Every finding on record at Blair Ridge Health Campus

Based on interviews and record reviews, the facility failed to follow their policy for reporting and investigating an allegation of misappropriation of medication, when one staff member gave another staff member a prescription medication from a residents private medication supply for 1 of 3 residents reviewed for misappropriation, (Resident M).The facility also failed to follow their policy regarding an allegation of abuse for 1 of 3 residents reviewed for abuse, (Resident H), where the allegation was not reported to the State Agency and was not thoroughly investigated.Finding includes:1.During an interview on 3/5/25 at 2:28 P.M., the Director of Nursing indicated she remembered in October of 2025, Licensed Practical Nurse (LPN) 2 instructed an unnamed nursing staff member to give Certified Nursing Assistant (CNA) 3, a Zofran (Ondansetron) for the CNA's stomachache, from Resident M's medication supply. The Director of Nursing indicated on 10/7/25 at 2:47 P.M., she sent a message to nursing staff through the facility communication application, Ready App, that Medication in the carts were for patient use only and that staff should not use medication for personal use. The Director of Nursing indicated she did not have a written statement of the event from CNA 7 or LPN2. The Director indicated the misappropriated Ondansetron was replaced by the pharmacy on 10/27/25. The Director of Nursing indicated she was not aware that the incident of misappropriation was a reportable incident so did not report the allegation of misappropriation to the State Agency.A printed copy of a text message between the Director of Nursing and LPN 2 dated 2/6/26 at 10:00 A.M., was provided by the Director of Nursing on 3/6/26 at 10:00 A.M. The message that indicated on an unknown date with an unknown initial message to which LPN 2 replied to the Director of Nursing on 10/7/25 at 2:48 P.M. and indicated, Does this include the.Zofran I gave somebody[?] LPN 2's text message was followed by a grimacing smiley face emoji and a laughing with tears smiley emoji. The Director of Nursing's' response text dated 10/8/25 at 7:56 A.M., indicated, We need additional statements. Can u come in[?] A form titled Teachable Moment, dated 10/8/25, was provided by the Director of Nursing on 3/6/26 at 10:00 A.M. and indicated LPN 2's teachable moment included the 5 rights of medication, medications in medication carts were for patient use only, and misappropriation of medications. The teachable moment was signed by the Director of Nursing and the Administrator.A document from the facility's Ready App text broadcast from the Director of Nursing to the nursing staff dated 10/7/25 at 2:47 P.M., was provided by the Director of Nursing on 2/6/26 at 10:00 A.M. The Ready App text broadcast indicated, Medication in the cart are for patient use only. Staff should not use medications for personal use. The application indicated 31 of 37 users read the message.On 3/10/26 at 11:05 A.M., Resident M's clinical record was reviewed. The resident was admitted to the facility from 10/1/25 to 10/29/26 with diagnoses that included but were not limited to hypertension and chronic obstructive pulmonary disease. Physician's Orders included but were not limited to Ondansetron 4 mg every 6 hours as needed for nausea and vomiting, dated 10/1/25 through10/8/2025.2.On 3/11/26 at 10:51 A.M., Resident H's clinical record was reviewed, diagnoses included but were not limited to dementia, weakness, and anxiety. Review of the most recent comprehensive Minimum Data Set (MDS) was a Quarterly assessment dated [DATE]. The MDS assessment indicated Resident H had mild cognitive impairment, demonstrated no negative behaviors, required substantial to maximal assistance for standing, transfers, and toileting.Resident H's Care Plans included but were not limited to, Profile Care Guide dated 7/23/24 with interventions that included approaches not limited to the extensive assistance of one person for transfers, the use of a walker, dated 4/9/25, and to encourage the resident to assume standing position slowly, dated 7/23/24.A Statement Witness Form dated 2/26/26, undocumented time, from the Employee Experience Manager, indicated the employee had been interviewed by the Director of Nursing. The statement indicated on 2/20/26 she was walking to her car in the parking lot when she received a text message from the Administrator who indicated she was needed to be the second person on a call to CNA 4. The document indicated the Administrator called CNA 4 and asked if there was anything the CNA could tell her about her shift on 2/20/26 ant that the Administrator let CNA 4 know there was an allegation and the CNA would be suspended pending an investigation. The document indicated CNA 4 indicated she would never hurt a resident.A Statement Witness Form dated 2/26/26, undocumented time, from LPN 9 indicated the employee had been interviewed by the Director of Nursing. LPN 9 indicated she worked 2/20/26 at 6:00 P.M. and received report from QMA 5 who reported that CNA 4 had yelled at Resident H. She indicated Resident H seemed to be upset in the afternoon and that QMA 5 had notified the appropriate people. CNA 10 reported she didn't know anything other than a CNA student said CNA 4 was being rude to her and to a resident. Re getting int the wheelchair. QMA 5 indicated she asked CNA 4 if the resident was walking that day and the CNA said he was not and he was hurting her back. QMA 5 indicated the resident was visibly upset, and when she asked the resident if he was okay, he replied no. QMA 5 indicated she reported the allegation to LPN 6. QMA 5 indicated the Administrator came to her and talked to her about the incident.A statement from QMA 5 taken by the Director of Nursing on 2/26/26 at 4: 39 P.M., indicated QMA 5 heard CNA 4 talking loudly in Resident H's room and believed she was speaking passive aggressively saying you need to stand up, you need to get up, stop doing that. If your're not going to stand then we'During an interview on 3/6/26 at 1:10 P.M., the Administrator indicated Certified Nursing Assistant (CNA) 4 never abused Resident H at any time. The Administrator indicated CNA 4 had been working with a trainee when on 2/20/26 at about 4:30 P.M., Qualified Nursing Aide (QMA) 5 reported that CNA 4 may have been verbally abusive to Resident H earlier that day. The Administrator indicated in response to the report, CNA 4 was immediately suspended pending an investigation, which the facility completed with no findings. The Administrator indicated the State was not notified of the allegation because abuse was not identified so there was nothing to report.On 3/9/26 at 2:38 P.M., during an interview with LPN 6, she indicated QMA 5 reported to her that CNA 4 was being mean to a resident but did not tell her who the resident was. LPN 6 indicated at about 4:30 P.M. on 2/20/25, she called the Administrator, who was in the building, and reported the allegation of abuse and indicated that QMA 5 reported CNA 4 had been mean to a resident. LPN 6 indicated the Administrator indicated she would take care of the concern and CNA 4 was suspended due to the allegation of abuse toward Resident H.On 3/9/26 at 2:52 P.M., during an interview with QMA 5, she indicated she notified the Administrator that CNA 4 had been verbally abusive to Resident H and to other staff. QMA 5 indicated she reported the allegation verbally as well as through a written statement that she was outside Resident H's door when she heard CNA 4 telling Resident H to, stop doing that! You need to stand up right now! If you don't stand up I'll put you in your wheelchair. QMA 5 indicated Resident H came out of his room and she asked the resident if he was okay. QMA 5 indicated the resident said he was not and was visibly upset. On 3/9/26 at 10:00 A.M., the Administrator provided the policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, dated 1/19 and most recently reviewed on 11/19/25, and indicated it was the current facility policy. The policy indicated, .The Executive Director and the Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures.ABUSE is the willful infliction of.intimidation.with resulting .mental anguish.it includes verbal abuse.MISAPPROPRIATION OF PROPERTY-means the deliberate.use of a resident's belongings.without the resident's consent.staff is required to report concerns.to.Executive Director and Director of Health Services.The Executive Director is responsible for: 1. Notification to the State Department of Health.and/or local law enforcement agencies, as indicated.Protection.Suspend suspected employee(s) pending outcome of investigation.Investigation i. The Executive Director is accountable for investigating and reporting.Identifying and interviewing all involved persons. Providing complete & thorough documentation of the investigation.Indiana- Incidents must be reported within 24 hours online.An incident.shall be reported by a provider.who.becomes aware of or receives information about an alleged incident.This citation relates to Intakes 2655113 and 2791217410 IAC (Indiana Administrative Code) 3.1-28(a)(c)(d)(e)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for a resident with dementia who had known exit seeking behaviors and was identified as an elopement risk, for 1 of 3 residents reviewed, who were at risk for elopement, (Resident G). This deficient practice resulted in the resident exiting onto facility grounds for 5 minutes before staff found the resident and brought him back inside the facility.Finding includes:During a review of a facility reported incident report, Incident Number 367, dated 2/22/26 at 5:20 P.M., reviewed on 3/5/2026 at 11:00 A.M., the report indicated Resident G had not been accounted for for approximately two minutes, based on employee interviews. The report indicated Resident G had remained on the facility campus throughout the incident.On 3/6/26 at 11:35 A.M., the Administrator provided a series of photographs, dated 2/22/26 beginning at 5:30 P.M. through 5:25 P.M. At 5:30 P.M., Resident G was pictured exiting the facility from the main entry door. He then turned left and followed the asphalt drive around the side of the building. Resident G was pictured outside the facility courtyard at 5:22 P.M. At 5:25 P.M. he was pictured being escorted back into the building through the doors near the courtyard area. Staff were pictured looking at the resident and calling out to him as other staff were noted going outside to collect the resident.Resident G's clinical record was reviewed on 3/6/26 at 1:43 P.M. Diagnoses included but were not limited to dementia with mood disturbances, depression with severe psychotic symptoms, and anxiety.The most recent comprehensive Minimum Data Set (MDS) assessment, dated 1/3/26, for a discharge with return anticipated return to the facility indicated Resident G demonstrated behaviors toward others, rejected care, and had exhibited wandering behaviors one to three of the previous 7 days. Resident G's Care Plans included but were not limited to; Resident demonstrates exit-seeking behaviors, dated 01/28/2026, and indicated the goal was Resident G would not elope from the facility and would be re-directed away from doors and exits as needed.An Observation Detail List Report form, dated 1/21/26 at 1:55 P.M., indicated Resident G was oriented to person but not to time or place and had a history of exit seeking.A physician's progress note, dated 2/18/26 at 11:21 A.M., indicated, Recent event: On 1/3/26 patient was having exit seeking behaviors and threatening self-harm. He had been refusing to sleep, medications.Resident G's Nursing Progress Note, dated 2/22/26 at 5:22 P.M., indicated Resident G had finished supper and had returned to his room where he put on his winter coat. Another resident and his family were visiting in the foyer at the front of the building where they noticed the resident leaving the building out the front door. Within two minutes, the Memory care staff had noticed the resident outside, opened an outside door and the resident had came back into the building willingly. Resident G had stated that was outside because he was going to talk to someone. The resident's hands were warm, as well as ears and face and he had not been injured and the assessment was negative for any injuries.During an interview on 3/6/26 at 11:35 A.M., the Administrator indicated the resident had walked out of the front doors and there had been approximately two minutes when the resident had not been visualized and was unsupervised. Although the resident had been wearing a magnetic alarm mechanism on his body, the mechanism failed to alarm when the resident opened the facility's front door and exited the building.On 3/9/26 at 11:30 A.M., the Corporate Compliance Nurse provided the policy, Guidelines: Elopement Risk Assessment and Prevention, dated 11/18/25, indicating it was the current facility policy. The policy indicated, The purpose of this policy is to:.implement prevention strategies for those identified as an elopement risk.a plan of care will be.implemented for each resident identified as having the potential to leave the facility unauthorized, requiring supervision for.wandering to an unsafe area.This citation relates to Intake 2790175410 IAC (Indiana Administrative Code) 3.1-27(a)(3)

Based on observation, interview and record review, the facility failed to store and prepare food in a sanitary manor related to food not sealed or dated and expired food items and food service equipement and dishes not clean in 1 of 1 kitchen observed. This deficient practice had the potential to affect 47 of 49 residents who consumed food from the kitchen.Findings include: 1. During the initial tour of the kitchen, on 7/22/2025 at 9:41 A.M., with the Dietary Manager, the following was observed in the walk-in cooler:- a brown paper bag with squash and other vegetables with a use by date of 7/20/2025.- 2 bags of vegetables cut in chunks with no date received or use by date. During an interview, on 7/22/2025 at 9:47 A.M., the Dietary Manager indicated the out dated vegetables should have been removed and the chunk cut vegetables should have been dated. 2. During a follow-up visit to the kitchen on 7/25/2025 at 9:30 A.M., the following was observed:- the plate warmer used to store clean dinner plates had yellow/rust colored grease along the bottom of the warmer- a small refrigerator used for drinks had a large build up of ice along the back wall extending down to the bottom surface of the refrigerator.- the sandwich cooler had dried specs of food substances along the bottom surface and along the rubber seals.- the char broiler had a large build up of black grease and dried food debris- two medium and two small steam table pans and two food serving scoops put away as clean and dry were visibly wet During an interview, on 7/25/2025 at 9:45 A M., the Dietary Manager indicated the plate warmer was not clean, the refrigerator should have been defrosted, the cooler was not clean, the char broiler should have been cleaned and the cooking utensils were not clean and should not have been put away wet. On 7/28/2025 at 2:15 P.M., the Administrator provided the policy titled, Food Labeling and Dating, dated 3/18/2019, an indicated the policy was the one currently use by the facility. The policy indicated . Any food product removed from its original container, had a broken seal, has been processed in any way must have a label that contains the following: 1. Item Name. 2. Date and Time the food was labeled. 3. Use by date. 4. Initials of the person labeling the item. 5. Securely cover the food item On 7/28/2025 at 2:15 P.M., the Administrator provided the policy titled, Storage Procedures, dated 5/31/2016, and indicated the policy was the one currently used by the facility. The policy indicated . 6. Open packagers are labeled, dated, and stored in closed containers . 3. Refrigeration equipment is routinely cleaned and defrosted and free from garbage and other waste . On 7/28/2025 at 2:15 P.M., the Administrator provided the policy titled, Retail Food Establishment Sanitation Requirements, and indicated the policy was the one currently used by the facility. The policy indicated .Food debris on equipment and utensils shall be: (1) scrapped over a waste disposal unit or garbage receptacle; or (2) removed in a ware washing machine with a prewash cycle. (b) If necessary for effective cleaning, utensils and equipment shall be pre-flushed, or presoaked, or scrubbed with abrasives . Equipment and utensils; air drying required. (a) After cleaning and sanitizing, equipment and utensils (1) shall be air-dried or used after adequate draining as specified . before contact with food 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure pre and post dialysis treatment assessments were completed for 1 of 1 residents reviewed for dialysis management (Resident 5). Finding includes:A record review was completed for Resident 5 on 7/24/2025 at 1:55 P.M. Diagnoses included, but were not limited to: hypertensive heart and chronic kidney disease, stage 5 chronic kidney disease and end stage renal disease. A Physician's Order, dated 6/17/2025 indicated Resident 5 was to receive dialysis treatments every Tuesday, Thursday and Saturday and staff were to complete the Dialysis Center Communication Observation form and send the form with the resident. A current Care Plan, dated 6/19/2025 indicated Resident 5 had renal failure resulting in the need for dialysis. Interventions included, but were not limited to: coordinate care with dialysis center and resident was to receive dialysis on Tuesday, Thursday and Saturday at 5:20 A.M. A review of Resident 5's Dialysis Center Communication Observations indicated the pre and post dialysis assessment were not completed as they lacked vital signs and weights on the following dates:6/21/20256/24/20257/10/20257/12/20257/15/20257/17/2025During an interview, on 7/28/2025 at 10:33 A.M., the DON indicated the Dialysis Communication Center Observations forms should have been completed prior to the resident leaving for dialysis and upon their return. She indicated the forms should have included the residents vital signs and weights.On 7/28/2025 at 11:26 A.M., the DON provided the facility policy titled, Guidelines for Dialysis, undated and indicated it was the policy currently used by the facility. The policy indicated, .Purpose: To provide communication to Dialysis Providers and monitoring of residents receiving dialysis. 4. A report (may be written or verbal) shall be requested from the Dialysis Provider that will alert the campus regarding: b. vital signs 3.1-37(a)

Based on observation, record review and staff interviews, the facility failed to ensure 1 of 2 nurses observed during medication administration was competent to provide safe medication administration. (LPN 3)Findings include: During an observation, on 7/22/2025 at 11:18 A.M., Resident 13 was observed laying on her bed fully dressed with her eyes closed. There was a partially eaten breakfast tray on her over bed table. Between her water container and a coffee cup, there was a clear plastic medicine cup containing five pills, a dark green oblong capsule, a pale green and yellow oblong capsule, and 3 white round tablets. The resident awakened indicated that she did not know what medications were in the cup or why the cup was sitting on her table. During an interview, on 7/22/2025 at 11:28 A.M., Licensed Practical Nurse (LPN) 3 was notified of the cup of medications discovered on Resident 13's breakfast tray. She indicated there should have been 6 pills in the medicine cup and that it appeared the iron tablet was missing. LPN 3 then removed the remaining 5 pills from the resident's room. LPN 3 indicated that she had prepared Resident 13's medications during the 8:00 A.M. medication pass and had left them on the resident's bedside table for the resident to take when she was ready. LPN 3 indicated she should have witnessed Resident 13 consume the medications and the medications should not have been left on the bedside table. LPN 13 indicated she had signed the medications as received on the Medication Administration Record. The record for Resident 13 was reviewed on 7/29/2025 at 12:00 P.M. The record indiated Resident 13 did not have a physician's order to self-administer her own medication. In addition, Resident 13 was moderately cognitively impaired and had a diagnosis of dementia.During an interview, on 7/29/2025 at 11:47 A.M., the interim DON indicated a few residents were able to self-administer medications but they must have a doctor's order and have completed the self-administration evaluation to ensure the resident's safety and understanding (of medications). The interim DON indicated the medications that were found in Resident 13's room should have been destroyed and hte MAR corrected to reflect the occurrence. Review of Resident 13's MAR indicated the documentation for the 7/22/2025 AM medications, dispensed between 6:00 A.M. and 10:00 A.M., had not been corrected A policy was provided, on 7/29/2025 at 11:42 A.M., by the interim DON. The policy titled, IIA2; Medication administration general guidelines. indicated , .when medications are administered by mobile cart and taken to the resident's location, medications are to be administered at the time they are prepared , 2.the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. If a dose of regularly scheduled medication is given at a time other than a scheduled time, it is documented on MAR or in the EHR. An explanatory note is also entered.

Based on observation, record review and interview, the facility failed to ensure appropriate interventions were implemented to address hyponatremia for 1 of 1 residents reviewed for a change in condition. (Resident 3)Finding includes:During an observation, on 7/22/2025 at 10:22 A.M., Resident 3 had four rows lined up of cartons of Jevity 237 milliliters (supplemental nutrition) and 3 plastic cups containing various amounts of water on the over-the-bed table at the end of his bed. During an observation, on 7/23/2025 at 8:57 A.M., Resident 3 was sitting in his room next to the window and his bed. He had four rows lined up of cartons of Jevity 237 milliliters and 3 plastic cups containing various amounts of water on the over-the-bed table at the end of his bed. A record review for Resident 3 was completed on 7/25/2025 at 1:06 P.M. Diagnoses included, but were not limited to: hemiplegia, protein-calorie nutrition, hyponatremia and dementia. An Annual Minimum Data Set (MDS) assessment, dated 6/27/2025, indicated Resident 3 had severe cognitive impairment and received tube feedings and fluids with 501 milliliters or greater of fluids provided via a gastronomy tube. A Nurse Practitioner Note, dated 6/25/2025 at 10:59 P.M. and recorded late on 6/29/2025 at 11:04 P.M., indicated Resident 3 had been seen related to laboratory results from 6/24/2025 that showed hyponatremia (low sodium level) with a sodium value of 131 mmol/L (millimoles per liter). The normal range per the laboratory test results was 136-145 mmol/L. The note indicated Resident 3 had been spending most of his time outdoors in the hot weather and received feedings and fluids via a PEG tube (percutaneous endoscopic gastronomy tube). Resident 3 had remained asymptomatic despite the hyponatremia. Resident 3 had a BUN (blood urea nitrogen) level of 22 mg/dL (milligrams per deciliter) and a creatinine level of 0.8 mg/dL. (The values of the BUN and creatinine were within normal range and could have indicated dehydration if elevated). The plan for the hyponatremia included to add an additional 90 milliliters of water at each bolus feeding (5 times a day) for 30 days due to Resident 3 spending an increased amount of time outdoors. However, the assessment and lab results did not support a dehydration diagnosis.A General Physician's Order was processed, on 6/25/2025 at 1:59 P.M., for an additional 90 milliliters of water at each bolus feeding, five times per day related to hyponatremia. A Nutritional Assessment, dated 7/16/2025, indicated Resident 3 required 2,345 milliliters of fluid daily. A Nutritional Progress Note, on 7/16/2025 at 12:56 P.M., indicated the Registered Dietician estimated Resident 3's fluid intake as the following:-Jevity 1.5 bolus five times daily equaling 900 milliliters of free fluid in the formula.-Water flush orders before and after bolus feeding of 60 milliliters equaling 600 milliliters.-Water flush orders of 90 milliliters, twice daily, equaling 180 milliliters.-Water flushes with medications of 180 milliliters equaling 960 milliliters.-An extra 90 milliliters at each bolus feeding for 30 days related to spending time outdoors equaling an additional 450 milliliters.-The total fluid via the g-tube (gastronomy tube) was 2,595 milliliters per day for 30 daysA Nursing Progress Note, on 7/23/2025 at 9:30 A.M., indicated the hyponatremia had been treated with additional G-tube fluids. A Care Plan, initiated on 4/6/2018 and updated on 7/11/2025, indicated Resident 3 was at risk for dehydration/fluid imbalance related to g-tube, dysphagia and NPO (nothing by mouth) status. The goal was for Resident 3 to remain adequately hydrated and not display signs or symptoms of dehydration. The interventions included, but were not limited to: observe for clinical signs and symptoms of dehydration including dry mouth, thirst, restlessness, irritability, tenting skin turgor, dry mucous membranes, sunken eyes, dry/warm skin decreased urinary output and etc. (et cetera).A professional reference from the Mayo Clinic, at https://www.mayoclinic.org syc-20373711, indicated, .In hyponatremia, one or more factors cause the sodium in the body to be diluted. These factors can range from an underlying medical condition to drinking too much water. When this happens, the body's water levels rise, and cells begin to swell. This swelling can cause many health problems, from mild to life-threatening. Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous electrolyte solutions and medications During an interview, on 7/29/2025 at 9:38 A.M., Resident 3's Nurse Practitioner indicated the treatment for hyponatremia would depend on the resident's situation including dehydration, chronic kidney disease and hypovolemia or hypervolemia and the medications the resident had received. She indicated she used intravenous fluids, stopped medication that could have caused the hyponatremia and assessed for symptoms of congestive heart failure. She indicated Resident 3 was in the garden all the time during hot weather and at the time of his assessment, looked diaphoretic, so she had increased the fluids a little bit. She indicated the professional reference of decreasing the fluids was correct and the treatment was not to give more fluids as extra fluids would further deplete sodium levels. She indicated a follow-up laboratory test for sodium should have been completed to follow up on the hyponatremia after the ordered treatment of extra fluids.A policy was requested for abnormal labs and electrolyte imbalances. On 7/29/2025 at 11:28 A.M., the Director of Nursing indicated the requested policies were not available. 3.1-37(a)

Based on observation, record review and staff interviews, the facility failed to ensure medications were administered according to physician's orders and professional standards for 5 of 32 opportunities resulting in a medication administration error rate of 15.63% (Resident 13)Findings include: During an observation, on 7/22/2025 at 11:18 A.M., Resident 13 was observed laying on her bed fully dressed with her eyes closed. On her bedside table, on her breakfast tray between her water container and her coffee cup was a clear plastic medicine cup containing five pills, a dark green oblong capsule, a pale green and yellow oblong capsule, and 3 white round tablets. During an interview, on 7/22/2025 at 11:28 A.M., Licensed Practical Nurse (LPN) 3 indicated there should have been six pills in the medication cup. She indicated she had prepared the medications for Resident 13 earlier in the morning, around 8:00 A.M. and had left them on the bedside table for the resident to take when she was ready. LPN 3 indicated she should have witnessed the resident take the medications and should not have left medications on the bedside table. During a record review, on 7/22/2025 at 2:00 P.M., Resident 13's Medication Administration Record (MAR) indicated that LPN 3 had documented that the following medications had been administered between 6:00 AM and 10:00 AM: Aggrenox ER (platelet inhibitor used to prevent strokes) 25 -200 mg 1 capsule, carvedilol (used to treat high blood pressure) 25 mg 1 tablet, FeroSul (iron supplement) 325 mg 1 tablet, Fluoxetine (anitdepressant) 20 mg and 10 mg tablets (2 tablets total), furosemide (diuretic) 40 mg 1 tablet, Namenda XR (used to treat dementia) 28 mg 1 tablet, and Vitamin D3 50 mcg 1 tablet for a total of eight individual pills. During an interview and observation, on 7/29/2025 at 10:07 A.M., LPN 4 provided Resident 13's medication pouches prepared by the pharmacy for review. The A.M. medication pouches were divided between 2 pouches with 5 pills in one pouch and 2 pills in the second pouch. The pouches included the following medications:Carvedilol 25 mg (large round tablet) for hypertensionFerrous Sulfate 325 (large round dark green tablet) for anemiaFluoxetine 20 mg capsule (green/yellow capsule) for depressionFluoxetine 10 mg capsule (all green capsule) for depressionVitamin D3 2000 mg (round white tablet) for low Vitamin D levelsNamenda XR 28 mg (dark green pill) for dementiaFurosemide 40 mg (round white tablet) for blood pressureIn addition, there was a separate pill bottle containing Aggrenox ER (large maroon and yellow capsule) for blood thinning).During an interview, on 7/29/2025 at 11:47 A.M., the interim DON indicated the medications that had been found in Resident 13's room should have been destroyed and the MAR corrected to reflect the errors of omissions However, review of Resident 13's MAR for the 7/22/2025 AM medications dispensed between 6:00 A.M. and 10:00 A.M. indicated they had all been administered, even though they had not been administered. In addition, there was no documentation the physician had been made aware of the medication omission errors.A policy was provided, on 7/29/2025 at 11:42 A.M., by the interim DON. The policy titled, IIA2; Medication administration general guidelines. indicated , .when medications are administered by mobile cart and taken to the resident's location, medications are to be administered at the time they are prepared , 2.the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. If a dose of regularly scheduled medication is given at a time other than a scheduled time, it is documented on MAR or in the EHR. An explanatory note is also entered.3.1-48(c)(1)

Based on record review and interview, the facility failed to provide a transfer/discharge form for 1 of 2 residents reviewed for hospitalizations. (Resident C)Finding includes:A record review for Resident C was completed on 7/25/2025 at 8:55 A.M. Diagnoses included, but were not limited to: dementia, mood disorder, anxiety disorder, psychotic disorder with hallucinations and sleep disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 6/20/2025, indicated Resident C had severe cognitive impairment, had delusions and verbal behaviors for one to three days of the 14-day look back period. A Nursing Progress Note, on 7/18/2025 at 10:37 A.M., indicated Resident C was admitted to a psychiatric hospital due to increased behaviors of hallucinations and delusions. A Transfer/Discharge Form could not be located in the medical record. During an interview, on 7/29/2025 at 1:01 P.M., the Executive Director indicated a transfer/discharge form had not been located. She indicated a transfer/discharge form should have been provided to the resident or the resident's representative when the resident was transferred to the mental health hospital. A current policy was provided on 7/29/2025 at 1:16 P.M., by the Executive Director. The policy titled, Guidelines for Transfer and Discharge, indicated, .According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .Procedures should include: a. Notify the resident in writing, and if known, a family member or legal representative, 30 days in advance, of the transfer or discharge, the effective date of transfer or discharge, the location to which the resident is transferred or discharged , and the reason for the transfer or discharge, according to the criteria for transfer or discharge. Exceptions to the a 30-day requirement are if/when a resident is endangering the health or safety of themselves or others, when a resident's health has improved to all an immediate transfer, or discharge, when a resident's urgent medical needs require immediate transfer, and when a has not resided in the facility for 30 days. b. Record the reasons for, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged in the medical record and on a discharge form or a letter. Give a copy of the discharge notice to the resident and his/her family legal representative 3.1-12(a)(8)

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served under safe and sanitary conditions related to appropriate cold food temperatures, disposal of outdated foods, labeling and dating of food items in the refrigerator and freezer, storage of dishware and appliance cleanliness for 1 of 1 kitchens. This had the potential to affect 51of 52 residents who consumed food from the kitchen. Findings include: During an initial observation of the kitchen with Culinary Assistant 5, on 7/11/2024 from 9:40 A.M. through 10:00 A.M., the following was observed: a. Individualized yogurt cups were sitting on the counter beside the refrigerator without being iced. At 10:00 A.M., the yogurt cups were no longer on the counter. Culinary Assistant 5 indicated she had placed them back in the refrigerator. The temperature of the yogurt cups was requested, and the yogurt cup tested was 60.8 Fahrenheit. While Culinary Assistant 5 was checking the temperature of the yogurt cups, she asked, What's it supposed to temp? b. The reach in freezer had an opened, undated box of Taquitos (original box) and French fries in a plastic bag with no date or label. c. The reach in refrigerator had chocolate pudding with a use by date of 7/9/2024, green beans with a use by date of 7/10/2024, mashed potatoes with a use by date of 7/10/2024, a small bag of lettuce with a use by date of 7/10/2024, and a large bag of wilted looking lettuce with no label or use by date. d. The kitchen stovetop was observed to have grease and food debris down the side, the reach in refrigerator had food debris down the side and front, the stove/oven had spillage on the side and food debris on the front, and the convection oven had food spillage and grease stains down the front. e. The storage area for dishware was observed to have large salad bowls, side plates, side bowls, and ramekins stored upright and not inverted. 2. During an observation of the kitchen, on 7/12/2024 at 1:31 P.M., the side bowls and ramekins were observed upright and not inverted. 3. During an observation on 7/16/2024 at 10:55 A.M. with the Culinary Director, the same debris and soilage was observed on the reach in refrigerator, stove/oven, and convection oven. During an observation on 7/17/2024 at 10:59 A.M. with the Culinary Director, multiple side dishes and clear bowls, large salad bowls, and a cupcake pan were not stored inverted. The same appliance debris/soilage was observed. During an interview on 7/17/2024 at 11:32 A.M., the Culinary Director indicated dishware should be stored upside down on open shelves, all food opened should be labeled and dated, food should be disposed of by the use by date by the end of the day, and cold foods should be stored on ice or refrigerated when serving. She indicated the appliances had a once-a-week rotation for cleaning. A current policy was provided on 7/17/2024 at 1:30 P.M. by the Director of Nursing. The policy titled, Storage Procedures, indicated, .Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance .Refrigerated Storage 7. Prepared perishable items as salads, puddings, milk, etc., are stored in a refrigerator and covered, labeled, and dated until used .Freezer Storage 3. All foods in the freezer are wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Items are labeled and dated A current policy was provided, on 7/17/2024 at 1:30 P.M., by the Director of Nursing. The policy titled, Food Production Guidelines, indicated, .Safe and sanitary handling of food will be employed during food production .6. Leftovers must be dated, labeled, covered, and immediately refrigerated or frozen for later use, Leftovers must be used within 72 hours A current policy was provided on 7/17/2024 at 1:30 P.M. by the Director of Nursing. The policy titled, Dish Machine, indicated, .Store ware in a clean dry area upside down to avoid direct contact with debris 3.1-21(h)(3)

Based on interview, record review, and interview, the facility failed to provide a transfer and discharge form for 1 of 3 residents reviewed for hospitalization s. (Resident 36) Finding includes: During an interview, on 7/12/2024 at 9:33 A.M., Resident 36 indicated he had not been hospitalized since his admission to the facility, but had been at the facility 3 times. A record review was completed on 7/15/2024 at 10:59 A.M. Diagnoses included, but were not limited to: infection of the spinal internal fixation device, osteomyelitis, and MSSA (Methicillin Sensitive Staphylococcus Aureus). An Admission Minimum Data Set (MDS) assessment, dated 6/5/2024, indicated Resident 36 was cognitively intact. The medical record indicated Resident 36 was discharged to the emergency roiagnom on [DATE] and returned to the facility on [DATE]. A Nurse's Note, dated 6/19/2024 at 12:49 P.M., indicated an order was obtained from Resident 36's surgeon to send to the emergency room due to his spinal surgical site dehiscence (reopening of a surgical wound) with purulent (pus) drainage. On 6/20/2024 at 2:34 A.M., a Nurse's Note indicated Resident 36 returned to the facility. During an interview, on 7/17/2024 at 10:10 A.M., LPN 6 indicated a transfer and discharge form should be given if a resident was transferred from the facility to another facility. She indicated the transfer and discharge form would have been scanned into the electronic health record. A policy was provided, on 7/17/2024 at 2:34 P.M., by the Assessment Support, titled, Guidelines for Transfer and Discharge, indicated, .According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. 1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility During an interview, on 7/17/2024 at 3:45 P.M., the Executive Director indicated the facility did not issue a transfer and discharge form on 6/19/2024. 3.1-12(a)(6)(A)

Based on record review and interview, the facility failed to ensure 1 of 2 residents received a PASRR(Preadmission Screening and Resident Review) assessment in a timely manner. (Resident 40) Finding includes: The record for Resident 40 was reviewed was on 7/11/2024 at 3:40 P.M. Diagnoses included, but were not limited to: dementia, psychotic disorder with hallucinations, mood disturbance and anxiety. A PASARR Level 1 assessment had been completed for Resident 40, on 4/3/2024, with no Level II assessment required. Resident 40 received a new qualifying diagnosis of psychotic disorder and medication change on 4/27/2024. During an interview, on 7/16/2024 at 11:39 A.M., the Social Service director indicated she could not locate an updated PASARR assessment and there should have been one updated for Resident 40 with the new diagnoses/medication. On 7/16/2024 at 4:07 P.M., the Director of Nursing indicated she did not have a policy for PASARR assessments.

Based on observation, interview, and record review, the facility failed to provide grooming services for 2 of 3 residents reviewed for activities of daily living. (Residents 27 and 29) Findings includes: 1. During an observation for Resident 27, on 7/11/2024 at 11:41 A.M., she had long white whiskers on her chin, upper lip, and cheeks. On 7/12/2024 at 10:40 A.M., during an observation and interview, Resident 27 continued to have the whiskers, and she indicated she had an electric razor her daughter had brought to the facility for management of her whiskers. She indicated she would like them removed. A record review for Resident 27 was completed on 7/15/2024 at 9:31 A.M. Diagnoses included, but were not limited to, dementia, visual hallucinations, and diabetes mellitus type 2. An Annual Minimum Data Set (MDS) assessment, dated 6/4/2024, indicated Resident 27 required substantial/maximal assistance for grooming, and had moderate cognitive impairment. A current Care Plan indicated Resident 27 had impairment in functional status. The care plan interventions did not address grooming assistance. During an observation, on 7/15/2024 at 9:48 A.M., Resident 27' continued with the whiskers observed previously. On 7/16/2024 at 10:02 A.M., Resident 27's whiskers continued to the upper lip, chin, and cheeks. During an interview on 7/17/2024 at 10:14 A.M., LPN 6 indicated facial hair was to be shaved whenever a resident needed to be shaved, not just on shower days. 2. During an observation, on 7/11/2024 at 10:23 A.M., Resident 29 was observed in his geri chair seated in the common area. He was unshaven with whiskers on his face, chin and had long fingernails. During an observation, on 7/12/2024 at 10:47 A.M., Resident 29 was unshaven with whiskers on his face, chin and had long fingernails. During an observation, on 7/15/2024 at 9:01 A.M., Resident 29 was observed seated at the dining table. He was unshaven, with whiskers on his face, chin and had long fingernails. A record review for Resident 29 was completed on, 7/16/2024 at 8:53 A.M. Diagnoses included, but were not limited to dementia, chronic kidney disease, weakness, chronic obstruction pulmonary disease, dysphagia and ataxic gait. A Quarterly Minimum Data Set (MDS) assessment, dated 4/26/2024, indicated Resident 29 had severe cognition impairment and was dependent on staff for showering, bathing and requires maximal assist with personal hygiene. A current Care Plan, dated 4/29/2024, indicated Resident 29 had an ADL (activities of daily living) self-care performance deficit and required substantial/max assist with personal hygiene. During an interview on 7/16/2024 at 9:47 A.M., LPN 2 (Licensed Practical Nurse) indicated the resident should have been shaved and his nails should have been trimmed. During an interview on 7/17/2024 at 2:18 P.M., the Regional Support Nurse indicated the facility does not have a policy for ADL care. The staff was to follow their resident procedure guide. 3.1-38(a)(3) 45120

Based on observation, interview, and record review, the facility failed to follow physician orders related to PICC (peripherally inserted central catheter) line dressing changes for 1 of 1 resident reviewed for antibiotic therapy (Resident 36) Finding includes: During an observation on 7/12/2024 at 9:19 A.M., Resident 36 was observed to have a PICC line inserted to the basilic vein of the right arm. The dressing was dated 7/2/2024, and had paper tape adhered to the upper lateral portion of the dressing, and the dressing was not adhered distal to the lateral portion of the dressing adhered with paper tape. Resident 36 indicated the date, of 7/2/2024, observed on the dressing was the date the dressing had been changed. A record review for Resident 36 was completed on 7/15/2024 at 10:59 A.M. Diagnoses included, but were not limited to, infection of the spinal internal fixation device, osteomyelitis, and MSSA (Methicillin Sensitive Staphylococcus Aureus). An Admission Minimum Data Set (MDS) assessment, dated 6/5/2024, indicated Resident 36 was cognitively intact. A Care Plan, dated 6/3/2024 and revised 7/9/2024, indicated resident 36 required intravenous medication related to bacteremia. The interventions included intravenous site care as ordered. A PICC Insertion Record, dated 7/2/2024 at 1:40 P.M., indicated the PICC line was inserted to the right basilic vein because the left sided midline did not draw blood when frequent blood draws were necessary A Physician's Order, dated 6/5/2024, indicated to change the PICC/Midline/CVAD (central venous access device) dressing every 5 days, and as needed. A Physician's Order, dated 6/28/2024, indicated Resident 36 was to receive Cefazolin (antibiotic) 2 grams per 100 milliliters every 8 hours through 7/27/2024. The Medication Administration Record (MAR), dated July 2024, indicated the PICC line dressing was to be changed on 7/5/2024. The nurse did not change the dressing but documented the following: .Dressing with new PICC changed 7/3/2024 The MAR indicated a dressing change was completed on 7/10/2024 and a PRN (as needed) dressing change was completed on 7/13/2024. A Nurse's Progress Note, dated 7/13/2024 at 9:58 P.M., indicated a single lumen PICC dressing to the right upper extremity was beginning to come off and was changed using a prepackaged dressing kit. During an interview, on 7/17/2024 at 10:12 A.M., LPN 6 indicated Resident 36's PICC line dressing was to be changed every 5 days. She was not able to find documentation the PICC line dressing was being changed per the Physician's Order. There was also no explanation given as to why the MAR for July 2024 indicated the PICC dressing had been changed on 7/10/2024 when the dressing observed on 7/12/2024 was dated 7/2/2024. A policy was provided on 7/17/2024 at 1:51 P.M. by the Director of Nursing who indicated the policy was the current facility policy. The policy titled, Catheter Insertion and Care, indicated, .Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings .General Guidelines 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way 3.1-47(a)(2)

Based on observation, interview and record review, the facility failed to ensure proper infection control practices were implemented related to lack of handwashing after glove removal during a blood glucose procedure and fanning an area that had been cleansed with alcohol pad during 1 of 3 medication administration observations. (RN 3) Finding includes: During a medication observation, on 7/16/2024 at 8:40 A.M., RN 3 obtained the supplies to perform a blood glucose level and administer insulin to a resident. RN 3 placed the glucometer device and supplies on the resident's bed, washed his hands and applied gloves. RN3 wiped the resident's finger with an alcohol pad and with an opened hand, fanned the area that had been cleansed. After RN 3 obtained the blood sample, he removed his gloves and without washing his hands, administered insulin to the resident. During an interview, on 7/16/2024 at 8:45 A.M., RN 3 indicated he should have washed his hands, placed the device on barrier and not fanned the area. On 7/16/2024 at 11:10 A.M., the Director of Nursing provided the policy titled, Glucometer, dated 9/17/2018, and indicated the policy was the one currently used by the facility. The policy indicated .2. Appropriate infection control techniques shall be followed during testing procedures On 7/16/2024 at 11:01 A.M., the Director of Nursing provided the policy titled, Guideline for Handwashing/Hygiene, with a review date of 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated .3. Health Care Workers (HCW) shall use hand hygiene and times such as: .d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc On 7/17/2024 at 1:51 P.M., the Director of Nursing provided the policy titled,Injectable Medication Administration, and indicated the policy was the one currently used by the facility. The policy indicated .To administer medication via subcutaneous, intradermal and intramuscular routes in a safe, accurate, and effective manner. Equipment Required: .F. Barrier (e.g.,disposable tray or plastic cup), if supplies or medication will be set down in a resident's room 3.1-18(b)

Based on record review, observation and interview, the facility failed to ensure proper admission assessment and orders were obtained for 1 of 4 residents to prevent the development of pressure ulcers. (Resident 30) Finding includes: During an initial interview with Resident 30 on 3/15/22 2:44 P.M., Resident 30 indicated she had been admitted to the facility with pressure ulcers and developed a pressure ulcer to her right shin due to wearing a AFO (ankle foot orthosis) brace. During an interview on 3/18/22 at 11:25 A.M., with Resident 30, she indicated she came to the facility with the AFO brace. Resident 30 indicated the brace kept her ankle in place and had worn the AFO brace for around 2 years. Resident 30 indicated she removed the AFO brace on her own at night and the CNAs would place a knee sock and the AFO brace to her left lower leg every morning. Resident 30 indicated she requested the area to her right lower extremity be assessed by the nurse due to pain. A record review of Resident 30 was completed on 3/17/22 at 3:13 P.M. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30 admitted to the facility on [DATE]. An Admission MDS (Minimum Data Set) Assessment, dated 2/17/2022, indicated the Resident 30 had a BIMS (Brief Interview Mental Status) score indicating no cognitive impairment and required extensive assistance with one staff member for bed mobility and toileting, and extensive assistance with two staff members for transfers. An Admission Assessment completed on 2/11/2022 at 3:18 P.M., indicated no skin impairment, and did not identify an AFO brace under musculoskeletal assistive devices of the assessment. A Weekly Skin Assessment on 2/16/2022 and 2/23/2022 on the 2:00 P.M.-10:00 P.M. shift, indicated old skin impairment related to the right groin region. A Nurses' Note on 2/25/2022 at 1:13 P.M., indicated Resident 30 had an abrasion to the left lower extremity (Resident 30 has a left lower [CONDITION(S)] at the hip) just above the ankle and appears to be from brace rubbing on leg. A treatment was ordered and the AFO brace was not to be applied to the right lower extremity. On 2/27/2022 at 4:06 P.M., a late entry Nurses' Note was written for 02/25/2022 at 4:04 P.M. The Nurses' Note indicated, .res (Resident 30) has a pressure wound on RLE (right lower extremity) that appears to be from brace rubbing against skin. Wound measures 7cm [centimeter] x 6cm x 0.1cm. Stage III, 100% granulation tissue to wound bed. Notified MD of wound On 3/15/2022 at 11:59 A.M., a Nurses' Note indicated, .Writer Spoke with res POA (Power of Attorney) with update on res (resident) pressure injury to right shin. Writer explained that it was caused from the brace that she wears. POA voiced understanding, she stated that res was wearing the brace r/t (related to) working on transferring. Res (Resident) is not transferring at this time, she asked if the brace was even necessary at this time. Writer explained that she was not wearing at this time r/t pressure injury On 3/15/2022 at 7:52 P.M., a Nurses' Note indicated, .continues to have a pressure wound on RLE that appears to be from brace rubbing against skin. Wound measures 6.1 cm x 3.5cm x 0.1 Stage III, 50 granulation tissue to wound bed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. On 2/25/2022, Leave splint off of right lower extremity 2. On 2/27/2022, (RIGHT LOWER LEG): cleanse wound with wound cleanser, apply skin prep to skin surrounding wound, apply [MEDICATION(S)] gel to wound bed, and cover with foam dressing change 5 days. 3. On 2/27/2022, Prostat (Protein Supplement) 30 ml twice daily 4. On 3/14/2022, Cleanse wound to RLE with wound cleanser, pat dry, apply skin prep to surrounding skin, cover with island dressing/border gauze, change daily, use adhesive remover to remove dressing 5. On 3/15/2022, low air loss mattress A Care Plan on 2/27/2022, indicated a problem of a pressure ulcer to the right lower extremity. During an interview on 3/18/22 at 2:55 P.M., the DON reviewed the Electronic Health Record and indicated an order was not obtained for the AFO brace at admission, and skin integrity assessments should have been completed by a nurse every shift for the use of the AFO brace. On 3/18/2022 at 3:08 P.M., a policy was requested for skin care with removable devices. A policy was not provided. Policies entitled, Pressure/Statis/Diabetic Wound Condition Guidelines, Guidelines of General Wound and Skin Care, and Guidelines for Weekly Skin Observation were provided. These policies did not address the prevention of pressure ulcers. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure a treatment supply cart and medication cart were locked when unattended, failed to ensure medication storage areas were free from loose medications, failed to ensure medications were dated and labeled in 3 of 4 medication storage areas. (400 hall treatment cart, 100 hall medication cart, Legacy Medication medication cart, 100 hall medication cart) Findings include: 1. During a random observation, on 3/17/2022 at 7:35 A.M., the 400 hall treatment cart was not locked with the top drawer opened with no licensed nursing staff within sight of the treatment cart. At 7:39 A.M., the Administrator walked towards the 400 hall, she stopped and locked the treatment cart. During an interview, on 3/17/2022 at 7:40 A.M., the Administrator indicated the treatment cart should have been locked. 2. During a medication administration observation, on 3/17/2022 at 8:30 A.M., LPN ( Licensed Practical Nurse) 2 removed the following medications from the 100 hall medication cart for Resident 244: [MEDICATION(S)] 7.5/325 mg (narcotic), [MEDICATION(S)] 10 mg (anti hypertensive), [MEDICATION(S)] 300 mg (nerve pain medication), [MEDICATION(S)] 50 mg (anti hypertensive) and placed the tablets in a medicine cup on the top of the unlocked medication cart. LPN 2 walked down the hall to resident 244's room, went in the room and then returned to the medication cart, leaving the med cup with medication on the cart. During an interview, on 3/17/2022 at 8:34 A.M., LPN 2 indicated she should not have walked away from the cart and the cart should have been locked. 3. During a medication storage observation, on 3/18/2022 at 11:02 A.M., of Legacy Lane medication cart, the following was observed: a box of Fisherman's Friend cough drops with no resident identifiers; 8 loose pills in the drawers; an opened/undated bottle of [MEDICATION(S)]; an opened/undated bottle of Almacone (antacid); an opened/undated bottle of Milk of Magnesium and an opened vial of [MEDICATION(S)] ([CONDITION(S)] solution) in a box with a sticker that indicated to use by 28 days after opening. The vial had a date of 11/19. During an interview, on 3/18/2022 at 11:19 A.M., QMA (Qualified Medication Aide) 7 indicated the medications should have a label and date on them, there should not be loose pills in the medication cart and the vial of [MEDICATION(S)] was outdated. 4. During a medication storage area observation, on 3/18/2022 at 11:23 A.M., on the 100 hall medication cart, the following was observed: 1 bottle of [MEDICATION(S)] vitamins, blueberry, tart cherry, milk [NAME], [NAME] berry, and wild cherry bark opened, undated with no resident identifiers on the bottles. Five (5) bottles of [MEDICATION(S)] ([MEDICATION(S)]) opened and undated, and 3 loose pills in the drawers. During an interview, on 3/18/2022 at 11:30 A.M., RN (Registered Nurse) 6 indicated all of the bottles should have had labels and dates on them and there should be no loose pills in the drawers. On 3/21/2022 at 1:15 P.M., the Corporate Nurse provided the policy titled, Medication Administration, dated 2018, and indicated the policy was the one currently used by the facility. The policy indicated . 5. Prior to administration of any medication, the medication and dosage schedule on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .15. During administration of medications, the medication cart is kept closed and locked when out of sight of the facility medication administration personnel. No medications are kept on top of the cart On 3/21/2022 at 1:15 P.M., the Corporate Nurse provided the policy titled, Medication Labels, dated 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated . A.If a label dose not fit directly on the product, e.g., eye drops, the label may be affixed to an outside container or carton, but the resident's name, at least must be maintained directly on the actual product container. F. Resident-specific non prescription medications (not floor stock) that are not labeled by the pharmacy are kept in the manufacture's original container and identified with the resident's name 3.1-25(j)(m)

Based on record review, observation and interview, the facility failed to develop a plan of care to meet the residents' needs for 3 of 21 residents reviewed for care plans. (Resident 7, 44 & 244) Findings include: 1. During an initial interview with Resident 7 on 3/16/22 8:54 A.M., Resident 7 indicated she had been hospitalized a few weeks ago for urinary tract infection, she was currently on an antibiotic for a urinary tract infection and develops urinary tract infections frequently. A record review of Resident 7 was completed on 3/16/22 at 11:23 A.M. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS (Minimum Data Set) Assessment, dated 1/7/2022, indicated Resident 7 had a BIMS (Brief Interview Mental Status) score indicating no cognitive impairment and was frequently incontinent of bladder. She required supervision with set-up assistance from a staff member for toileting. A Nurses' Note on 1/16/2022 at 8:10 P.M., indicated Resident 7 was sent to the emergency room for slurred speech and a feeling of a thick tongue. On 1/17/2022 at 1:59 A. M., a Nurses' Note indicated Resident 7 returned to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order for [MEDICATION(S)] (antibiotic) intravenously for four days was received upon returning from the emergency room . On 1/18/2022 at 1:10 P.M., a Nurses' Note indicated Resident 7 was slurring her words with right sided facial droop. Resident 7 was sent to the emergency room . On 1/18/2022 at 7:21 P.M., Resident 7 returned to the facility. The emergency room nurses indicated the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A urinalysis obtained on 3/5/2022, indicated positivity for a urinary tract infection. The culture and sensitivity indicated Escherichia coli as the bacteria and resistance to many antibiotics. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 7 was prescribed [MEDICATION(S)] ([MEDICATION(S)]) one gram intravenously once a day from 1/18/2022 to 1/21/2022. Resident 7 was also prescribed fosomycin [MEDICATION(S)] packet three grams by mouth every three days for [CONDITION(S)] (multi-drug resistant organism) [CONDITION(S)] from 3/1/2022 through 3/16/2022. A Care Plan could not be located for the urinary tract infection or intravenous antibiotic use. During an interview on 3/18/2022 at 2:04 P.M., RN (Registered Nurse) 4 indicated floor staff do not participate in the development of care plans for new orders or conditions. RN 4 indicated a box can be checked with the order that updates the care plan. During an interview on 3/21/22 at 10:50 A.M., the Regional Nurse indicated a care plan or event (an assessment for an ongoing problem that serves as a care plan) should have been developed for the urinary tract infection. 2. A clinical record review was completed on 3/18/2022 at 8:31 A.M., and indicated resident 44's, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/22/2021 a new order was received for Hospice to eval and treat, and she was accepted. During an interview on 3/18/2022 at 10:15 A.M., the MDS nurse indicated she should have had a care plan for Hospice. 3. A clinical record review was completed on 3/17/2022 at 11:19 A.M. Resident 244's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 244's current physician orders, dated 3/11/2022, indicated oxygen at 2 liters per nasal canula continuous; change oxygen tubing monthly; clean external concentrator filter every two weeks; head of bed elevated to alleviate/reduce shortness of breath while lying flat; monitor oxygen saturation every shift; assess for signs and symptoms of shortness of breath while lying flat and [MEDICATION(S)] inhaler every 6 hours as needed. The clinical record lacked a care plan for the use of the oxygen and respiratory needs. During an interview, on 3/17/22 at 11:45 A.M., the Director of Nursing (DON) indicated the resident's needs are communicated with Matrix computer program. Matrix has a header for specific care needs. She indicated that residents on oxygen should have a care plan reflecting interventions for oxygenation. On 3/18/2022 at 10:51 A.M., RN 14 provided the policy titled, Comprehensive Care Plan Guideline, dated 5/22/2018, and indicated the policy was the one currently used by the facility. The policy indicated .Acute problems that arise with the resident are expected to be resolved within a short time frame will be addressed on the event form specific to that problem. Address problems that become ongoing or chronic with a new comprehensive care plan. Comprehensive care plans need to remain accurate and current. New interventions will be added and updated during or directly following CCM meeting. Newly recognized problems will have a care plan developed and added after CCM (care conference meeting) meeting 3.1-35(a)

Based on record review, observation and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Finding includes: A clinical record review was completed on 3/16/2022 at 11:37 A.M. Resident 31's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) assessment, dated 8/29/2021, indicated Resident 31 had a stage III and stage IV pressure area to her coccyx and left heel. A Quarterly MDS (Minimum Data Set) assessment, dated 2/19/2022 indicated Resident 31 required extensive assist of 2 staff for bed mobility, transfers dressing and toilet use and only had a stage III pressure area. Physician orders, dated 3/2022, indicated Resident 31 was to wear a heel protector on the left heel at all times when in bed or in the wheelchair. The heel protector was ordered 8/26/2021. A current care plan, dated 9/7/2021, indicated the resident was at risk for skin breakdown related to impaired mobility and pressure ulcers. Interventions included, but were not limited to: lifting device as needed for bed mobility, pressure reduction mattress, and cushion, keep clean and dry, minimize exposure to moisture, keep linens dry and clean, float heels as needed, encourage and assist to turn and reposition and weekly skin assessment. During an observation, on 3/16/2022 at 2:35 P.M., Resident 31 was observed sitting in her wheelchair with no heel protector on her left foot. During an observation, on 3/17/2022 at 9:26 A.M., Resident 31 was lying in bed with no heel protector on her left foot. During an observation, on 3/15/2022 at 10:10 A.M., Resident 31's left foot had a dark area to the outer aspect of the heel. During an interview, on 3/17/2022 at 10:10 A.M., C.N.A (Certified Nursing assistant) 12 indicated the resident did not wear a boot or protector to her feet. During an observation, on 3/17/2022 at 11:15 A.M., Resident 31 was observed in her wheelchair with no heel protector to the left foot. During an observation, on 3/17/2022 1:21 P.M., Resident 31 was observed in her wheelchair with no heel protector to the left foot. During an observation, on 3/17/2022 at 2:07 P.M., Resident 31 was observed in her wheelchair with no heel protector to the left foot. Weekly skin assessments completed on, 3/7/2022 and 3/14/2022, indicated a (2) old impairment, with no other information documented. During an observation, on 3/18/2022 at 2:07 P.M., LPN (Licensed Practical Nurse) 2 indicated the area to the residents' left foot looked like a deep tissue injury, and indicated the resident had an area there before and it was healed. LPN 2 indicated the order for the foot protector was not listed on the treatment sheet and could not be signed off as completed if the order was not there. During an observation, on 3/21/2022 at 8:55 A.M., Resident 31 was in bed with a piece of lambs wool under the left heel. The Corporate Nurse and the Director of Nursing indicated the area to Resident 31's foot was a bruised area and the Nurse Practitioner had seen the resident today and indicated it was a bruise. The Corporate Nurse indicated there had been a pressure area there before but it was healed. The left heel was red but not boggy and had white flaky peeling skin to the area. A policy on following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-37

Based on record review, observation and interview, the facility failed to provide oxygen therapy equipment per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 30 & 43) Findings include: 1. During an initial observation with Resident 30 on 3/15/22 2:52 P.M., Resident 30 was receiving oxygen therapy via nasal cannula from an oxygen concentrator. A plastic respiratory storage bag was observed hanging from the oxygen concentrator with no date written on the bag. Resident 30 had a portable oxygen tank attached to the rear of her wheelchair. The nasal cannula attached to the concentrator and the portable oxygen tank did not have a date indicating when the oxygen tubing had been changed. On 3/18/2022 at 11:55 A.M., during an observation, the nasal cannula for the oxygen concentrator and portable oxygen tank did not have a date indicating when the tubing had been changed. A record review of Resident 30 was completed on 3/17/22 at 3:13 P.M. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) Assessment, dated 2/17/2022, indicated the Resident 30 had a BIMS (Brief Interview Mental Status) score indicated no cognitive impairment and received oxygen therapy. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 6/12/2018, indicated .Potential for SOB (shortness of breath) while lying flat r/t [CONDITION(S)] Interventions of the care plan indicated, .Administer oxygen per MD order and as needed 2. During an initial observation with Resident 43 on 3/15/22 10:13 A.M., Resident 43 had a portable oxygen tank attached to the rear of his wheelchair. Resident 43 was receiving oxygen therapy via nasal cannula from the portable oxygen tank. An oxygen concentrator was at bedside. A plastic respiratory storage bag was observed hanging from the oxygen concentrator with a date of 2/7/2022. The nasal cannula attached to the concentrator and the portable oxygen tank did not have a date indicating when the oxygen tubing had been changed. A record review of Resident 43 was completed on 3/16/2022 at 2:36 P.M. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, dated 3/4/2022, indicated the Resident 43 had a BIMS (Brief Interview Mental Status) score indicated severe cognitive impairment and received oxygen therapy. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 12/1/2022, indicated .Potential for SOB (shortness of breath) while lying flat [CONDITION(S)] and dyspnea Interventions of the care plan indicated, .Meds per MD order During an interview, on 3/18/22 at 1:57 P.M., RN (Registered Nurse) 4 indicated the oxygen tubing gets changed monthly, oxygen tubing should be dated, and the plastic respiratory storage bag should be changed with the oxygen tubing monthly or as needed. On 3/18/2022 at 3:47 P.M. a policy entitled, Guidelines for the Administration of Oxygen was provided by the Regional Nurse. The policy indicated, .14. Date the tubing for the date it was initiated. a. Tubing should be changed monthly and PRN 3.1-47(6)

Based on record review, observation and interview, the facility failed to update/revise care plans for discontinued medications, and a hand splint for 2 of 21 residents whose care plans were reviewed. (Resident 6 and 15) Findings include: 1. A clinical record review was completed on 3/17/2022 at 11:20 A.M. Resident 6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan, dated 4/14/2014, indicated Resident 6 was at risk for developing adverse effects from the use of anti-convulsant medications. A current care plan, dated 10/7/2016, indicated Resident 6 was at risk for adverse consequences related to received hypnotic medication. A current care plan, dated 7/1/2019, indicated Resident 6 received anti [CONDITION(S)] medication to treat irritability, anger and chronic pain. Resident 6's current medication orders, dated 3/2022, lacked the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 3/21/2022 at 9:37 A.M., Social Service staff indicated the care plans were not revised and should have been. 2. A clinical record review was completed, on 3/16/2022 at 11:02 A.M., and indicated Resident 15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated 3/11/2021, indicated resident is at risk for decline in ROM (range of motion) related to poor cognition and weakness with an intervention apply L (left) hand splint. The order for the hand splint was discontinued on 12/6/2021. On 3/17/2022 at 9:19 A.M., the Director of Nursing indicated that the care plan should have been revised when the hand splint was discontinued. On 3/18/2022 at 10:51 A.M., RN/MDS (Registered Nurse/Minimum Data Support) provided a policy titled Comprehensive Care Plan Guideline, dated 5/22/2018, and indicated the policy was the one currently used by the facility. The policy indicated . 5. If the resident is readmitted to the campus, the previous care plan will be reviewed and updated to meet the resident's current needs. a. If a previous care plan is no longer needed, it will be resolved from the active care plans. b. Resident's 24-hour CRCA (Certified Resident Care Assistant) assignment sheet or Care Tracker profile will be updated upon readmission. 6. Comprehensive care plans need to remain accurate and [MEDICATION(S)]. a, New interventions will be added and updated during or directly following CCM (care conference meeting). b. Newly recognized problems will have a care plan developed and added after CCM meeting 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure resident to resident physical and verbal abuse were thoroughly investigated by the facility administrator, after one resident on the dementia unit was known to be physically and verbally abusive to staff and residents (Residents E, F, G, B, H and J), causing fear in multiple other residents for 7 of 7 residents reviewed for abuse. (Resident D) In addition to the resident in the immediate jeopardy, the facility failed to thoroughly investigate allegations of staff to resident abuse for 1 of 3 residents reviewed for abuse. (Resident B) The immediate jeopardy began on 10/01/2019 when the facility failed to investigate a resident to resident physical abuse situation when Resident D hit Resident [NAME] unprovoked and then continued with recurring abusive behavior towards other staff and residents. The Executive Director, Director of Nursing, Assistant Director of Nursing, Corporate Support Nurse and Assessment Support Nurse were notified of the immediate jeopardy on 1/30/2020 at 1:08 P.M. The immediate jeopardy was removed on 1/31/2020, but noncompliance remained at the lower scope and severity of pattern, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The record for Resident D was reviewed on 1/29/2020 at 12:30 P.M. The [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 12/31/19, indicated Resident D had a BIMS (Brief Interview of Mental Status) score of 0, severe cognitive impairment and was receiving antipsychotic, antianxiety and antidepressant medications. An incident report, dated 10/1/19, indicated Resident [NAME] was seated in the dining room following lunch and had his eyes closed. Resident D walked up to Resident [NAME] and struck him in the face. The incident was unprovoked. A progress note, dated 10/2/19, indicated on 10/1/19, Resident D was agitated and became abusive with staff and that she also slapped a resident. A progress note, dated 10/10/19 at 3:25 P.M., indicated Resident D was observed standing over Resident F who was still seated at the table. Resident D had her fist drawn back with apparent intent to hit Resident F. A progress note, dated 10/10/19 at 3:45 P.M., indicated a staff member had witnessed Resident D hit Resident F two times and Resident F hit her back once before staff intervened. An incident report, dated 10/11/19, indicated Resident D and Resident F were witness hitting each other with their fists. A progress note, dated 10/11/19 at 3:30 P.M., indicated Resident D was observed using a closed hand to make contact to the right side rib area of Resident G who was sitting in a wheelchair. Resident D then used both hands to pull Resident G's wheel chair at which time staff assisted Resident G to stand up. Resident D then proceeded to use a closed hand to swing at staff. An altercation event, dated 10/11/19 at 3:55 P.M., indicated Resident G was tearful and expressed fear of Resident D. A psychiatric progress note, dated 10/15/19, indicated [MEDICATION NAME] (anti [MEDICAL CONDITION] medication that can be used for mood stabilization) was increased to 50 mg (milligrams) daily for emotional lability due to Resident D being verbally and physically aggressive with staff and other residents. A progress note, dated 10/20/19 at 2:35 P.M., indicated Resident D hit Resident B in the abdomen. A progress note, dated 1/9/2020 at 10:53 P.M., indicated Resident D had hit Resident H in the hand and the CNA in the arm after she had become upset. A progress note, dated 1/26/2020 at 1:38 [NAME]M., indicated Resident D was found in Resident J's room, standing by the bed and holding Resident J's arm. It took several minutes for CNA to get Resident D to let go of Resident J's right arm. On 1/29/2020 at 2:00 P.M., Resident D was observed up walking in the dining/activity room on the locked dementia unit. She was observed again at 3:30 P.M., sleeping in a reclined geri-chair. During an interview, on 1/29/2020 at 3:24 P.M. the ED (Executive Director) indicated he did not complete investigations with staff and other residents on the dementia unit for resident to resident abuse, only if there were staff to resident abuse allegations. 2. The record for Resident B was reviewed on 1/28/2020 at 10:00 [NAME]M. The [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 10/25/19, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 00, severe cognitive impairment, and was receiving antipsychotic medications. A care plan, dated 1/16/2020, indicated Resident B would make accusations against others when she didn't remember how she got a bruise, aches or skin tears. The goal was her accusations would be investigated and intervention was staff would assess her when she accused others of abuse. A physician progress notes [REDACTED].M., indicated the physician was asked to see this patient with history of dementia with delusions who had 2 inpatient psychiatric hospital stays due to aggressive behavior such as hitting staff, cursing, disruptive, and making false allegations of abuse This patient is clearly suffering from demential with delusions. After listening to the various reports by staff of her disruptive behavior, personally witnessing this disruptive behavior, and now hearing report of her accusing staff of abuse that has clearly not occurred, I feel this patient would be better suited on a more structured environment than what can be offered at this facility. An investigation, dated 1/16/2020, indicated on 1/7/2020 at 5:00 P.M. Resident B and her daughter had alerted staff that a staff member had hit Resident B and both were upset. An investigation, dated 1/15/2020, indicated the local Sheriff's department had come to the facility to speak with QMA (qualified medication aide) 3 in regards to an ongoing investigation related to Resident B. During an interview, on 1/28/2020 at 12:22 P.M., the Staff Development Coordinator indicated Resident B had alleged that QMA 3 had hit her on the chest on 1/7/2020 and that she had reported the allegation to the DON, ADON and the ED. During an interview, on 1/28/2020 at 12:46 P.M., the DON indicated that on 1/7/2020 the daughter of Resident B had alleged that someone had hit her mom. She indicated the Sheriff had come to the facility on [DATE] for an investigation due to Resident B's daughter accusing QMA 3 of hitting her mother. During an interview, on 1/28/2020 at 1:00 P.M., the ED indicated he was made aware of the allegation for someone hitting Resident B on 1/7/2020. He indicated the Sheriff had come to the facility on [DATE] and indicated the allegation was against QMA 3. He indicated it there was no investigation completed until the Sheriff came to the facility on [DATE] to complete the Sheriff department's investigation. He indicated there were cameras available on the unit in which the allegation was made, but he did not review the video of that day. On 1/29/2020 at 9:30 [NAME]M., the ED provided the Abuse and Neglect Procedural Guidelines, dated 8/29/19, and indicated this was the policy currently being used by the facility. The policy indicated the .Executive Director was accountable for investigating Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse has occurred, the extent ad cause. Providing complete and through documentation of the investigation The immediate jeopardy began on 10/1/19 was removed on 1/31/2020 when Clinical Support in-serviced the ED and DON on the proper completion of Abuse investigation. All incidents potentially fitting reportable guidelines would be reviewed and investigated if indicated by campus ED and DHS, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the need for continued monitoring and further inservicing. This Federal tag relates to complaint IN 140 3.1-28(d)

Based on observation, interview and record review, the facility failed to ensure resident to resident physical and verbal abuse were reported immediately to the facility administrator and to the State Agency after one resident on the dementia unit was known to be physically and verbally abusive to staff and residents (Resident H and multiple unknown residents), causing fear in multiple other residents, for 2 of 3 residents reviewed for abuse. (Resident D) This deficient practice had the potential to affect 16 of 16 residents residing on the locked unit. In addition to the resident in the immediate jeopardy, the facility failed to report allegations of staff to resident abuse for 1 of 3 residents reviewed for abuse. (Resident B) The immediate jeopardy began on 10/05/2019 when the facility failed to report resident to resident abuse immediately to the facility administrator and to the State Agency after a resident was shown to be very agressive and was charging towards other residents. The Executive Director, Director of Nursing, Assistant Director of Nursing, Corporate Support Nurse and Assessment Support Nurse were notified of the immediate jeopardy on 1/30/2020 at 1:08 P.M. The immediate jeopardy was removed on 1/31/2020, but noncompliance remained at the lower scope and severity of pattern, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The record for Resident D was reviewed on 1/29/2020 at 12:30 P.M. The [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 12/31/19, indicated Resident D had a BIMS (Brief Interview of Mental Status) score of 0, severe cognitive impairment and was receiving antipsychotic, antianxiety and antidepressant medications. A progress note, dated 10/5/19 at 9:16 P.M., indicated Resident D had been very hateful and aggressive towards staff and had charged towards two other residents with her fist gathered and appeared the she was going to strike them. A progress note, dated 10/31/19 at 8:01 P.M., indicated Resident D had been pacing through the unit giving very dirty looks and would stop and stare at another resident and attempted to walk towards another resident until staff tried to redirect her. A progress note, dated 11/2/19 at 3:22 P.M., indicated Resident D was walking up and down the halls cursing at staff and other residents. A progress note, dated 11/2/19 at 7:33 P.M., indicated Resident D was pacing the unit with a magazine rolled up in her hand, swearing at staff. Then she proceeded to walk up to a resident that was sitting on the couch in the unit lobby and stood behind resident with her arm drawn up as if she was going to strike resident. A progress note, dated 11/2/19 at 8:36 P.M., indicated Resident D had entered another residents room, causing the other resident to scream out and become frightened. Staff attempted to redirect Resident D, Resident D became aggressive, slapped, pushed and attempted to pull staff members hair. Another staff member had to come help get Resident D out of the other resident's room. A progress note, dated 11/5/19 at 10:00 P.M., indicated Resident D was being combative towards staff and other residents. A progress note, dated 11/5/19 at 10:54 P.M., indicated Resident D had become physically aggressive toward staff and was charging toward fell ow residents with her fists raised and cursing toward them. Several staff members stood between Resident D and other resident's rooms while Resident D was raging and cursing. A one-time order for [MEDICATION NAME] 1 mg IM (intramuscular) as received from nurse practitioner. A progress note, dated 11/5/19 at 11:40 P.M., indicated Resident D suddenly picked up speed and charged at another resident in the hall. A progress note, dated 11/8/19 at 7:10 [NAME]M., indicated Resident D was verbally and physically aggressive with staff. Resident then went down hall going in and out of rooms while staff stayed back watching resident so they wouldn't increase her agitation. Resident entered another residents room and would not leave. Staff member entered the room and resident stated Resident D had hit her. A progress note, dated 11/18/19 at 10:04 P.M., Resident D was wandering in and out of other residents rooms taking their things and getting progressively more and more agitated. A progress note, dated 1/9/2020 at 10:53 P.M., indicated Resident D had hit Resident H in the hand and the CNA in the arm after she had become upset. A progress note, dated 1/12/2020 at 5:13 P.M., indicated Resident D was wandering in and out of other resident's rooms and bathrooms, staff unable to redirect, resident began swinging and hitting at staff and was upsetting other residents and resident families. A progress note, dated 1/23/2020 at 6:46 P.M., indicated Resident D was in another resident room and when staff attempted to redirect, Resident D hit staff in stomach and kicked staff with feet. [MEDICATION NAME] 1 mg IM was administered. During an anonymous interview, it was indicated Resident B had verbal and physical behaviors of hitting residents and staff members. The behaviors tend to happen in public places in front of other residents. Some of the residents were frightened and scared of her. Resident B was most effected by the behaviors of Resident D. It was indicated that the scariest thing about Resident D was she is so unpredictable, you never know when she is going to switch. On 1/29/2020 at 2:00 P.M., Resident D was observed up walking in the dining/activity room on the locked dementia unit. She was observed again at 3:30 P.M., sleeping in a reclined geri-chair. During an interview, on 1/29/2020 at 3:24 P.M. the ED (Executive Director) indicated he was not aware of the multiple resident to resident altercations that Resident D had documented in the progress notes, no one had reported them to him as an allegation of abuse. He indicated the verbal aggression and threatening behaviors should have been reported as allegation of abuse to the State Agency, but had not been. 2. The record for Resident B was reviewed on 1/28/2020 at 10:00 [NAME]M. The [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 10/25/19, indicated Resident B had a BIMS (Brief Interview of Mental Status) score of 00, severe cognitive impairment, and was receiving antipsychotic medications. A care plan, dated 1/16/2020, indicated Resident B would make accusations of abuse against others when she didn't remember how she got a bruise, aches or skin tears. The goal was her accusations would be investigated and interventions were that staff would assess her when she accused others of abuse. A physician progress notes [REDACTED].M., indicated the physician was asked to see this patient with history of dementia with delusions who had 2 inpatient psychiatric hospital stays due to aggressive behavior such as hitting staff, cursing, disruptive, and making false allegations of abuse. .This patient is clearly suffering from demential with delusions. After listening to the various reports by staff of her disruptive behavior, personally witnessing this disruptive behavior, and now hearing report of her accusing staff of abuse that has clearly not occurred, I feel this patient would be better suited on a more structured environment than what can be offered at this facility. An investigation, dated 1/15/2020, indicated the local Sheriff's department had come to the facility to speak with QMA (qualified medication aide) 3 in regards to an ongoing investigation related to Resident B. A facility investigation, dated 1/16/2020, indicated on 1/7/2020 at 5:00 P.M. Resident B and her daughter had alerted staff that a staff member had hit Resident B and both were upset. During an interview, on 1/28/2020 at 12:22 P.M., the Staff Development Coordinator indicated Resident B had alleged that QMA 3 had hit her on the chest on 1/7/2020 and that she had reported the allegation to the DON (Director of Nursing), ADON (Assistant Director of Nursing) and the ED (Executive Director). During an interview, on 1/28/2020 at 12:46 P.M., the DON indicated on 1/7/2020 the daughter of Resident B had alleged that someone had hit her mom. She indicated the Sheriff had come to the facility on [DATE] for an investigation due to Resident B's daughter accusing QMA 3 of hitting her mother. She indicated the allegation was not reported to the State Agency because Resident B made these statements all the time. She indicated the facility had spoken with their corporate office and it was not reported because too much time had passed. During an interview, on 1/28/2020 at 1:00 P.M., the ED indicated he was made aware of the allegation for someone hitting Resident B on 1/7/2020 and he did not report, we just saw it in the context of the many times she had made allegations. He indicated the Sheriff had come on 1/15/2020 and indicated the allegation was against QMA 3. He indicated it was not reported because there was nothing to it. On 1/29/2020 at 9:30 [NAME]M., the ED provided the Abuse and Neglect Procedural Guidelines, dated 8/29/19, and indicated this was the policy currently being used by the facility. The policy indicated any person with knowledge of suspicion of suspected violations shall report immediately abuse the shift supervisor or manager is identified as responsible for initiating and/or continuing the reporting process, immediately notify the Executive Director the ED was responsible for notification to the local State agency any staff member, resident, visitor or resident representative may report known or suspected abuse to the local or state agencies. Ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later the 24 hours The immediate jeopardy began on 10/5/19 was removed on 1/31/2020 when the facility inserviced facility staff on Abuse and Neglect Procedural Guidelines and on Effective Coping with Challenging Behaviors. The inservice included: what to do with behaviors, the basics of behaviors, how to identify behaviors that can escalate, investigation behaviors, ideas to investigate behaviors, intervention ideas, providing a safe environment and implementing interventions for all residents, staff to report resident to resident abuse and notify the nurse of incidents, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm because of the need for continued monitoring, interventions and inservicing. This Federal tag relates to complaint IN 140 3.1-28(c)

Based on observation, interview and record review the facility failed to ensure residents were free from physical and verbal abuse from a resident that frequently displayed verbal and physical aggression towards staff and other residents (Resident E, F, G, B, H and J) resulting in other residents being fearful (Resident G) for 7 of 7 residents reviewed for abuse. (Resident D) The immediate jeopardy began on 10/01/2019 when the facility failed to prevent reoccuring incidents of resident to resident about when Resident D hit Resident [NAME] unprovoked and continued a pattern of being verbally and physically aggressive to staff and other residents, causing fearfulness in her fell ow residents. The Executive Director, Director of Nursing, Assistant Director of Nursing, Corporate Support Nurse and Assessment Support Nurse were notified of the immediate jeopardy on 1/30/2020 at 1:08 P.M. The immediate jeopardy was removed on 1/31/2020, but noncompliance remained at the lower scope and severity of pattern, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: The record for Resident D was reviewed on 1/29/2020 at 12:30 P.M. The [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 12/31/19, indicated Resident D had a BIMS (Brief Interview of Mental Status) score of 0, severe cognitive impairment and was receiving antipsychotic, antianxiety and antidepressant medications. A care plan for [MEDICAL CONDITION] drug use, dated 1/8/2020, indicated Resident D was at risk for adverse consequences related to use. A care plan, dated 10/11/19, indicated Resident D demonstrated inappropriate behaviors including: becoming physically aggressive with peers and staff as evidenced by hitting peers and staff when upset with them. Interventions included, but were not limited to, assist resident away from other residents and observe resident closely to ensure she is kept away from peers that she has become physically aggressive with. There were no new interventions implemented since 10/11/19. A care plan, dated 7/1/19, indicated Resident D demonstrated inappropriate behaviors including: cursing at staff and residents, hitting staff and residents, crying, irritability and restlessness. The interventions included, but were not limited to, assess for unmet needs (7/1/19), assist resident away from other residents (7/1/19), observe for triggers of inappropriate behaviors (7/1/19) and sensor on bedroom door that chimes at nurses station to alert staff that resident is up in the night (1/27/2020). An incident report, dated 10/1/19, indicated Resident [NAME] was seated in the dining room following lunch and had his eyes closed. Resident D walked up to Resident [NAME] and struck him in the face. The incident was unprovoked. A progress note, dated 10/2/19, indicated on 10/1/19, Resident D was agitated and became abusive with staff and she also slapped a resident. (Resident E) A progress note, dated 10/5/19 at 9:16 P.M., indicated Resident D had been very hateful and aggressive towards staff and had charged towards two other residents with her fist gathered and appeared as though she was going to strike them. (Residents unknown) A progress note, dated 10/10/19 at 3:25 P.M., indicated Resident D was observed standing over Resident F who was still seated at the table. Resident D had her fist drawn back with apparent intent to hit Resident F. A progress note, dated 10/10/19 at 3:45 P.M., indicated a staff member had witnessed Resident D hit Resident F two times and Resident F hit her back once before staff intervened. An incident report, dated 10/11/19, indicated Resident D and Resident F were witness hitting each other with their fists. A progress note, dated 10/11/19 at 3:30 P.M., indicated Resident D was observed using a closed hand to make contact to the right side rib area of Resident G who was sitting in a wheelchair. Resident D then used both hands to pull Resident G's wheel chair at which time staff assisted Resident G to stand up. Resident D then proceeded to use a closed hand to swing at staff. An altercation event, dated 10/11/19 at 3:55 P.M., indicated Resident G was tearful and expressed fear of Resident D. A psychiatric progress note, dated 10/15/19, indicated [MEDICATION NAME] (anti [MEDICAL CONDITION] medication that can be used for mood stabilization) was increased to 50 mg (milligrams) daily for emotional lability due to Resident D being verbally and physically aggressive with staff and other residents. A progress note, dated 10/20/19 at 2:35 P.M., indicated Resident D hit Resident B in the abdomen. A progress note, dated 10/21/19 at 4:27 P.M., indicated SSD (Social Service Director) had met with Resident B regarding the altercation with another resident in which the resident showed signs of aggression. Resident B was still stating unhappiness and anger toward the other resident feeling as though the other resident would not leave her alone. A progress note, dated 10/31/19 at 8:01 P.M., indicated Resident D had been pacing through the unit giving very dirty looks and would stop and stare at another resident and attempted to walk towards another resident until staff tried to redirect her. A progress note, dated 11/2/19 at 3:22 P.M., indicated Resident D was walking up and down the halls cursing at staff and other residents. (Residents unknown) A progress note, dated 11/2/19 at 7:33 P.M., indicated Resident D was pacing the unit with a magazine rolled up in her hand, swearing at staff. Then she proceeded to walk up to a resident that was sitting on the couch in the unit lobby and stood behind resident with her arm drawn up as if she was going to strike a resident. (Resident unknown) A progress note, dated 11/2/19 at 8:36 P.M., indicated Resident D had entered another residents room, causing the other resident to scream out and become frightened. Staff attempted to redirect Resident D, Resident D became aggressive, slapped, pushed and attempted to pull staff members hair. Another staff member had to come help get Resident D out of the other resident's room. A psychiatric progress note, dated 11/4/19 at 1:50 P.M., indicated the dementia for Resident D was progressing. States her moods can change from calm to verbally/physically aggressive. A progress note, dated 11/5/19 at 10:00 P.M., indicated Resident D was being combative towards staff and other residents. (Residents unknown) A progress note, dated 11/5/19 at 10:54 P.M., indicated Resident D had become physically aggressive toward staff and was charging toward fell ow residents with her fists raised and cursing toward them. Several staff members stood between Resident D and other resident's rooms while Resident D was raging and cursing. A one-time order for [MEDICATION NAME] 1 mg IM (intramuscular) as received from nurse practitioner. A progress note, dated 11/5/19 at 11:40 P.M., indicated Resident D suddenly picked up speed and charged at another resident in the hall. (Resident unknown) A progress note, dated 11/8/19 at 7:10 [NAME]M., indicated Resident D was verbally and physically aggressive with staff. Resident then went down hall going in and out of rooms while staff stayed back watching resident so they wouldn't increase her agitation. Resident entered another residents room and would not leave. Staff member entered the room and resident stated Resident D had hit her. A progress note, dated 11/8/19 at 2:32 P.M., indicated Resident D had grabbed the wrist of the nurse and then slapped nurse in the face. A progress note, dated 11/11/19 at 10:04 P.M., indicated Resident D had punched staff member in the neck three times. A progress note, dated 11/17/19 at 6:17 P.M., indicated Resident D was agitated, cursing and charging at staff. A progress note, dated 11/18/19 at 10:04 P.M., Resident D was wandering in and out of other residents rooms taking their things and getting progressively more and more agitated. (Residents unknown) A progress note, dated 11/19/19 at 11:45 P.M., indicated Resident D was being discharged to local psychiatric hospital. A progress note, dated 12/23/19 at 5:13 P.M,, indicated Resident D had returned to the facility. There were no updates to Resident D's behavioral care plans to manage any future behaviors and ensure the safety of other residents. No discharge instructions from the hospital were available for review. A progress note, dated 12/24/19 at 7:04 P.M., indicated Resident D had received an [MEDICATION NAME] injection, but no behaviors were documented on this date. A progress note, dated 12/27/19 at 10:16 P.M., indicated Resident D had become agitated with staff member and punched her in the face, then removed her shoe and started swinging the shoe at staff, striking them several times. A progress note, dated 12/30/19 at 8:55 [NAME]M., indicated CNA was only staff member on the unit and had to call for help because Resident D began wailing on her. A progress note, dated 12/30/19 at 3:47 P.M., indicated Resident D smacked a staff member across the face and was swinging her fist at another staff member. A progress note, dated 1/9/2020 at 10:53 P.M., indicated Resident D had hit Resident H in the hand and the CNA in the arm after she had become upset. A progress note, dated 1/12/2020 at 5:13 P.M., indicated Resident D was wandering in and out of other resident's rooms and bathrooms, staff unable to redirect, resident began swinging and hitting at staff and was upsetting other residents and resident families. (Residents unknown) A progress note, dated 1/23/2020 at 6:46 P.M., indicated Resident D was in another resident room and when staff attempted to redirect, Resident D hit staff in stomach and kicked staff with feet. [MEDICATION NAME] 1 mg IM was administered. A progress note, dated 1/26/2020 at 1:38 [NAME]M., indicated Resident D was found in Resident J's room, standing by the bed and holding Resident J's arm. It took several minutes for CNA to get Resident D to let go of Resident J's right arm. A progress note, dated 1/26/2020 at 12:30 P.M, indicated Resident D hit staff in the side of the head in the unit lobby. During an anonymous interview, it was indicated Resident B had verbal and physical behaviors of hitting residents and staff members. The behaviors tend to happen in public places in front of other residents. Some of the residents were frightened and scared of her. Resident B was most effected by the behaviors of Resident D. It was indicated that the scariest thing about Resident D was she is so unpredictable, you never know when she is going to switch. On 1/29/2020 at 2:00 P.M., Resident D was observed up walking in the dining/activity room on the locked dementia unit. She was observed again at 3:30 P.M., sleeping in a reclined geri-chair. During an anoyomous interview, it was reported that the dementia unit had been a very combative unit and the combativeness by Resident D occurred to some residents and in front of others. It was indicated that some residents were frightened by the incidents. One in particular was upset and would refuse to come out of her room, she would beg staff not to have to come of her room and pretend she was sick so she could stay in bed. Prior to the escalation of combativeness, this resident wanted to get up and do things, She was motherly. It was indicated that Resident B and Resident D would escalate each other. It was reported that the behaviors for Resident B has increased after she found out her exhusband had passed away. During an anoyonous interview, it was indicated that a lot of residents were frightened by the verbal and physical aggression that was occuring on the dementia unit. It was reported one resident would grab herself and start repeating, I wanna go home another resident would place her hands in air, stating oh oh with hands and appeared to be scared. It was indicated that Resident B had behavior and would make racial slurs at Resident D that would escalate her. It was reported that the incidents of verbal and physical aggression would happen in commom areas in front of other residents. During an interview, on 1/29/2020 at 3:15 P.M., the DON indicated the interventions that had been implemented for Resident D were medication changes, DNA testing, room changes, and a chime alarm on her door that was added on 1/28/2020. She indicated there is only CNA/QMA on midnight shift on the dementia unit and the alarm would let them know if Resident B had left her room. She indicated there were 16 residents currently on the dementia unit. During an interview, on 1/29/2020 at 3:24 P.M. the ED (Executive Director) indicated he did not complete investigations with staff and other residents on the dementia unit for resident to resident abuse, only if there were staff to resident abuse allegations. He indicated he was not aware of the multiple resident to resident altercations that Resident D had documented in the progress. He indicated he reported the incident with Resident [NAME] from 10/1/19, Resident F from 10/10/19, Resident G from 10/11/19, Resident B from 10/20/19, Resident H from 1/9/2020 and Resident J from 1/26/2020. He indicated the verbal aggression and threatening behaviors should have been reported as allegation of abuse. On 1/29/2020 at 9:30 [NAME]M., the ED provided the Abuse and Neglect Procedural Guidelines, dated 8/29/19, and indicated this was the policy currently being used by the facility. The policy indicated processes were implemented in an effort to provide a comfortable and safe environment. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain and mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately. Verbal abuse includes the use of oral, written or gestured communication or sounds to residents within hearing distance, regardless of age, ability to comprehend, or disability. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting and kicking. Mental/emotional abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Prevention: Assure the prevention techniques are implemented. Identify, correct and intervene in situations where abuse and/or neglect are more likely to occur. Sufficient staffing on all shifts to meet the needs of the population served, identification of residents with needs and/or behaviors which might lead to conflict or neglect. Staff is required to report concerns, incidents and grievances immediately to manager and/or ED and DON. The immediate jeopardy began on 10/1/19 was removed on 1/31/2020 when the facility inserviced facility staff on Abuse and Neglect Procedural Guidelines and on Effective Coping with Challenging Behaviors. The inservice included: what to do with behaviors, the basics of behaviors, how to identify behaviors that can escalate, investigation behaviors, ideas to investigate behaviors, intervention ideas, providing a safe environment and implementing interventions for all residents, staff to report resident to resident abuse and notify the nurse of incidents, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm because of the need for continued monitoring, interventions and inservicing. This Federal tag relates to complaint IN 140. 3.1-27(a)(1) 3.1-27(b)

Based on record review and interview, the facility failed to adequately monitor a medication and ensure a resident with impaired renal function did not receive [MEDICATION NAME] (a heart medication used to maintain a normal, steady heartbeat) while experiencing [MEDICAL CONDITION] (low heartrate) and also receiving [MEDICATION NAME] (an antibiotic that can exacerbate the effects of [MEDICATION NAME]) and was subsequently admitted to the hospital with [REDACTED]. (Resident C) The immediate jeopardy began on [DATE] when the facility failed to follow nursing standard of practice and gave Resident C's prescribed [MEDICATION NAME] dose when her heartrate was 53. Resident C got 7 more of her daily dose of [MEDICATION NAME] with a heartrate documented at 60 or below before being sent to the ER (emergency room ) and was diagnosed with [REDACTED]. The Executive Director, Director of Nursing, Assistant Director of Nursing, Corporate Support Nurse and Assessment Support Nurse were notified of the immediate jeopardy on [DATE] at 1:08 P.M. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Finding includes: The record for Resident C was reviewed on [DATE] at 10:13 [NAME]M. The [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident C had a BIMS (Brief Interview of Mental Status) of 15, cognitively intact and required extensive assist with ADLs (activities of daily living). A care plan for potential of cardiovascular distress, dated [DATE], indicated Resident C had [DIAGNOSES REDACTED]. The interventions included, but were not limited to, administer medications as ordered, observe for and report side effects as needed and obtain vital signs as ordered and needed. There was no care plan available that addressed the use of [MEDICATION NAME]. The admission orders [REDACTED]. A progress note, dated [DATE] indicated Resident C was admitted from local hospital after a motor vehicle accident. A prescription order, dated [DATE], indicated an order for [REDACTED]. There were no parameters or hold orders for pulse rate indicated. A laboratory test, dated [DATE], indicated the [MEDICATION NAME] level for Resident C was 1.9 (normal therapeutic range is 0.5 to 2.0). The vital signs for Resident C on [DATE] were: pulse 80 and blood pressure ,[DATE]. The Medication Administration History, for (MONTH) 2019, indicated Resident C had received [MEDICATION NAME] 500 mg on [DATE] and 250 mg on [DATE], [DATE], [DATE], [DATE] and [DATE] for an upper respiratory infection. She had received [MEDICATION NAME] 0.25 mg daily from [DATE]- [DATE]. The documented pulse on [DATE] was 53 and on [DATE] it was 56. The [MEDICATION NAME] was held on [DATE] per nurse indicating not administered due to condition, pulse rate was 52. The [MEDICATION NAME] was administered on [DATE] with a pulse rate 51 and was held on [DATE] due to condition (blood pressure ,[DATE] and pulse of 52). [MEDICATION NAME] was administered on [DATE] (pulse 62), [DATE] (pulse 60) and on [DATE] with a pulse rate of 55. There was no documentation available for physician notification for pulses below 60. The Medication Administration History, for (MONTH) 2020, indicated Resident C had received [MEDICATION NAME] on [DATE] with a pulse rate of 55 and on [DATE] with a pulse rate of 54. A nurses note, dated [DATE] at 8:53 P.M., indicated went into residents room to get vital signs before administering medications. Blood pressure was ,[DATE] and heart rate was 44. Resident stated she did not feel good and had not felt good most of the day. Physician was notified but resident refused to go to the ER at this point. A nurses note, dated [DATE] at 2:00 [NAME]M., indicated Resident C's family member came to the nursing desk and requested Resident C be transferred to the local ER. Current blood pressure was ,[DATE] and heartrate was 52. Blood pressure [DATE] at 12:00 [NAME]M. was ,[DATE] and heart rate 56. At 1:55 [NAME]M. blood pressure was ,[DATE] and heart rate was 50. 911 was called at 2:03 [NAME]M. The emergency room report from (local hospital), dated [DATE] at 2:53 [NAME]M., indicated Resident C presented to the emergency room due to low blood pressure, which was found low yesterday. At 2:00 in the morning it was still low so the facility called the ambulance. She was previously active until she was involved in a severe vehicle accident on [DATE]. Medical decision making indicated the EKG (electrocardiogram) showed [MEDICAL CONDITION] with slow ventricular response. There were slightly more prominent ST depression in the anterior leads when compared to a previous EKG, one would wonder about [MEDICATION NAME] toxicity. The physician suspected her [MEDICAL CONDITION] and EKG changes were secondary to her [MEDICATION NAME] toxicity. The recommendation was made to send Resident C to a larger hospital 54 miles from local hospital. The [DIAGNOSES REDACTED]. The triage emergency report, dated [DATE] at 3:08 [NAME]M., indicated the nurse from the facility indicated Resident C's blood pressure was low on [DATE] and the attending physician had been notified of this. A [MEDICATION NAME] level, dated [DATE] at 3:50 [NAME]M., indicated a critical result of 3.0 (concentrations greater than 2.0 ng/ml are often associated with toxic symptoms.) A History and Physical (from second hospital resident was transferred to), dated [DATE] at 1:11 P.M., indicated Resident C was transferred to hospital from local emergency room where she was found to have mild [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION]. [MEDICATION NAME] level was elevated, magnesium and potassium were low. The [DIAGNOSES REDACTED]. A consultant note from second hospital, dated [DATE], indicated Resident C was admitted from local hospital on [DATE] for [MEDICAL CONDITION] with bigeminy (serious heart arrhythmia) and [MEDICATION NAME] toxicity and appeared to be evolving acute [MEDICAL CONDITION]. A hospital discharge summary, dated [DATE], indicated Resident C was sent to the emergency room of the local hospital for [MEDICAL CONDITION]. There she was found to be bradycardic and hypotensive. [MEDICAL CONDITION] was treated with intravenous fluids and corrected. However she continued to be bradycardic and was found to be [MEDICATION NAME] toxic past. She was transferred here at that point and admitted to the MICU (Medical Intensive Care Unit). [MEDICATION NAME] was held. Blood pressure was maintained however she was becoming weaker. She did have periods of bigeminy, she became increasingly dyspneic (trouble and labored breathing), and continued to deteriorate with [MEDICAL CONDITION]. Her code status was change to DNR (do not resuscitate) and she was kept comfortable until she expired (time of death [DATE] at 5:25 [NAME]M.) The discharge [DIAGNOSES REDACTED]. During an interview, on [DATE] at 2:30 P.M., the DON (Director of Nursing) indicated a pulse should be assessed prior to the administration of [MEDICATION NAME] and, most the time, the hold order parameter was for a pulse below 60. She indicated it was a nursing measure to hold [MEDICATION NAME] for a pulse below 60 and to notify the physician. She indicated a hold order for pulse less than 60 should be present with a [MEDICATION NAME] order, and some complications that could occur if [MEDICATION NAME] was administered to a resident with a pulse below 60 where the pulse would drop even more and [MEDICATION NAME] toxicity was something the nurse should watch for. She indicated signs of [MEDICATION NAME] toxicity included, but were not limited to, low pulse, yellowing of the eyes confusion, loss of appetite, irregular pulse and nausea/vomiting diarrhea. She indicated she was aware Resident C was taking [MEDICATION NAME] but was unaware if there were any orders to hold for pulse below 60. She indicated Resident C had been alert and oriented prior to being transferred to the local emergency roiagnom on [DATE] in the middle of the night. During an interview, on [DATE] at 4:10 P.M., the Medical Director indicated that [MEDICATION NAME] should not have been given when the resident's pulse was below 60. He indicated the facility had notified him of the low pulse the day prior to Resident C being sent out, but not before that. He indicated he would have given the order to hold [MEDICATION NAME] if pulse was below 60 on the days the [MEDICATION NAME] was administered as documented in the MAR. During an interview, on [DATE] at 4:15 P.M., a pharmacist from the facility's pharmacy indicated that [MEDICATION NAME] could potentially increase the toxicity of [MEDICATION NAME] due to its drug class (macrolide), causing a change in heart rate. He indicated the drug-drug interaction of [MEDICATION NAME] and [MEDICATION NAME] was a level 2 and it was at the professional decision of the pharmacist to send an alert to the facility. He indicated an alert had not been sent because the facility nurse's should have been monitoring the heart rate. He indicated the hold order perimeters for a pulse were at the physician's discretion. During an interview, on [DATE] at 2:22 P.M., LPN (Licensed Practical Nurse) 4 indicated she was the nurse on duty on [DATE] in evening. She indicated Resident C's husband was not present in the facility and that she had not notified him of the resident's change in condition. She indicated Resident C had stated she would go to the hospital if the physician thought it was necessary. LPN 4 indicated that she felt Resident C needed to go the hospital and indicated she did not tell the physician. She indicated the conversation with the physician was completed via text messaging. An email from the the Vice President of Clinical Services for the pharmacy to the facility DON, dated [DATE] at 4:27 P.M., indicated the severity of this interaction is 'moderate' which would coincide with a level of severity at the pharmacy that allows for pharmacist discretion in whether their profession judgement the interaction should be called on. In reading the attached I do see where there is a possibility of increased concentrations .It is also important to note this patient was in a skilled nursing facility under nursing supervision and not living independently which might cause one to be more cautious with a drug interaction that could cause . During an interview, on [DATE] at 5:03 P.M., the ADON (Assistant Director of Nursing) indicated that pharmacist consult had informed them Resident C's kidney had been declining and had significant decline by the time she got to the hospital and he indicated this could cause increase in [MEDICATION NAME] toxicity. She indicated he was comparing laboratory results for kidney function (BUN, Creatinine). She indicated there were no hold orders for low pulse (<60) for the [MEDICATION NAME]. If she was the nurse working the floor she would have called to clarify for hold orders. She indicated she was unaware that Resident C had received the [MEDICATION NAME] on the days her pulse was less than 60 and the medication should have been held and the physician should have been notified. On [DATE] at 5:00 P.M., a policy for [MEDICATION NAME] administration was requested and the ADON indicated there was no policy available. On [DATE] at 4:30 P.M., the DON provided the medication description of [MEDICATION NAME], and indicated this was from the medication book the facility uses to reference medications. The medication description indicated [MEDICATION NAME] was identified as a medication with a safety alert. The alert indicated that factors to consider when dosing a regimen is selected include body weight, age, renal function, concomitant drugs and disease. Toxic levels of [MEDICATION NAME] are only slightly higher than therapeutic levels. Before given drug, take apical-radial pulse for 1 minute. Record and notify prescriber of significant changes. Adverse reactions included, but were not limited to, fatigue, stupor, arrhythmias (life threatening) and visual changes. Antibiotics (macrolides) may increase risk of cardiac glycoside toxicity, monitor patient of toxicity. Effects on lab tests, may prolong PR interval or depress ST segment of EK[NAME] Nursing considerations: drug induced arrhythmias may increase severity of heart failure and [MEDICAL CONDITION]. Monitor patient for toxicity. Toxic effects on the heart may be life-threatening and require immediate attention. Patients with low body weight, advanced age, renal impairment and electrolyte disturbances are at increased risk. Alert: Excessively slow pulse rate (60 beats/minute or less) may be a sign of [MEDICATION NAME] toxicity. Withhold drug and notify the prescriber. The immediate jeopardy began on [DATE] was removed on [DATE] when the facility received parameters for different drug classifications from the medical director and inserviced licensed nursing and QMAs on importance of following parameters, also to notify the physicians when medications are held or when results are below parameter, including monitoring, presence of adverse consequences for drug classifications, and the pharmacy enhanced its policy to require all interactions with anti-arrhythmics to be handled as Level 1 interaction, but the noncompliance remained at the lower scope and severity of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the need for further inservicing and monitoring. This Federal tag related to compliant IN 140. 3XXX,[DATE](a)(5)

Based on observation, record review and interviews, the facility failed to ensure interventions were implemented to prevent pressure ulcer development on a lower extremity for 1 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in the development of an unstageable pressure ulcer. (Resident #62) Finding includes: The clinical record for Resident #62 was reviewed on 09/16/2015 at 9:51 A.M. Resident #62 was admitted to the facility on [DATE], with diagnoses, including but not limited to status [REDACTED]. The initial Minimum Data Set (MDS) assessment, completed on 07/17/15, indicated the resident was at risk for the development of pressure ulcers but did not have any pressure ulcers. The care plan related to the resident's risk for pressure ulcers, initiated on 07/22/15, included the following interventions: Avoid shearing resident's skin during positioning, transferring, and turning, keep clean and dry as possible. Minimize skin exposure to moisture, keep linens clean, dry, and wrinkle free, maintain the head of the bed at the lowest degree of elevation possible, provide incontinence care after each incontinent episode ., reduce friction injuries by using lubricants, protective films, protective dressing, and/or protective padding as needed, report any signs of skin breakdown, use lifting device as needed, and use moisture barrier product to perineal area. A skin assessment of Resident #62's left lower leg, completed on 08/31/15, indicated there were intact sutures in the left lower leg, one plus [MEDICAL CONDITION] in his foot, and an ace wrap was applied to his left leg. There was no impaired skin noted on the assessment. A skin assessment, completed on 09/01/15, indicated the incision was intact and there was an abrasion on his left great toe which had been present prior to his discharge on 08/24/15. A skin assessment in progress note, dated 09/02/15, indicated there was a scabbed area to the left lateral ankle measuring 1 cm (centimeter) by 1 cm with no redness, [MEDICAL CONDITION], or discomfort. A nursing note, dated 09/03/15, indicated redness to left lateral ankle continued. A nursing note, dated 09/04/15 at 3:56 P.M., indicated : Left lateral leg: 5 cm x 6 cm. Abdomen: 1.5 cm by 2 cm. There was no explanation as to exactly what areas the measurements were assessing. A pressure ulcer wound assessment, completed on 09/04/15, indicated the physician was notified on 09/04/15. A nursing note, dated 09/05/15 at 12:57 A.M., indicated Pressure area to left lateral foot cont. (continues). Heel floating. HOB (Head of Bed) elevated for comfort et (and) call light within reach. A wound assessment, dated 09/08/15 at 3:16 P.M., indicated there was an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the ulcer bed) black/purple wound on the left outer ankle (sic) the wound measured 2 cm by 1.5 cm with irregular wound edges, no tunneling or drainage, no signs of infection, periwound skin pink and blanchable. Resident stated the area was made by his shoe. Nursing note, dated 09/08/15 at 10:13 A.M., indicated the physician and family were notified of the wound. A physician's orders [REDACTED]. A physician's orders [REDACTED]. An observation of the pressure area for Resident #62, completed on 09/17/2015 at 1:52 P.M., indicated the resident had a dime sized black dry unstageable pressure ulcer on his left outer ankle bone. The skin directly surrounding the black area was dry and peeling. There was slight [MEDICAL CONDITION] of the foot noted. The nurse wiped the area with sure prep and put his sock and a blue heel protector back onto his foot. There were no specific interventions implemented regarding protecting the resident's foot until after the pressure ulcer on the resident's ankle developed. 3.1-40(a)

Based on record review and interviews, the facility failed to ensure bowel movements were monitored and a bowel protocol was implemented to treat constipation for 1 of 1 residents reviewed for bowel incontinence. This deficient practice resulted in severe abdominal pain, the need for transport to an acute care facility and treatment for [REDACTED].#63) Finding includes: The clinical record for Resident #63 was reviewed on 09/17/2015 9:48:03 A.M. Resident #63 was admitted to the facility on [DATE], with diagnoses, including but not limited to dementia, dysphagia, history of urinary [MEDICATION NAME], hypothyrodism, anxiety state, hypertension, [MEDICAL CONDITION], history of venous [MEDICAL CONDITIONS] reflux, [MEDICAL CONDITION], weakness, altered mental state, constipation and [MEDICAL CONDITION]. A Nursing progress note, dated 09/15/15 at 12:27 A.M., indicated the resident was exhibiting signs of distress, moaning, having abdominal pain and distention. The resident was sent to the acute care facility emergency room . A CT (computerized tomography) scan, completed on 09/15/15, indicated a 10 x 11 centimeter (cm) ball of stool in the rectal vault and the resident was diagnosed with [REDACTED]. The computerized Vitals record, which included bowel movement documentation, indicated the resident was not documented to have had a bowel movement from 09/07/15 to 09/15/15. The physician's medications orders, dated 5/17/15, for Resident #63 indicated to administer a [MEDICATION NAME] (laxative) suppository 10 milligrams (mg) rectally as needed for constipation. If the resident had no bowel movement in 72 hours, the resident was to receive 2 Tablespoons of a Natural Laxative. If there were no results in 24 hours from the Natural Laxative, the resident was to receive 30 cc (cubic centimeters) of Milk of Magnesia (laxative). If the resident had no results from the Milk of Magnesia in 12 hours, the resident was to receive a [MEDICATION NAME] (laxative) suppository. If no results from the suppository in 2 hours then the resident was to receive a Fleets enema. The September 2015 Medication Administration Record [REDACTED]. During an interview, on 09/18/2015 at 9:00 A.M., the Director of Nursing (DON) indicated the facility's computer system generated a resident message regarding no bowel movements documented for 3 days and these were to be reviewed for the CCM (Clinical Care Meetings) by Department heads and addressed. She also indicated the staff nurses received the messages and were supposed to take action but they were waiting on the CCM meeting to catch the issues. In addition, she indicated the bowel movement documented while the resident was out of the building had occurred just before she was transported but was not documented timely or appropriately. She did not know if there were any other bowel movements missed on the documentation or why the nurses did not realize the lack of bowel movements and implement the ordered medications. The current facility policy and procedure, provided on 09/18/15 at 8:30 A.M., included the following: .5. The Bowel and Bladder Circumstance form or Ineffective Bowel Pattern form shall be initiated for any resident not having a BM with 72 hours (unless this has been determined to be a usual bowel pattern for the individual). a. The 72 Hour follow up on the B and B Circumstance form should be completed until the resident has a BM or the bowel pattern returns to normal for the resident. b. The Ineffective Bowel Pattern form should be completed each shift until the resident has a BM or bowel pattern has returned to normal for the resident. c. The assessment of the abdomen shall be completed each shift that includes abdominal distention, pain and bowel sounds. 6. Nursing staff shall assess for effectiveness within 24 hours of the first step before proceeding to the next level The current Guidelines for Use of Care Tracker for Bowel and Bladder Documentation policy, provided on 09/18/15 at 8:30 A.M., included the following: .18. Completion of Bowel and Bladder services will be validated through the use of the Care Tracker Bowel and Bladder reports. This will be accomplished by the DHS (Director of Health Services) or designee. The Care Tracker Compliance Report and No BM in the last 3 days cross tab report will be reviewed and utilized during the morning stand-up interdisciplinary team meeting to assure provision of services 3.1-37(a)

Based on record review and interview, the facility failed to ensure adequate supervision was provided and interventions were implemented to prevent falls for 2 of 3 residents reviewed for falls which resulted in a subdural hematoma injury for Resident B and a lower hip/buttock injury for Resident D. Findings include: 1. The record of Resident "B" was reviewed on 06/03/13 at 5:30 a.m. Resident "B", who resided on the dementia unit, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS Assessment (Minimum Data Set: a tool to provide guidance for planning resident care), dated 02/19/13, indicated the resident was cognitively impaired, required extensive assistance of 1 staff for transfers, ambulation and toileting needs. The resident had incurred a fall on 11/28/12 with no injury. The next fall for Resident "B" occurred on 05/22/13, at 1:15 a.m., which resulted in a subdural hematoma. Review of a "FALL CIRCUMSTANCE, ASSESSMENT AND INTERVENTION" form indicated: "Date of fall: 05/22/13; Time of fall: 0115 (1:15 a.m.); Location of fall: bathroom (room number); witnessed: N (no);...Injury location: back of head; Hit head: (checked)... Neurochecks: WNL (Within Normal Limits)" The resident's vital signs were listed and the form indicated the resident did not complain of pain and was transferring self. The form indicated the physician and family were notified but did not include the date and time. The area for "Other Comments" was blank and did not include any further information. The fall investigation did not distinguish between interventions utilized prior to the fall or if interventions were added post fall. Review of "NURSE'S NOTES" indicated a note from 05/13/13. The next entries indicated: "05/22/13 1050 (10:50 a.m.) N.O. (New Order) rec'd (received) for: UA (urinalysis) C&S (Culture & Sensitivity). "05/22/13 1435 (2:35 p.m.) N.O. rec'd for head CT (Computerized Tomography) s (without) contrast. (name of family member) notified." "05/22/13 1645 (4:45 p.m.) Resident admitted to (Acute Care Facility: hospital name) per MD orders (name of family member) notified." The DNS (Director Nursing Services) was interviewed on 06/04/13 at 9:00 a.m. The DNS provided an "ACCIDENT/INCIDENT REPORT," completed on 05/22/13. The DNS indicated the form is an internal investigation report for facility use that does not appear in residents records for physician or outside review. The report indicated: "Describe exactly what happened:....Res (resident) transferred herself to the toilet, bed alarm sounded, when CRCA (CNA) (name) entered the room, res was laying on the bathroom floor." The form indicated the physician was notified on 05/22/13 at 3:00 p.m. for the fall. The area regarding family notification was blank. The report did not indicate information to explain the resident's bed alarm going off and the CNA not responding to the alarm until the resident had ambulated into the bathroom and sustained a fall. Review of the ACF (Acute Care Facility: hospital) discharge summary indicated the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The report indicated: "PROCEDURES:...3. Head CT, May 22, 2013, showing acute parenchymal hemorrhage with a small portion of the right parietal lobe. There is a small amount of acute subarachnoid hemorrhage in this region...." Care Plans, including but not limited to, Cognition, ADL (Activities of Daily Living: transfers, hygiene, locomotion, toileting needs) Self-Care Deficit, and Restraint/Enabler (for 1/2 siderails) were reviewed. There was no Care Plan specific to falls in the resident's record. The Care Plans were last updated 03/2013. The Restraint/Enabler Care Plan indicated, and included but was not limited to: "Problems: weakness 2* (secondary to) osteoporosis; bed mobility, transfer's; Interventions:...Bed alarm, Mat...beside bed, Low bed, ...Encourage use of call light, Respond to call light promptly...Anticipate resident needs, Respond promptly to needs...." The DNS was interviewed on 06/04/13 at 1:00 p.m. The DNS indicated CNA's no longer had preprinted CNA worksheets (a paper with residents listed by room/unit which included quick reference information related specific to each resident). The DNS indicated the facility now utilized a kiosk for resident information where a CNA could visually reference information, if needed, in regards to a specific resident. The DNS provided a 1 page printout of the form for Resident "B," which was in narrative style, from 08/06/12 through 05/30/13, that included but was not limited to, and indicated: "09/12/12: Wanders." "0/12/12 Fall risk. Bed alarm. Self-releasing wheel chair seat belt. Bed in low position. Floor mat while in bed. Wears glasses. Assist of one for transfers....Observe for wandering...." Interview with the DNS, at the time, indicated the CNA referral information was updated as needed. 2. The record of Resident "D" was reviewed on 06/03/13 at 6:50 a.m. Resident "D" was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS Assessment (Minimum Data Set: a tool to provide guidance for planning resident care), dated 05/07/13, indicated Resident "D", who resided on the dementia unit, was cognitively impaired, required extensive assist of 2 or more staff for transfers, ambulation, and toileting, and was frequently incontinent of bowel and bladder. Resident "D" had incurred 8 falls between 02/26/13 and 05/23/13. Review of the "FALL CIRCUMSTANCE, ASSESSMENT AND INTERVENTION" forms for the falls, which included but was not limited to, injuries and root causes, indicated: "02/26/13 0230 (2:30 a.m.) No injury... Root cause: Non-compliant c (with) safety measure)." "03/05/13 2:15 p.m. No injury...Root cause: Slipped out of w/c (wheelchair)." "03/12/13 1145 (11:45 a.m.) No injury...Root cause: Attempting to get out of recliner unassisted." "03/13/13 11:50 p.m. No injury. Rood cause: Non-compliant c transfers & need to toilet." "03/23/13 0050 (12:15 a.m.) No injury...Root cause: blank" "03/25/13 2310 (11:10 p.m.) Injury: (R) (right) lower hip/buttocks...Root cause: Non-compliant c safety measures." "04/19/13 1430 (2:30 p.m.) No injury...Root cause: self transferring." "05/23/13 0245 (2:45 a.m. Injury: Back of head & (L) (left) side of back. Hit head...Root cause: Balance. Non-compliant resident." Review of the information on the forms indicated numerous times the cognitively impaired resident removed or unplugged alarms located on the bed and or chair. The 8 of 8 forms reviewed for Resident "D" were not completely filled out. The fall investigations did not distinguish between interventions utilized prior to the falls and what interventions were added post fall. Review of "NURSE'S NOTES," for narrative documentation, from admission to survey, indicated: "05/23/13 0600 (6:00 a.m.) N.O. (New Order) received for: may send to ER to eval & treat...." "05/23/13 1000 (10:00 a.m.) N.O. decrease Lasix to 40 mg 1 daily, decrease Potassium to 10 mEq (milliequivalent) 1 daily." The narrative did not include any information in regards to the head injury described in the "FALL CIRCUMSTANCE REPORT". There was no documentation in the NURSE's NOTES in reference to the 03/25/13 fall with (R) lower hip/buttock injury or in regard to any of the falls incurred since admission. The DNS (Director Nursing Services) was interviewed on 06/04/13 at 9:00 a.m. The DNS provided an "ACCIDENT/INCIDENT REPORT," for each fall. The DNS indicated the forms are internal investigation reports for facility use that do not appear in resident records for physician or outside review. The reports referred to the cognitively impaired resident being educated on using the call light and instructions to not unplug/disable the alarms. The investigations did not address interventions other than reminding the cognitively impaired resident to use her call light or to monitor alarms. Review of Care Plans for Resident "D," included but were not limited to, COGNITIVE FUNCTION, ADL: SELF-CARE DEFICIT, INCONTINENCE and FALLS. Review of the FALLS Care Plan, initiated on 11/21/12 and updated on 02/19/13, included but were not limited to: "Problems: History of falls, dementia, and unsteady gait. Goals: Resident will have reduced risk of fall related injury by utilizing fall precautions. Interventions:...Call light within reach...Remind resident and reinforce safety awareness: Lock breaks on bed, chair, etc before transferring; When rising from a lying position, sit on side of bed for a few minutes before transferring/stand...." The DNS was interviewed on 06/04/13 at 1:00 p.m. The DNS indicated CNA's no longer had preprinted CNA worksheets (a paper with residents listed by room/unit which included quick reference information related specific to each resident). The DNS indicated the facility now utilized a kiosk for resident information where a CNA could visually reference information, if needed, in regards to a specific resident. The DNS provided a 1 page printout, dated 05/20/13, of the form for Resident "D," which included 2 entries: "05/20/13 bed and chair alarms, dycem to chair, self releasing seatbelt alarm, bed in low position. I require the assistance of one for transferring. I also have a tendency to shut off my alarms so please listen closely for them." "05/20/13 I have a [DIAGNOSES REDACTED]. Please remind me that he is ok. Activities that I have stated that I enjoy include cards, crafts, exercise, talking, cooking and watching TV. I enjoy having things available to read. Visitors are welcomed. I enjoy taking care of my personal items. My family come to visit me. I prefer for them to be involved in my care. My goal for activities will be to remain engaged in activities that bring me pleasure. Please reevaluate my interest by 08/17/13." Confidential interviews were conducted with staff members on all three shifts throughout the survey, which included, but were not limited to, RN's, LPN's, and CNA's. LPN #3 indicated the CNA's no longer utilized CNA worksheets and could only access resident care direction by prior knowledge, inquiring of a nurse or another CNA, or accessing the kiosk which provided care information for each resident. LPN #3 indicated the kiosks were located in the hallways and could only be accessed by one CNA at a time. CNA #4 was interviewed and indicated resident care needs were accessed through the kiosk. The CNA indicated if unfamiliar with care needs and a call light went off, the kiosk was the only access point for information beyond prior knowledge or asking a co-worker. A Policy and Procedure, titles, "FALLS MANAGEMENT PROGRAM GUIDELINES: 03/2008" was provided by the DNS on 06/04/13 at 8:45 a.m. Review of the Policy and Procedure indicated: "PROCEDURE: 1....b. Care plan interventions should be implemented that address the resident's risk factors... 3. Should the resident experience a fall, the attending nurse shall complete the "Fall circumstance and Reassessment Form". The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT (Intra Disciplinary Team) to evaluate thoroughness of the investigation and appropriateness of the interventions. 4. An "Accident and Incident Report" should be completed at the time of the incident. 5. The staff member attending to the resident at the time of the incident should notify the attending physician or medical director in the absence of the attending physician and the responsible party... 7. The nursing assistant assignment sheet and resident care plan should be updated to reflect any new or change in interventions. 8. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours...." This Federal tag relates to Complaint IN 650. 3.1-45(a)(2)

Based on record review and interviews, the facility failed to ensure the safety of 1 resident who incurred an unwitnessed fall resulting in a fractured finger for 1 resident reviewed for falls in a sample of 5. Findings include: The record of Resident "F" was reviewed on 03/29/12 at 12:20 p.m. Resident "F" was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial tour, between 10:00 a.m. and 10:30 a.m. on 03/28/12, accompanied by the Clinical Care Coordinator (CCC-RN), Resident "F" was identified as incurring a fall at home resulting in a (R) hip & (R) wrist fracture and as being a short-term skilled resident. Resident "F" was identified as not interviewable and requiring assist of 2 staff for transfers and toileting. The CCC-RN indicated Resident "F" had an unwitnessed fall since admission to the facility. A confidential interview, during the survey, indicated Resident "F" had fallen and fractured a finger after admission. The interview indicated Resident "F" had relayed she had to go to the bathroom and attempted to get up by herself. The interview indicated Resident "F" "could not find her call light." The interview indicated the family was not in the facility on 03/25/12 until after the fall. Review of all records dated before 03/25/12 indicated Resident "F" had a (R) hip fracture and (R) wrist fracture, with no mention of a finger fracture. Review of physician's orders [REDACTED]. "...PT (Physical Therapy) gait training WBAT (weight bearing as tolerated) (R) LE (lower extremity).. ABD pillow (abductor pillow: a device placed and secured between the legs of a patient following hip surgery to prevent hip dislocation) @ (at) ALL times while in bed..." Review of the "Fall Circumstance Assessment and Intervention", initiated 03/25/12, indicated: "Activity at time of fall: Transferring self...." "Environmental Inspection: Other: found "waffle mattress" on bed placed by family...." "Root cause: family placed waffle mattress on bed...." Review of Nurses's notes indicated: "03/24/12 1000 (10:00 a.m.) Staples removed from (R) hip s (without) difficulty....Cast D&I (dry & intact) on (R) FA (forearm). Fingers pink, warm, freely movable." The next entry indicated: "03/25/12 0930 (9:30 a.m.) Pt (patient) found on floor beside bed leaning on (R) side resting on closet door. Had been incont (incontinent) BM (bowel movement) & (and) urine. Very confused to time & place...." "03/26/12 1030 (10:30 a.m.) Called (Orthopedic Surgeon) re: (R) hand swollen & (and) cast appears to be to (sic) tight around fingers. (Orthopedic Surgeon) not in today. Suggest we send her to ER for eval (evaluation)..." Review of the pre admission x-rays and the post fall x-rays indicated: "03/07/2012 6:55 p.m.: Findings: ...Comminuted impacted Colles' fracture...distal shaft of radius....Ulnar styloid fracture is also appreciated....Soft tissues: Unremarkable..." "03/26/2012 2:27 p.m.: Findings:...There is an acute transverse comminuted fracture of the base of the proximal phalanx of the fifth finger....There is soft tissue swelling over the dorsum of the hand... IMPRESSION: Acute comminuted intra-articular fracture of the base of the proximal phalanx of the fifth finger...." The DNS (Director Nursing Services) was interviewed on 03/29/12 at 1:30 p.m. The DNS indicated the resident was in the facility for respite care. The DNS indicated the finger fracture probably occurred prior to admission and did not inquire further in regards to the post fall x-ray. The DNS indicated the fall was caused by Resident "F" sliding out of bed after a waffle mattress was placed on the bed by the family. The DNS indicated staff were unaware the waffle mattress was on the bed until after the fall. The DNS was queried in regards to the resident being checked for toileting throughout the night and if the staff would have been aware the waffle mattress was present at the time. The DNS was also queried if the resident's abductor pillow was in place when the resident was found on the floor. The DNS indicated the investigation did not address the resident being checked for toileting or the abduction pillow. The DNS indicated the TARs (Treatment Administration Record) would indicate if the abductor pillow was in place. Review of the TAR, dated 03/2012, for Resident "F" indicated: "03/19/12 Cont (continue) abduction pillow while in bed x 2 weeks, then D/C (discontinue) 04/02/12". The TAR addressed each shift with a signature: 6:00 a.m.-2:00 p.m.; 2:00 p.m.-10:00 p.m.; 10:00 p.m.-6:00 p.m. The TAR did not identify when the abduction pillow was put on or removed. Review of the "Nursing Admission Assessment & Data Collection" dated 03/12/12, indicated: "Mobility and ADL's (Activities of Daily Living): Transfers/Wheelchairs: Assist of 2. Assistive Device: Abductor pillow..." "Mobility and ADL Plan of Care: Transfer with assist of x 2;... Use fracture precautions per protocol...Encourage use of call light for assistance...." "Elimination:...Incontinence product use: Briefs;...Usual Voiding Pattern: Upon rising, After meals, Before bed;...Urge Incontinence: Y (yes); ...Wakes at night: Y; uses bedpan;..." "Elimination Plan of Care:..Toilet upon rising, before/after meals, before bedtime; Use toilet/bedpan,...; Use Night time brief to eliminate waking at night; Provide assistance as needed." "Safety: Has a history of falls: Y; Requires assistance to transfer: Y; Requires Assistance to ambulate: Y;...Resident is unable use call lights: forgets to use: Y..." "Safety Plan of Care: Provide assistance for transfers and ambulation as needed;...Ensure call light is within reach;...Instruct resident on use of call light." This Federal tag relates to Complaint #IN 485. 3.1-45(a)(2)