out of the secure memory care unit back to his prior room, and that family would provide 1 on 1 with him until mentation improved or the resident discharged to home. A nurses note dated 10/7/22 at 8:41 p.m. daughter called and stated the resident was taken from a doctor's appointment to the emergency room (ER) and was being readmitted to the hospital. A Medicare 5 day Minimum Data Set (MDS) assessment completed on 10/7/22, indicated Resident B had the ability to make himself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 3 indicated severe cognitive impairment. No signs or symptoms of delirium, behaviors, rejection of care, or wandering. Extensive assistance of 1 person physical assist for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Mobility devices included a wheelchair and walker. A handwritten witness statement by staff member 6, dated 10/6/22, indicate, Pulling in the parking lot at 6 am. As I was walking in I seen a resident being walked back to the building. [CNA 9] was escorting him back. A handwritten witness statement by Licensed Practical Nurse (LPN) 8, dated 10/6/22 at 6:00 a.m., indicated, I saw 1 staff member arm in arm with resident. They were walking from in between cars in south parking lot going towards the 500 hall door. They entered the door and assisted resident into a wheelchair. Staff immediately notified supervisors and directed to take resident to 400 hall. Resident complied without issues. A handwritten witness statement by CNA 9, dated 10/6/22, indicated, around 6:00 am on Tuesday 6th of Oct he was called by his wife who dropped him off at work, said she saw someone maybe staff or resident walking from the parking lot. Look was and after clock in at 6:00 am I went back outside to see what was going on and I talk to this man and I bring him to the building before I knew he was one of the residents. E-mail correspondence between the facility and the Regional Director of Operations, included pictures and descriptions to include, a. Picture of electronic panel with note, Door is alarmed but the alarm was silenced. b. Picture of a door, This is the door that should have a keypad added. c. Picture of a door, This door had an automatic opener that is very slow and leaves the door open for several seconds. d. Picture of Evacuation Plan on the wall, The service hallway on the evacuation plan is the area that the door is located that the resident exited. A memo posted by an alarm panel in the nurse's station, signed by the Executive Director (ED), indicated, These alarms are to always remain on! If they are found to be turned off, disciplinary action up to and including termination will occur. A work order, created 10/6/22 at 12:00 p.m., updated 10/16/22 at 11:06 a.m., indicated the service door going to the generator needed a keypad installed. This was from an elopement in the building. The Maintenance Supervisor indicated the keypad was installed between 10/10/22 and 10/12/22. A list of residents known for wandering included documentation of six (6) residents, 2 of which continued to reside on the 500 hallway, Residents F and G. During an interview on 1/18/23 at 9:15 a.m., Housekeeper 13 indicated the first exit door on the left in the service hallway recently had a keypad lock applied. If the wrong code was entered an alarm was supposed to sound at the nurse's station. During an interview on 1/18/23 at 9:23 a.m., CNA 7 indicated, the door leading onto the service hall had not closed properly for a couple of years, staff had repeatedly reported the door to management, and Resident B was not the first resident to go out that door. The night Resident B eloped, he had wanted to go outside to smoke, and the night shift staff did not routinely take residents out to smoke. To her knowledge, CNA 9's wife had seen Resident B near a gate to a nearby housing addition just standing outside. She had thought there was snow on the ground at that time and was unsure if the resident had a coat on. Resident B had to have gone thru the service door that did not latch and then out through the side exit door on the service hallway that was not alarmed. There was a paved sidewalk straight to the back parking lot towards a newer housing addition. During an interview on 1/18/23 at 9:30 a.m., CNA 9 indicated on 10/6/22 his wife had dropped him off at work at 6:00 a.m. He entered the facility to clock in and his wife called, indicated when she turned around and was coming back by the employee entrance her headlights spotted a gentleman crossing the parking lot road and walking onto the grass near the back yard of a nearby housing addition. CNA 9 went back outside and with the help of his wife backing up and turning her car headlights towards the housing addition was able to see a man underneath some trees on the grass. CNA 9 was not sure if the gentleman was a resident or not but assisted him from behind the trees, down across the grass, through the parked car, and into the facility and helped him into a wheelchair and took him to the nurse's station. A night nurse identified Resident B as a new resident from the prior evening. The resident was dressed in a short sleeved red button-up t-shirt with no coat carrying a small bag, and it was cold outside. CNA 9 indicated he was not sure how long the resident had been outside or how he got out but speculated the service door had not latch with staff going through to either take out the trash or laundry and the resident went out the unsecured exit door on the service hallway that was a straight path to where he was found in the trees. Resident B seemed confused, and when asked if he was okay, replied he was not doing good and I'm tired. Indicated after the resident was found outside, he was initially placed on the secured memory care unit, but the family did not want him to be back there, so he was returned to the 500 unit room. The plan was for family to 1:1 with the resident, but they would stay periods of time then leave. CNA 9 acknowledged Resident B was found near the neighboring housing addition, hidden in the trees in the dark, confused, and if his wife had not found the resident he could have walked away and got to the road or highway nearby without anyone knowing where he had gone. During an interview on 1/18/23 at 9:53 a.m., the ADCS indicated she did not have prior knowledge of the service door not consistently latching. Indicated on 10/6/22 she was told at around 5:00 a.m. Resident B had been seen at the nurse's station and staff redirected him back to his room. When day shift started arriving around 5:30 a.m. - 6:00 a.m. the resident was observed by the employee entrance. She thought Resident B had gone through the service door that was slow to close after an employee had gone through. The resident then got out of an unlocked exit door on the service hallway. All the exterior doors of the building when opened would alarm at the nurse's station, and the alarm panel at the nurse's station was found to have been silenced that night. The resident was supposed to have assistance with ambulation but would walk around independently. Family indicated Resident B lived alone before surgery, but after surgery his mental status was totally different, even from the day before a lot different. During an interview on 1/18/23 at 9:57 a.m., the Maintenance Supervisor indicated, he was not made aware of issues with the service door not latching until that today. Upon review, he had no maintenance slips regarding the service doors from January 2022 to present. During an interview on 1/18/23 at 10:32 a.m., the Regional Nurse indicated, the alarm in the nurse's station had sounded on 10/6/22, but there were no nurses in the nurse's station and the alarm was not loud enough to be heard on the hallways. There had always been a maglock alarm (locking device that consists of an electromagnet attached to the doorframe that bonds to an armature plate on the door when shut) on the exit door down the service hallway that faced the parking lot by the generator, but the keypad was new. During an interview on 1/19/23 at 9:56 a.m., Licensed Practical Nurse (LPN) 19 indicated when anyone accessed any hallway exit door, a loud alarm would sound in the nurse's station from a panel on the wall. A button would light up on the panel to indicated which door was opened. Staff were to go to the door and visualize to see who set it off, and not just turn off the alarm until a determination made was it not a resident outside. On 1/17/23 at 3:00 p.m., the Director of Clinical Services (DCS) provided an Elopement/Missing Resident Policy, revised 10/22, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the responsibility of all personnel to report a cognitively impaired resident found outside the facility or attempting to leave the facility to the change nurse immediately .Facilities are responsible for identifying and assessing a resident's risk for leaving the facility without notification to staff and developing interventions to address the risk Using the reasonable person concept, it is likely that this would lead to mental anguish including anger, distrust, and chronic or recurrent fear and anxiety. This Federal tag relates to Complaint IN00391937. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to follow their policy to ensure all newly hired employees had a criminal background check completed and reviewed before starting work at the facility for 1 of 5 randomly selected new hire employees reviewed for criminal background checks (Housekeeper 25). This deficient practice had the potential to effect 120 of 120 residents who resided in the facility. Findings include: On 8/15/22 during the entrance conference State Form 5440, employee records was provided to the Executive Director for completion. On 8/18/22 at 10:15 a.m., the employee record form and 5 new hire employee files, randomly selected, were reviewed. The file for Housekeeper 25, hired on 6/14/22, did not contain a criminal background check. On 8/18/22 at 1:25 p.m., the file was returned to the Business Office Manager (BOM) for verification. On 8/19/22 at 11:00 a.m., during an interview, the Director of Nursing (DON) indicated Housekeeper 25 was a minor.The facility's background check company did not do background checks for minors. The facility had sent her to a private fingerprint company to be fingerprinted for an Indiana State Police criminal record review. The company was supposed to mail the verification to the minor's parent's home address. The mother also worked at the facility and was known to them. The mother told the facility the report had not been received. Housekeeper 25 was not currently working any shifts at the facility because she was back in school, for the fall. The DON provided a (Name of Company) registration record for Housekeeper 25 to be finger printed on 8/19/22 at 4:10 p.m. She indicated they had requested she be re-finger printed since they had not received the first results. A printout of Housekeeper 25's time card indicated she had worked at the facility for 27 shifts between 6/14/22 and 8/18/22, for a total of 170.25 hours. On 8/22/22 at 12:03 p.m., the DON provided a current policy, dated as reviewed on 4/25/08, titled Required Criminal History Checks for Minor Employees. This document indicated To adhere to the State Department of Health's requirement as stated in IC 16-28-13 for obtaining criminal histories on all employees including minors. It is the policy of [Name of Corporation] to require that an Indiana State Police Limited Criminal History be obtained for minor employees prior to but no later than the first day of employment 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's (Resident 21) physician was notified for a change in condition related to increased pain and limited range of motion, and failed to notify the physician after it had been noted she spit out medication for 1 of 2 residents reviewed for pain. Findings include: On 8/15/22 at 10:30 a.m., Resident 21 was observed as she laid in bed. She laid on her right side, and her knees were pulled up towards her chest, almost in a fetal position. She grimaced her face and indicated she hurt all over. During a confidential interview, it was indicated Resident 21 was recently moved from the secured memory care unit, to the far back of the 500-Long Term Care Hall. It was right by an exit door, and not a day after she moved, Resident 21 was agitated and attempted to get out of the door. Over the weekend she remained restless and had a fall. She had been in bed ever since. On 8/16/22 at 2:18 p.m., Certified Nursing Assistant (CNA) 20 was observed as she passed ice water at Resident 21's room. At this time she indicated Resident 21 was new to the hall, she moved from the memory care unit. CNA 20 had been off over the weekend, but when she returned to work that morning, Resident 21 was not her normal self. Usually Resident 21 could independently transfer, and liked to get out of bed, but now she stayed in bed and complained of pain. CNA 20 indicated her pain was localized to the left hip area. During an interview on 8/16/22 at 3:02 p.m., Registered Nurse (RN) 21 indicated yesterday the CNA had informed him that Resident 21 was complaining of pain. When he assessed her, it appeared she had some increased pain which she showed in her face and increased limited range of motion in her lower extremities. She was still on fall follow up from her fall over the weekend, so he had documented his assessment in the fall follow up assessment but had not called the Physician or DON at that time. He had not been down to check on her so far, as she had been sleeping when he arrived on his shift. On 8/16/22 at 3:15 p.m., RN 21 was observed as he went to assess Resident 21. She was pleasant and cooperative as he moved her arms and hands. However, when he attempted to have Resident 21 straighten her legs, she began to cry out in pain. He stopped and indicated it was similar to her reaction yesterday. When he attempted range of motion on her left leg a second time, Resident 21 cried out, Ow! Get off of me! RN 21 indicated he would the let Nurse Practitioner know and see if she would order an x-ray. On 8/16/22 at 3:57 p.m., a Mobil x-ray technician indicated he was able to complete 2 views of Resident 21's left hip. It took longer than usual, because she was in a great deal of pain, and it was difficult to get her positioned. During an interview on 8/16/22 at 4:13 p.m., the Director of Nursing (DON) indicated, RN 21 did note Resident had increased pain and limited range of motion on his post fall assessment, but should have notified the NP, or the DON at that time, so that an x-ray could have been ordered sooner. He had administered her pain medication at that time. On 8/17/22 at 9:00 a.m., the DON indicated, Resident 21's x-ray results had been received and were negative for fracture. On 8/17/22 at 9:39 a.m., Resident 21 was observed. She laid in bed with the head of her bed slightly elevated. Her eyes were open. There was a blue streaking stain observed on her bottom lip and upon closer observation, small white capsule/beads were observed stuck to her bottom lip. A partially dissolved blue capsule was observed on the resident's chest, with more small white capsule/beads coming out of it. There was a second circular white pill on her chest. At this time CNA 19 entered the room to check on Resident 21. The CNA was alerted to the pills, and she indicated, it appeared as if Resident 21 had spit them out. She wrapped the pills in a paper-towel and indicated she would let the nurse know. During a follow up interview on 8/19/22 at 11:41 a.m., CNA 19 indicated, she had taken the pills to the Unit Manager, During an interview on 8/19/22 at 11:43 a.m., Registered Nurse (RN) 4 indicated, CNA 19 had let her know Resident 21 spit out two pills and brought them to her. The pills had been administered by the QMA (qualified medication aid) on the medication cart, but were too disintegrated to identify, so she disposed of them in the sharps container. She had not notified the physician and did not know if the QMA had notified the physician either. During an interview on 8/19/22 at 11:47 a.m., the Assistant Director of Nursing (ADON) indicated, if medications were noted to have been spit out, the nurse should notify the physician to get an order to monitor the resident, especially if they were unable to determine what medications might have been missed and what side effects that might cause. On 8/16/22 at 4:30 p.m., Resident 21's medical record was reviewed. She had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had physicians order for the following scheduled daily medications: [MEDICAL RECORD OR PHYSICIAN ORDER] a. Aspirin (a blood thinning medication) 81 mg (milligrams) b. [MEDICATION(S)] 5 mg (an antianxiety medication) c. [MEDICATION(S)] (a medication used to treat high blood pressure) 240 mg extended release d. [MEDICATION(S)] (a medication used to treat dementia) 5 mg e. [MEDICATION(S)] (a narcotic pain medication used to treat pain) 50 mg f. [MEDICATION(S)] (an antidepressant medication) 100mg She had a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her census record indicated she had been moved to the Long-Term Care 500 hall on 8/9/22. A nursing progress note dated 8/10/22 at 1:38 p.m., (the day after her from the secured memory care unit) indicated, Resident 21 had become agitated and transferred out of her wheelchair and was walking in the hallway. She attempted to get out of the 500-hall back door and was hitting the window screaming I want to go home, and let me out, staff immediately assisted and attempted to redirect res, unsuccessful for several minutes until res became weak and needed to sit down in her wheelchair. A nursing progress note dated 8/14/222 at 4:38 p.m., indicated, Resident 21 had a fall. An IDT (interdisciplinary team) progress note dated 8/15/22 at 12:36 p.m., indicated Resident 21's fall was reviewed. She had been ambulating in the hallway, when she was noted to become weak and fell to the floor. An intervention was added for staff to offer Resident 21 assistance with ambulating prior to dinner. A post fall evaluation dated 8/15/22 at 5:00 p.m. indicated Resident 21 had limited right lower extremity limitations. The record lacked documentation the physician had been notified of the new limited range of motion. The record lacked documentation the physician had been notified of the two pills Resident 21 had spit out. On 8/16/22 at 4:30 p.m., the DON provided a current facility policy titled, Pain Evaluation, dated 5/2012, revised 3/2020. The policy indicated, .Residents will have a pain evaluation completed upon admission, quarterly, and when the resident experiences new pain in a different location . when completing the pain evaluation, the nurse will assess the resident pain level at the time the evaluation is completed . nursing will document any complaints and sings/symptoms of pain in the progress notes as indicated On 8/19/22 at 1:50 p.m., the DON provided a copy of current facility policy titled, Physician/Clinician/Family/Responsible Party Notification for Change in Condition, dated 6/2014, revised 2/2022. The policy indicated, To ensure that medical/psychological care problems are communicated to the attending physician/clinician and family/resident representative in a timely manner . The facility must immediately inform the resident; consult with the resident's physician/clinician; an notify, consistent with his or her authority, the resident representative(s) when there is . a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due adverse consequences, or to commence a new form of treatment 3.1-5(a)(3)

Based on observation and interview, the facility failed to properly dispose of of medication containers with confidential information identifying resident and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 08/18/22 at 8:49 a.m., during a random medication storage observation of the 300 Hall medication cart, the trash can on the side of the cart had medication packaging visible with resident names on the container/package. An opened [MEDICATION(S)] (pain patch) patch label for Resident 71 indicated: [MEDICATION(S)] Patch 4 % Apply to lower back topically one time a day for pain. Pharmacy Active 12/2/2021 07:00 12/1/2021 An open bottle of omeprazole suspension, partially full, with a smeared label for Resident 44 indicated: Omeprazole Suspension 2 MG/ML Give 20 ml by mouth one time a day for [CONDITION(S)]. Pharmacy Active 8/20/2022 07:00 8/19/2022 On 8/18/22 at 8:55 a.m., during an interview, Licensed Practical Nurse (LPN) 14 indicated the resident names should have been marked out in black marker before throwing medication packages in the trash to make them unidentifiable. She did not put them in the trash and did not know who did. LPN 14 had the medication cart keys and opened the cart to complete the medication storage observation. On 8/18/22 at 1:56 p.m., the Director of Nursing (DON) provided a current policy, dated as revised on 12/21, titled Notice of Privacy Practices. This policy indicated .Although your health record is the physical property of the nursing facility, the information in your record belongs to you On 8/22/22 at 11:00 a.m., the DON provided a current policy, dated as revised on 2/22, titled Drug Disposition. This policy indicated Non-unit dose drugs not qualifying for return to the issuing pharmacy and drugs left by residents discharged from the facility shall be destroyed .destroyed in the presence of two (2) licensed .persons witnessing the distribution/disposal of drugs must date and sign the drug disposition record . 3.1-3(o)

Based on observation, interview, and record review, the facility failed to prevent falls with injuries for residents with histories of numerous falls which resulted in harm when Resident E was admitted to the hospital with a subarachnoid hemorrhage; and the facility failed ensure fall interventions were personalized, updated, effective, and followed for 4 of 4 residents reviewed for accidents (Residents E, C, D, and P). Findings include: 1. During an interview on 4/19/22 at 10:06 a.m., Resident E's Power of Attorney (POA) indicated she was angry and upset with the facility staff. Resident E had multiple falls during her short time in the facility after being admitted for rehabilitation and diagnoses to include seizures. The day after Resident E's admission she had fallen and had bruising to her shoulder requiring an x-ray, and the staff failed to assess her mother, perform neuro (neurological) checks, or document the incident until days later after the daughter reported the fall to the administrative staff. The resident continued to have falls and there was never a consistent explanation of the cause for the falls. The most recent fall had occurred on Monday 4/18/22 around 1:00 a.m. and it had been completely preventable. Around 2:00 a.m., the night nurse had called her and indicated the resident had fallen forward out of her wheelchair when being taken to the bathroom by an aide. The nurse indicated the aide was pushing the wheelchair, and the resident attempted to stand up and fell forward hitting her head. There were no footrests on the wheelchair despite the resident's dependence and diagnoses of [CONDITION(S)]. The nurse indicated she had contacted the physician and was told to monitor the resident in the facility. The POA asked what interventions were being done for the resident due to hitting her head and having a history of having seizures and being on blood thinners ([MEDICATION(S)] and Aspirin), and the nurse responded she had a cool rag on the resident's head. A that point the POA requested to have the resident sent to the hospital for evaluation and treatment. The resident was admitted to a local hospital with diagnoses to include a brain bleed, her left eye was swollen shut, and she had a dark bruise on to top of her left toes. During the conversation with the night nurse, the nurse indicated she would put a sign up in Resident E's room to put foot pedals on the resident's wheelchair, and the POA responded that should have been common sense when transporting a resident who was dependent. A hospital emergency department report for Resident E, dated 4/18/22, indicated chief complaint fall. Patient arrived at the facility following frequent falls for the past week. Patient with a fall out of wheelchair the morning of 4/18/22 and had a hematoma to left eye. Patient presented with a ground level fall. Patient lived in memory care unit, had a history of dementia, and was on [MEDICATION(S)]. Apparently fell forward after being pushed in wheelchair and struck the left side of her head. Diagnoses or management options included [MEDICATION(S)] head injury, periorbital hematoma to left eye, and subarachnoid hemorrhage following injury. Patient admitted to the Progressive Care Unit (PCU). Resident E's record was reviewed on 4/19/22 at 9:53 a.m. Diagnoses on Resident E's profile included, but were not limited to, [CONDITION(S)], muscle weakness, difficulty walking, and need for assistance with personal care. The resident's record lacked a diagnoses of frequent falls. An Admission MDS (Minimum Data Set), dated 3/22/22, assessed Resident E as having the ability to make herself understood and to understand others. A BIMS (Brief Interview for Mental Status) score of 12 indicated moderately impaired cognition. No signs or symptoms of [CONDITION(S)], behaviors, or rejection of care. Extensive assistance of two or more persons physical assist for bed mobility. Extensive assistance of one person physical assist for transfers, walking in room and corridor, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Mobility devices included a walker and wheelchair. Frequently incontinent of bladder and always continent of bowel. History of falls in the past month and last 2-6 months prior to admission. No falls since admission. No restraints, or alarming device used to monitor resident's movement. Physician's orders for Resident E indicated, a. On 3/10/22: [MEDICATION(S)] Tablet ([MEDICATION(S)] blood thinner) give 75 mg (milligrams) by mouth one time a day for [CONDITION(S)]. b. On 3/10/22: Aspirin 81 Tablet Chewable (to prevent heart attack or clot related strokes) give 81 mg by mouth one time a day for heart heath. A Quarterly Risk Evaluation for Resident E, dated 3/10/22, indicated a score of 10 moderate fall risk. Assessments related to falls for Resident E, dated 3/10/22 - 4/19/22, indicated the resident was documented as having 8 falls, dated 3/12, 3/28, 3/29, 4/3/, 4/7, 4/13, 4/14, and 4/18/22. A Late Fall IDT Note, created on 3/29/22 at 10:09 a.m. by the DON (Director of Nursing), effective date 3/14/22 at 4:03 p.m., incident on 3/12/2022 at 6:00 a.m. resident was found on the floor in her room. Resident E was lying next to her bed and unable to state what she was attempting to do. Root cause of fall: resident appeared to have been attempting to get out of bed unassisted and fell to the floor. Intervention and care plan updated to include resident would be encouraged to wear nonskid footwear at all times. A fall note for Resident E, dated 3/28/22 at 7:23 a.m., indicated the resident fell at 6:30 a.m. in her room. The resident was found on her stomach next to her bed. The resident stated she was getting out of bed to get back into bed. The resident record lacked documentation to indicated neuro checks and a Post Fall Note were completed. A Fall IDT note, dated 3/28/22 at 10:02 a.m., indicated the resident was found on the floor in her room. Resident was noted to be incontinent of both bowel and bladder. Resident E stated that she had gotten herself out of bed and fell to the floor. A fall note for Resident E, dated 3/29/22 at 6:51 a.m., indicated the resident fell at 6:10 a.m. next to her bed. The resident's call light was sounding, and the CNA came into the and room found the resident sitting on the floor next to her bed. The resident's pants were below her buttocks, and her legs were outstretched in front of her. Immediate intervention: remind resident frequently to use call light for assistance. A Fall IDT Note, dated 3/30/22 at 8:46 a.m., indicated Resident E fell on [DATE] and was found on the floor in her room. Intervention and care plan updated to include the resident would be offered assistance with getting up for the day if she was noted to be awake on the last rounds of night shift. A fall progress note for Resident E, dated 4/3/22 at 6:45 a.m., indicated the resident was found sitting on the floor at 6:45 a.m. inside her room close to her bed. The resident stated she had a bad dream and she tried to get out of her bed and ended up on the floor. A Fall IDT noted, dated 4/4/22 9:55 a.m., indicated Resident E was found sitting on the floor in her room next to her bed. Intervention and care plan updated to include the resident would be encouraged to call for assistance prior to attempting to transfer herself. A fall progress note, dated 4/7/22 at 9:06 p.m., indicated Resident E fell at 8:00 p.m. beside her bed. The resident was witnessed attempting to transfer herself, resident appeared unsteady, and staff intercepted and lowered resident to the floor. A Fall IDT note dated 4/8/22 at 10:08 a.m., indicated Resident E was witnessed attempting to transfer herself from her wheelchair to the bed, and staff lowered resident to the floor. Intervention and care plan updated to include staff would offer resident assistance with evening care prior to going to bed. A Late Fall IDT note for Resident E created on 4/18/22 at 10:23 a.m. by the ADON, effective date 4/8/22 at 10:08 a.m., indicated fall occurred on 04/07/22 not 04/08/2022. A progress note for Resident E, dated 4/12/22 at 4:51 a.m., indicated the resident had attempted to get out of bed unassisted times two. The CNA offered to toilet the resident and she refused. The resident later put on her call light to be toileted. A fall progress note, dated 4/13/22 at 9:21 p.m., indicated Resident E fell in her room at 4:30 p.m. This nurse entered the room and observed the resident sitting on the floor between her wheelchair and her bed on the left side. Resident was facing the bed and her back was leaning on the front of the wheelchair. Resident stated that she was trying to get in her wheelchair to be ready for physical therapy. A fall progress note, dated 4/14/22 at 8:01 a.m., indicated Resident E fell at 7:10 a.m. in her room at bedside. The nurse had just walked out of another resident's room and saw Resident E's legs hanging down at the side of her bed. As nurse was approaching the resident's room she stood up while also reaching for her wheelchair and fell on to her buttocks. A Fall IDT note, dated 4/14/22 at 9:35 a.m., indicated on 4/13/22 Resident E was found sitting on the floor in her room. Resident was sitting on the left side of her bed. She was in between the bed and the wheelchair. Resident stated that she was attempting to get from her bed and into her wheelchair and fell to the floor. Intervention and care plan updated included staff will offer resident assistance into her wheelchair prior to dinner. A Fall IDT note, dated 4/14/22 at 9:39 a.m., indicated on 4/14/22 Resident E was in her room when a nurse was walking by resident's room and saw resident standing from the side of her bed. Staff attempted to assist resident and resident fell to the floor. Resident stated that she was attempting to get into her wheelchair. Intervention and care plan updated included resident would have her wheelchair removed from her line of sight to encourage her to call for assistance prior to transfers. A progress note, dated 4/16/22 at 7:01 p.m., indicated when an aide was getting Resident E ready for bed, she took her to the bathroom and told the resident to hold on to the bar so she could stand up, but instead of holding to the bar she moved herself on the edge of the wheelchair and bent her leg and was trying to get up. Good thing the aide was in front of her to prevent her from falling. The resident was educated to help herself and the aide to stand up and turn so she could use the toilet, but the resident kept insisting she could not stand up and do it. The nurse was called to the bathroom and observed the resident trying to lean forward and bend her knees and not holding on the rail of the bed to stand up. The resident was refusing to help herself from getting up. An eInteract SBAR Summary for Providers Change in Condition form, dated 4/18/22 a 1:30 a.m., indicated the CNA transferred Resident E to a wheelchair to take her the bathroom per the resident's request. For some unknown reason, the resident decided to lean forward suddenly and fell on her face on the floor. The CNA nor the resident could explain why this happened. The on-call physician recommended the standard protocol of neuro checks, vital signs, monitoring for 72 hrs., and to put an ice pack on hematoma to reduce swelling. When the nurse notified the resident's POA, she requested the resident be sent to the hospital for a CT scan. The resident was transported via 911 to a local hospital. A fall progress note, dated 4/18/22 at 5:04 a.m., indicated Resident E fell at 1: 30 a.m. in her room. The resident leaned forward unexpectedly and fell on her face onto the floor. The resident was noted to have swelling on the left eyebrow. An ice pack was placed on swollen left eyebrow. The resident was assisted back to a wheelchair by 2 staff members using a gait belt. The resident was taken to the toilet, then back into her wheelchair, then back to bed. The POA was notified of the fall and wanted the resident sent to the hospital for a CT scan and was admitted . An eInteract Transfer Form, Discharge to Hospital for Resident E, dated 4/18/22, indicated, Resident has a hematoma on left eyebrow from fall today 4/18/2022 at 1:30 a.m. Ice pack held on face to reduce swelling. Resident has history of frequent falls. Resident fell [DATE]th, 29th, April 3rd, 7th, 13th and 14th. A fall care plan for Resident E, dated 3/10/22, indicated she had falls related to weakness. Her goal was to minimize her risk for falls resulting in serious injury. Interventions included, a. On 3/10/2 the resident was to wear proper footwear or non-slip footwear when up. Pain care plan was be followed when she was in pain to reduce risk of falls. b. On 3/28/22 the resident was to have personal items that she used frequently within reach. Her wheelchair was to be removed from her line of sight to encourage her to call for assistance prior to transfers. Staff would offer her assistance with toileting on last rounds of night shift. c. On 3/30/22 staff would offer resident assistance with getting ready for the day if noted to be awake on the last rounds of night shift. d. On 4/3/22 staff to remind resident to change position slowly. e. On 4/4/22 resident would be encouraged to call for assistance prior to transfers. f. On 4/14/22 staff were to offer resident assistance with transferring to my wheelchair prior to dinner. 2. A confidential written statement, reviewed during the survey, indicated they were concerned with Resident C's wheelchair having a broken brake causing her to fall during a transfer with a staff member. The resident had reported to have fallen on 3 separate occasions. On 4/20/22 10:40 a.m., Resident C was observed sitting in the doorway of her room conversing with 2 peers who were sitting outside her doorway. The resident indicated she had falls and was not able to stay upright anymore. On 4/21/22 at 11:00 a.m., Resident C was observation sitting in a wheelchair in her room facing her bedside table, making broth. The resident indicated she had recently had a fall. Indicated she had been in the bed preparing to get out into her wheelchair and the wheelchair was facing the bed. The resident had been holding the right side arm of the wheelchair to stabilize for transfer, and an aide was on the left side supposed to be holding the wheelchair while the resident transferred. During the transfer the aide did not hold the left side of the wheelchair, and the wheelchair was not locked, causing the chair to swing out, the resident missed the wheelchair, and she fell to the floor hitting the right side of her face on the floor causing the entire right side of her face to be bruised. Resident C indicated facility staff had taken pictures of her face. Pictures of the resident's face had been requested but were not provided during the survey. Resident care plan interventions observed as not being followed, resident wearing crocs and sitting on a cushion in her wheelchair, both interventions mentioned on the care plan as not to do. Resident C's record was reviewed on 4/18/22 at 9:44 a.m. Diagnoses on Resident C's profile included, but were not limited to, chronic heart failure, [CONDITION(S)], and need for assistance with personal care. Physician's orders for Resident C indicated, a. On 3/7/22: [MEDICATION(S)] (anticoagulant used to treat and prevent blood clots) take one 5 mg tablet twice daily for [CONDITION(S)]. b. On 3/2/22: Aspirin take one 81 mg tablet daily for congestive heart failure. Fall Assessments for Resident C, dated 1/9/22 - 3/23/22, indicated the resident was documented as having fallen 3 times on 1/9/22, 2/4/22, and 2/23/22. The quarterly MDS assessment, completed on 3/17/22, indicated Resident C had the ability to make herself understood and to understand others. BIMS score of 13 indicated cognitively intact. No signs of symptoms of [CONDITION(S)], behaviors, rejection of care, or wandering. Extensive assistance of 2 or more persons required for physical assist for bed mobility, transfers, and toileting. No walking in the room or corridor was observed. Extensive assistance of one person required for physical assist for locomotion on the unit. Total assistance of one person physical assist required for locomotion off the unit, dressing, and personal hygiene. Supervision and set up only needed for eating. Resident was always incontinent of bladder and bowel. Resident had no falls since admission/entry or reentry or the prior assessment. A fall progress note for Resident C, dated 1/8/22 at 5:56 a.m., indicated resident was found on the floor next to her bed. Resident indicated she had been repositioning self and rolled out onto the floor. Hematoma to right forehead noted to be quarter-sized. Immediate intervention was to lower bed to the floor. A Post Fall Note, dated 1/9/22, indicated Resident C had small bruises on right hand near pinkie knuckle, and right side of face by brow. The resident record lacked documentation to indicate indicated neuro checks and the Post Fall Note were completed. A Fall IDT note, dated 1/10/22 at 3:38 p.m., indicated Resident C fell on [DATE] at 4:45 a.m. The resident was found lying on the floor next to her bed. Resident states she was attempting to reposition herself in bed and slid out. Intervention and care plan updated to include resident was provided a bigger bed. A progress note for Resident C, dated 1/11/22 at 12:59 a.m., indicated bruising continues to right eye and forehead, tender to touch per patient. A progress note for Resident C, dated 2/4/22 at 9:04 p.m., indicated the resident slid out of her wheelchair. The resident was lowered to the floor by a CNA. The CNA stated the resident did not hit her head. The resident record lacked documentation of a Post Fall Note or fall follow up was completed. A late entry Fall IDT Note, dated 2/7/22 at 10:41 a.m., indicated on 2/4/22 staff was in room and assisted Resident C to the floor. Resident was attempting to adjust herself in wheelchair with a pad underneath her when she slid out of the wheelchair. Intervention and care plan updated to include staff will ensure that a pad was not placed in resident's wheelchair. A fall progress note for Resident C, dated 3/23/22 at 6:14 p.m., indicated around 5:45 a.m. during a staff assisted transfer, resident had a witnessed fall. Resident was transferring from the bed to her wheelchair and just as she was about to sit down on the wheelchair, it slid from behind her, and resident fell to the ground. Resident was wearing gripper socks and her night clothes, and her brief was wet. The light in her room was on. It was found the locks on her wheelchair were not engaged. The resident did hit her head and had a hematoma over the right eyebrow, and a skin tear to the left forearm. The resident record lacked documentation a Post Fall Note or neuro checks had been completed. A Fall IDT note for Resident C, dated 3/24/22 at 10:04 a.m., indicated resident was being assisted with a transfer from her bed and into her wheelchair. Resident was noted to be wearing nonskid footwear, she was noted to be soiled with urine, and the room was well lit. Resident went to sit in the wheelchair and the chair slid out from behind her. Resident had already started to sit, and staff assisted her in lowering to the floor. Root cause of fall: resident was being transferred from her bed to her wheelchair, and the wheelchair was noted to not be locked. Resident was lowered to the floor. Intervention and care plan updated: resident's wheelchair was serviced to ensure that brakes are functioning properly. A progress note for Resident C, dated 3/25/22 at 1:52 p.m., indicated bruise to left upper arm and forehead, skin tear to right forearm. A Weekly Skin Observation for Resident C, dated 3/25/22, indicated redness to right eye. There was no documentation of a measurement or reason for the redness. A Weekly Skin Observation for Resident C, dated 3/30/22, indicated skin tear left outer forearm, acquired in-house. A progress note for Resident C, date 3/28/22 at 9:44 a.m., indicated, new physician's order to cleanse left arm skin tear with wound cleanser, pat dry, and apply hydrogel and foam every three days. A progress note for Resident C, dated 3/30/22 at 5:11 p.m., indicated skin tear to right forearm resolved and treatment orders discontinued. Hematoma to face and bruise to left arm were improving. A fall care plan for Resident C, dated 10/18/20, indicated she was at risk for falls related to weakness and impaired mobility. The goal, dated 9/28/21, indicated she would minimize her risk for falls resulting in serious injury. Interventions included: a. On 4/22/19 resident was going to wear proper footwear or non-slip footwear when up. b. On 10/1/19 the resident would be assisted back to bed upon my request and would have her personal items that she used frequently within reach. c. On 10/29/20 resident would be encouraged not to wear crocs when transferring d. On 1/10/22 resident would have a bigger bed. e. On 2/14/22 resident would be educated and reminded to lock her brakes before transferring. f. On 2/17/22 staff would ensure that a pad was not placed in the wheelchair. g. On 3/24/22 resident's wheelchair would be serviced to ensure that brakes were functioning properly. On 4/22/22 at 11:10 a.m., LPN 12 indicated, she worked the 2:00 p.m. - 6:00 a.m. shift on the weekend and most often on Resident C's hallway. Recently when Resident C fell during a staff assisted transfer in her room, it was close to shift change and LPN 12 was at the nurse's station and did not remember the aide's name. Resident C was transferring from the bed into her wheelchair when the chair came out from behind her. LPN 12 indicated she assumed the breaks were not locked. Usually, Resident C was good about locking her wheelchair or reminding staff to lock the chair for her. Resident C hit head and had a bruise/hematoma on her head and skin tear on her arm. LPN 12 indicated after the fall she had checked the resident's vital signs, started neuro checks, and dressed her injury. She notified the on-call physician, DON, and MOD (manager on duty) but did not notify the POA as the resident was cognitively intact. Documentation after a fall included using a paper fall packet check list that prompted neuro checks, eInteract form, a Post Fall assess, and fall note in the EMR (electronic medical record). Care plans were routinely updated in morning meeting. On 4/22/22 at 11:43 a.m., the Maintenance Supervisor indicated the facility used an electronic tracking system for maintenance requests and repairs. Staff could go into the electronic system on their desk top computers, put in room number/resident name, concern, and the request was then sent electronically to the Maintenance Supervisor to view on his cellphone or desktop computer. Maintenance Supervisor indicated he knew Resident C and remembered fixing her wheelchair, indicated the brakes needed tightened and that had been completed. Observation of a printout from the computer with the Maintenance Supervisor, indicated the request was generated on 3/24/22 at 4:01 p.m., and on 3/25/22 at 2:37 p.m., the Maintenance Supervisor set to cancel, indicated he had completed the work order. A Work Order for Resident C, undated, indicated medium priority. There was no description of the request. On 4/21/22 at 4:59 p.m., the DON indicated Resident C had not fallen during a transfer to her wheelchair, she had thrown herself out of the wheelchair due to attention seeking behaviors. 3. During an interview on 4/21/22 at 12:25 p.m., LPN 7 indicated she had been working on 3/23/22 when Resident D fell forward out of his wheelchair in the lounge. The resident had oxygen on and was in the lounge as he kept throwing his legs over the side of the bed attempting to climb out. LPN 7 initially got Resident D out of bed and took him inside the nurse's station with her. The resident was confused stating he thought her was a prior president of the USA. LPN 7 gave the resident a dose of [MEDICATION(S)] (antianxiety medication) due to restlessness. After she felt the medication was effective, she put Resident D in the lounge on the carpeted area and went to lunch. There was no staff in particular monitoring the resident, and to her knowledge the resident did not have footrests on his wheelchair. LPN 7 indicated she had gone to lunch when Resident D fell and did not know who had completed his initial fall assessments, or why he had to been sent to the hospital to be evaluation for a head injury. Observation of the EMR (electronic medical record) with LPN 7 indicated she had signed as having initiated neuro checks. Resident D's record was reviewed on 4/18/22 at 2:01 p.m. Diagnoses on Resident D's profile included, but were not limited to, history of falling, [CONDITION(S)] and collapse, [CONDITION(S)], and muscle weakness. An admission MDS, completed on 3/1/22, assessed Resident D as having the ability to make himself understood and to understand others. A BIMS score 15 indicated cognitively intact. No signs or symptoms of [CONDITION(S)], behaviors, rejection of care, or wandering observed. Extensive assistance of two or more persons required physical assist for bed mobility, transfers, toilet use. Total dependence of one person required for physical assistance for locomotion on and off the unit, and personal hygiene. Limited assistance of one person physical assistance required for eating. Mobility devices used were a walker and wheelchair. Resident was occasionally incontinent of bladder and bowel. There was no pain documented. Resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Had falls in the last month prior to admission/entry, no falls after admission. Fall Assessments for Resident D indicated the resident was documented as having 7 falls on the following dates: 3/8/22, 3/10/22, 3/10/22, 3/18/22, 3/21/22, 3/21/22, and 3/23/22. A Quarterly Risk Evaluation for Resident D, dated 2/25/22, indicated the resident had a moderate risk for falls. A late entry Nurse Note for Resident D, created on 3/8/22 at 5:15 a.m. by the ADON, indicated effective date, 3/4/2022 9:14 a.m., new orders obtained for chest x-ray (CXR), basic metabolic panel (BMP), complete blood count (CBC), and a urinary analysis (UA) due to resident having episodes of being unresponsive. Resident and family were aware of new order. A Nurse Note for Resident D, dated 3/8/22 at 1:13 a.m., indicated patient tried to transfer self and end up on floor. No injury noted. Resident record lacked documentation a Post Fall Note or neuro checks were completed. A Nurse Note for Resident D, dated 3/8/22 at 1:14 a.m., indicated patient observed on floor without any injury. A late entry eInteract SBAR Summary for Providers for Resident D, created on 3/11/22 at 8:22 a.m. by the ADON, indicated effective date 3/8/2022 2:00 a.m., falls, no new orders. The documentation indicated the physician notification for the first fall was sent after the resident had a second fall on 3/10/22. A Fall IDT Note, dated 3/8/22 at 1:23 p.m., indicated Resident D found on floor next to bed attempting to transfer without assistance. Intervention and care plan updated included if the resident was noted to be awake at night staff would offer assistance to his chair. A Nurse Note, dated 3/10/22 at 3:53 a.m., indicated fall in resident room. Resident D was found sitting on the floor in his room. He had his brief pulled down and urinated on the floor. His wheelchair was directly next to him. His left hand was caught in the wheelchair. Small skin tear to the back of the left hand, near the base of the pinky, slight bruising to the left pinky. Immediate intervention was to assist the resident into dry clothes and back to bed. Resident record lacked documentation a Post Fall assessment or neuro checks were completed. A Fall IDT Note, dated 3/10/22 at 9:53 a.m., indicated Resident D was found on the floor in his room sitting on the floor next to his bed. His left hand was noted to be caught in the wheelchair. Resident had attempted to stand up and use the urinal and there was urine noted on the floor. The resident appeared to have slipped and fell to the floor. Intervention and care plan update included resident would be encouraged to call for assistance with using the urinal. A Nurse Note, dated 3/10/22 at 2:54 p.m., indicated Resident D tried to transfer self and ended up on the floor. Immediate intervention was to assist him back to bed. Resident record lacked documentation a Post Fall assessment or neuro checks were completed. A Nurse Note for Resident D, dated 3/11/22 at 9:40 a.m., indicated fall. A Nurse Note, dated 3/18/22 at 3:06 a.m., indicated at approximately 1:00 a.m. Resident D was heard calling for help from his room. When staff entered the room, resident was found lying on the floor next to his bed on the side closest to the door. He was lying in a semi-fetal position laying on his left side with his feet facing the door. He had taken his gown off and was not wearing footwear of any kind. His brief was wet. He had also pulled the sub-q button from his abdomen as well. Small amount of bruising observed to bilateral forearms as well as small scrapes to both shins. During a later neuro check, the resident continued to be very anxious. Immediate intervention included notification to the physician and family. Resident record lacked documentation a Post Fall assessment or neuro checks were completed. A Fall IDT Note, dated 3/18/22 at 10:34 a.m., indicated Resident D was heard calling for help from his room and upon entry staff found the resident lying on the floor next to his bed. Resident was wet and very anxious at time of the fall. Root cause of fall, resident was attempting to take self to restroom. Intervention and care plan updated to include he would be offered a room closer to the nurses' station. A Nurse Note, dated 3/20/22 at 6:25 p.m., indicated Resident D was notably confused but had remained mostly calm and in good spirits so far this evening. A Nurse Note, dated 3/21/22 at 1:48 a.m., indicated Resident D was heard calling out for help. Upon entering the room, resident was found on the floor next to his bed. He was kneeling on his right knee, with his right leg behind him. His left leg was resting in front of him. He was leaning against the air conditioning unit. His feet were bare, and he had taken his gown completely off. His brief was very wet. Minor scrapes noted to both toes. Immediate intervention included notifying the physician and responsible party. Resident record lacked documentation a Post Fall assessment or neuro checks were completed. A Fall IDT Note, dated 3/21/22 at 10:12 a.m., indicated resident was found on the floor in his room. Staff heard resident calling for help and entered room. Resident was noted to be kneeling next to his bed leaning against the AC unit, and the room was dark. Root cause of fall: resident was attempting to get out of bed unassisted and fell to the floor. Intervention and care plan updated included resident would have frequent checks while in bed to assist with toileting. On 3/21/22 at 1:57 p.m., resident alert with some confusion. CNA informed Resident D had an unwitnessed fall. Resident stated he was attempting to get in bed. Resident slid from wheelchair to floor, resident found sitting on bottom with head leaned against wall. Resident record lacked documentation a Post Fall assessment or neuro checks were completed. A Fall IDT Note, dated 3/22/22 at 9:51 a.m., indicated Resident D was found on the floor in his room. Resident had previously been in his wheelchair with his call light within reach but did not call for assistance prior to fall. Resident had attempted to transfer himself from his chair to his bed and fell to the floor. Intervention and care plan updated to include staff would offer resident assistance in lying down after lunch. A Nurse Note, dated 3/23/22 at 12:56 p.m., indicated Reside [TRUNCAT

Based on observation, record review, and interview, the facility failed to follow CDC guidance during a pandemic and ensure infection control practices for COVID-19 were implemented for a resident with symptoms of COVID-19 who resided on the memory care unit with 30 other residents (Resident B), a resident who was exposed to COVID-19 who resided on a green unit (a unit that houses residents with low risk of infection/who have not been exposed) with 27 other residents (Resident C), and 2 residents with symptoms of COVID-19 who resided on green units with 27 other residents prior to being moved to a red unit (an isolation unit for residents with COVID-19) (Residents D and F) resulting in potential exposure of other residents to COVID-19 for 4 of 4 residents reviewed for infection control. The Immediate Jeopardy began on 6/03/20, when Resident B was observed in the memory care lounge with 8 other residents, Resident C was observed in her room on the green unit, room door open, with no isolation precautions (special precautions to prevent the spread of germs) in place, and Residents D and F were found to have resided on a green unit with no isolation precautions with symptoms COVID-19 prior to being moved to a red unit. The Administrator, Director of Clinical Services, and Regional Director of Quality were notified of the Immediate Jeopardy at 5:13 p.m. on 6/04/20. The immediate jeopardy was removed on 6/05/20, but noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On 6/04/20 at 12:34 p.m., Resident B was observed in the memory care unit lounge area, with eight other residents. No residents were wearing masks. Resident B's record was reviewed on 6/04/20 at 2:19 p.m. [DIAGNOSES REDACTED]. A Physician's Order, dated 10/03/19, indicated the resident resided on a secure memory care unit. A quarterly Minimum Data Set (MDS) assessment, dated 4/06/20, indicated the resident had a severe cognitive impairment and required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Physician's Orders, dated 6/03/20, indicated [MEDICATION NAME] (an antibiotic) 100 milligrams (mg) by mouth twice daily for pneumonia for seven days and obtain COVID-19 test. Current Physician's Orders lacked documentation of an order for [REDACTED]. A change in condition evaluation, dated 6/03/20, indicated the resident had shortness of breath, diminished lung sounds, complained of pain in the left rib area when breathing, and an elevated white blood cell count. The physician was notified and ordered a chest x-ray. A chest x-ray, dated 6/03/20, indicated increased patchy densities in the right lung base since a prior study, consistent with atelectasis (lung collapse) or infiltrate. A bed board, dated 6/03/20, indicated 31 residents resided on the memory care unit. During an interview, on 6/04/20 at 11:58 a.m., the Director of Clinical Services (DCS) indicated Resident B was only tested for COVID-19 because she was diagnosed with [REDACTED]. During an interview, on 6/04/20 at 3:03 p.m., the Regional Director of Quality indicated when a resident had symptoms of COVID-19, they should have been put on droplet plus isolation precautions (infection prevention and control interventions to be used in addition to routine practices and are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions) and tested . A Physician's Order should have been in place for the isolation precautions. During an interview, on 6/04/20 at 3:41 p.m., the DCS indicated Resident B was tested for COVID-19 on 6/03/20. The sample was sent to the lab, but results were not available yet. 2. On 6/04/20 at 11:36 a.m., Resident C was observed in her room, lying in bed. There was no signage on the door to indicate isolation precautions (special precautions to prevent the spread of germs), and no personal protective equipment (PPE) cart was observed. The resident's door was open. Resident C's record was reviewed on 6/04/20 at 2:35 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 4/15/20, indicated the resident had a moderate cognitive impairment and required limited staff assistance with bed mobility, transfers, and toilet use. A Physician's Order, dated 6/03/20, indicated obtain COVID-19 test. Current Physician's Orders lacked documentation of an order for [REDACTED]. A bed board, dated 6/03/20, indicated 28 residents resided on the green unit (a unit that houses residents with low risk of infection). During an interview, on 6/04/20 at 11:34 a.m., Certified Nursing Assistant (CNA) 4 indicated Resident C was tested for COVID-19 because her previous roommate (Resident F) was positive for COVID-19, and she was exposed. Isolation precautions were not required because the resident was not symptomatic. During an interview, on 6/04/20 at 11:58 a.m., the Director of Clinical Services (DCS) indicated Resident C should have been on isolation precautions because she was tested for COVID-19 on 6/03/20. She thought the order was in place. Resident C's previous roommate was positive for COVID-19, so Resident C was exposed. The results of the COVID-19 test were not available yet. 3. Resident D's record was reviewed on 6/04/20 at 2:20 p.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 4/28/20, indicated the resident had a moderate cognitive impairment and required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A change in condition note, dated 5/26/20, indicated the resident had an oxygen saturation (the amount of oxygen in the blood) of 74 percent without oxygen, decreased appetite, and nonproductive cough. Physician's orders, dated 5/26/20, indicated chest x-ray to be obtained, oxygen at two liters (l) via nasal cannula to keep oxygen saturation above 90 percent every shift for shortness of breath, and COVID-19 test. Physician's orders, dated 5/26/20 to 6/3/20, lacked documentation of an order for [REDACTED]. A lab result, dated 5/26/20, indicated the sample was collected on 5/26/20, and was positive for COVID-19. A nurse's note, dated 5/27/20, indicated the resident's COVID-19 test was positive, and the resident would be moved to the COVID-19 unit. The note lacked documentation of any isolation precautions in place prior to the resident's move. Census information indicated the resident moved from the green unit (a unit that houses residents with low risk of infection) to the red unit (an isolation unit for residents with COVID-19) on 5/27/20. 4. Resident F's record was reviewed on 6/04/20 at 2:47 p.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 4/27/20, indicated the resident was cognitively intact and required extensive staff assistance with bed mobility, dressing, toilet use, and personal hygiene. A nurse's note, dated 6/01/20, indicated the resident complained of weakness and tiredness. A COVID-19 test was ordered. The note lacked documentation the resident required isolation precautions. A Physician's Order, dated 6/1/20, indicated COVID-19 test. A lab result, dated 6/1/20, indicated the sample was collected on 6/1/20, and was positive for COVID-19. A Physician's Order, dated 6/03/20, indicated oxygen to maintain oxygen saturation (the amount of oxygen in the blood) above 90 percent. Current Physician's Orders lacked documentation of an order for [REDACTED]. A nurse's note, dated 6/03/20, indicated the resident's COVID-19 test was positive, and the resident would be moved to the COVID unit. The note lacked documentation of any isolation precautions in place prior to the resident's move. Census information indicated Resident F was Resident C's roommate on the green unit until Resident F was moved to the red unit on 6/3/20. A bed board, dated 6/03/20, indicated 28 residents resided on the green unit. An untitled document, provided by the DCS on 6/04/20 at 11:58 a.m., indicated 19 residents in the facility tested positive for COVID-19. During an interview, on 6/04/20 at 3:03 p.m., the Regional Director of Quality indicated when a resident had symptoms of COVID-19, they should have been put on droplet plus isolation precautions (infection prevention and control interventions to be used in addition to routine practices and are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions) and tested . A Physician's Order should have been in place for the isolation precautions. On 6/5/20 at 5:30 p.m., the DCS provided an untitled document and indicated it was a list of residents who were found to not be isolated appropriately during the facility wide audit. There were three residents who should have been isolated, but were not isolated and had no physician's order, three residents who were isolated but had no physician's order, two residents who were not isolated, had no physician's order, but were found to no longer need isolated, and four residents who no longer needed isolated. Any issues found were corrected during the audit. On 6/04/20 at 11:58 a.m., the Director of Clinical Services (DCS) provided a document titled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), and indicated it was the policy currently being used by the facility. The policy, last revised 3/17/20, indicated, .Policy: It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 and to adhere to Federal and State/Local recommendations (to include, for example: .Precautions: Standard, Contact, Droplet and/or Airborne Precautions .) Procedure: Resident Care: .A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put into place. Place resident in an AIIR if available. If no AIIR, place on both contact and droplet precautions .In the event of a facility outbreak, institute outbreak management protocols: .Place residents in private rooms on standard, contact, droplet (airborne if available) precautions The ISDH Guidance for out-of-hospital facilities, dated 3/29/20, indicated, The following is guidance for out of hospital facilities who house patients with a confirmed or suspected case of COVID-19. There are a few guiding principles: 1. Placement of patient /resident in contact-droplet precautions with proper PPE, including gown, glove, mask with face shield or eye protection. 2. Proper donning and doffing of personal protection equipment when in contact with COVID-19 residents Reduce the movement of staff between patients with and without COVID-19 precautions with proper PPE- gown, glove, mask with face shield or eye protection .Patients/residents with known or suspected COVID-19 should be cared for in a single-person (private) room with the door closed. Airborne infection isolation rooms (AIIR) are not required. Patients/residents with known or suspected COVID-19 should not share bathrooms with other patients/residents. All patients/residents returning from the hospital with suspected or confirmed COVID-19 should be cared for in a private room, or Cohorted with other patients of the same status in the same unit, wing, hallway, or building. Patients with close contact with a confirmed COVID-19 patient (e.g., roommate or infected staff without wearing PPE) should be isolated and follow 14 day self-monitoring guidelines. If they develop symptoms, and are confirmed or suspected to have COVID-19, they should remain isolation until at least 7 days after symptom onset and 72 hours after resolution of fever, without use of antipyretic medication, and improvement in symptoms (e.g., cough), whichever is longer . The CDC guidance - Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, indicated, If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Room sharing might be necessary if there are multiple residents with known or suspected COVID-19 in the facility. As roommates of symptomatic residents might already be exposed, it is generally not recommended to separate them in this scenario. Public health authorities can assist with decisions about resident placement .If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected [DIAGNOSES REDACTED].g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident . The immediate jeopardy that began on 6/03/20 was removed on 6/05/20 when the facility reviewed all residents and residents with symptoms/known exposure were tested and placed in isolation with appropriate door signage and orders for isolation. Staff were reeducated on the isolation policies and procedures, and a plan was created to monitor for isolation procedures for residents with symptoms/pending tests or known exposures. The noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 071. 3.1-18(a)

Based on interview and record review, the facility failed to assess and immediately notify a physician of a resident's change in condition related to concerns of lethargy and dehydration voiced by the family member, which resulted in hospitalization for dehydration. This deficient practice affected 1 of 3 residents reviewed for physician notification (Resident B). Findings include: Resident B's record was reviewed on 12/3/2015 at 3:45 p.m. Resident B had [DIAGNOSES REDACTED]. The record lacked indication of a system for ensuring fluids were increased and the resident was monitored for signs of dehydration. A physician's progress report, dated 11/24/2015, indicated the Nurse Practitioner had evaluated Resident B for [MEDICAL CONDITION] with regard to her sodium level of 150 drawn on 11/12/2015. The Nurse Practitioner indicated the facility was to encourage Resident B to drink oral fluids and recheck her BMP on 11/30/2015. A nurse's note, dated 11/25/2015 at 9:06 p.m., indicated Resident B's daughter called the facility twice during the shift and expressed concerns regarding her mother's lethargy during the afternoon and requested her anti-anxiety medication be placed on hold. This note indicated Resident B's anti-anxiety medication had been placed on hold and the resident had been put on the doctor's board for assessment during his next visit to the facility. A nurse's note, dated 11/26/2015 at 6:29 p.m., indicated Resident B's routine pain medication had not been administered because the resident appeared tired. A nurse's note, dated 11/26/2015 at 8:00 p.m., indicated Resident B's daughter arrived at the facility at 7 p.m. and expressed concern regarding her mother's lethargy, decreased responsiveness and lack of eating and drinking. She requested the facility transfer her mother to the emergency room for evaluation. This note indicated the ambulance transported Resident B to the emergency room at 7:50 p.m. A review of Resident B's November 2015 Vital Signs Report, dated 12/7/2015, indicated Resident B's blood pressure, temperature, pulse, respirations and oxygen level had not been assessed during the month of November until 11/26/2015 at 7 p.m. A Physician's Progress Note, dated 11/26/2015 at 11:29 p.m., indicated Resident B had a critically high sodium level of 182 and would be admitted to the hospital from the Emergency Department for further evaluation. An Admission History and Physical Note, dated 11/27/2015 at 2:58 a.m. indicated Resident B was admitted to the hospital with [REDACTED]. During an interview on 12/7/2015 at 11:23 a.m., the Director of Nursing (DON) indicated she could not provide documentation of a nursing assessment on Resident B after her family voiced concerns of the resident's condition. During an interview on 12/7/2015 at 12:07 p.m., the DON indicated Resident B had an order to encourage oral fluids due to her high sodium levels and to increase hydration. She indicated the facility encouraged and monitored oral fluid intake with documentation. No other assessments were in place to assess hydration. During an interview on 12/7/2015 at 12:25 p.m., the DON indicated she expected her staff to perform an assessment of a resident when a family member voiced concerns regarding a change in the resident's condition. During an interview on 12/7/2015 at 2:49 p.m., Licensed Practical Nurse (LPN) #7 indicated non-emergent concerns regarding a resident are placed on the doctor's board. The physicians visit the facility at least twice a week and will review the doctor's board in the facility. Emergency concerns regarding a resident should be called into the physician. During an interview on 12/7/2015 at 3:55 p.m., the DON indicated an assessed change of condition should be reported to the physician immediately. A policy titled Physician/Family/Responsible Party Notification for Change in Condition, dated 8/2013, and identified as current by the Nurse Consultant on 12/7/2015 at 3:35 p.m., indicated, .Purpose: To ensure that medical care problems are communicated to the attending physician and family/responsible party in a timely, efficient, and effective manner .Policy: Physician and family/responsible party notification is to include, but is not limited to: .change in level of consciousness, change in condition that may warrant a change in current treatment .Physician and Family/Responsible Party notification will be documented in the progress notes, it should contain information regarding the resident condition, physician notification, and any physician orders [REDACTED]. 3.1-5(a)(1)

Based on interview and record review, the facility failed to complete an immediate assessment of a resident following a family member's voiced concerns of a change in condition, which resulted in a hospitalization of the resident due to critical sodium lab values and severe dehydration (Resident B). Findings include: Resident B's record was reviewed on 12/3/2015 at 3:45 p.m. Resident B had [DIAGNOSES REDACTED]. The record lacked documentation of a nursing assessment performed for Resident B on 11/25/2015, following the concerns of the resident's family member. The record lacked indication of a system for ensuring fluids were increased and the resident was monitored for signs of dehydration. A Basic Metabolic Panel (BMP) lab report, dated 11/12/2015, indicated Resident B had a high sodium level of 150 milliequivalents per liter (mEq/L). The reference range for sodium levels is between 135- 145 mEq/L. A Basic Metabolic Panel (BMP) lab report, dated 11/12/2015, indicated Resident B had a high sodium level of 150 milliequivalents per liter (mEq/L). The reference range for sodium levels is between 135- 145 mEq/L. A physician's progress report, dated 11/24/2015, indicated the Nurse Practitioner had evaluated Resident B for [MEDICAL CONDITION] with regard to her sodium level of 150 drawn on 11/12/2015. The Nurse Practitioner indicated the facility was to encourage Resident B to drink oral fluids and recheck her BMP on 11/30/2015. A nurse's note, dated 11/25/2015 at 9:06 p.m., indicated Resident B's daughter called the facility twice during the shift and expressed concerns regarding her mother's lethargy during the afternoon and requested her anti-anxiety medication be placed on hold. This note indicated Resident B's anti-anxiety medication had been placed on hold and the resident had been put on the doctor's board for assessment during his next visit to the facility. A nurse's note, dated 11/26/2015 at 1:00 p.m., indicated Resident B's routine pain medication had not been administered per her daughter's request. A nurse's note, dated 11/26/2015 at 6:29 p.m., indicated Resident B's routine pain medication had not been administered because the resident appeared tired. A nurse's note, dated 11/26/2015 at 8:00 p.m., indicated Resident B's daughter arrived at the facility at 7 p.m. and expressed concern regarding her mother's lethargy, decreased responsiveness and lack of eating and drinking. She requested the facility transfer her mother to the emergency room for evaluation. This note indicated the ambulance transported Resident B to the emergency room at 7:50 p.m. A review of Resident B's November 2015 Vital Signs Report, dated 12/7/2015, indicated Resident B's blood pressure, temperature, pulse, respirations and oxygen level had not been assessed during the month of November until 11/26/2015 at 7 p.m. A Physician's Progress Note, dated 11/26/2015 at 11:29 p.m., indicated Resident B had a critically high sodium level of 182 and would be admitted to the hospital from the Emergency Department for further evaluation. An Admission History and Physical Note, dated 11/27/2015 at 2:58 a.m. indicated Resident B was admitted to the hospital with [REDACTED]. During an interview on 12/7/2015 at 11:23 a.m., the Director of Nursing (DON) indicated she could not provide documentation of a nursing assessment on Resident B after her family voiced concerns of the resident's condition. During an interview on 12/7/2015 at 12:07 p.m., the DON indicated Resident B had an order to encourage PO fluids due to her high sodium levels and to increase hydration. She indicated the facility encouraged and monitored oral fluid intake with documentation. No other assessments were in place to assess hydration. During an interview on 12/7/2015 at 12:25 p.m., the DON indicated she expected her staff to perform an assessment of a resident when a family member voiced concerns regarding a change in the resident's condition. During an interview on 12/7/2015 at 12:45 p.m., the DON indicated the facility had no numeric parameters for fluid to maintain Resident B's hydration. During an interview on 12/7/2015 at 2:49 p.m., Licensed Practical Nurse (LPN) #7 indicated non-emergent concerns regarding a resident are placed on the doctor's board. The physicians visit the facility at least twice a week and will review the doctor's board in the facility. Emergency concerns regarding a resident should be called into the physician. During an interview on 12/7/2015 at 3:55 p.m., the DON indicated an assessed change of condition should be reported to the physician immediately. During an interview on 12/7/2015 at 4:00 p.m., the DON indicated she could not provide a facility policy regarding nursing assessments of a resident for a change in condition. A policy titled Physician/Family/Responsible Party Notification for Change in Condition, dated 8/2013, and identified as current by the Nurse Consultant on 12/7/2015 at 3:35 p.m., indicated, .Purpose: To ensure that medical care problems are communicated to the attending physician and family/responsible party in a timely, efficient, and effective manner .Policy: Physician and family/responsible party notification is to include, but is not limited to: .change in level of consciousness, change in condition that may warrant a change in current treatment .Physician and Family/Responsible Party notification will be documented in the progress notes, it should contain information regarding the resident condition, physician notification, and any physician orders [REDACTED]. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer prevention interventions were evaluated and revised to prevent a resident who was admitted without a pressure ulcer to his coccyx from developing an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely observed by slough and/or eschar in the wound bed) pressure ulcer that later became a stage 3 (full thickness skin loss) for 1 of 3 residents reviewed for pressure ulcers (Resident #158). Findings include: During an interview on 11/30/2015 at 2:56 p.m., Licensed Practical Nurse (LPN) #1 indicated Resident #158 had a stage 3 pressure ulcer (full thickness skin loss) to his coccyx. During an observation on 12/4/2015 at 1:46 p.m., Wound Nurse #2 changed a dressing to Resident #158's stage 3 pressure ulcer to his coccyx, that had been measured as 1 centimeter (cm) by 0.5 cm by 0.1 cm during a wound assessment on 12/2/2015. The wound had two small areas of sloughing visible at the edges of the wound. The old dressing had a scant amount of serosanguinous (containing or relating to both blood and the liquid part of blood) drainage. Resident was observed lying on a composure mattress. Resident #158's record was reviewed on 12/3/2015 at 9:45 a.m. Resident #158's [DIAGNOSES REDACTED]. A Skin observation sheet, dated 6/3/2015, indicated a Certified Nursing Assistant (CNA) discovered Resident #158's open area to his coccyx on 6/3/2015 at 9:04 p.m. This document indicated the open area to Resident #158's coccyx was new and acquired after his admission to the facility. An Initial Pressure Ulcer Report, dated 6/4/2015, indicated Resident #158 had an unstageable pressure ulcer to his coccyx, that had been measured as 3.2 cm by 1.3 cm by 0.1 cm. This pressure ulcer was not present on his admission to the facility. The wound report comments indicated Resident #158 had a recent surgery to his right hip. The pressure ulcer to his coccyx occurred due to repeated exposure to pressure while in bed and chair. The mattress was changed to composure on 6/2/2015 and a Roho cushion had been placed in his wheelchair. A Braden Scale for Predicting Pressure Sore Risk on Admission assessment, dated 6/10/2015, indicated Resident #158 had a mild risk of pressure ulcer development with a score of 15 out of 23. A skin integrity care plan, dated 6/10/2015, indicated Resident #158 was at risk for developing pressure ulcers related to his immobility. The care plan goal indicated his risk for pressure ulcer development would be minimized through his care plan interventions. The interventions included: cushion in chair, turn and reposition frequently, observe skin weekly and as needed, remind resident to turn and reposition when choosing not to, and rest on a special support surface. A pressure ulcer care plan, dated 6/10/2015, indicated Resident #158 had a stage 3 wound to his coccyx that was previously noted as unstageable. The interventions included: will have a cushion in chair for pressure redistribution, receive treatments as ordered, rest on a composure mattress, assist with incontinence care, and assist with turning and repositioning every two hours and more frequently as needed. A Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #158 was at risk for developing pressure ulcers, and had one stage 3 pressure ulcer that had not been present on admission. Resident #158 required extensive assistance of at least 2 staff to assist him with bed mobility, transfers, and toileting. The resident required extensive assistance of 1 staff member for locomotion on the unit in his wheelchair. Pressure Ulcer Progress Reports for Resident #158's pressure ulcer to his coccyx indicated the resident's pressure ulcer to his coccyx was identified and measured as an unstageable pressure ulcer on 6/4/2015 with measurements of 3.2 cm by 1.3 cm by 0.1 cm. Resident #158's pressure ulcer progressed to a stage 3 pressure ulcer on 6/10/2015 with measurements of 2 cm by 1.3 cm by 0.1 cm. Resident #158's pressure ulcer to his coccyx remained at a stage 3 on 12/4/2015 with measurements of 1.8 cm by 0.5 cm by 0.1 cm. During an interview on 12/3/2015 at 3:35 p.m., Wound Nurse #2 indicated Resident #158 developed his pressure ulcer to his coccyx after his admission. She indicated the resident was encouraged to lay down after meals to relieve pressure from his coccyx. She indicated the pressure ulcer development to his coccyx was due to the lack of staff turning and repositioning him frequently. During an interview on 12/4/2015 at 11:31 a.m., LPN #3 indicated staff encouraged Resident #158 to lay down after meals and he often refused. He sat up in his wheelchair for meals and with locomotion on the unit. During an interview on 12/7/2015 at 10:56 a.m., Wound Nurse #2 indicated Resident #158 had dementia and had periods when he would not comply with the intervention of laying in bed after meals to alleviate pressure to his coccyx. She indicated Resident #158 received too much pressure to his coccyx sitting up in his wheel chair for long periods of time and a Roho cushion had been placed in his wheelchair after the unstageable pressure ulcer to his coccyx developed. During an interview on 12/7/2015 at 11:51 a.m., the Director of Nursing (DON) indicated Resident #158 was identified at risk for the development of pressure ulcers on admission. She indicated his care plan interventions for the prevention of pressure ulcers had not been individualized. She indicated after the facility identified the resident's non-compliance with laying down and after meals and repositioning, additional pressure reducing devices and a specialized turning and repositioning schedule should have been implemented before the development of his unstageable pressure ulcer to his coccyx. A Wound Prevention Protocol policy, dated 4/2012, and identified as current by the DON on 12/7/2015 at 10:00 a.m., indicated the following, .Identify residents that are high risk for developing pressure areas using the Braden scale. Relieve or remove pressure to prevent tissue trauma. Initiate nursing interventions along with medical orders to prevent tissue trauma .Resident specific interventions will be care planned 3.1-40(a)(1)

Based on interview and record review, the facility failed to assess and immediately notify a physician of a resident's change in condition related to concerns of lethargy and dehydration voiced by the family member, which resulted in hospitalization for dehydration. This deficient practice affected 1 of 3 residents reviewed for physician notification (Resident B). Findings include: Resident B's record was reviewed on 12/3/2015 at 3:45 p.m. Resident B had [DIAGNOSES REDACTED]. The record lacked indication of a system for ensuring fluids were increased and the resident was monitored for signs of dehydration. A physician's progress report, dated 11/24/2015, indicated the Nurse Practitioner had evaluated Resident B for [MEDICAL CONDITION] with regard to her sodium level of 150 drawn on 11/12/2015. The Nurse Practitioner indicated the facility was to encourage Resident B to drink oral fluids and recheck her BMP on 11/30/2015. A nurse's note, dated 11/25/2015 at 9:06 p.m., indicated Resident B's daughter called the facility twice during the shift and expressed concerns regarding her mother's lethargy during the afternoon and requested her anti-anxiety medication be placed on hold. This note indicated Resident B's anti-anxiety medication had been placed on hold and the resident had been put on the doctor's board for assessment during his next visit to the facility. A nurse's note, dated 11/26/2015 at 6:29 p.m., indicated Resident B's routine pain medication had not been administered because the resident appeared tired. A nurse's note, dated 11/26/2015 at 8:00 p.m., indicated Resident B's daughter arrived at the facility at 7 p.m. and expressed concern regarding her mother's lethargy, decreased responsiveness and lack of eating and drinking. She requested the facility transfer her mother to the emergency room for evaluation. This note indicated the ambulance transported Resident B to the emergency room at 7:50 p.m. A review of Resident B's November 2015 Vital Signs Report, dated 12/7/2015, indicated Resident B's blood pressure, temperature, pulse, respirations and oxygen level had not been assessed during the month of November until 11/26/2015 at 7 p.m. A Physician's Progress Note, dated 11/26/2015 at 11:29 p.m., indicated Resident B had a critically high sodium level of 182 and would be admitted to the hospital from the Emergency Department for further evaluation. An Admission History and Physical Note, dated 11/27/2015 at 2:58 a.m. indicated Resident B was admitted to the hospital with [REDACTED]. During an interview on 12/7/2015 at 11:23 a.m., the Director of Nursing (DON) indicated she could not provide documentation of a nursing assessment on Resident B after her family voiced concerns of the resident's condition. During an interview on 12/7/2015 at 12:07 p.m., the DON indicated Resident B had an order to encourage oral fluids due to her high sodium levels and to increase hydration. She indicated the facility encouraged and monitored oral fluid intake with documentation. No other assessments were in place to assess hydration. During an interview on 12/7/2015 at 12:25 p.m., the DON indicated she expected her staff to perform an assessment of a resident when a family member voiced concerns regarding a change in the resident's condition. During an interview on 12/7/2015 at 2:49 p.m., Licensed Practical Nurse (LPN) #7 indicated non-emergent concerns regarding a resident are placed on the doctor's board. The physicians visit the facility at least twice a week and will review the doctor's board in the facility. Emergency concerns regarding a resident should be called into the physician. During an interview on 12/7/2015 at 3:55 p.m., the DON indicated an assessed change of condition should be reported to the physician immediately. A policy titled Physician/Family/Responsible Party Notification for Change in Condition, dated 8/2013, and identified as current by the Nurse Consultant on 12/7/2015 at 3:35 p.m., indicated, .Purpose: To ensure that medical care problems are communicated to the attending physician and family/responsible party in a timely, efficient, and effective manner .Policy: Physician and family/responsible party notification is to include, but is not limited to: .change in level of consciousness, change in condition that may warrant a change in current treatment .Physician and Family/Responsible Party notification will be documented in the progress notes, it should contain information regarding the resident condition, physician notification, and any physician orders [REDACTED]. This Federal tag relates to Complaint IN 020. 3.1-5(a)(1)

Based on interview and record review, the facility failed to complete an immediate assessment of a resident following a family member's voiced concerns of a change in condition, which resulted in a hospitalization of the resident due to critical sodium lab values and severe dehydration (Resident B). Findings include: Resident B's record was reviewed on 12/3/2015 at 3:45 p.m. Resident B had [DIAGNOSES REDACTED]. The record lacked documentation of a nursing assessment performed for Resident B on 11/25/2015, following the concerns of the resident's family member. The record lacked indication of a system for ensuring fluids were increased and the resident was monitored for signs of dehydration. A Basic Metabolic Panel (BMP) lab report, dated 11/12/2015, indicated Resident B had a high sodium level of 150 milliequivalents per liter (mEq/L). The reference range for sodium levels is between 135- 145 mEq/L. A Basic Metabolic Panel (BMP) lab report, dated 11/12/2015, indicated Resident B had a high sodium level of 150 milliequivalents per liter (mEq/L). The reference range for sodium levels is between 135- 145 mEq/L. A physician's progress report, dated 11/24/2015, indicated the Nurse Practitioner had evaluated Resident B for [MEDICAL CONDITION] with regard to her sodium level of 150 drawn on 11/12/2015. The Nurse Practitioner indicated the facility was to encourage Resident B to drink oral fluids and recheck her BMP on 11/30/2015. A nurse's note, dated 11/25/2015 at 9:06 p.m., indicated Resident B's daughter called the facility twice during the shift and expressed concerns regarding her mother's lethargy during the afternoon and requested her anti-anxiety medication be placed on hold. This note indicated Resident B's anti-anxiety medication had been placed on hold and the resident had been put on the doctor's board for assessment during his next visit to the facility. A nurse's note, dated 11/26/2015 at 1:00 p.m., indicated Resident B's routine pain medication had not been administered per her daughter's request. A nurse's note, dated 11/26/2015 at 6:29 p.m., indicated Resident B's routine pain medication had not been administered because the resident appeared tired. A nurse's note, dated 11/26/2015 at 8:00 p.m., indicated Resident B's daughter arrived at the facility at 7 p.m. and expressed concern regarding her mother's lethargy, decreased responsiveness and lack of eating and drinking. She requested the facility transfer her mother to the emergency room for evaluation. This note indicated the ambulance transported Resident B to the emergency room at 7:50 p.m. A review of Resident B's November 2015 Vital Signs Report, dated 12/7/2015, indicated Resident B's blood pressure, temperature, pulse, respirations and oxygen level had not been assessed during the month of November until 11/26/2015 at 7 p.m. A Physician's Progress Note, dated 11/26/2015 at 11:29 p.m., indicated Resident B had a critically high sodium level of 182 and would be admitted to the hospital from the Emergency Department for further evaluation. An Admission History and Physical Note, dated 11/27/2015 at 2:58 a.m. indicated Resident B was admitted to the hospital with [REDACTED]. During an interview on 12/7/2015 at 11:23 a.m., the Director of Nursing (DON) indicated she could not provide documentation of a nursing assessment on Resident B after her family voiced concerns of the resident's condition. During an interview on 12/7/2015 at 12:07 p.m., the DON indicated Resident B had an order to encourage PO fluids due to her high sodium levels and to increase hydration. She indicated the facility encouraged and monitored oral fluid intake with documentation. No other assessments were in place to assess hydration. During an interview on 12/7/2015 at 12:25 p.m., the DON indicated she expected her staff to perform an assessment of a resident when a family member voiced concerns regarding a change in the resident's condition. During an interview on 12/7/2015 at 12:45 p.m., the DON indicated the facility had no numeric parameters for fluid to maintain Resident B's hydration. During an interview on 12/7/2015 at 2:49 p.m., Licensed Practical Nurse (LPN) #7 indicated non-emergent concerns regarding a resident are placed on the doctor's board. The physicians visit the facility at least twice a week and will review the doctor's board in the facility. Emergency concerns regarding a resident should be called into the physician. During an interview on 12/7/2015 at 3:55 p.m., the DON indicated an assessed change of condition should be reported to the physician immediately. During an interview on 12/7/2015 at 4:00 p.m., the DON indicated she could not provide a facility policy regarding nursing assessments of a resident for a change in condition. A policy titled Physician/Family/Responsible Party Notification for Change in Condition, dated 8/2013, and identified as current by the Nurse Consultant on 12/7/2015 at 3:35 p.m., indicated, .Purpose: To ensure that medical care problems are communicated to the attending physician and family/responsible party in a timely, efficient, and effective manner .Policy: Physician and family/responsible party notification is to include, but is not limited to: .change in level of consciousness, change in condition that may warrant a change in current treatment .Physician and Family/Responsible Party notification will be documented in the progress notes, it should contain information regarding the resident condition, physician notification, and any physician orders [REDACTED]. This Federal tag relates to Complaint IN 020. 3.1-37(a)

A1. Based on observation, interview, and record review, the facility failed to follow the resident's plan of care for administer pain medication when staff was aware it was ordered and needed to prevent unnecessary pain during care for 1 of 2 residents observed with symptoms of pain (Resident #134). During care observation the resident cried out multiple times in pain. B2. Based on observation, interview, and record review, the facility failed to implement interventions in accordance with residents' plan of care to promote healing and prevent pressure ulcers and skin break down for 1 of 3 residents reviewed for pressure ulcers (Resident #134). Findings include: A1. During an observation on 12/5/2013 at 1:28 P.M., Certified Nursing Assistants (CNA) #31 and #32 were observed transferring Resident #134 with a mechanical lift from her chair to her bed. While she was being transferred Resident #134 was observed to moan and cry out. During the transfer Resident #134 stated, "Don't, don't, don't, oh dear, oh dear, please don't do that. It hurts. Oh shoot. Don't do that. Oh no, oh no, oh no, oh no, oh no, oh no, oh no, oh no, oh no, no, oh no, oh no, oh no, no. I don't want to lay down. I don't want to lay down. I don't want to lay down. Oh no, oh no, oh no, oh no, oh no, oh no, oh no...They are so rough...." After Resident #134 was transferred to her bed CNA #31 and CNA #32 were observed to pull Resident #134's contracted legs apart so they could pull the brief through her legs. Resident #134 continued to moan and cry out until all care was finished and the head of the bed was elevated. Resident #134's record was reviewed on 12/5/2013 at 9:56 A.M. Resident #134 had [DIAGNOSES REDACTED]. An annual MDS (minimum data set assessment tool) dated 6/13/2013, indicated Resident #134 was severely cognitively impaired, had long and short term memory loss, required extensive assistance for transfers and bed mobility, and had lower extremity impairment on both sides. A care plan dated 12/2/13, indicated Resident #134 had pain related to a history of a pelvic fracture with a goal for her to voice a level of comfort through the next review. The care plan indicated [MEDICATION NAME] medication would be administered as ordered to meet this goal. A physician's orders [REDACTED].M., indicated Resident #134 had an order for [REDACTED]. Behavior sheets dated 10/10/2013 at 1:13 P.M., 11/20/2013 at 2:05 P.M., and 12/4/2013 at 1:03 P.M., indicated Resident #134 was resistant to care and/or yelled and screamed out. The MARs for October, November, and December 1-6 were reviewed on December 6, 2013. The MAR for October 2013, lacked documentation Resident #134 was administered PRN pain medication. The Mar for November 2013, indicated Resident #134 was administered PRN pain medication on November 1, 2013 at 10:36 A.M., and November 29, 2013 at 1:15 P.M. The MAR for December 1-6, 2013 lacked documentation Resident #134 was administered PRN pain medication. A pain evaluation document dated 12/6/2013 at 10:37 A.M., indicated Resident #134 verbalized pain, had [DIAGNOSES REDACTED]. An untimed physician's progress note dated 12/6/2013, indicated, "...inadequate pain control reported yelling out...hurts "all over." Resident unable to pin point pain.... " This note indicated an order to increase Resident #134's schedule pain medication from twice a day to three times a day in addition to the as needed narcotic pain medication. During an interview on 12/5/2013 at 1:28 P.M., CNA #31 stated, "She is so constricted... It hurts her so bad.... Her little legs...(Resident #134 named) we are going to lift you... it is the only way we can get you in the bed... sorry (Resident #134 named)... she doesn't want to be moved because her little legs hurt so bad... We have to pry her legs apart.... She does this every day. I hate doing it...." During an interview on 12/5/2013 at 1:40 P.M., LPN #30 indicated Resident #134 had scheduled pain medication which was administered at 7:30 A.M. and in the evening around 4:00 P.M. LPN #30 indicated Resident #34 also had PRN (as needed) narcotic pain medication ordered for pain and could be administered the pain medication every four hours if needed. LPN #30 indicated Resident #134 complained of pain when she was repositioned for care or transferred from one place to another. LPN #30 indicated Resident #134 was not given a lot of PRN pain medication because she only complained of pain when she was moved. LPN #30 indicated Resident #134 had to be transferred with a lift to get out of bed, to lie down after each meal, and for incontinent care all which required extensive moving. LPN #30 indicated she had planned to administer Resident #134 PRN pain medication prior to her being transferred to bed but she failed to do so. LPN #30 stated, "I planned on giving it to her before lunch but never got around to it." During an interview on 12/5/2013 at 1:46 P.M., the Director of Nursing (DON) was informed of the above observations. At this time documentation of pain assessments, medication administration records for October, November, and December 2013, the facility's pain management policy, and care plans for Resident #134 were requested. The DON indicated Resident #134 had an order for [REDACTED]. During an interview on 12/9/2013 at 10:45 A.M., with the DON and the facility's wound care nurse (LPN #33) present, LPN #33 indicated the physician evaluated Resident #134 on 12/6/2013, and increased her scheduled pain medication from twice a day to three times a day. During this interview the DON indicated staff had reported Resident #134 was "doing much better" since the physician increased the pain medication on 12/6/2013. The facility's pain management policy dated 3/2012, indicated, "Pain Evaluation Purpose: 1. To establish guidelines to measure a resident's level of pain. 2. To provide optimal comfort through a pain control plan, which is established with the members of the health care team...." B1. During an observation on 12/5/13 at 11:10 A.M., Resident #134 was observed sitting in a broda chair with a pillow under her lower legs. Her feet were dangling-not elevated. Her left foot was bare. A pressure ulcer was observed on her left foot. A small amount of pink/reddish serous drainage was observed dripping down her left foot. Resident #134 was observed in a gown with her brief and thighs exposed. Her thighs and knees were touching one another. There was not a sheet in between her bare skin. During observations on 12/5/2013 at 11:37 A.M. and 12:04 P.M., Resident #134 was observed sitting in her chair. Her feet were dangling off the end of a pillow. They were not elevated She did not have a sheet between her bare legs and knees. During an observation on 12/5/2013 at 12:04 P.M. and 12:39 P.M., Resident #134 was observed seated in her chair, no sheet between her bare knees and/or thighs, and her feet were not elevated. During an observation on 12/5/2013 at 1:28 P.M., Certified Nursing Assistants (CNA) #31 and #32 were observed transferring Resident #134 with a mechanical lift from her chair to her bed. The chair she was transferred out of did not have a cushion in it. Resident #134 did not have a sheet between her bare legs. Resident #134's record was reviewed on 12/5/2013 at 9:56 A.M. Resident #134 had [DIAGNOSES REDACTED].. An annual MDS (minimum data set assessment tool) dated 6/13/2013, indicated Resident #134 was severely cognitively impaired, had long and short term memory loss, required extensive assistance for transfers and bed mobility, and had lower extremity impairment on both sides. A care plan dated 12/3/3013, indicated Resident #134 had a pressure ulcer present on her left bunion due to immobility and contractures. A goal indicated her pressure ulcer would show signs of healing and remain free from infection. Interventions indicated to meet this goal included: "Cleanse left foot bunion with wound cleanser...cover with foam and secure with [MEDICATION NAME] every two days, cushion in wheelchair... limit time up in char, lie down after meals...." A care plan dated 12/3/2013 indicated Resident #134 was at risk for pressure ulcers related to immobility. A goal indicated she would have intact skin free by the next review. Interventions listed to meet this goal included: A cushion in the wheel chair, her heels were to be up, she was to be put to bed after each meal, and a sheet was to be placed between her bare knees and thighs when she was up in a chair. CNA flow sheets identified as current by the DON on 12/5/2013 at 12:06 P.M., indicated Resident #134 was to be put to bed after meals. During an interview on 12/03/2013 at 9:50 A.M., Licensed Practical Nurse (LPN) #30 indicated Resident #134 had a pressure ulcer on her left foot. During an interview on 12/5/2013 at 11:15 A.M., Licensed Practical Nurse (LPN) #30 was queried when she planned to change Resident #134's dressing on her foot. She indicated she would change it after lunch around 1:00 P.M. During an interview on 12/5/2013 at 12:20 P.M., the facility wound nurse LPN #33 indicated she saw Resident #134 in her room without a dressing on her foot so she put a dressing on it. She stated, "I walked by the room and saw it wasn't on so I thought oops we better get it on. They cleaned her up this morning and it must have come off." During an interview on 12/5/2013 at 1:20 P.M., CNA #33 indicated the hospice aide put Resident #134 in her chair around 7:45 A.M. She indicated after breakfast staff took her to activities and then she was left reclined in her chair. She further indicated she had not attempted to put her back to bed but would after lunch. During an interview with CNA #33 and LPN #30 present, LPN #30 indicated Resident #134 was to be put to bed after each meal. During an interview on 12/5/2013 at 1:28 P.M., CNA #31 indicated Resident #134 did not have a cushion for her chair. CNA #31 stated, "She use to have something between her knees but she is so constricted they can't put it there anymore... I don't know how long it has been." She further indicated she did not put anything between Resident #134's legs because it was too painful for her. During an interview on 12/9/2013 at 9:45 A.M., the facility's consultant nurse indicated Resident #134 should of had a sheet between her bare legs, Resident #134 should of had a cushion in her chair, and staff should have informed the nurse her pressure ulcer dressing had fallen off and needed changed. 3.1-35(g)(2)

Based on observation, interviews, and record review, the facility failed to administer pain medication as ordered to ensure residents were as free of pain as possible during care. This deficient practice resulted in unnecessary pain and suffering for 1 of 2 residents reviewed for pain management (Resident #134). During care obsevation the resident cried out in pain multiple times. Findings include: During an observation on 12/5/2013 at 1:28 P.M., Certified Nursing Assistants (CNA) #31 and #32 were observed transferring Resident #134 with a mechanical lift from her chair to her bed. While she was being transferred Resident #134 was observed to moan and cry out. During the transfer Resident #134 stated, "Don't, don't, don't, oh dear, oh dear, please don't do that. It hurts. Oh shoot. Don't do that. Oh no, oh no, oh no, oh no, oh no, oh no, oh no, oh no, oh no, no, oh no, oh no, oh no, no. I don't want to lay down. I don't want to lay down. I don't want to lay down. Oh no, oh no, oh no, oh no, oh no, oh no, oh no...They are so rough...." After Resident #134 was transferred to her bed CNA #31 and CNA #32 were observed to pull Resident #134's contracted legs apart so they could pull the brief through her legs. Resident #134 continued to moan and cry out until all care was finished and the head of the bed was elevated. Resident #134's record was reviewed on 12/5/2013 at 9:56 A.M. Resident #134 had [DIAGNOSES REDACTED]. An annual MDS (minimum data set assessment tool) dated 6/13/2013, indicated Resident #134 was severely cognitively impaired, had long and short term memory loss, required extensive assistance for transfers and bed mobility, and had lower extremity impairment on both sides. A care plan dated 12/2/13, indicated Resident #134 had pain related to a history of a pelvic fracture with a goal for her to voice a level of comfort through the next review. The care plan indicated [MEDICATION NAME] medication would be administered as ordered to meet this goal. A physician's orders [REDACTED].M., indicated Resident #134 had an order for [REDACTED]. Behavior sheets dated 10/10/2013 at 1:13 P.M., 11/20/2013 at 2:05 P.M., and 12/4/2013 at 1:03 P.M., indicated Resident #134 was resistant to care and/or yelled and screamed out. The MARs (Medication Administration Record) for October, November, and December 1-6 were reviewed on December 6, 2013. The MAR for October 2013, lacked documentation Resident #134 was administered PRN pain medication. The Mar for November 2013, indicated Resident #134 was administered PRN pain medication on November 1, 2013 at 10:36 A.M., and November 29, 2013 at 1:15 P.M. The MAR for December 1-6, 2013 lacked documentation Resident #134 was administered PRN pain medication. A pain evaluation document dated 12/6/2013 at 10:37 A.M., indicated Resident #134 verbalized pain, had [DIAGNOSES REDACTED]. An untimed physician's progress note dated 12/6/2013, indicated, "...inadequate pain control reported yelling out...hurts "all over." Resident unable to pin point pain.... " This note indicated an order to increase Resident #134's schedule pain medication from twice a day to three times a day in addition to the as needed narcotic pain medication. During an interview on 12/5/2013 at 1:28 P.M., CNA #31 stated, "She is so constricted... It hurts her so bad.... Her little legs...(Resident #134 named) we are going to lift you... it is the only way we can get you in the bed... sorry (Resident #134 named)... she doesn't want to be moved because her little legs hurt so bad... We have to pry her legs apart.... She does this every day. I hate doing it...." During an interview on 12/5/2013 at 1:40 P.M., LPN #30 indicated Resident #134 had scheduled pain medication which was administered at 7:30 A.M. and in the evening around 4:00 P.M. LPN #30 indicated Resident #34 also had PRN (as needed) narcotic pain medication ordered for pain and could be administered the pain medication every four hours if needed. LPN #30 indicated Resident #134 complained of pain when she was repositioned for care or transferred from one place to another. LPN #30 indicated Resident #134 was not given a lot of PRN pain medication because she only complained of pain when she was moved. LPN #30 indicated Resident #134 had to be transferred with a lift to get out of bed, to lie down after each meal, and for incontinent care all which required extensive moving. LPN #30 indicated she had planned to administer Resident #134 PRN pain medication prior to her being transferred to bed but she failed to do so. LPN #30 stated, "I planned on giving it to her before lunch but never got around to it." During an interview on 12/5/2013 at 1:46 P.M., the Director of Nursing (DON) was informed of the above observations. At this time documentation of pain assessments, medication administration records for October, November, and December 2013, the facility's pain management policy, and care plans for Resident #134 were requested. The DON indicated Resident #134 had an order for [REDACTED]. During an interview on 12/9/2013 at 10:45 A.M., with the DON and the facility's wound care nurse (LPN #33) present, LPN #33 indicated the physician evaluated Resident #134 on 12/6/2013, and increased her scheduled pain medication from twice a day to three times a day. During this interview the DON indicated staff had reported Resident #134 was "doing much better" since the physician increased the pain medication on 12/6/2013. The facility's pain management policy dated 3/2012, indicated, "Pain Evaluation Purpose: 1. To establish guidelines to measure a resident's level of pain. 2. To provide optimal comfort through a pain control plan, which is established with the members of the health care team...." 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and residents who had pressure areas were provided treatment and services to promote healing for 2 of 3 residents reviewed for pressure ulcers (Resident #184 and Resident #134). Resident # 184 pressure ulcers were not assessed and timely treatment obtained to prevent the worsening of a documented "blister" to a Stage 3 ulcer. Findings include: 1. Resident #184's closed record was reviewed on 12/9/2013 at 9:30 A.M. Resident #184 was admitted to the facility from an acute care hospital on June 14, 2013. Resident #184 had [DIAGNOSES REDACTED]. An untimed admission assessment dated 6 /14/2013, indicated Resident #184 was admitted with two pressure ulcers to his coccyx. An untimed skin assessment dated [DATE], indicated, "Stage 3 left ulcer present on admission. Seen by WCS today. 20% pale yellow slough 80% pale granulation amount of serous drainage no odor periwound is pale in color. Bilateral lower extremities with 3 plus [MEDICAL CONDITION]." An untimed and undated document, identified as "a report sheet" by the consultant DON on 12/9/2013 at 9:30 A.M., indicated Resident #184 had a "broken blister-Achilles L (left)." During an interview on 12/9/2013 at 9:30 A.M., with the Director of Nursing (DON)and the facility's consultant nurse present, the consultant nurse indicated the nurse who admitted Resident #184 failed to document skin break down on his left Achilles and because she was no longer employed by the facility she was not available for an interview. She further indicated the ulcer was not observed until Monday, June 17, 2013 (four days after Resident #184 was admitted ), when the wound nurse completed a skin assessment on him. During an interview on 12/9/2013 at 10:59 A.M., with the DON and the facility's wound nurse LPN #33 present, LPN #33 indicated she assessed Resident #184 on Monday, June 17, 2013 at which time she noted a dry dressing over his left ankle. She removed the dressing and noted a stage three pressure ulcer which measured 1.5 centimeters (cm) length X 2.5 cm width, X 0.2 cm depth. LPN #33 indicated the facility's protocol indicated the the admitting nurse was to do an initial skin assessment and notify a physician of any open areas to obtain orders. She further indicated her own responsibilities included performing skin assessments on all new residents regardless of the condition of their skin. LPN #33 indicated because it was the weekend when he was admitted she did not see Resident #184 until Monday. She indicated when she found the stage three pressure ulcer on his left Achilles she cleansed it, obtained an order for [REDACTED].#184 had a broken blister on his left Achilles. She indicated hospital records alluded to an "old wound" to the area but was unable to find documentation to support Resident #184 was admitted to the facility with a pressure ulcer to his ankle. An undated document titled "PCC Wound Documentation Protocol" identified as current by the facility's nurse consultant on 12/9/13 at 11:38 P.M., indicated, "...On admission the admitting nurse will document any wounds or skin conditions on the Admission/Re-admission Observations. The wound nurse will complete the initial pressure and/or initial non-pressure skin reports within 24 hours of admission when a resident is admitted on Sunday-Thursday and with 72 hours of admission when a resident is admitted on Friday or Saturday. ....The admitting nurse will not stage areas, however they should describe the wound. The description should contain the measurements, a description of the periwound, a description of the wound bed....Initial Pressure Ulcer Report-To be completed by the nurse that found the pressure ulcer. Also completed upon admission, if there are pressure ulcers present on admission. Must be completed. The building may not simply choose not to use this form...." 2. During an observation on 12/5/13 at 11:10 A.M., Resident #134 was observed sitting in a broda chair with a pillow under her lower legs. Her feet were dangling-not elevated. Her left foot was bare. A pressure ulcer was observed on her left foot. A small amount of pink/reddish serous drainage was observed dripping down her left foot. Resident #134 was observed in a gown with her brief and thighs exposed. Her thighs and knees were touching one another. There was not a sheet in between her bare skin. During observations on 12/5/2013 at 11:37 A.M. and 12:04 P.M., Resident #134 was observed sitting in her chair. Her feet were dangling off the end of a pillow. They were not elevated She did not have a sheet between her bare legs and knees. During an observation on 12/5/2013 at 12:04 P.M. and 12:39 P.M., Resident #134 was observed seated in her chair, no sheet between her bare knees and/or thighs, and her feet were not elevated. During an observation on 12/5/2013 at 1:28 P.M., Certified Nursing Assistants (CNA) #31 and #32 were observed transferring Resident #134 with a mechanical lift from her chair to her bed. The chair she was transferred out of did not have a cushion in it. Resident #134 did not have a sheet between her bare legs. Resident #134's record was reviewed on 12/5/2013 at 9:56 A.M. Resident #134 had [DIAGNOSES REDACTED].. An annual MDS (minimum data set assessment tool) dated 6/13/2013, indicated Resident #134 was severely cognitively impaired, had long and short term memory loss, required extensive assistance for transfers and bed mobility, and had lower extremity impairment on both sides. A care plan dated 12/3/3013, indicated Resident #134 had a pressure ulcer present on her left bunion due to immobility and contractures. A goal indicated her pressure ulcer would show signs of healing and remain free from infection. Interventions indicated to meet this goal included: "Cleanse left foot bunion with wound cleanser...cover with foam and secure with [MEDICATION NAME] every two days, cushion in wheelchair... limit time up in char, lie down after meals...." A care plan dated 12/3/2013 indicated Resident #134 was at risk for pressure ulcers related to immobility. A goal indicated she would have intact skin free by the next review. Interventions listed to meet this goal included: A cushion in the wheel chair, her heels were to be up, she was to be put to bed after each meal, and a sheet was to be placed between her bare knees and thighs when she was up in a chair. CNA flow sheets identified as current by the DON on 12/5/2013 at 12:06 P.M., indicated Resident #134 was to be put to bed after meals. During an interview on 12/03/2013 at 9:50 A.M., Licensed Practical Nurse (LPN) #30 indicated Resident #134 had a pressure ulcer on her left foot. During an interview on 12/5/2013 at 11:15 A.M., Licensed Practical Nurse (LPN) #30 was queried when she planned to change Resident #134's dressing on her foot. She indicated she would change it after lunch around 1:00 P.M. During an interview on 12/5/2013 at 12:20 P.M., the facility wound nurse LPN #33 indicated she saw Resident #134 in her room without a dressing on her foot so she put a dressing on it. She stated, "I walked by the room and saw it wasn't on so I thought oops we better get it on. They cleaned her up this morning and it must have come off." During an interview on 12/5/2013 at 1:20 P.M., CNA #33 indicated the hospice aide put Resident #134 in her chair around 7:45 A.M. She indicated after breakfast staff took her to activities and then she was left reclined in her chair. She further indicated she had not attempted to put her back to bed but would after lunch. During an interview with CNA #33 and LPN #30 present, LPN #30 indicated Resident #134 was to be put to bed after each meal. During an interview on 12/5/2013 at 1:28 P.M., CNA #31 indicated Resident #134 did not have a cushion for her chair. CNA #31 stated, "She use to have something between her knees put she is so constricted they cant put it there anymore... I don't know how long it has been." She further indicated she did not put anything between Resident #134's legs because it was too painful for her. During an interview on 12/9/2013 at 9:45 A.M., the facility's consultant nurse indicated Resident #134 should of had a sheet between her bare legs, Resident #134 should of had a cushion in her chair, and staff should have informed the nurse her pressure ulcer dressing had fallen off and needed changed. 3.1-40(a)(1) 3.1-40(a)(2)

BASED ON RECORD REVIEW, OBSERVATION AND INTERVIEW THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO MAINTAIN ACCEPTABLE BODY WEIGHT FOR 1 OF 6 RESIDENTS REVIEWED FOR WEIGHT LOSS. THE resident sustained [REDACTED]. (RESIDENT #134) FINDINGS INCLUDE: THE RECORD FOR RESIDENT #134 WAS REVIEWED ON 6-8-10 AT 1:15 P.M. [DIAGNOSES REDACTED]. THE "VITAL STATISTICS" RECORD INDICATED ON 3-4-10 RESIDENT #134 WEIGHED 71 POUNDS, WHICH REPRESENTED A 2 POUND, OR 2.7%, LOSS SINCE HER ADMISSION TO THE FACILITY 10-15-09, 41/2 MONTHS PRIOR. THE DIETARY PROGRESS NOTES DATED 2-15-10 INDICATED SHE WAS ON A PUREED DIET WITH VARIED INTAKES AT MEALS, WITH DIETARY INTERVENTIONS OF HEALTH SHAKES 3 TIMES DAILY, A MULTI VITAMIN, SUPERCEREAL AT BREAKFAST, EXTRA BUTTER ON MEAL TRAYS AND WHOLE MILK. AT THAT TIME THE DIETICIAN RECOMMENDED THE ADDITION OF PROMOD TWICE EACH DAY WITH MEDICATIONS. THE VITAL STATISTICS RECORD INDICATED HER WEIGHT ON 4-5-10 WAS 65 POUNDS, WHICH INDICATED A 6 POUND OR 8.4% WEIGHT LOSS. DURING AN INTERVIEW ON 6-9-10 AT 9:45 A.M. THE DIETARY MANAGER INDICATED "SOMETIME IN February OR MARCH" OF THIS YEAR THE RESIDENT'S FAMILY CHOSE TO CHANGE TO THE "SELECTIVE MENU" SYSTEM INSTEAD OF THE COMPUTERIZED SYSTEM WHICH HAD PREVIOUSLY BEEN USED TO PROVIDE THE INFORMATION FOR STAFF TO KNOW WHAT FOOD TO PLACE ON HER TRAY. WITH THE SELECT MENU SYSTEM, DIETARY RECOMMENDATIONS WOULD BE HAND WRITTEN ON EACH RESIDENT'S MEAL TICKET OR ON THE INDIVIDUAL RESIDENT'S MEAL TICKET STICKER WHICH INCLUDED THE RESIDENT'S NAME, DIET AND DINING ROOM WHERE SHE ATE. THE DIETARY PROGRESS NOTE DATED 4-24-10 INDICATED THE REGISTERED DIETICIAN (RD)THOUGHT THE RESIDENT WAS RECEIVING A PUREED DIET WITH VARIED INTAKES, A MULTIVITAMIN DAILY, HEALTH SHAKES BETWEEN MEALS, EXTRA BUTTER, SUPERCEREAL AT BREAKFAST, WHOLE MILK AND PROMOD WITH MEDICATIONS. AT THAT TIME THE RD RECOMMENDED ADDING CHOCOLATE MILK WITH EACH TRAY AND PUTTING EXTRA SUGAR PACKETS ON HER TRAY AS SHE PREFERRED SWEETENED FOODS. THIS DIETARY PROGRESS NOTE ALSO INDICATED SHE HAD DEVELOPED A "NEW OPEN AREA RIGHT BUTTOCKS STAGE II PER WOUND NURSE." THE VITAL STATISTICS RECORD INDICATED HER WEIGHT ON 5-3-10 WAS 61 POUNDS, WHICH INDICATED A 10 POUND, OR 14%, WEIGHT LOSS SINCE 3-4-10. THE DIETARY PROGRESS NOTE DATED 5-4-10 INDICATED THE REGISTERED DIETICIAN (RD)THOUGHT THE RESIDENT WAS RECEIVING A PUREED DIET WITH VARIED INTAKES, A MULTIVITAMIN DAILY, HEALTH SHAKES BETWEEN MEALS, SUPERCEREAL AT BREAKFAST,CHOCOLATE MILK ON EACH TRAY, ICE CREAM AT BEDTIME, EXTRA SUGAR AT EACH MEAL AND PROMOD WITH MEDICATIONS. AT THAT TIME THE RD RECOMMENDED ADDING EXTRA BUTTER ON EACH TRAY. THIS DIETARY PROGRESS NOTE ALSO INDICATED, "SKIN- RIGHT BUTTOCKS STAGE III- WORSE." THE VITAL STATISTICS RECORD INDICATED HER WEIGHT ON 6-2-10 WAS 60 POUNDS, WHICH INDICATED AN 11 POUND, OR 15.4%, WEIGHT LOSS SINCE 3-4-10. DURING OBSERVATION OF THE EVENING MEAL ON 6-8-10 HER TRAY CONTAINED PUREED BEEF STEW, COTTAGE CHEESE, FRUIT COCKTAIL AND WHOLE MILK. NO CHOCOLATE MILK EXTRA SUGAR OR EXTRA BUTTER WAS ON THE TRAY. WHEN ASKED IF SHE HAD ADDED ANYTHING TO THE FOOD, CNA #2 INDICATED SHE HAD NOT PUT ANYTHING EXTRA (BUTTER OR SUGAR) IN HER FOOD. THE TRAY TICKET STICKER FOR RESIDENT #134 INCLUDED HER NAME, TYPE OF DIET (PUREED), AND DINING ROOM ASSIGNMENT. IT DID NOT INCLUDE ANY OF THE MEALTIME INTERVENTIONS MADE BY THE RD. DURING OBSERVATION OF THE LUNCH MEAL ON 6-9-10 HER TRAY CONTAINED PUREED PORK SUPREME, POTATOES, PEACHES, ICE CREAM, AND WHOLE MILK. NO CHOCOLATE MILK EXTRA SUGAR OR EXTRA BUTTER WAS ON THE TRAY. WHEN ASKED IF SHE HAD ADDED ANYTHING TO THE FOOD, LPN #6 INDICATED SHE HAD NOT PUT ANYTHING EXTRA (BUTTER OR SUGAR) IN HER FOOD. THE TRAY TICKET STICKER FOR RESIDENT #134 INCLUDED HER NAME, TYPE OF DIET (PUREED), AND DINING ROOM ASSIGNMENT. IT DID NOT INCLUDE ANY OF THE MEALTIME INTERVENTIONS MADE BY THE RD. THE "RESIDENTS AT NUTRITIONAL RISK" PRESENTED BY THE DIETARY MANAGER AS CURRENT ON 6-10-10 AT 10:30 A.M. INCLUDED THE FOLLOWING: "PROCEDURE: IF THE DIETICIAN'S RECOMMENDATIONS REQUIRE A CHANGE IN THE RESIDENT'S PLAN OF CARE, THE FOOD SERVICE SUPERVISOR WILL IMPLEMENT CHANGES IN THE COMPUTER PROGRAM SELECTIVE SYSTEM BY HAND WRITING OR GENERATING COMPUTER PRINTED MEAL TICKETS THAT INCLUDE THE DIETICIAN'S RECOMMENDATION WITHIN 3 DAYS OF RECEIVING THE REQUEST FOR CHANGE." DURING THE INTERVIEW 6-9-10 AT 9:45 A.M., THE DIETARY MANAGER INDICATED THE DIETARY RECOMMENDATIONS SHOULD HAVE BEEN HANDWRITTEN ON THE TRAY TICKET OR PRINTED ON THE TRAY TICKET STICKER. SHE INDICATED RESIDENT #134 MAY HAVE BEEN NOT RECEIVING THE DIETARY INTERVENTIONS RECOMMENDED BY THE RD SINCE SHE CHANGED TO THE SELECTIVE MENU IN February OR MARCH. 3.1-46(a)(1)