Every finding on record at Betz Nursing Home

Based on observation, interview and record review the facility failed to ensure staff were present for medication administration for 2 of 3 residents reviewed (Resident B, Resident C).Findings include:1.During an interview, on 9/15/25 at 10:10 AM, Resident B's family indicated the facility often left medications at bedside. Resident B's family indicated Resident B could not self administer their own medications safely.Resident B's record was reviewed on 9/15/25 at 10:35 AM, diagnoses included end stage renal disease. There were no self administration of medications evaluations documented for Resident B. There were no physician orders for self administration of medications for Resident B. 2. During an observation, on 9/15/25 at 11:23 AM, Resident C's medications were observed at bedside.During an interview, on 9/15/25 at 11:23 AM, Resident C indicated Licensed Practical Nurse (LPN) 3 placed his medications at bedside for his lunch. Resident C indicated he didn't receive lunch until around 1 PM.During an interview, on 9/15/25 at 11:28 PM, LPN 3 indicated no residents in the facility were able to self-administer their medications. LPN 3 indicated she placed Resident C's medications at bedside to take during his lunch. LPN 3 indicated no medications were allowed at bedside. During an interview, on 9/15/25 at 12:09 PM, the Director of Nursing (DON) indicated no residents were able to self-administer their medications. The DON indicated Resident C's medications should not be left at bedside.Resident C's record was reviewed on 9/15/25 at 11:46 AM. Diagnoses included end stage renal disease and type 2 diabetes mellitus. There were no physician orders for self administration of medication for Resident C. An admission care plan, dated 8/7/25, indicated the nurse was to administered Resident C's medications as ordered.An admission Minimum Data Set (MDS) assessment, indicated Resident C had a Brief Interview of Mental Status (BIMS) of 15/15 (cognitively intact). There were no self-administration of medication evaluations documented for Resident C.During an interview, on 9/15/25 at 11:17 AM, Registered Nurse (RN) 4 indicated medications were never left at bedside. RN 4 indicated the nurse waited for the resident to take the medication prior to the nurse leaving the room. A policy, last revised 1/2015, titled Self Administration of Medications, was provided by the Regional Nurse on 9/15/25 at 12:11 PM. The policy indicated a self-administration assessment and order were completed for residents who self- administered medications. This finding relates to Intake 2595411. 3.1-25(b)(3)

Based on observation, interview, and record review the facility failed to ensure privacy for 2 of 7 residents reviewed (Resident 17, and Resident 58). Findings include: 1. During an observation and interview on 7/11/24 at 8:51 AM with Certified Nurse Aide (CNA) 5 and Registered Nurse (RN) 6, Resident 17 was observed with her gown covering her shoulders and her breasts. Her abdomen, incontinence brief and legs were exposed and visible from the hallway. The privacy curtain was pulled less than halfway across its track leaving the exposed resident's body parts visible from the hallway. Resident 17's bed was near the window and the windows blinds were open. CNA 5 indicated Resident 17 should not have been able to be seen from the hallway when her body was not completely covered. She indicated the resident tends to throw covers off while in bed, so staff should have ensured the privacy curtain was pulled to ensure any exposed body parts were not visible from the hallway. RN 6 Indicated the window blinds should have been closed to prevent visibility from outside the building. Resident 17's record was reviewed on 7/11/24 at 11:17 AM. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus without complications, and need for assistance with personal care. Resident 17's current quarterly Minimum Data Set (MDS)dated 6/10/24 indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated she required substantial or maximal assistance with upper and lower body dressing. 2. During an observation and interview on 7/8/24 between 09:53 AM and 10:05 AM, Resident 58 was observed from the hallway wearing a hospital gown backward. The gown was loosely tied at the top and the gown fell open below the tie exposing her left breast. She was sitting in a standard chair with a walker placed in front of her. She indicated she was waiting for staff to come and help her get dressed. She indicated she was not supposed to walk in her room by herself. Physical Therapist 2, CNA 3 and Nurse Aide in Training 4 were observed walking past the room in the time frame of the observation. No employee was observed approaching Resident 58 to offer assistance. Resident 58's record was reviewed on 7/11/24 at 11:46 AM. Diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, limitation of activities due to disability, and unsteadiness on feet. Resident 58's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated she required substantial or maximal assistance with upper body dressing. During an interview on 7/12/24 at 10:07 AM, the Director of Nursing indicated resident's private body parts should not be visible from the hallway. A current policy, undated, titled Resident Rights, provided by Administrator on 7/11/24 at 11:12 AM indicated residents have a right to a dignified existence. 3.1-3(a)

Based on observation, interview, and record review the facility failed to ensure kitchen sanitation was maintained for 76 of 76 residents who ate meals prepared in the kitchen. During an observation with the dietician on 6/20/23 at 9:23 AM, A tray of eggs was observed on a shelf inside the walk-in cooler. The tray contained 15 intact eggs on one side and the other side contained eggshells with a clear slimy substance visible on the shells and on the tray around the shells. The dietician indicated cracked shells from egg use should not be stored with clean, intact eggs. In the walk-in freezer, two plastic grocery bags were observed on a shelf filled with containers of ice cream. The Dietician indicated the containers had been opened and were not labeled. The Dietician indicated items should be dated upon opening. In an interview on 6/20/23 at 9:28 AM, Cook 3 indicated she had used the tray of eggs observed in the walk-in cooler during breakfast that morning. She indicated she cracked each egg, discarded its shell on the same tray containing the clean supply and placed the tray in the walk-in cooler after breakfast service was over. She also indicated the ice cream containers in the walk-in freezer belonged to the activities department and the employee who opened them should have dated them upon opening. During an observation of a storage rack containing stacks of baking dishes, clear liquid dripped from 3 of 4 stacks of bakeware when separated. The Dietician indicated the bakeware should have been air dried prior to stacking and storing. A container of cut up cabbage was observed on the countertop. A serving spoon and tongs were lying on top of the cabbage with the handles touching the food supply. The Dietician indicated the handles should not touch the food supply. During an observation with Cook 2 on 6/20/23 at 10:43 AM, Cook 2 indicated she had never tested chemical levels in sanitizer water. Cook 2 indicated she did not know how to tell if sanitizer levels were correct. Cook 3 handed Cook 2 a test strip and instructed her to immerse it in the sanitizer water. After immersion, Cook 3 indicated the sanitizer levels were low and the water should be changed. During an interview with Cook 2 on 6/20/23 at 10:57 AM, Cook 2 indicated she did not know how to test sanitizer water because she was a new employee. During a record review on 6/20/23 at 11:15 AM, an Employee Records document provided by the Administrator indicated Cook 2 was hired on 10/26/22. A current skills validation form dated 11/17 provided by the Administrator on 6/21/23 at 10:25 AM identified staff testing of sanitizer solution for appropriate sanitizer concentration as a skill required for cleaning and sanitizing kitchen surfaces. A current policy titled Food Storage dated 5/23 provided by the Dietician on 6/20/23 at 11:25 AM indicated food should be clearly labeled and marked to indicate the date by which the food should be used or discarded. A current policy titled Manual Dishwashing dated 6/23 provided by the Administrator on 6/21/23 at 11:19 AM indicated all items should be air dried before use or storage. A current policy titled FDA Food Code dated 2022 provided by the Administrator on 6/21/23 at 11:19 AM indicated food preparation and dispensing utensils should be stored with their handles above the top of the food container. During an interview with the Administrator on 6/21/23 at 11:19 AM, she indicated the facility did not have a policy specific to egg handling and storage. 3.1-21(i)(2)(3)

Based on interview and record review the facility failed to ensure the provision of timely laboratory testing to monitor warfarin (blood thinner) for 1 of 4 residents reviewed. (Resident 183) Findings include: Resident 183's record was reviewed on 6/26/23 at 2:19 PM. Diagnoses included a history of a blood clots. Resident 183's current Comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated their Brief Interview for Mental Status (BIMS) was 15 (no cognitive deficit). The MDS indicated the resident was being administered a blood thinner for a history of blood clots. A physician order dated 6/16/23 indicated a PT/INR (blood test for blood thinning medication) was to be performed on 6/23/23. Progress notes dated 6/23/23 through 6/26/23 had no indication of a PT/INR blood draw attempt. In an interview on 6/26/23 at 3:24 PM the Director of Nursing (DON) indicated the PT/INR scheduled for 6/23/23 was not performed due to Resident 183 having had difficult veins. The DON indicated the PT/INR was collected on 6/26/23 and results were anticipated between 5:00 PM and 6:00 PM. The DON indicated the ADON notified the Nurse Practitioner (NP) on 6/23/23 of the missed blood test and received an order to perform the blood test on 6/26/23. In a telephone interview on 6/26/23 at 3:32 PM a Laboratory Representative (Lab Rep) 5 indicated there was no physician order for Resident 183's PT/INR to be performed on 6/26/23. Lab Rep 5 indicated the only physician order for Resident 183's PT/INR was dated 6/22/23 at 7:59 PM. The blood draw should have been performed on 6/23/23. In an interview on 6/26/23 at 3:36 PM the DON indicated the facility had followed the physician order to perform the PT/INR on 6/26/23. The DON indicated the NP was made aware of the failed PT/INR attempt by the ADON on 6/23/23. The DON indicated on 6/23/23 the NP gave an order to the ADON for the PT/INR to be drawn 6/26/23. The DON indicated the PT/INR was collected the morning of 6/26/23 and results were pending. The DON indicated lab results were generally received from the lab between 5:00 PM and 6:00 PM due to the lab's location being in Indianapolis. In an interview on 6/26/23 at 4:02 PM Resident 183 indicated the nurse had drawn their blood. Resident 183 indicated there were no other attempts at drawing their blood on 6/26/23. The resident indicated a lab technician had failed at obtaining a blood sample on Friday morning 6/23/23. The resident indicated there had been no attempts to draw her blood between 6/23/23 and 6/26/23. In an interview on 6/26/23 at 4:15 PM Registered Nurse (RN) 4 indicated they had drawn Resident 183's blood at approximately 3:30 PM. On 6/27/23 at 8:45 AM Resident 183's record was reviewed. A progress noted entered by RN 4 dated 6/26/23 at 3:37 PM indicated Resident 183's blood was drawn due to the lab being unable to obtain a redraw. The entry was invalidated on 6/26/23 at 3:47 PM. A PT/INR lab report indicated Resident 183's blood was drawn on 6/26/23 at 3:30 PM. A review of a PT/INR Tracking Log indicated Resident 183's PT/INR test was performed on 6/16/23 and the next PT/INR test should be completed on 6/23/23. There was no documentation of the missed lab draw, physician notification or an order to draw the lab on an alternate date. A progress note entered by the ADON dated 6/23/23 at 3:25 PM recorded as a late entry on 6/26/23 at 3:27 PM indicated the NP was informed Resident 183's PT/INR had not been drawn and could be drawn on 6/26/23. A progress note entered by the NP dated 6/23/23 at 3:29 PM recorded as a late entry on 6/26/23 at 3:34 PM indicated PT/INR results were pending due to an inability to collect the sample on 6/23/23. In an interview on 6/27/23 at 10:15 AM the DON indicated the blood was drawn by RN 4 on 6/26/23 at 3:30 PM due to the lab had been unable to collect blood on the morning of 6/23/23. The DON indicated they had no knowledge as to why the progress note related to the blood draw dated 6/26/23 at 3:37 was invalidated on 6/26/23 at 3:47 PM. The DON indicated they were unaware as to why there was no documentation in the progress notes related to an unsuccessful lab draw. The DON indicated they were unaware as to why there was no documentation related to the unsuccessful lab draw and updated physician order on the resident's PT/INR Tracking Log. The DON indicated they were unaware as to why the physician order to obtain a PT/INR on 6/26/23 was not included on the physician order sheet. The DON indicated they were unaware as to why the lab did not have a physician order to draw a PT/INR on 6/26/23. A current policy dated 1/2016 provided by the DON on 6/26/23 at 3:36 PM indicated residents requiring warfarin would receive adequate monitoring. The policy indicated all PT/INR results, current warfarin dose, dosage change, physician notification, and relevant comments would be documented on the PT/INR Tracking Log. 3.1-49(a) and (b)

Based on record review and interview, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed in the required time frame for 2 of 2 residents reviewed. (Resident 17 and Resident 25) Findings include: 1. Resident 17's record review began on 7/26/22 at 3:00 PM. The record indicated an annual MDS was accepted with warning on 3/30/22. The assessment reference date was 3/29/22. In addition, the record indicated a quarterly review had been in process since 6/22/22, but had not been transmitted by the time of survey exit. 2. Resident 25's record was reviewed on 7/26/22 at 9:30 am. The record indicated an annual MDS was accepted with warning on 3/30/22. The assessment reference date was 3/25/22. In addition, the record indicated a quarterly review had been in process since 6/16/22, but had not been transmitted by the time of survey exit. The Director of Nursing was interviewed on 7/26/22 at 9:34am. She indicated MDS quarterly assessments were to be done within 92 days of the previous assessment. The MDS coordinator was interviewed on 7/26/22 at 11:50am. She indicated MDS quarterly assessments were to be completed within ninety-two (92) days from the last assessment. She indicated the quarterly review dated 6/16/22 should have been completed by 6/30/22 and transmitted within 31 days after the assessment was completed. A policy, dated 10/2019, entitled, RAI OBRA-required Assessment Summary was received from the DON on 7/26/22 at 9:59am. The policy indicated the assessment reference date was required to be within 92 days of the last assessment. The policy also indicated the completion date should have been within 14 days of the assessment reference date. 3.1-31(d)(3)

Based on interview and record review the facility failed to ensure quarterly care plan meetings were completed for 2 of 2 residents reviewed. (Resident 10, Resident 46) Findings Include: 1. Resident 10 was interviewed on 7/24/22 at 12:47 PM. Resident 10 indicated she did not have care plan meetings. Resident 10's record was reviewed on 7/25/22 at 3:25 PM. An Minimum Data Set (MDS) assessment, dated 3/24/22 indicated Resident 10 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Social Service (SS) notes were reviewed for Resident 10 from 2/1/22 - 7/25/22. The notes indicated there were care plan meetings on 2/24/22 and 7/14/22. There was no other documentation regarding care plan meetings. 2. Resident 46 was interviewed on 7/24/22 at 12:18 PM. Resident 46 indicated she did not have care plan meetings. Resident 46's record was reviewed on 7/25/22 at 2:03 PM. An MDS assessment, dated 5/17/22 indicated Resident 46 had a BIMS score of 15 indicating cognitively intact. SS notes were reviewed for Resident 46 from 2/1/22 - 7/25/22. The notes indicated there were care plan meetings on 2/24/22 and 7/7/22. There was no other documentation regarding care plan meetings. The Social Service Director (SSD) was interviewed on 7/25/22 at 3 PM. The SSD indicated care plan meetings were completed quarterly. The SSD indicated Resident 10 and Resident 46 should have had a care plan meeting in May 2022. A policy, revised 10/2019, titled IDT Comprehensive Care Plan Policy, was provided by the Director of Nursing on 7/26/22 at 12:40 PM. The policy did not indicate how often care plan meetings should be completed. A review of CMS.GOV website under MDS Care plan timing Chapter 5, Care plan meetings must be held within 7 days of MDS completion. 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure nail care was completed for 1 of 1 resident reviewed. (Resident 44) Findings include: Resident 44's record was reviewed on 7/24/22 at 1:50 PM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated Resident 44 required extensive assistance with activities of daily living. An interview was conducted with the family of Resident 44 on 7/24/22 at 12:44 PM. A family member indicated there was a dark brown substance visible under Resident 44's fingernails. The family member indicated she witnessed Resident 44 placing her hands in feces during care on several occasions in the past. An observation was made on 7/24/22 at 12:44 PM. Resident 44's fingernails were of various lengths with some jagged edges and a dark brown substance was under the nails on both hands. An observation was made on 7/25/22 at 10:44 AM. Resident 44's fingernails were of various lengths with some jagged edges and a dark brown substance was under the nails on both her hands. In an interview on 7/26/22 at 11:09 AM, Licensed Practical Nurse (LPN) 3 indicated Certified Nursing Assistant's (CNA) normally provide nail care. In an interview on 7/26/22 at 11:13 AM, CNA 4 indicated resident nails are to be checked during care and cleaned when indicated. Resident 44's shower report dated 7/24/22 indicated nail care had been given on that day. In an interview on 7/25/22 at 2:55 PM, the DON indicated that there was no formal policy for nail care, and nail care was considered a standard of CNA care. During an observation on 7/26/22 at 9:27 am, Resident 44's nails were of consistent length with no jagged edges and no dark brown substance was visible under the nails. 3.1-38(a)(3)(E)

Based on interview and record review, the facility failed to provide oxygen therapy per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 5/12/22 at 11:29 A.M., Resident D's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had been hospitalized for a pleural effusion of the right lung and required chest tube placement. He returned to the facility on [DATE] with the chest tube removed and orders for continuous oxygen at 2 liters per minute (LPM), per nasal cannula. A nurse progress note, dated 4/15/22 at 11:41 a.m., indicated the hospital reported the resident's discharge was delayed. He was to have a procedure completed then would return to the facility. He was on continuous oxygen at 2 LPM. He'd had a chest tube removed on 4/13/22, the area covered with a dressing. At 9:50 p.m., he arrived at the facility. He complained of difficulty breathing upon arrival but improved after he laid down. A hospital discharge summary, dated 4/15/22 at 4:50 p.m., indicated the resident was ordered oxygen therapy but did not indicate the amount of oxygen to be administered. Review of the April 2022 MAR (Medication Administration Record) and TAR (Treatment Administration record) hadn't indicated oxygen was ordered and/or administered upon the resident's return from the hospital on 4/15/22. Vital sign documentation indicated the resident had received oxygen at 2 LPM per nasal cannula on 4/15/22 at 10:11 p.m. and on 4/16/22 at 9:35 a.m. He was not administered oxygen on 4/17/22 at 11:30 a.m. nor at 3:48 p.m. At 8:22 p.m., vital sign documentation indicated the resident was administered 4 LPM per nasal cannula. On 5/16/22 at 11:12 A.M., the Director of Nursing Services (DNS) was interviewed. She indicated oxygen therapy orders had not been clarified for the amount/duration and hadn't been put onto the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident should have been provided with oxygen as ordered on 4/17/22. This Federal tag relates to Complaint IN 183. 3.1-47(6)

Based on interview and record review, the facility failed to ensure a resident receiving [CONDITION(S)] medications had behavioral monitoring and documentation in place for targeted behaviors for 1 of 1 residents reviewed (Resident F). Findings include: On 5/16/22 at 12:36 P.M., Resident F's record was reviewed. Diagnoses included, but were not limited to, Alzheimer's dementia, major depressive disorder, anxiety disorder, delusional disorder, muscle weakness, and repeated falls. The resident resided on the secured memory care unit. A quarterly MDS (Minimum Data Set) assessment, dated 3/16/22, indicated the resident had severely impaired cognition. Staff assessment of the resident's mood indicated she had no symptoms of mood issues. She had daily occurrences of behaviors not directed towards others. The resident's balance was steady when walking and she required only supervision while ambulating in her room or in the hallway. A care plan, dated 2/20/22, indicated the resident had episodes of becoming aggressive with staff. At times, she would hit, kick, and swing at staff members during care and redirection. She had dementia with agitation and had antipsychotic medication place to stabilize her mood. The goal was she would cause no harm to herself or others. Interventions were to document her behaviors 2 times per day. When the resident had behaviors of hitting, kicking, or swinging at staff during care and redirection, staff were to offer her a snack or beverage to divert her attention, provide a soothing subject change, and/or assess for pain or discomfort and treat as indicated. Nurses were to document these behaviors on the Behavior Administration form. A care plan, dated 8/24/21, indicated the resident was at risk for adverse side effects related to use of [CONDITION(S)] medications. She had diagnoses of delusional disorder, depression, and [CONDITION(S)]. The goal was for her to have no adverse side effects. Interventions included: observe for side effects, administer meds as ordered, document side effects, attempt to gradually reduce doses, and pharmacist to review medications routinely. A Behavior Administration form dated April 2022 indicated the resident was monitored for episodes of becoming aggressive with staff. She would hit, kick, and swing at staff during care and redirection. When she had these behaviors, staff were to 1. offer her a snack or beverage 2. provide a soothing subject change and 3. assess for pain or discomfort and treat as indicated. The Behavior Administration form indicated nurses should document every day shift between 6:00 a.m. and 6:00 p.m. and night shift between 6:00 p.m. and 6:00 a.m. If the resident had behaviors, nurses would document the number of times the behavior occurred, which interventions were tried, and if the interventions were effective. The form indicated the resident had behaviors on the following dates, interventions used and effectiveness of the interventions: -1 behavior on 4/2/22 during night shift with interventions of 1. offer a snack and 2. provide soothing subject change which were effective. -3 behaviors on 4/3/22 during day shift with interventions of 1, 2, and 3-assess for pain which were effective. -2 behaviors on 4/4/22 during day shift with interventions of 1 and 2 which were effective. -1 behavior on 4/6/22 during day shift with intervention of 2 which was effective. -1 behavior on 4/11/22 during day shift with interventions of 1 and 2 which were effective. A psychiatric NP (Nurse Practitioner) progress note, dated 3/15/22 at 11:00 a.m., indicated the resident was seen for follow up to being placed on [MEDICATION(S)] (anti-anxiety) medication for increase in behaviors of yelling and irritability. The resident was placed on [MEDICATION(S)] 5 mg (milligrams) by mouth 3 times per day for anxiety, restlessness and yelling, on 3/12/22. The resident was currently being treated for delusions with a reduced dose of [MEDICATION(S)] (anti-psychotic) 0.125 mg by mouth at bedtime daily until 3/22/22 when the medication would be discontinued. Assessment/Plan was to continue to provide support and encouragement, provide a structured and calm environment, document depressive symptoms, observe for changes in mood and behaviors, promote good sleep hygiene and encourage resident to be awake during the day. A progress note, dated 3/18/22 at 7:15 p.m., indicated the resident had a fall and sustained a laceration to the right side of her head. A fall intervention, put into place following the fall, was to have her medications reviewed as a possible cause of the fall. A progress note, dated 3/21/22 at 2:18 p.m., indicated the psychiatric NP had been contacted regarding the resident's fall and continued behaviors of restlessness, wandering without awareness of surroundings, and irritability. The NP ordered the [MEDICATION(S)] be discontinued, give the last dose of [MEDICATION(S)] on 3/22/22, then discontinue as planned. Progress notes from 3/22/22-4/1/22 indicated the following: -3/22/22 at 8:30 p.m., the resident had several loud outbursts after dinner. -3/24/22 at 3:01 p.m., resident's mood was pleasant this shift and she had no behaviors. -3/25/22 at 9:05 a.m., resident had noted improvement in her overall condition and mood with recent discontinuation of psychoactive medications. She was pleasantly confused, wandered, and had less irritability and decreased episodes of yelling out. Social Service progress notes indicated the following: -4/1/22 at 7:45 p.m., the resident had been observed, on this day, to have increased wandering, episodes of screaming out angrily at inanimate objects, restlessness and 2 falls due to unsteady gait. Staff had attempted to engage the resident in diversional activities and handling tangible items for sensory stimulation, walks, snacks, beverages which were ineffective and the resident continued to be agitated and yell out. The psychiatric NP was notified and orders received to start [MEDICATION(S)] (mood stabilizer) 125 mg by mouth 2 times per day for agitation and restlessness. -4/2/22 at 5:27 p.m., resident continued with nonstop wandering. She had been in a pleasant mood with interaction, had continuous outbursts of loud yelling out and made noises in a singing manner. She hadn't napped all day and was difficult to feed due to inability to sit still. -4/3/22 at 2:45 p.m., resident had continued outbursts of yelling out and becoming irritable. She screamed at objects without apparent triggers. The psychiatric NP was notified and order given to administer a one time dose of [MEDICATION(S)] 250 mg by mouth and increase [MEDICATION(S)] from 125 mg to 250 mg 2 times per day for agitation/restlessness. At 6:30 p.m., the resident continued with agitation and anxiety. She had been given a dose of [MEDICATION(S)] 250 mg at 5:00 p.m. and since that time, had increased screaming out and cursing at objects. She hadn't slept all day and paced the halls. The psychiatric NP was notified and orders received to discontinue all [MEDICATION(S)] medications and administer a one time dose of [MEDICATION(S)] (anti-anxiety) 0.5 mg for distressing anxiety and agitation. -4/4/22 at 1:58 p.m., the psychiatric NP was notified that the resident had tolerated the [MEDICATION(S)] well. New orders were given for [MEDICATION(S)] 0.5 mg 2 times per day for anxiety and restlessness for 14 days and start [MEDICATION(S)] (tricyclic antidepressant) 10 mg by mouth every day at 5:00 p.m. for major depression. -4/7/22 at 10:50 a.m., resident had recent medication changes to stabilize mood and behavior. She continued with wandering aimlessly while awake, had outbursts of yelling and irritability which had lessened, her sleep and rest patterns had improved since the change in medications. A Psychiatric NP progress note, dated 4/7/22 at 5:29 p.m., indicated the resident had been visited for follow up on mood and behaviors. She'd recently been taken off all her [CONDITION(S)] medications but had started with increased agitation and behaviors. She was started on [MEDICATION(S)] 125 mg 2 times per day but she continued with yelling, pacing hallways, singing loudly and restlessness which had been difficult to redirect. The [MEDICATION(S)] was increased to 250 mg and a dose given which was ineffective. A dose of [MEDICATION(S)] was ordered and found to be effective. Resident will be continued on [MEDICATION(S)] and [MEDICATION(S)] for restlessness, agitation, and anxiety. A progress note, dated 4/9/22 at 12:32 p.m., indicated the resident had a fall. A new order was received to decrease [MEDICATION(S)] from 0.5 mg 2 times per day to 0.5 mg 1 time per day until 4/17/22 and then discontinue. A Social Service progress note, dated 4/19/22 at 10:30 a.m., indicated the resident had anxiety and depression as evidenced by daily restlessness, tearfulness and sad facial expressions. The psychiatric NP ordered the resident's [MEDICATION(S)] be increased to 25 mg at bedtime to facilitate sleep at night and start [MEDICATION(S)] (anti-depressant) 75 mg by mouth daily to help with depressive and anxiety symptoms. A Social Service progress note, dated 4/23/22 at 5:59 p.m., indicated the resident had no adverse reactions or behavioral changes related to the increase in [MEDICATION(S)] and start of [MEDICATION(S)] medication. Staff reported the resident had a slight tremor and had been jittery but no excess sleepiness. Her episodes of anxiety and yelling out had lessened and she appeared to rest more frequently between episodes. A psychiatric NP progress note, dated 4/26/22 at 12:15 p.m., indicated the resident was visited for follow up after a recent increase in [MEDICATION(S)] and start of [MEDICATION(S)]. She continued to aimlessly wander and pace on the unit and had a recent fall. She was observed pacing and talking in jibberish per her usual. Assessment/Plan: Continue [MEDICATION(S)] with goal of improving her moods and sleep, promote good sleep hygiene, and encourage her to be awake during the day. Continue with [MEDICATION(S)] and observe for changes in her mood and behaviors. There was no behavior monitoring put into place nor care plan update for the use of [CONDITION(S)] medications to treat the residents behaviors. On 5/16/22 at 11:30 A.M., the Social Services Director was interviewed. She indicated she documented behaviors she observed Resident F had and nurses documented their observations on the Behavior administration form. On 5/16/22 at 2:30 P.M., the Director of Nursing Services was interviewed. She indicated nurses were to document targeted behaviors observed for which [CONDITION(S)] medications were prescribed to treat. Current facility policies titled [CONDITION(S)] Management and Behavior Management were provided by the Administrator on 5/16/22 at 3:07 p.m., and stated the following: -[CONDITION(S)] Management: .A [CONDITION(S)] drug is any drug that affects brain activities associated with mental processes and behavior which include drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic .6. All residents who are taking antipsychotic, anxiolytic, sedative/hypnotic or anticonvulsant medication are required to have a behavior monitoring program in place identifying targeted behavioral symptoms being monitored as well as personalized non-pharmacological interventions -Behavior Management: Care plans should be initiated for any behavioral issue that affects, or has the potential to affect, the resident or other residents. Care plans should also be initiated for the behavioral symptoms that relate to [CONDITION(S)] medication use .when a behavior occurs, the nurse records the behavior on the monitoring form, including what interventions were attempted during the episode and whether or not they were effective This Federal tag relates to Complaint IN 878. 3.1-48(a)

Based on interview and record review, the facility failed to ensure licensed nurse coverage for 6 hours on one shift. 69 residents reside in the facility. Findings include: The Indiana Department of Health received an anonymous complaint indicating the facility had no licensed nurse on the premises from 10 p.m. to 4 a.m. the night of 2/11/22 to the morning of 2/12/22. On 3/30/22 at 10:02 A.M., the as-worked time sheets for licensed nurses, scheduled to work on 2/11 and 2/12/22, were reviewed and indicated the following: 2/11/22- RN 2 (Registered Nurse) worked 6:30 a.m. to 9:20 p.m. - RN 3 worked 5:00 a.m. to 7:20 p.m. - RN 4 worked 10:55 a.m. to 4:18 p.m. - RN 5 worked 8:00 a.m. to 11:15 a.m. - LPN 7 (Licensed Practical Nurse) worked 5:13 p.m. to 10:05 p.m. - LPN 9 who served as the Unit Manager and was the on-call manager for the weekend; worked 8:19 a.m. to 3:27 p.m., 4:02 p.m. to 5:01 p.m., and 6:59 p.m. to 9:18 p.m. - QMA 10 (Qualified Medication Aide) worked 5:50 a.m. to 6:04 p.m. - QMA 11 worked 6:01 p.m. to 6:59 a.m. 2/12/22- RN 3 worked 4:06 a.m. to 8:33 a.m. - RN 5 worked 6:02 a.m. to 6:44 p.m. - LPN 6 worked 6:00 a.m. to 2:33 p.m. - LPN 8 worked 5:48 a.m. to 4:00 p.m. - LPN 9 worked 7:00 a.m. to 11:06 a.m. The time sheets indicated there was no licensed nursing staff in the facility from 2/11/22 at 10:05 p.m. until 2/12/22 at 4:06 a.m. On 3/30/22 at 11:54 A.M., the Executive Director (ED) and Director of Nursing Services (DNS) were interviewed. The ED indicated an agency nurse had been scheduled to work on 2/11/22 from 10 p.m. to 2/12/22 at 6 a.m. The agency nurse never showed up which left only QMA 11 and 3 CNA's (Certified Nurse Assistants) in the facility, without a licensed nurse, from 2/11/22 at 10 p.m. until 2/12/22 at 4 a.m. when RN 3 came in to work. Both the ED and DNS indicated they were not notified the agency nurse hadn't shown up until Monday morning, 2/14/22, when they arrived at the facility. The DNS indicated if she had been notified of the agency nurses absence, she would have come to the facility to ensure there was a licensed nurse present. The ED indicated staffing for the night shift should consist of 1 licensed nurse and a QMA or 2 licensed nurses and the facility. She indicated the facility should never be without a licensed nurse on the premises. This Federal tag relates to Complaint IN 643. 3.1-17(a) 3.1-17(b)

Based on observation, record review, and interview the facility failed to ensure rooms were in good repair for 6 of 6 rooms reviewed for homelike environment. Findings include: 1. During an observation in Room 411 by bed 2 on 5/26/21 at 11:30 AM, there was a hole in the wall that was approximately 5 inches by 6 inches that could be seen behind the resident's chair. During an interview with the resident in room 411 on 6/1/21 at 11:18 AM, the resident indicated the hole had been in the wall for a few months. The resident indicated maintenance knew about the hole but hadn't fixed it yet. The resident also indicated she would like it fixed. 2. During an observation in room 417 by bed 2 on 5/26/21 at 3:22 PM, paint was scratched off the walls on two walls. The areas where the paint was scratched off was approximately 2 feet by 3 feet on both walls. During an interview with the resident in room 417 on 5/26/21 at 3:22 PM, the resident indicated she would like to have her walls repaired. The resident indicated the facility had known about the scratched paint on the walls for a couple of months, but they had not repaired it. 3. During a facility tour on 6/2/21 from 12:07 PM to 12:41 PM, the following was observed: Room 504 had 6 quarter sized holes on the north wall behind the bed. Room 505 had paint scratched off the wall. The scratches were approximately 4 inches around and were a 1/4 inch deep. Room 509 had paint scratched off the north wall. The scratches were approximately 4 inches long and a 1/2 inch wide. Room 405 had scratches on the north wall. The scratches were approximately 2 inches long by 1/2 inch wide. According to the Facility Matrix provided by the Director of Nursing Services (DON) on 5/26/21 at 1:30 PM, there was one resident residing in room 504, one resident residing in room 505, one resident residing in room 509, one resident residing in room 405, two residents residing in room 411, and one resident residing in room 417. There was no documentation in the Preventative Maintenance log that indicated the walls in the rooms needed fixed. The Administrator was interviewed on 6/2/21 at 1:57 PM. During the interview the Administrator indicated the holes and scratches in the rooms should have been fixed. 3.1-19 (e)

Based on observation, record review and interview the facility failed to provide oxygen humidification services for 2 of 2 residents reviewed for respiratory care. (Resident 3 and Resident 36). Findings include: A record review was completed on 5/27/21 at 3:19 P.M. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Resident 36 was interviewed on 5/26/21 at 11:47 A.M. Resident 36 indicated she had been out of humidification water for a couple days and she had notified the staff each day. Resident 36 also indicated the staff told her the facility was out of humidification water bottles. Resident 36 indicated she had wanted the humidification water for her oxygen so her nose would not be dry. An observation was made on 5/26/21 at 11:47 A.M. that Resident 36's humidity bottle was empty. Resident 36 was interviewed on 5/27/21 at 9:45 A.M. Resident 36 indicated she was still waiting on humidification water. An observation was made on 5/27/21 at 9:45 A.M and 10:50 A.M., Resident 36's humidity bottle was empty. 2. A record review was completed on 05/27/21 03:25 PM. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 5/26/21 at 3:22 P.M., Resident 3's oxygen concentrator did not have a humidity bottle. An observation was made on 5/27/21 at 9:56 A.M., Resident 3's oxygen concentrator did not have a humidity bottle. The Director of Nursing (DON) was interviewed on 5/27/21 at 10:51 A.M. The DON indicated staff should change the humidity water when empty. One humidification bottle would usually last 3-4 days. The DON also indicated the humidify water should have been changed when it was empty. A policy titled Oxygen Concentrator was provided by the DON on 5/27/21 at 11:30 A.M. The policy indicated daily maintenance .check the water level in the humidity bottle. Change the bottle every 7 days or as needed. 3.1-47(a)(6)

Based on observation, interview, and record review the facility failed to ensure PPE was properly worn when interacting with 1 of 1 residnet reviewed (Resident 4) Findings include: 1. During an observation on 2/2/21 at 10:01 A.M., Licensed Practical Nurse (LPN) 2 had on a face shield with a mask, but his mask was not covering his nose or mouth. He was sitting at the nurse's station between the 600 and 700 hall. Two staff members were about 3 feet from LPN 2 when his mask was not covering his nose and mouth. LPN 2 and the staff memebrs were conversing. During an observation on 2/2/21 at 10:28 A.M., Staff 3 had on a face shield and maks, but his mask was not covering his nose. Staff 3 was in the area between the 600 hall and 700 hall. During an observation on 2/2/21 at 12:58 A.M., Staff 3 had on a face shield and mask, but his mask was not covering his nose. Staff 3 was in the area between the 600 hall and 700 hall. During an observation on 2/2/21 at 1:05 P.M., LPN 2 was in Resident 4's room sitting on the bed about 3 feet from Resident 4 who was also sitting on the bed. LPN 2 did not have on a mask or protective eyewear. Resident 4 did not have on a mask. During an observation on 2/2/21 at 1:09 P.M., LPN 2 was sitting at the nurse's station between the 600 hall and 700 hall. LPN 2 had on a face shield and mask, but his mask was not covering his nose. A staff member was sitting about 3 feet from him, conversing, when his mask was not covering his nose. During an observation on 2/2/21 at 1:11 P.M., Staff 3 had on a face shield and mask, but his mask was not covering his nose. He was about 4 feet from and conversing with 2 other staff members between the 600 hall and 700 hall. During an observation on 2/21/21 at 2:26 P.M., LPN 2 was sitting at the nurse's station between the 600 hall and 700 hall. He had on a face shield and mask, but his mask was below his nose and mouth. Two other staff members were about 4 feet from him at the nurse's station, cincersing with him. During an interview with LPN 2 on 2/2/21 at 1:38 P.M., the following was observed: LPN 2 was asked a question. He had on a face shield. He pulled his mask below his nose and mouth to answer the question and then pulled it back up over his nose and mouth. He then pulled his mask below his nose and mouth to cough. He pulled the mask back over his nose and mouth. He indicated he was pulling his mask below his nose and mouth because he had a tickle in his nose. He indicated he had COVID-19 a while ago and he was not currently being tested , but his 90 days would be up in a week or two and he would start to be tested again. The Director of Nursing (DON) was interviewed on 2/2/21 at 1:52 P.M. During the interview the DON indicated staff should be wearing a mask over their nose and mouth when on the floor or near a resident area or resident hall. She indicated masks should be worn over the nose and mouth when within 6 feet of another staff member as well. The Infection Preventionist (IP) was interviewed on 2/2/21 at 2:41 P.M. During the interview the IP indicated staff should always have a mask on over their nose and mouth in resident areas and halls like the 600 hall and 700 hall and the area between the halls. She indicated staff should be wearing a mask over their nose and mouth when around other staff as well. The IP indicated the facility followed CDC, ISDH, CMS and corporate guidance regarding COVID-19. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (December 2020) was retrieved on 2/5/21 from the Centers for Disease Control (CDC) website. The guidance indicated Source control refers to use of well-fitting cloth masks or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19 .HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. 2. During an observation on 2/2/21 at 1:05 P.M., LPN 2 was in Resident 4's room sitting on the bed about 3 feet from Resident 4 who was also sitting on the bed. LPN 2 did not have on a mask, protective eyewear, a gown, or gloves. Resident 4 did not have on a mask or protective eyewear. A Daily Census Report dated 2/2/21 provided by the DON on 2/2/21 at 2:53 P.M., indicated Resident 4 was a new admission to the facility. LPN 2 was interviewed on 2/2/21 at 1:38 P.M. During the interview LPN 2 indicated newly admitted residents are placed in transmission-based precautions for 14 days. LPN 2 indicated when going in rooms of new admissions staff should wear a mask, gown, and protective eyewear. LPN 2 indicated gloves would only be worn if staff were giving insulin or IV's (Intravenous therapy). He indicated he had COVID-19 a while ago and he was not currently being tested , but his 90 days would be up in a week or two and he would start to be tested again. The DON was interviewed on 2/2/21 at 1:52 P.M. During the interview the DON indicated Resident 4 was admitted to the facility on [DATE]. The DON indicated when residents are newly admitted they are placed on isolation for 14 days. She indicated staff should be wearing an N-95 mask, protective eyewear, a gown, and gloves into these rooms. She indicated staff going into Resident 4's room should be wearing an N-95 mask, gown, gloves, and protective eyewear. The Infection Preventionist (IP) was interviewed on 2/2/21 at 2:41 P.M. During the interview the IP indicated the facility followed CDC, ISDH, CMS, and corporate guidance regarding COVID-19. A policy, dated 11/2020, was provided by the DON on 2/2/21 at 2:53 P.M., titled Standard and Transmission-Based Precautions (Isolation) Policy. The policy indicated .DROPLET PLUS PRECAUTIONS: is used to designate transmission-based precautions beyond droplet precautions for residents with unknown COVID-19 status under 14-day observation, COVID-19 suspected or positive residents, and the use of N-95 or approved KN95 mask .PPE must be donned prior to room entry (gown, gloves, N-95 respirator or approved KN95 mask, and eye protection). Preparing for COVID-19 in Nursing Homes (November 2020) was retrieved on 2/5/21 from the Centers for Disease Control website. The guidance indicated to Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. 3.1-18(b)

Based on observation, interview, and record review the facility failed to ensure measures to prevent the potential spread of COVID were in place according to current CDC guidelines. This had the potential to effect 15 of 15 residents residing on the 700 hall. 1. During a continuous observation on 12/4/20 from 1:04 P.M. to 1:10 P.M., the following was observed: CNA 2 went into Resident 4's room, picked up a finished lunch tray, went into the hall with the tray, and placed it into the food cart. CNA 2 then went into Resident 5's room, picked up a finished lunch tray, went into the hall with the tray, and placed it into the food cart. CNA 2 then went into Resident 6's room, picked up a finished lunch tray, went into the hall with the tray, and placed it into the food cart. CNA 2 went back into Resident 6's room, and helped the resident adjust a blanket that was covering the her. CNA 2 left Resident 6's room. CNA 2 was not observed to use hand sanitizer or wash her hands during the entire observation. The Director of Nursing Services (DON) was interviewed on 12/4/20 at 2:54 P.M. During the interview the DON indicated staff should wash hands or use hand sanitizer before going to another resident's room or after touching something. A policy, dated 11/2020, was provided by the DON on 12/4/20 at 11:05 A.M., titled Standard and Transmission-Based Precautions (Isolation) Policy. The policy indicated, .Always assume that every resident is potentially infected or colonized with an organism that could be transmitted in the healthcare setting. The following infection prevention and control practices should be used during delivery of care to all residents: Hand Hygiene. Hand Washing- washing hands with soap and water. Hand rub- use of alcohol-based hand rub (ABHR). Perform hand hygiene: Before having direct contact with a resident .After contact with the resident .After touching resident surroundings (objects and surfaces in the resident's environment. 2. During a continuous observation on 12/4/20 from 2:02 P.M. until 2:08 P.M. the following was observed: CNA 2 and CNA 3 went into Resident 8's room with a metal lift. After using the lift with Resident 8, CNA 2 and CNA 3 placed the lift in the hall across from Resident 8's room. CNA 2 and CNA 3 were not observed to clean the metal lift after using it with Resident 8 before placing it in the hallway. CNA 3 was interviewed on 12/4/20 at 2:33: P.M. During the interview CNA 3 indicated the metal lift had not been cleaned after using it with Resident 8 before use or after placing it in the hallway. CNA 3 also indicated it should have been cleaned after use with a disinfectant before placing it in the hallway. The Director of Nursing Services (DON) was interviewed on 12/4/20 at 2:54 P.M. During the interview the DON indicated metal lifts should be cleaned after using them with a resident or before placing them in the hallway after use. The DON also indicated the facility followed CDC, ISDH, and corporate guidance regarding infection control. Preparing for COVID-19 in Nursing Homes (November 2020) was retrieved on 12/10/20 from the Centers for Disease Control (CDC) website. The guidance indicated Environmental Cleaning and Disinfection: Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. 3. During a continuous observation on 12/4/20 from 2:07 P.M. until 2:11 P.M., the following was observed: CNA 2 put on plastic gloves while entering Resident 9's room. CNA 2 left Resident 9's room with the gloves on and walked through the hall to Resident 10's room. CNA 2 started to removed her gloves while entering Resident 10's room and threw the gloves away in Resident 10's trashcan. CNA 2 was not observed to use hand sanitizer or wash her hands after exiting Resident 9's room or before entering Resident 10's room. The Director of Nursing Services (DON) was interviewed on 12/4/20 at 2:54 P.M. During the interview the DON indicated gloves should be removed before exiting a resident's room and hand hygiene should be performed. A policy, dated 11/2020, was provided by the DON on 12/4/20 at 11:05 A.M., titled Standard and Transmission-Based Precautions (Isolation) Policy. The policy indicated, .Gloves .Remove gloves using proper technique. Do not use the same pair of gloves for the care of more than one resident. Do no wash gloves or reuse gloves. 4. During an observation on 12/4/20 at 2:16 P.M., CNA 2 went into Resident 9's room. CNA 2 came out of Resident 9's room carrying a wet washcloth in her bare hands through the hall. CNA 2 placed the wet washcloth into a large trash bin with a lid on it. CNA 2 then wheeled the trash bin through the facility. CNA 2 was not observed to use hand sanitizer or wash her hands during the observation. The Director of Nursing Services (DON) was interviewed on 12/4/20 at 2:54 P.M. During the interview the DON indicated wet wash rags should not be carried through the hall. They should be put in plastic bags before exiting a room with them. She also indicated hand hygiene should have been preformed before exiting a resident's room. 3.1-18(a)

Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse according to facility policy for 1 of 1 residents reviewed (Resident M). Findings include: An Indiana State Department of Health Reportable Unusual Occurrence Report, dated 8/30/20 at 9:40 a.m., indicated Resident M alleged she had been inappropriately touched by CNA 5 (Certified Nurse Assistant) when he had assisted her with changing her brief. CNA 5 was suspended pending investigation and only female caregivers were to be assigned to care for Resident M. Further interventions would be put into place upon completion of the investigation and staff would continue psycho-social monitoring of Resident M. On 10/29/20 at 12:28 P.M., Resident M's record was reviewed. [DIAGNOSES REDACTED]. how someone feels). A quarterly MDS (Minimum Data Set) assessment, dated 9/3/20, indicated the resident had a BIMS (Brief Interview Mental Status) score of 13 which signified she had no cognitive impairment. She had 1 mood indicator of trouble falling asleep with unknown symptom frequency and had no behaviors. She required extensive assistance from 2 staff members for bed mobility and toileting and extensive assistance from 1 staff member for personal hygiene. The resident was always incontinent of bowel and bladder and wore briefs. Care Plans indicated the following: -2/21/20 and reviewed/revised on 10/12/20-Behavior symptoms: Resident was at risk for fluctuating moods as evidenced by sad facial expressions, withdrawal, tearfulness, laughing, yelling out,[MEDICAL CONDITION]/or verbalization of depression; resident had a [DIAGNOSES REDACTED]. Interventions included, but were not limited to, allow resident to express feelings, offer validation, utilize her support system, and provide medications per orders. -10/29/18 and reviewed/revised on 10/17/20-Behavioral symptoms: Resident has a history of false allegations towards staff. The goal was that the resident would be reassured that her needs would be met. Interventions were: (10/29/18) Inform Resident M the care that would be given before giving care to her; (10/29/18) Offer 1:1 conversation, validate feelings; and (10/29/18) Offer resident drink and/or snack. Behavior Symptom Monthly Summary Forms indicated the following: -August 2020: Behavior being monitored was the resident's risk for fluctuating moods as evidenced by sad facial expressions, withdrawal, tearfulness, laughing, yelling, crying,[MEDICAL CONDITION] verbalization of depression. Resident had a [DIAGNOSES REDACTED]. The total behaviors for August was 1 which occurred in the evening. The previous months total: July-0 behaviors. -September 2020: Behavior being monitored was the resident's risk for fluctuating moods as evidenced by sad facial expressions, withdrawal, tearfulness, laughing, yelling, crying,[MEDICAL CONDITION] verbalization of depression. Resident had a [DIAGNOSES REDACTED]. Total behaviors for September was 0 and all interventions were effective at this time. On 10/29/20 at 1:30 P.M., Resident M was observed seated in her room next to her bed, her back to the hallway and her call light on. She appeared disheveled and indicated she had just finished lunch. An unidentified CNA came into the room to answer her light. The resident asked for some chocolate ice cream which the CNA said she would go get. Resident M was questioned about the care provided at the facility. She stated some days good, some days bad and some staff are nice, some are not. The resident was asked twice if she received care by male caregivers however, she answered that she had mail and wanted to get some but didn't. The resident was friendly and open with her answers despite the difficulty communicating due to wearing of masks and face shields. The CNA returned to the room with chocolate ice cream and the resident began to eat. After exiting the room, the CNA was asked if she was caring for the resident today and she indicated she was. When questioned, the CNA indicated the resident preferred female caregivers but didn't know why. She didn't know where that information was kept but indicated it was something passed along in report. If a male caregiver was assigned to the hall, only the female caregivers would provide care to Resident M. On 10/29/20 at 1:40 P.M., the facility investigation into Resident M's allegation of abuse was reviewed. The Executive Director (ED) provided a folder that contained all the information on the investigation which included the ISDH Unusual Occurrence Report, sent on 8/30/20 with follow up reported on 9/4/20. There was a written statement by CNA 2 that had worked with Resident M on 8/30/20. The statement indicated when she arrived to the facility for 1st shift, she received verbal report from CNA 5, who was going off duty. He had indicated that he had not provided any assistance to the residents on the hall where Resident M resided and the CNA assigned to that hall during the night shift, had left the facility at 2:00 a.m. The statement indicated, 2 times that morning, Resident M told CNA 2 that she didn't want CNA 5 taking care of her because he had touched her inappropriately while assisting her to change her brief. CNA 2 immediately reported the allegation. The investigation was initiated and CNA 5 was suspended. The SSD (Social Service Director) conducted 5 interviews with interviewable residents who resided on the hall including Resident M and her roommate. The interviews consisted of 5 questions with yes or no answers regarding resident care: was the resident afraid of any staff, did they feel safe, etc. All 5 interview forms had no answers circled, the name of the resident interviewed, and signature of the SSD. The forms had no dates or times of the interviews. A current facility policy, titled Abuse Prohibition, Reporting, and Investigation was provided on 10/29/20 at 10:30 a.m. by the ED. The policy stated the following: Investigation-Resident abuse-staff member .1. The resident(s) involved in the incident will be protected and/or removed from the situation immediately .3. Any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until an investigation is completed .5. The resident(s) involved in the incident will be assessed for injuries. 6. The physician will be notified .7. The family of the resident(s) and or responsible party will be notified. 8. An incident report will be initiated within 2 hours of the allegation .9. Residents will be questioned (if alert) about the nature of the incident and their statements will be put in writing .11. The investigation will include: Facts and observations by involved employees, by witnessing employees, by witnessing non-employees, from others who might have pertinent information, by the supervisor or individual whom the initial report was made, other employees who work with the alleged staff member .12. Follow up assessments will be completed/documented every shift until the resident is stable and the resident safety is maintained .16. A comprehensive record of the abuse investigation will be kept by the Executive Director and/or Director of Nursing Services Review of Resident M's nurse progress notes, NP (Nurse Practitioner) progress notes, physician progress notes [REDACTED]. There was no documentation of physician/NP or family notification and no social services notes regarding the incident. There was no written or verbal statement obtained from Resident M nor was there a written statement obtained from the alleged perpetrator or others who may have had pertinent information regarding the allegation. On 10/29/20 at 2:28 P.M., the ED and SSD were interviewed. The SSD indicated she had spoken with the resident about the allegation but she had not documented it. She indicated the resident couldn't remember making the allegation therefore she didn't pursue the matter. The SSD indicated she should have documented her interview with the resident and should have monitored her for any psycho-social outcomes related to the allegation. The ED indicated she had not obtained a written statement but did provide a photograph of a text message that she had sent to CNA 5 regarding the incident, after he had finished his shift and had left the facility. CNA 5 denied the allegation. When questioned how the allegation was determined to be unsubstantiated, the ED indicated she had based this on the resident stating she couldn't remember the incident and the text received by the CNA. CNA 5 had worked Saturday night into Sunday morning, 8/30/20 and had then been scheduled off on Monday, 9/1/20. The ED indicated he returned to work on Tuesday 9/2/20 and was not scheduled to work with Resident M, however, review of CNA documentation indicated CNA 5 provided care to Resident M on 9/18/20. This Federal tag relates to Complaint IN 214. 3.1-28(d)

Based on interview and record review, the facility failed to ensure a resident was permitted to exercise thier right to refuse for 1 of 3 residents reviewed (Resident R). Findings include: On 10/23/19 at 11:45 [NAME]M., Resident R's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 7/24/19, indicated the resident had a BIMS (Brief Interview Mental Status) score of 14 which signified he had no cognitive impairment. On 10/23/19 at 12:34 P.M., Resident R's POA (Power of Attorney) was interviewed. During the interview, he indicated the resident had notified him of an altercation between he and another resident that occurred during the night on 10/4/19. Resident R indicated he was frightened to use the bathroom because of the other resident. The POA indicated when he spoke with the Social Services Director (SSD) on 10/4/19 about the altercation and resident fears, she indicated staff were in the process of investigating the incident. The POA requested Resident R be moved back to the room he had been in previously, for his safety, but alleged he was told that was not possible because of the resident's payer source. When questioned, the POA indicated he had not been notified of the room change and neither he nor the resident knew why he'd had been moved. The resident was still receiving skilled therapy services. He indicated the resident had not been given a choice but was told he had to move rooms. An Intra-Facility Transfer Notice of Room Change form, dated 10/2/19 at 10:07 a.m., indicated Resident R was informed that it was necessary to move him from a private room on one hallway to another private room in a different hallway of the facility. The form indicated the transfer would be taking place on 10/1/19. The reason for the transfer was improved roommate compatibility. The form indicated the resident had waived his right to 48 hours notice, right to a relocation planning conference, and the right to receive the notice in writing. The form indicated the resident's legal representative had not received the notice. On 10/23/19 at 1:14 P.M., the SSD was interviewed. During the interview, she indicated the resident had been admitted to the facility for short term rehabilitation however, he had not progressed in his abilities and was still receiving therapy services. She indicated the resident had been moved to a room on a hallway where long term care residents resided. On 10/23/19 at 4:20 P.M., the Director of Nursing Services (DNS) provided a current copy of the facility titled Intra-facility Transfers/Roommate Notification Policy which stated the following: An intra-facility transfer refers to moving rooms within the same certified unit of the facility .Resident will be moved within the facility only when given appropriate notice and when meeting the qualifications listed .Intra-facility transfers will be initiated only when one or more of the following exists: a. The move is necessary for medical reasons b. The move is necessary for the welfare of the resident or other residents c. Resident request .An intra-facility transfer form will be completed prior to the room change. Information included in the form are the following: a. Reason for the transfer b. Effective date of the transfer .Notification of the transfer will be made to the resident and/or representative and recorded on the intra-facility form. The legal representative may be notified by phone prior to the transfer which shall be recorded on the intra-facility transfer form. The resident/representative will receive the notice in writing unless they waive their right to do so This Federal tag relates to Complaint IN 894. 3.1-12(a)(14)

Based on interview and record review, the facility failed to notify a resident's POA (Power of Attorney) of a resident incident for 1 of 3 residents reviewed (Resident R). Findings include: On 10/23/19 at 11:45 [NAME]M., Resident R's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 7/24/19, indicated the resident had a BIMS (Brief Interview Mental Status) score of 14 which signified he had no cognitive impairment. On 10/23/19 at 12:34 P.M., Resident R's POA was interviewed. During the interview, he indicated the resident had notified him, on 10/4/19 at approximately 11:00 a.m., that he had been attacked by another resident. The resident recounted he had been awakened at 2:00 a.m. on 10/4/19, by a confused resident who had tried to get into his bed. Resident R pushed the other resident away and a scuffle occurred. Resident R was struck on the chin and sustained a cut prior to staff intervening and removing the confused resident from his room. The resident indicated he was frightened to use the bathroom after the altercation. The POA indicated after speaking with the resident, he tried contacting the facility but had to leave a voice message for the staff to return his call. He indicated while waiting for a call back from the facility, friends of the resident stopped in to visit him and noted Resident R had dried blood all over his chin, on his clothing and his bedding. The friends contacted the POA to see if he had been notified of the altercation and that the resident had sustained a cut to his chin. After speaking with the resident's friends, the POA, again, tried to contact the facility and was able to speak with the Social Services Director (SSD). The SSD indicated staff were in the process of investigating the incident. A Behavior Communication Event form, dated 10/4/19 at 2:00 a.m., indicated another resident had tried to get into Resident R's bed with him, broke his laptop and table, and tried to remove his clothes. The residents were separated and safety/prevention interventions put into place. The form indicated the Resident Representative was notified by the DNS (Director of Nursing Services) on 10/4/19 at 3:51 a.m. On 10/23/19 at 4:45 P.M., the DNS was interviewed. During the interview, she indicated she had not notified the POA of the incident and injury as documented on the Behavior Communication Event form dated 10/4/19 at 2:00 a.m. Resident Progress Notes, dated 10/4/19-10/9/19, did not indicate the POA had been notified of the incident and injury to the resident's chin. The resident was discharged on [DATE]. On 10/23/19 at 5:22 P.M., the DNS provided a current copy of the facility policy titled Resident Change of Condition Policy which stated the following: It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party .2. Acute Medical Change .c. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. d. All nursing actions/interventions will be documented in the medical record as soon as possible after the resident needs have been met This Federal tag relates to Complaint IN 894. 3.1-5(a)(1)

Based on observation, interview and record review the facility failed to ensure prevention treatments regarding range of motion were in place for 1 of 3 residents reviewed (Resident 41). Findings include: The clinical record for Resident 41 was reviewed on 4/10/19 at 2:47 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment from 2/18/19, indicated Resident 41 had a Brief Interview for Mental Status(BIMS) score of 15 (cognitively intact). During an observation on 4/10/19 at 10:47 A.M., Resident 41 was unable to extend 4 fingers on her right hand past 90 degrees. Resident 41 was interviewed on 4/10/19 at 10:47 A.M. During the interview Resident 41 indicated no one at the facility had addressed the limited range of motion in her right hand . She also indicated she could no longer write, dress or use her right hand like she used to be able to and she would have liked to be doing exercises to prevent further decline. She did indicate her hand had limited range of motion when she was admitted and it had not gotten worse. The Director of Nursing Services (DNS) was interviewed on 4/15/19 at 12:14 P.M. During the interview the DNS indicated Resident 41 had limited range of motion in her right hand, it should have been addressed and it had not been. She indicated preventative measures should have been in place so the resident did not have a further decline in range of motion in her right hand. 3.1-42(a)(2)

Based on record review and interview, the facility failed to ensure a resident was offered dental services annually for 1 of 3 residents who were reviewed for dental services.(Resident 33) The clinical record of Resident 33 was reviewed on 4/11/19 at 2:21 P.M., and indicated [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE], indicated Resident 33 was severely cognitively impaired. An undated form titled Complimentary Dental Assessment indicated the resident's husband had declined dental services and signed the form on (MONTH) (YEAR), the date was illegible. Resident 33's dental Care Plan revised on 2/5/19, indicated the resident had some or all of their own natural teeth and to obtain dental consults on an as needed basis. On 4/09/19 at 2:34 P.M., during an interview, the resident's husband indicated it had been 2 years since the resident had seen a dentist. On 4/12/19 at 11:12 A.M., during an interview, the Social Services Director indicated they were unable to find documentation in Resident 33's chart in regard to dental visits. On 4/12/19 at 1:38 P.M., during an interview, the Director of Nursing Services (DNS) indicated the resident is private pay so Resident 33's husband would have to inform staff he wanted the resident to be seen by a dentist. The DNS indicated the resident's husband had not informed the staff he wanted his wife to be seen by a dentist. The most current policy titled Dental Services/Missing Dentures dated 8/1998 and revised on 9/2017, was received from the DNS on 4/15/19 at 3:30 P.M. The policy titled Dental Services/Missing Dentures indicated .The facility will ask each resident upon admission if they would like to be seen by the dental services company servicing the facility For residents who chose to refuse services, dental service options may be reviewed with the resident as needed with applicable changes in condition. 3.1-24(a)

The facility failed to ensure medication on a medication cart was safely stored. This had the poential to affect 5 of 5 residents residing on the 600 hall. Findings include: During an observation on 4/16/19 at 12:32 P.M., RN 4 was observed to be standing in front of a medication cart on the 600 hall. RN 4 walked away from the medication cart and went into a resident's room. A small plastic cup with a white pill was observed to be unattended on the medication cart. RN 4 then walked out of the resident's room, walked past the medication cart and walked off the 600 hall. The small plastic cup with a white pill was observed to be on the medication cart while the nurse was off the floor. During an observation with Unit Manager 3 on 4/16/19 at 12:35 P.M., the small plastic cup with a white pill was unattended on the 600 hall medication cart. During an interview Unit manager 3 indicated medication should never be left unattended. The Director of Nursing Services (DNS) was interviewed on 4/16/19 at 1:01 P.M. During the interview the DNS indicated medications should not be left unattended. 3.1-25

Based on record review and interview the facility failed to prevent a fall for 1 resident (A) in a sample of 3 resident records reviewed for falls. This resulted in resident (A) having pain, experiencing a decline in his ability to transfer and suffering a fracture. Finding includes: Review of the clinical record for resident (A) on 8/21/14 at 2:00 p.m. indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS (Minimum Data Set Assessment) dated 5/17/14 indicated the resident was alert but had confusion, required extensive assistance of 2 staff for transfers and limited assistance of 1 staff for ambulation. The resident also was not steady , only able to stabilize with staff assistance when moving off of the toilet. Review of a fall incident report, dated 5/31/14 at 9:20 a.m. indicated resident (A) fell off of the toilet in the central hall shower room. Staff indicated they had placed the resident on the toilet and had left the shower room to obtain a brief for the resident and upon returning to the bathroom observed the resident lying on the floor on his right side with his pants on. Review of nursing notes indicated the following: 5/31/14 at 9:20 a.m. "Unwitnessed fall in shower room. Was alerted by aide that resident was laying on the shower room floor. Found resident laying on floor on his back. Resident was laying about 3 to 4 feet away from shower chair that he was sitting in using the toilet. Apparently he had got up on his own and walked a few feet. No injuries noted anywhere on his body. When asking resident if he hurt anywhere he states all over but apparently has a habit of saying this in general. " 5/31/14 at 12:30 p.m.-"Resident's wife in dining room with resident stating resident is complaining of left leg pain. When asking resident where he is hurting he states it is his right leg, not left leg and was found laying on the right side." 5/31/14 at 12:32 p.m.-"Dr. paged regarding right leg pain." 5/31/14 at 12:35 p.m.-" Dr returned page and informed him of residents pain right leg & he gave order to have x-ray done of right hip and leg." On 8/22/14 at 8:45 a.m. review of the x-ray report dated 5/31/14 indicated the following: "HIP UNI 1 V-R - The visualized osseous structures demonstrate faint lucency and cortical irregularity in the subcapital region of the right hip. Primary consideration should be given to a nondisplaced subacute fracture in this region until otherwise ruled out. Follow-up AP and frog leg lateral views recommended. AP VIEW RIGHT HIP - The examination is limited by an uncooperative patient. The visualized osseous structures demonstrate faint and cortical irregularity in the subcapital region of the right hip. Primary consideration should be given to a nondisplaced subacute fracture in this region until otherwise ruled out. No dislocation is seen. Mild joint space narrowing is noted. FEMUR 2V-R. - The visualized osseous structures demonstrate faint lucency and cortical irregularity in the subcapital region of the right hip. Primary consideration should be given to a nondisplaced subacute fracture in this region until otherwise ruled out. IMPRESSION: Views of the right femur were obtained. The examination is limited by an uncooperative patient. The visualized osseous structures demonstrate faint lucency and cortical irregularity in the subcapital region of the right hip. Primary consideration should be given to a nondisplaced subacute fracture in this region until otherwise ruled out. No dislocations is seen. TIB/FIB 2V-RT - Limited right tibia-fibula no acute fracture. If clinically indicated follow-up. IMPRESSION: Views of the right tibia-fibula were obtained. The examination is limited by an uncooperative patient. The visualized osseous structures demonstrate no evidence of an acute fracture or dislocation." Interview with Nurse #1, on 8/22/14 at 10:00 a.m. indicated she was working when the x-ray results came into the facility. She indicated she called the physician on the phone and also faxed the results to his office. Further interview indicated the physician did not give the facility any new orders for the resident. Further review of nursing notes on 8/22/14 at 10:15 a.m. indicated a note dated 6/6/14 at 3:18 p.m. "Staff reported that resident has had a decline in ability to assist with transfers. Stated that when 2 staff stood resident with gait belt, resident became weak and was difficult to transfer. Staff at that time performed transfer with a SARA lift (mechanical standing lift used to assist a resident with standing and transfers) and resident stood with this, holding where appropriate and bearing weight to legs without difficulty. New order noted to begin SARA lift for transfers and referral made to therapy related to decline in transfer status POA (Power of Attorney) updated. On 8/22/14 at 10:30 a.m. review of the clinical record did not indicate any therapy notes or orders. Interview with the Director of Nursing on 8/22/14 at 11:20 a.m. indicated therapy did not receive the order from nursing for an evaluation related to the residents decline in transfer status dated 6/6/14. Review of nursing notes on 8/22/14 at 10:30 a.m. indicated that on 6/21/14 at 6:20 a.m. "...(x-ray company) called and repeat x-ray of right hip ordered. X-ray is scheduled for today, but could possibly be tomorrow if schedule is to full." There was no documentation in the nursing notes which indicated why an x-ray was being ordered for resident (A). There was no documentation resident A had any other falls between 5/31/14 and 6/21/14. Interview with the Director of Nursing on 8/22/14 at 1:50 p.m. indicated the resident's wife had approached the unit manager on 6/21/14 and felt the resident was in pain and wanted an x-ray done.. Nursing notes dated 6/21/14 at 11:22 p.m. indicated "X-ray result received. On-call MD notified. X-ray results read to MD and previous x-ray results reviewed. Due to resident's dementia and behaviors, MD states it would be more beneficial to resident to stay at facility until actual x-ray films can be reviewed by Ortho MD. Order received to notify attending physician for Ortho referral on Monday, non-weight bearing status, no walking, may sit up in chair. Due to late hour, will notify wife of new orders in morning. On 8/22/14 at 1:30 p.m. review of the x-ray results for resident (A) dated 6/21/14 indicated the following: "There is a right subcapital femoral neck fracture with mild displacement. The joint shows no dislocation. The pubic rami are intact. The bony structures appear osteopenic. There is no significant callus since 5/31/14. No significant healing of prior right femoral neck fracture as above. The resident was sent to the hospital on [DATE] per request of the family. Review of a nursing note dated 6/23/14 at 11:16 p.m. indicated staff had called the hospital for an update on the resident. Information given was the resident was admitted to the surgical floor for a hip fracture. This Federal Tag is related to Complaint IN 757 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure 1 resident in a sample of 2 with a feeding tube, Resident #149, received the proper treatment for [REDACTED]. Findings include: The closed record for Resident #149 was reviewed on [DATE], at 3:27 p.m., and indicated the resident was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The resident status indicated the resident was a full code. Further review of the closed record, at 11:09 a.m., on [DATE], indicated the resident was discharged to the hospital on [DATE] where respirations had ceased. Review of a History and Physical, dated [DATE], from the hospital, indicated the resident was admitted to the hospital on [DATE] due to Ventilator-dependent [MEDICAL CONDITION], status [REDACTED]. Review of the resident progress nursing notes indicated the following: [DATE] 8:58 p.m. Resident was alert and oriented times 3 and cooperative, and able to follow simple tasks and answer questions appropriately. Gastrostomy tube ([DEVICE]) dressing was dry and intact and no redness noted. Feeding through [DEVICE] was patent and less than 300 cubic centimeters (cc) of [MEDICAL CONDITION] content was noted. [DATE] at 12:41 a.m. The weekly nursing note indicated the resident usually slept throughout the night without difficulty, and awakened easily with verbal and tactile stimuli. The note indicated oxygen was given at 2 liters per minute via nasal cannula, respirations were even and unlabored, no distress or shortness of breath, abdomen was soft and nontender, and Glucerna was infusing through the [DEVICE]. The nursing note further indicated the resident was complaining of stomach upset and nausea, and a medication was given through the [DEVICE] for this. [DATE] at 2:15 a.m., indicated the resident was taking his oxygen tubing off numerous times during the shift, but no distress or shortness of breath was noted. [DATE] at 6:13 a.m., indicated the resident was noted to have 2 medium emesis of undigested tube feeding, no residual was noted, the abdomen was soft and nontender, bowel sounds present in all quadrants, and the resident stated he was coughing before the emesis. The resident also refused his breathing treatment saying it caused him to cough and get sick from the medication. The note indicated the physician was notified. [DATE] 12:17 p.m., The resident did not complain of any nausea or vomiting this shift and the [DEVICE] was patent and no residual noted when placement was checked. [DATE] 12:20 p.m., The [DEVICE] dressing was changed and the area around the [DEVICE] was red with a slight amount of brown drainage noted. Review of vital sign documentation, dated [DATE] at 1:03 a.m., indicated the resident's temperature was 97 degrees, pulse was 97 beats per minute, respirations were 18 per minute, blood pressure recorded at ,[DATE], and the oxygen saturation level was 92%. There were no further nursing progress notes documented until 8:05 p.m. on [DATE] when the note indicated the physician was called regarding the resident's condition; the resident was noted to be short of breath and [MEDICAL CONDITION] and showed signs of cyanosis. Vital signs were taken and the pulse was 104, respirations 20, blood pressure ,[DATE], and oxygen saturation level between 45 and 85. The next entry indicated the physician was called again at 8:15 p.m. on [DATE], and a nursing note dated [DATE] at 8:25 p.m., indicated the physician called and left orders to send the resident to the hospital emergency room . The note also indicated the resident's family was called. A nursing note, dated [DATE] at 8:57 p.m., indicated the physician was notified again and agreed for the EMS to transport the resident to the emergency room . There was no further documentation in the medical record regarding this incident. QMA # 6 was interviewed at 1:47 p.m., on [DATE]. She indicated she worked on East hall on the evening shift of [DATE], passing medications down both halls. She indicated Resident #149 had a [DEVICE] so the nurse gave the resident his medications. She remembered the resident was transferred using a hoyer lift and remembered she had assisted him on the evening of [DATE] to use the urinal or bedpan. She indicated he was able to communicate his needs. She indicated the resident had an emesis and she reported this to the RN #5. She indicated at approximately 5:00 p.m., on [DATE], LPN #9 who was working on another hall had come over to help RN #5. She indicated she knew the resident was sick, and had reported the episode of emesis to RN#5. She indicated when she received report that day she was told to keep an eye on the resident because he was sick. QMA #6 indicated she went into the resident's room [ROOM NUMBER] or 3 times that evening because the resident had turned his call light on, one time for a bedpan and one time because of the emesis. LPN #8 was interviewed, at 2:06 p.m., on [DATE], and indicated on the morning of [DATE], during shift report, the previous shift reported the resident had vomited on the night shift. LPN #8 indicated she went in the resident's room and checked for residual from the feeding tube and there was none. She indicated the resident had a good day, was up in his chair, had visitors, went to therapy, had no vomiting. and did not complain of anything during her day shift. She indicated when she left the facility at 2:15 p.m., on [DATE], the resident was fine. RN #5 was interviewed, on the telephone, at 2:42 p.m., on [DATE]. She indicated she had worked at the facility approximately one year. She indicated she worked the evening shift on [DATE] and was told in report the resident had vomited on third shift. She indicated that evening after the CNAs transferred the resident to bed from his chair, they called her and told her the resident was "turning blue." She indicated she did not remember what time this occurred, but she called the physician, who did not respond right away. She indicated she called him again and was told to send the resident to the hospital. She indicated she started working at 2:00 p.m., on [DATE], and the resident was fine at that time. She indicated he did refuse his breathing treatment, and indicated he was nauseous, and had an emesis in bed. She indicated she could not remember if she gave the resident anything through the feeding tube that night, but indicated she did not turn the feeding tube off that evening. She indicated the CNA called the nurse from the other hall and that nurse turned off the feeding. She indicated when the CNAs called her into the resident's room, he was cyanotic. She indicated at that time she told the CNAs to elevate his head because when she had gone into the room the resident was in bed and his head was "a little flat." She indicated she assessed the resident and took his vital signs, and then called the physician. She indicated the 2 CNAs were in the room when she left to call the physician. She indicated when the ambulance arrived, the resident was still breathing. CNA #7 was interviewed, on the telephone, at 4:28 p.m. on [DATE]. She indicated she worked the East hall quite often and had taken care of the resident on [DATE] as well as [DATE]. She indicated the resident was heavy set, was a 2 person assist, was younger, had a feeding tube and had to sit up and not lie down due to this. She indicated when she took care of him on [DATE], and the resident was fine. She indicated she and another CNA, who no longer worked at the facility, worked together on the East hall. She indicated at approximately 2:00 p.m., or so, she remembered seeing the resident, when she was checking rooms and indicated the resident didn't look like he was feeling well. She indicated he was sitting in the recliner, and looked "drained and tired." She indicated she and the other CNA did rounds, checking all the residents, toileting, and getting set up for dinner. She indicated Resident #149's call light went off around 6 p.m., and she asked the other CNA to go into the resident's room with her. She indicated the resident had vomited and was kind of "stooped over " in the chair. She indicated he seemed fairly alert, and told the CNAs he didn't feel good, and wanted to go to bed as he was afraid he would fall out of the chair. CNA #7 indicated they cleaned the resident up and put him to bed. She indicated he seemed a little better for 20 minutes or so, and they were in the room with him a large "chunk " of time that night. She indicated after 20 minutes, he vomited again. She indicated he was vomiting after that, sometimes a little bit, sometimes "quite a bit." She indicated around 7:30 -8 p.m., he "kind of went unresponsive." She indicated the first time the resident vomited she told RN #5. She indicated the nurse came in the room, and questioned the resident to see how he was doing. She indicated the resident was trying to tell them he was having trouble breathing. He would frequently take off his oxygen tubing, but indicated he had also done this prior to this night. CNA #7 indicated she didn't see any other nurses other then RN#5 in the resident's room that evening. She indicated RN#5 had hooked up a vital sign monitor in the room and his oxygen was "really low." She indicated she could see the resident's pulse and oxygen level on the monitor. She indicated the nurse had placed the vital sign monitor on him the first time he vomited. She indicated the resident had been unresponsive even before the ambulance arrived. She indicated the resident turned a "bluish purple" color before the ambulance arrived, and he was making a "coughing-gurgling" noise and it seemed he was "aspirating on his own vomit even though we had him sitting up." She indicated she and the other CNA were checking him often and called the nurse in quite a few times. She indicated the ambulance arrived around 9 p.m. and before this time the resident's oxygen level was running between 40 and 80, and most of the time bounced around the mid 50 to low 60's. She indicated the resident at first was trying to talk, but as time went on, was making hand gestures, moving his head around, and was not verbal. She indicated about ,[DATE] hour before the ambulance arrived, they could not get any response out of him, and he would just open his eyes. She indicated she noticed his skin started turning blue around 7:30 -8:00 p.m. The Director of Nursing Services (DNS) and LPN #1, the East hall Unit Manager were interviewed at 10:34 a.m., on [DATE]. The DNS indicated she had only been employed at the facility since August, 2012 and was not employed at the time of the incident, however, LPN #1 was employed at that time. LPN #1 indicated she was not in the facility at the time of the incident, but received a phone call from RN #5 and RN #11, the evening shift supervisor. She indicated she was not available when they first called, but then called them back and was told about the resident's condition. She indicated by the time she returned their call, the resident had already been taken to the hospital. The DNS and LPN #1 were informed regarding the concerns about the documentation and assessment, and indicated they would investigate to see if they could find other documentation. The Director of Nursing Services (DNS) was interviewed, at 2:40 p.m., on [DATE], and indicated she could not find any further documentation in the clinical record. She indicated she spoke with LPN #9 who indicated she had helped RN#5 on [DATE], and had turned off the feeding tube herself. The DNS indicated the corporate nurse had reviewed the entire record on [DATE], and was not able to find any further documentation. LPN #9 was interviewed, at 2:48 p.m., on [DATE], with the DNS present. She indicated she had worked on Central hall on the evening of [DATE], and the CNAs had come from East hall sometime on the evening of [DATE], and asked her to come to East Hall and check Resident #149. She indicated she thought they came to her because she had worked on East Hall for a long time and they knew her. She indicated when she went into the resident's room, he was in bed, and was not doing well. She indicated his color was very pale. She indicated his feeding tube was running and she turned it off as the CNAs had told her the resident had been vomiting. She indicated RN #5 was not in the resident's room when she went in, but after she left the room, she went and told RN #5 that she needed to call the physician and send the resident out to the hospital. She indicated she had never seen the resident before this, but his breathing was not good. She indicated she took his oxygen level and didn't remember what it was, but indicated it was not good. She indicated she did not observe cyanosis, but the resident was just "really pale." She indicated she didn't remember if he had his eyes opened, but he was not responsive. She indicated she listened to his chest and indicated, "I thought he had probably aspirated." The DNS was interviewed at 9:29 a.m., on [DATE], and indicated the only inservice completed related to the incident on Resident #149 was regarding calling 911 if the physician could not be reached. Review of the inservice, dated [DATE], and provided by the DNS, at this time, indicated, "send full code residents 911 for resp (respiratory) failure" and "get code status immediately upon admission to facility. " RN #11 was interviewed, with the DNS present, at 9:45 a.m., on [DATE]. She indicated she had worked the evening of [DATE], and was the unit manager on Central hall. She indicated LPN #9 had told her that RN #5 was sending one of the residents to the hospital. RN #11 indicated she only went to the resident's room for approximately 5 minutes prior to the ambulance arriving, and did not assist with the resident, but only helped with the paper work. Review of an Emergency Medical Services (EMS) prehospital patient care report, dated [DATE], indicated they had responded to a 911 call regarding a resident with difficulty breathing. When they arrived at the resident's room, the resident was lying in a supine position in bed in a dark room. The resident had oxygen at 2 liters per minute via nasal cannula, and "has a feeding tube running. " The report indicated, "there was a lot of vomit in the patient's bed and all over the floor next to the bed and soiled hospital gown and linens on the chair next to the patient. Nursing staff reports that the patient had began to vomit at about 1800 this evening and that they believe that he had aspirated at that time. Nursing staff reports that at that point the (sic) moved the patient to the bed. Patients skin was purple and with respirations at 4 per minute. Patient still vomiting large amounts from nose and mouth." The resident was taken by cot and bagged using oxygen. The resident was suctioned "many times while in the ambulance" and when placed on the monitor showed asystole , no pulse, no respirations, and the pupils were dilated and non reactive. CPR was started without improvement or change. Review of the policy for change in condition, provided by the DNS, at 9:45 a.m., on [DATE], indicated the following: "It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention occurs. " The Procedure for life threatening change indicated the licensed nurse would initiate appropriate first aid measures until emergency response personnel arrived on the scene, the licensed nurse would inform the attending physician, alternate physician, or Medical Director of resident status as soon as possible before, during, or after the change of condition occurred or when the resident crisis had been managed, and document the notification. Also, all nursing actions, physician contacts, and resident assessment information would be documented in the medical record, and the nursing supervisor would be notified immediately of life threatening changes of condition. The "Acute Medical Change" procedure indicated the following: Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior would be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention. All nursing actions/interventions would be documented in the medical record as soon as possible after resident needs have been met. Review of the facility policy for Enteral Therapy, provided by the DNS, at 11:50 a.m., on [DATE], indicated It was the policy of the facility to ensure the physician's plan of care was specific and that licensed nurses implement the physician's plan of care in a consistant manner. The policy indicated a licensed nurse will take, note, and implement physician orders for enteral therapy, and orders should be obtained as follows: [MEDICAL CONDITION] residual check frequency with intervention, and placement verification frequency. 3XXX,[DATE](a)(2)

Based on record review and interview, the facility failed to promptly notify the physician after an acute change in condition, failed to discontinue a continuous tube feeding after the resident had vomited, and failed to document an assessment and emergency medical treatment before being transported to the hospital, where the resident expired, for 1 of 1 resident reviewed for hospitalization (Resident #149). Findings include: The closed record for Resident #149 was reviewed on [DATE], at 3:27 p.m., and indicated the resident was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The resident status indicated the resident was a full code. Further review of the closed record, at 11:09 a.m., on [DATE], indicated the resident was discharged to the hospital on [DATE] where respirations had ceased. Review of a History and Physical, dated [DATE], from the hospital, indicated the resident was admitted to the hospital on [DATE] due to Ventilator-dependent [MEDICAL CONDITION], status [REDACTED]. Review of the resident progress nursing notes indicated the following: [DATE] 8:58 p.m. Resident was alert and oriented times 3 and cooperative, and able to follow simple tasks and answer questions appropriately. Gastrostomy tube ([DEVICE]) dressing was dry and intact and no redness noted. Feeding through [DEVICE] was patent and less than 300 cubic centimeters (cc) of [MEDICAL CONDITION] content was noted. [DATE] at 12:41 a.m. The weekly nursing note indicated the resident usually slept throughout the night without difficulty, and awakened easily with verbal and tactile stimuli. The note indicated oxygen was given at 2 liters per minute via nasal cannula, respirations were even and unlabored, no distress or shortness of breath, abdomen was soft and nontender, and Glucerna was infusing through the [DEVICE]. The nursing note further indicated the resident was complaining of stomach upset and nausea, and a medication was given through the [DEVICE] for this. [DATE] at 2:15 a.m., indicated the resident was taking his oxygen tubing off numerous times during the shift, but no distress or shortness of breath was noted. [DATE] at 6:13 a.m., indicated the resident was noted to have 2 medium emesis of undigested tube feeding, no residual was noted, the abdomen was soft and nontender, bowel sounds present in all quadrants, and the resident stated he was coughing before the emesis. The resident also refused his breathing treatment saying it caused him to cough and get sick from the medication. The note indicated the physician was notified. [DATE] 12:17 p.m., The resident did not complain of any nausea or vomiting this shift and the [DEVICE] was patent and no residual noted when placement was checked. [DATE] 12:20 p.m., The [DEVICE] dressing was changed and the area around the [DEVICE] was red with a slight amount of brown drainage noted. Review of vital sign documentation, dated [DATE] at 1:03 a.m., indicated the resident's temperature was 97 degrees, pulse was 97 beats per minute, respirations were 18 per minute, blood pressure recorded at ,[DATE], and the oxygen saturation level was 92%. There were no further nursing progress notes documented until 8:05 p.m. on [DATE] when the note indicated the physician was called regarding the resident's condition; the resident was noted to be short of breath and [MEDICAL CONDITION] and showed signs of cyanosis. Vital signs were taken and the pulse was 104, respirations 20, blood pressure ,[DATE], and oxygen saturation level between 45 and 85. The next entry indicated the physician was called again at 8:15 p.m. on [DATE], and a nursing note dated [DATE] at 8:25 p.m., indicated the physician called and left orders to send the resident to the hospital emergency room . The note also indicated the resident's family was called. A nursing note, dated [DATE] at 8:57 p.m., indicated the physician was notified again and agreed for the EMS to transport the resident to the emergency room . There was no further documentation in the medical record regarding this incident. QMA # 6 was interviewed at 1:47 p.m., on [DATE]. She indicated she worked on East hall on the evening shift of [DATE], passing medications down both halls. She indicated Resident #149 had a [DEVICE] so the nurse gave the resident his medications. She remembered the resident was transferred using a hoyer lift and remembered she had assisted him on the evening of [DATE] to use the urinal or bedpan. She indicated he was able to communicate his needs. She indicated the resident had an emesis and she reported this to the RN #5. She indicated at approximately 5:00 p.m., on [DATE], LPN #9 who was working on another hall had come over to help RN #5. She indicated she knew the resident was sick, and had reported the episode of emesis to RN#5. She indicated when she received report that day she was told to keep an eye on the resident because he was sick. QMA #6 indicated she went into the resident's room [ROOM NUMBER] or 3 times that evening because the resident had turned his call light on, one time for a bedpan and one time because of the emesis. LPN #8 was interviewed, at 2:06 p.m., on [DATE], and indicated on the morning of [DATE], during shift report, the previous shift reported the resident had vomited on the night shift. LPN #8 indicated she went in the resident's room and checked for residual from the feeding tube and there was none. She indicated the resident had a good day, was up in his chair, had visitors, went to therapy, had no vomiting. and did not complain of anything during her day shift. She indicated when she left the facility at 2:15 p.m., on [DATE], the resident was fine. RN #5 was interviewed, on the telephone, at 2:42 p.m., on [DATE]. She indicated she had worked at the facility approximately one year. She indicated she worked the evening shift on [DATE] and was told in report the resident had vomited on third shift. She indicated that evening after the CNAs transferred the resident to bed from his chair, they called her and told her the resident was "turning blue." She indicated she did not remember what time this occurred, but she called the physician, who did not respond right away. She indicated she called him again and was told to send the resident to the hospital. She indicated she started working at 2:00 p.m., on [DATE], and the resident was fine at that time. She indicated he did refuse his breathing treatment, and indicated he was nauseous, and had an emesis in bed. She indicated she could not remember if she gave the resident anything through the feeding tube that night, but indicated she did not turn the feeding tube off that evening. She indicated the CNA called the nurse from the other hall and that nurse turned off the feeding. She indicated when the CNAs called her into the resident's room, he was cyanotic. She indicated at that time she told the CNAs to elevate his head because when she had gone into the room the resident was in bed and his head was "a little flat." She indicated she assessed the resident and took his vital signs, and then called the physician. She indicated the 2 CNAs were in the room when she left to call the physician. She indicated when the ambulance arrived, the resident was still breathing. CNA #7 was interviewed, on the telephone, at 4:28 p.m. on [DATE]. She indicated she worked the East hall quite often and had taken care of the resident on [DATE] as well as [DATE]. She indicated the resident was heavy set, was a 2 person assist, was younger, had a feeding tube and had to sit up and not lie down due to this. She indicated when she took care of him on [DATE], and the resident was fine. She indicated she and another CNA, who no longer worked at the facility, worked together on the East hall. She indicated at approximately 2:00 p.m., or so, she remembered seeing the resident, when she was checking rooms and indicated the resident didn't look like he was feeling well. She indicated he was sitting in the recliner, and looked "drained and tired." She indicated she and the other CNA did rounds, checking all the residents, toileting, and getting set up for dinner. She indicated Resident #149's call light went off around 6 p.m., and she asked the other CNA to go into the resident's room with her. She indicated the resident had vomited and was kind of "stooped over " in the chair. She indicated he seemed fairly alert, and told the CNAs he didn't feel good, and wanted to go to bed as he was afraid he would fall out of the chair. CNA #7 indicated they cleaned the resident up and put him to bed. She indicated he seemed a little better for 20 minutes or so, and they were in the room with him a large "chunk " of time that night. She indicated after 20 minutes, he vomited again. She indicated he was vomiting after that, sometimes a little bit, sometimes "quite a bit." She indicated around 7:30 -8 p.m., he "kind of went unresponsive." She indicated the first time the resident vomited she told RN #5. She indicated the nurse came in the room, and questioned the resident to see how he was doing. She indicated the resident was trying to tell them he was having trouble breathing. He would frequently take off his oxygen tubing, but indicated he had also done this prior to this night. CNA #7 indicated she didn't see any other nurses other then RN#5 in the resident's room that evening. She indicated RN#5 had hooked up a vital sign monitor in the room and his oxygen was "really low." She indicated she could see the resident's pulse and oxygen level on the monitor. She indicated the nurse had placed the vital sign monitor on him the first time he vomited. She indicated the resident had been unresponsive even before the ambulance arrived. She indicated the resident turned a "bluish purple" color before the ambulance arrived, and he was making a "coughing-gurgling" noise and it seemed he was "aspirating on his own vomit even though we had him sitting up." She indicated she and the other CNA were checking him often and called the nurse in quite a few times. She indicated the ambulance arrived around 9 p.m. and before this time the resident's oxygen level was running between 40 and 80, and most of the time bounced around the mid 50 to low 60's. She indicated the resident at first was trying to talk, but as time went on, was making hand gestures, moving his head around, and was not verbal. She indicated about ,[DATE] hour before the ambulance arrived, they could not get any response out of him, and he would just open his eyes. She indicated she noticed his skin started turning blue around 7:30 -8:00 p.m. The Director of Nursing Services (DNS) and LPN #1, the East hall Unit Manager were interviewed at 10:34 a.m., on [DATE]. The DNS indicated she had only been employed at the facility since August, 2012 and was not employed at the time of the incident, however, LPN #1 was employed at that time. LPN #1 indicated she was not in the facility at the time of the incident, but received a phone call from RN #5 and RN #11, the evening shift supervisor. She indicated she was not available when they first called, but then called them back and was told about the resident's condition. She indicated by the time she returned their call, the resident had already been taken to the hospital. The DNS and LPN #1 were informed regarding the concerns about the documentation and assessment, and indicated they would investigate to see if they could find other documentation. The Director of Nursing Services (DNS) was interviewed, at 2:40 p.m., on [DATE], and indicated she could not find any further documentation in the clinical record. She indicated she spoke with LPN #9 who indicated she had helped RN#5 on [DATE], and had turned off the feeding tube herself. The DNS indicated the corporate nurse had reviewed the entire record on [DATE], and was not able to find any further documentation. LPN #9 was interviewed, at 2:48 p.m., on [DATE], with the DNS present. She indicated she had worked on Central hall on the evening of [DATE], and the CNAs had come from East hall sometime on the evening of [DATE], and asked her to come to East Hall and check Resident #149. She indicated she thought they came to her because she had worked on East Hall for a long time and they knew her. She indicated when she went into the resident's room, he was in bed, and was not doing well. She indicated his color was very pale. She indicated his feeding tube was running and she turned it off as the CNAs had told her the resident had been vomiting. She indicated RN #5 was not in the resident's room when she went in, but after she left the room, she went and told RN #5 that she needed to call the physician and send the resident out to the hospital. She indicated she had never seen the resident before this, but his breathing was not good. She indicated she took his oxygen level and didn't remember what it was, but indicated it was not good. She indicated she did not observe cyanosis, but the resident was just "really pale." She indicated she didn't remember if he had his eyes opened, but he was not responsive. She indicated she listened to his chest and indicated, "I thought he had probably aspirated." The DNS was interviewed at 9:29 a.m., on [DATE], and indicated the only inservice completed related to the incident on Resident #149 was regarding calling 911 if the physician could not be reached. Review of the inservice, dated [DATE], and provided by the DNS, at this time, indicated, "send full code residents 911 for resp (respiratory) failure" and "get code status immediately upon admission to facility. " RN #11 was interviewed, with the DNS present, at 9:45 a.m., on [DATE]. She indicated she had worked the evening of [DATE], and was the unit manager on Central hall. She indicated LPN #9 had told her that RN #5 was sending one of the residents to the hospital. RN #11 indicated she only went to the resident's room for approximately 5 minutes prior to the ambulance arriving, and did not assist with the resident, but only helped with the paper work. Review of an Emergency Medical Services (EMS) prehospital patient care report, dated [DATE], indicated they had responded to a 911 call regarding a resident with difficulty breathing. When they arrived at the resident's room, the resident was lying in a supine position in bed in a dark room. The resident had oxygen at 2 liters per minute via nasal cannula, and "has a feeding tube running. " The report indicated, "there was a lot of vomit in the patient's bed and all over the floor next to the bed and soiled hospital gown and linens on the chair next to the patient. Nursing staff reports that the patient had began to vomit at about 1800 this evening and that they believe that he had aspirated at that time. Nursing staff reports that at that point the (sic) moved the patient to the bed. Patients skin was purple and with respirations at 4 per minute. Patient still vomiting large amounts from nose and mouth." The resident was taken by cot and bagged using oxygen. The resident was suctioned "many times while in the ambulance" and when placed on the monitor showed asystole , no pulse, no respirations, and the pupils were dilated and non reactive. CPR was started without improvement or change. Review of the policy for change in condition, provided by the DNS, at 9:45 a.m., on [DATE], indicated the following: "It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention occurs. " The Procedure for life threatening change indicated the licensed nurse would initiate appropriate first aid measures until emergency response personnel arrived on the scene, the licensed nurse would inform the attending physician, alternate physician, or Medical Director of resident status as soon as possible before, during, or after the change of condition occurred or when the resident crisis had been managed, and document the notification. Also, all nursing actions, physician contacts, and resident assessment information would be documented in the medical record, and the nursing supervisor would be notified immediately of life threatening changes of condition. The "Acute Medical Change" procedure indicated the following: Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior would be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention. All nursing actions/interventions would be documented in the medical record as soon as possible after resident needs have been met. 3XXX,[DATE](a)

Based on observation, record review and interview, the facility failed to evaluate the use of an immobilizer and develop care plans to prevent the development of pressure ulcers for one of four residents (#88) reviewed for pressure ulcers in a sample of 19. Findings include: Review of Resident #88's clinical record on 9/7/11 at 9:30 A.M., indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The record indicated on 8/9/11, the resident had a fracture of her left fibula. A physician's orders [REDACTED]. An interdisciplinary team progress note from 8/22/11 indicated the resident had two areas of skin concerns: "Area #1 measures 5.8 centimeters (cm) x 8.7 cm with depth of 0.1 cm-coccyx and left buttocks." "Area #2 is left lateral head of fibula-Area is serous filled intact blister measuring 3.0 cm x 1.8 cm." During an observation of the wounds on 9/8/11 at 9:45 A.M., the Stage II pressure ulcer on the left lower extremity, below the left outer knee was approximately 3.0 cm x 1.5 cm blister without fluid, skin intact. The second Stage II pressure ulcer on the coccyx was approximately 2.0 cm x 0.3 cm with a depth of less than 0.1 cm. The wound was pink and without drainage. Review of the resident's health care plan, dated 12/10/10, indicated the resident was at risk for skin breakdown due to limited mobility, diabetes mellitus, [MEDICAL CONDITIONS] and incontinence. Approaches to be used included: turn and reposition at least every 2 hours; incontinent care as needed using peri wash and moisture barrier; assess and document skin condition weekly and as needed; encourage resident to eat at least 75% of meals; pressure reducing/redistribution cushion in chair/wheelchair; preventative treatment as ordered. On 8/18/11, a significant change Minimum Data Set (MDS) assessment was completed on the resident due to the fractured fibula on 8/9/11. The MDS of 8/19/11 indicated a decrease in the range of motion for the left lower body. On 8/25/11, following the development of the two pressure ulcers, the facility started a new health care plan for risk for skin breakdown due to decreased mobility from recent fractured distal femur, diabetes mellitus, [MEDICAL CONDITIONS] and incontinence. An interview with the Director of Nursing (DN) on 9/9/11 at 8:50 A.M., indicated she had talked with the wound nurse who indicated the resident was active in attending activities the day after the fracture on 8/9/11 and the resident was able to change positions independently. She indicated the resident already had a wheelchair cushion and didn't add any other interventions after the fall and the use of the immobilizer for the left lower extremity. The DN did not have any other information why the health care plan for risk for pressure ulcers was not updated after the fracture on 8/9/11 until after the development of the pressure ulcers, first noted on 8/22/11. 3.1-40(a)(1)

Based on record review, the facility failed to ensure a resident was transferred safely and in accordance with care plan interventions for 1 of 8 residents reviewed for falls in the sample of 19. This resulted in the resident sustaining an upper leg fracture. (Resident #88) Findings include: Review of Resident #88's clinical record on 9/7/11 at 9:30 A.M, indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a "Fall Circumstance Report" from 8/8/11 at 11:30 A.M., indicated Resident #88 was using the toilet with CNA #8 present and when the CNA went to put the resident back in her wheelchair, the wheelchair rolled back. The CNA lowered the resident to the floor. No injuries were noted during the initial exam after the fall. The nurse's notes of 8/9/11 at 2:30 P.M., indicated the resident was complaining of pain in her left knee. At 4:00 P.M., the physician was notified of left knee swelling and complaints of pain and received instructions to monitor area for increased pain and swelling. At 5:00 P.M., a physician's orders [REDACTED]. At 8:30 P.M., the x-ray results indicated the resident had a fracture of left distal femur. Review of Resident #88's health care plan from 12/10/10 indicated the resident required extensive assist of two for transferring and toileting. Review of the undated initial facility fax incident reporting form included under preventative measures taken, CNA #8 was given a written warning and one on one training with staff development educator on proper transferring. Review of the employee communication form included the employer statement indicating CNA #8 transferred Resident #88 by herself when the resident required a two person assistance. 3.1-45(a)(2)

Based on observation, interviews and record review, the facility failed to provide supervision and implement interventions to prevent a confused resident from falling out of bed. This deficient practice resulted in a fall with an abrasions and a hematoma and affected 1 of 3 residents reviewed, who sustained falls, in a sample of 5. (Resident #F) Findings include: The closed clinical record of Resident #F was reviewed on [DATE] at 9:30 a.m. and indicated the resident was admitted to the facility on [DATE] following treatment at the hospital for a closed head injury. The hospital admission history and physical, dated [DATE], indicated Resident #F was admitted to the hospital after a fall. The report indicated the resident was working on a shelf at home and fell hitting his head in the right temporal region and then fell again hitting the right occipital region of the head sustaining a closed head injury. A consultation report, dated [DATE]. indicated the resident had an abnormal CT (Computed Tomography) Scan, "question intracranial hemorrhage versus mass." A nursing admission assessment, dated [DATE], identified no discolorations or swelling on Resident #F's head. The interim admission nursing care plan, dated [DATE], indicated Resident #F was at risk of falls. The care plan indicated, in part, the following: Observe for fall risk contributors such as medications, hypotension, pain, unsteady gait; Encourage and remind to use call light; Refer to therapy for screening; Provide assistance for transfers, bed mobility; Fall risk assessment; Provide appropriate assistive devices such as walker, low bed, mats on floor, alarms on chairs/bed. The fall risk assessment, dated [DATE], indicated the resident had fall risk factors, including; a history of falls, anti-hypertensive medications, evidence of impaired gait and confusion. The medication administration record for February 2011, indicated the resident was to have a canary alarm on for seven days starting on [DATE]. One half side rails for mobility, physical therapy, speech therapy and occupational therapy were ordered on [DATE]. Nursing notes indicated the following: On [DATE] at 12:00 midnight, Resident #F was trying to climb out of bed causing his alarm to sound. The note indicated the resident's gait was unsteady and he was answering questions inappropriately. On [DATE] at 10:40 p.m., Resident #F was pulling the call light out and standing up setting off the canary alarm. The note indicated the alarm was sounding and when the writer entered the room the resident was sitting on the side of the bed attempting to stand and was very confused. The resident's glasses were noted to be broken into pieces and he was taken to the lounge to be monitored because he kept setting off his alarm and trying to get up. The note indicated "Res (Resident) also has started new medication @ (at) 8p Ativan (a medication used for anxiety) 1 mg tonight..." On [DATE] at 2:15 a.m., Resident #F's "...canary going off again. This has been an ongoing issue all night. Res (resident) found on floor. Res has climbed out of bed again setting off alarm et (and) fell on floor hitting head with small lump noted to crown. Res also has 5 in by 1 in abrasion noted to right upper back area..." The nursing note indicated Resident #F was placed in the wheelchair and taken to the lounge for observation. A neurological assessment log was initiated. The fall circumstances report, dated [DATE], indicated the resident fell on [DATE] at 1:50 a.m. The report indicated Resident #F was found in his room sitting on the floor with the canary alarm sounding. The report further indicated the resident climbed out of bed and hit his head. The report indicated the resident had an abrasion on his back, a scratch on the elbow, and a "small goose egg to crown of head." The resident's CQI (Quality Improvement) incident reporting slip, dated [DATE], indicated the resident's functional level at the time of the fall was "extensive assistance" and "totally dependent." On [DATE] at 11:30 a.m., a low bed and floor mat were ordered. Although Resident #F had a care plan to implement appropriate assistive devices, including but not limited to, low bed and floor mat and was noted to be climbing out of bed unassisted on [DATE] and [DATE], the low bed and floor mat were not ordered or implemented until after the resident fell . On [DATE] at 11:30 a.m., The Director of Nursing was interviewed and indicated the low bed and floor mat were not implemented until after the fall. On [DATE] at 2:40 p.m., LPN #10, who worked on the evening shift on [DATE] and the night shift on [DATE] when the resident fell , was interviewed and indicated Resident #F was in the lounge earlier in the evening so he could be watched but was returned to his bed about an hour before he fell . LPN #10 indicated she was assisting the aide with rounds on the 200 hall of the west wing. The LPN indicated the aide heard an alarm sounding and found Resident #F on the floor. LPN #10 indicated the resident told her he hit his head. The nurse did not measure the bump on the head. She indicated the resident was in a standard bed (in a low position) and did not have a low bed until after the fall. On [DATE] at 3:00 p.m., Resident F's room (102) was observed. The resident's room was on a different hall and was not visible from the 200 hall where the nurse and aide were working when the resident fell . On [DATE] at 3:50 p.m., CNA #11, who was working on the night shift when Resident #F fell was interviewed. CNA #11 indicated she and the nurse were on the floor assisting a resident on the 200 hall and after they finished assisting the resident, they came out of the room and heard the alarm sounding. CNA #11 indicated she ran to the 100 hall because she was not sure how long the alarm had been sounding and found the resident sitting on the floor. On [DATE] at 4:15 p.m., CNA #12 who worked on Resident #F's hall on the evening of [DATE], was interviewed and indicated Resident #F was repeatedly attempting to get out of bed so the nurse brought him to the lounge. She indicated she sat with the resident in the lounge for about one-half hour until she went home at 10:00 p.m. She indicated she told the oncoming night shift staff that the resident was agitated, attempting to get up and needed to be watched. On [DATE], physician progress notes [REDACTED]." On [DATE], comfort measures were ordered. On [DATE] at 6:15 a.m., nursing notes indicated Resident #F expired in the facility. The death certificated listed the cause of death as "cerebrovascular accident." The Fall Management Program, revised ,[DATE], provided by the Director of Nursing was reviewed on [DATE] 4:30 p.m. and indicated "It is the policy of American Senior Communities to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychological guidelines to prevent injury related to falls..." 3XXX,[DATE](a)(2)