Every finding on record at Brickyard Healthcare - Merrillville Care Center

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 3 residents observed during medication pass. Two errors were observed during 25 opportunities for errors during medication administration. This resulted in a medication error rate of 8%. (Resident G)Finding includes:During a morning Medication Pass Observation on 2/24/26 at 9:21 a.m., RN 1 indicated Resident G's glucometer reading was 285 and Lantus insulin 46 units and Novolog insulin six units were to be administered. She removed two insulin pens from the cart and dialed in 46 units on the Lantus pen and six units on the Novolog pen without priming the insulin pens. She then entered the resident's room and was stopped. She indicated she was unsure about priming the insulin pens and was unsure of the correct way to prime the insulin pens. The Clinical Education Nurse, at the time of the observation, instructed RN 1 to prime both pens with two units of insulin, then to dial in the correct dosage. The insulin was then administered to the resident.Resident G's record was reviewed on 2/24/26 at 2:24 P.M. The diagnoses included, but were not limited to, diabetes mellitus.A Physician's Order, dated 12/3/26, indicate Lispro (Novolog) insulin was to be administered per the results of the blood sugar level (sliding scale) four times a day. The dose for the blood sugar level of 285 was six units.A Physician's Order, dated 2/13/26, indicated 46 units of Glargine (Lantus) insulin was to be administered daily.During an interview on 2/24/26 at 2:20 p.m., the Director of Nursing indicated RN 1 was new to the facility and had been orientated to the medication pass policy and procedures.The facility's insulin pen administration policy, dated 2025 and received per e-mail from the Administrator in Training as current, indicated the insulin pen was to be primed with two units of insulin prior to the administration of the ordered amount of insulin.This citation relates to Intake 2740908.3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure residents had a clean and homelike environment related to dirty bed linens on made beds for 4 of 7 resident beds observed on the Advanced Alzheimer's Care Unit (AACU). (Residents E, H, F, and G)Finding includes:During observations of the bed linen, on the AACU on 1/15/26 at 9:42 a.m. through 9:50 a.m., with the AACU Supervisor the following was observed:Resident E's bed had been made with a bottom sheet, top sheet and blanket. There was a moderate amount of a brown substance located on the top sheet that was hanging over the side of the bed. The AACU Supervisor acknowledged the brown substance. CNA 1 entered the room and indicated the night shift had made the resident's bed.Resident H's bed had been made with a bottom sheet sheet, top sheet and bed cover. The top sheet and cover were removed and there were brown stains on the bottom sheet.Resident F's bed had been made with a bottom sheet, top sheet and bed cover. The top sheet and cover were removed and there were food crumbs in the bed on the bottom sheet and a brown substance on the pillow case.Resident G's bed had been made with a bottom sheet and a bath blanket cover. The bath blanket was removed and there were brown stains on the bottom sheet.During an interview on 1/15/26 at 9:50 a.m., the AACU Supervisor indicated the four beds had soiled linens and were made without the linen being changed by the night shift.During an interview on 1/15/26 at 11:42 a.m., the Administrator indicated she had notified the night shift staff and was informed they had not made the beds and the day shift staff were interviewed and they informed her they had not made the beds. She indicated the residents may have made the beds. She indicated there was no facility policy for changing the linen.a. During an observation on 1/15/26 at 1:00 p.m., Resident E was ambulating in the hall. She entered her room and walked past her bed, which was not neatly made, looked out the window, then left the room and ambulated down the hall. No attempt was made to remake the bed.Resident E's record was reviewed on 1/15/26 at 12:18 p.m The diagnoses included, but were not limited to, Alzheimer's disease.An admission Minimum Data Set (MDS) assessment, dated 12/29/25, indicated a severely impaired cognitive status and required supervision for toileting and dressing, was dependent on staff for bed mobility, bathing and transfers and was independent for ambulation. She was occasionally incontinent of bowel and bladder.A Care Plan, dated 12/24/25, indicated assistance was required for activities of daily living (ADL's) and she would make her own bed at times. The interventions indicated one to two staff members were required to assist with ADL's and short and simple instructions were required for her to self complete the ADL of bathing.A Care Plan, dated 1/6/26, indicated she had impaired cognitive function/dementia or impaired thought processes. The interventions indicated to ask yes/no questions to determine the resident's needs, cue, reorient and supervision as needed, task segmentation was required and tasks were to be broken up into one step at a time.b. During an interview on 1/15/26 at 12:59 a.m., CNA 1 assisted Resident H to her room via a wheelchair. CNA 1 indicated the resident was unable to ambulate.Resident H's record was reviewed on 1/15/26 at 12:45 p.m. The diagnoses included, but were not limited to, vascular dementia.A Quarterly MDS assessment, dated 12/21/25, indicated a severely impaired cognitive status and was dependent on staff for toileting, showers, dressing, bed mobility, transfers, and ambulation. She was frequently incontinent of bowel and bladder.A Care Plan, dated 8/14/25, indicated one to two staff members were required to assist the resident with ADL's.A Care Plan, dated 9/17/25, indicated there was limited physical mobility and she required restorative active range of motion and a walking program.A Care Plan, dated 8/14/25, indicated an impaired cognitive function or impaired thought processes. Tasks were to broken down to one step at a time.There was no care plan that indicated the resident made her own bed.c. During an observation on 1/15/26 at 1:02 p.m., Resident F was sitting in the dining room. There was no verbal response to verbalization. The resident just stared with attempted communication.Resident F's record was reviewed on 1/15/26 at 12:34 p.m. The diagnoses included, but were not limited to, dementia and bi-polar.A Quarterly MDS assessment, dated 10/28/25, indicated maximum assistance was required for oral care, toileting, dressing, and sitting to standing movement. Moderate care was required for hygiene, bed mobility and transfers. She was frequently incontinent of bowel and bladder.A Care Plan, dated 9/1/25, indicated one to two staff members were required for bathing, bed mobility, dressing and toileting. A Care Plan, dated 1/2/25, indicated an impaired cognitive function. The staff were to cue, reorient, and supervise as needed.There was no care plan that indicated the resident made her own bed.d. During an observation on 1/15/26 at 1:02 p.m., Resident G was sitting at a table in the dining room.Resident G's record was reviewed on 1/15/26 at 12:45 p.m. The diagnoses included, but were not limited to, Alzheimer's disease.A Quarterly MDS assessment, dated 12/4/25, indicated a severely impaired cognitive status, was dependent on staff for showers, toileting, and dressing, required supervision for bed mobility, was independent for transfers and ambulation, and was frequently incontinent of bowel and bladder.A Care Plan, dated 9/24/25, indicated an impaired cognitive status. The interventions indicated one though, idea, question, or command was to be give at a time.An ADL Care Plan, dated 9/29/25, indicated one-two staff assistance was required for ADL care.There was no care plan that indicated the resident made his own bed.This citation relates to Intake 2689569.3.1-19(f)(5)

Based on observation, record review and interview, the facility failed to ensure a sanitary kitchen was maintained related to testing of the chemical dishwasher. This had the potential to affect all residents who received meals prepared in the Main Kitchen. Finding includes:On 8/4/25 at 9:00 a.m., the Initial Kitchen tour was completed with the Dietary Service Manager (DSM). The DSM indicated the dishwasher was a chemical system. He indicated the dishwashing solution was tested every shift. He obtained a test strip from a bottle on top of the dishwasher. The test strip was weaved into the tines of a fork and placed on a tray that was put through the dishwasher. When completed, the DSM removed the test strip and indicated it read 50 parts per million (ppm), he indicated it should be 150 ppm. He then indicated they were the incorrect strips. He retrieved the correct strips and again wove the strip into the tines of a fork and ran it through the dishwasher. When the cycle was complete, the strip had washed away. He attempted again and the strip again washed away. He then took a strip and dipped it into the dishwashing solution. The strip did not register any ppm reading. Dietary Aides 1, 2 and 3 were present washing dishes and indicated they had not tested the solution that day. The August 2025 Dish Machine Temperature Log indicated on 8/1, 8/2, 8/3 and 8/4 the wash temperature was 160 degrees Fahrenheit, and the rinse temperature was 150 degrees. The ppm column was blank. The current policy, Dishwasher Temperature, indicated, .4. For low temperature dishwashers (chemical sanitation): .b. The sanitizing solution shall be 50 ppm hypochlorite (chlorine) on dish surface in final rinse . and, .5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to discolored ceiling tiles, dirty ceiling vents, broken window curtains, peeling wallpaper around window sill, gouges in walls, and marred floors for 3 of 3 units. (Reflections, C-wing, and D-wing) Findings include:During the Environmental Tour on 8/7/25 at 3:21 p.m., with the Regional Maintenance Director and the Housekeeping Manager, the following was observed: 1. C-wing a. There were several ceiling tiles that were discolored and stained. b. The ceiling vents were dirty throughout the unit. c. The window curtain fasteners were broken in room [ROOM NUMBER]. There were two resident's residing in the room. d. In the lounge/common area, the window sills had peeling wallpaper underneath them. e. There were two large gouges in the wall across from the nurses' station. 2. D-wing a. The flooring in room [ROOM NUMBER] was marred and had black scuff marks throughout the room. There were two resident's residing in the room. 3. Reflections a. There were several ceiling tiles that were discolored and stained. b. The ceiling vents were dirty throughout the unit. During an interview with the Regional Maintenance Director and the Housekeeping Manager at the time, they both indicated the above were in need of cleaning and/or repair. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure infection control guidelines were in place and implemented, related to incorrect use of alcohol wipes during insulin administration for 1 of 1 resident observed for insulin administration and lack of physician's orders for contact isolation for 2 of 3 residents reviewed for transmission based precautions. (Residents 42, 39, and 14) Findings include: 1. During a medication pass observation on 8/5/25 at 11:06 a.m., RN 3 was observed preparing to administer an insulin injection for Resident 42. She performed hand hygiene and donned clean gloves. She opened the container holding the insulin lispro 100 unit/milliliter vial and wiped the top with an alcohol wipe. She used the same alcohol wipe and cleaned an area on the resident's abdomen to prepare the area for a subcutaneous injection. She then removed 24 units from the insulin lispro vial with a syringe and injected the medication into the resident's abdomen. During an interview on 8/5/25 at 11:36 a.m., RN 3 indicated she used the same alcohol swab for the insulin vial and to wipe the abdominal site because she had only brought one alcohol wipe with her. She usually used two separate wipes, but she didn't bring enough with her at the time so she just used one side for the vial and the other to wipe the resident's abdomen. The [NAME] President of Regulatory Compliance was made aware of the concern on 8/5/25 at 11:51 a.m. She had no further information to provide. A facility policy was requested and an applicable policy was not available. 2. On 8/6/25 at 1:30 p.m., Resident 39's room was observed to have a contact isolation sign posted at the entrance. Resident 39's record was reviewed on 8/7/25 at 2:00 p.m. The August 2025 Physician's Order Summary indicated the resident was on enhanced barrier precautions. A Physician Note, dated 7/23/25 at 4:24 p.m., indicated the resident was being seen for a follow-up of antibiotics as he continued to take vancomycin every Monday, Wednesday, and Friday with dialysis for 6 weeks total. The antibiotic course was ordered by a prior provider for left shoulder surgery with methicillin-resistant staphylococcus aureus (MRSA) bacterial infection. There were no physician's orders for contact isolation. There was no care plan related to contact isolation. During an interview on 8/7/25 at 2:30 p.m., the Infection Preventionist and Assistant Director of Nursing indicated the resident was on contact isolation for MRSA. There should have been an order for contact isolation. 3. Resident 14's record was reviewed on 8/7/25 at 2:04 p.m. A Progress Note, dated 7/14/25 at 3:51 p.m., indicated the resident arrived to the facility on a stretcher. He had a colostomy and suprapubic catheter. He was positive for Clostridioides difficile (C. difficile) infection (bacterial infection that causes diarrhea). A Physician Note, dated 7/17/25 at 4:03 p.m., indicated the resident was being treated with vancomycin until 7/25/25 for C. difficile. The resident was to be on isolation per the facility protocol. Per patient's report, he was still having diarrhea. The July 2025 Physician's Order Summary indicated the resident was on enhanced barrier precautions beginning on 7/15/25. There were no orders for contact isolation. During an interview on 8/7/25 at 2:39 p.m., the Infection Preventionist and Assistant Director of Nursing indicated there should have been an order for contact isolation due to the resident testing positive for Clostridioides difficile infection. The CDC Guideline for Isolation Precautions: Appendix A, indicated, .Infection: Clostridium difficile .Type of precaution: Contact + Standard .Duration of Precaution: Duration of illness . A facility policy titled, Transmission-Based (Isolation) Precautions indicated, .9. Initiation of Transmission-Based Precautions .b. An order for transmission-based precautions/isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. c. The order for transmission-based precautions/isolation will specify the type of precaution and reason for the transmission-based precautions. The duration will depend upon the infectious agent or organism involved . 3.1-18(b)

Based on record review and interview, the facility failed to ensure a care plan was developed and in place for a resident receiving an anti-anxiety medication for 1 of 33 residents reviewed for care plan development. (Resident 11)Finding includes:Resident 11's record was reviewed on 8/6/25 at 10:17 a.m. Diagnoses included, but were not limited to, fracture of the right femur, rheumatoid arthritis and generalized anxiety disorder. The admission Minimum Data Set (MDS) assessment, dated 6/27/25, indicated the resident was cognitively intact and was dependent for toileting, bed mobility and transfer assistance. The resident received anti-anxiety medications. A Nurse Practitioner Note, dated 7/30/25, indicated the resident's medications included chlordiazepoxide 5 milligram (mg) capsules, every 8 hours as needed for anxiety for 14 days. The current Physician Order Summary indicated clonazepam 5 mg every 12 hours for anxiety. There was no care plan related to anti-anxiety medication use. On 8/7/25, the Director of Nursing provided care plans related to a mood problem, psychotropic medication use and discharge planning. The care plans did not include any indication the resident was using anti-anxiety medications or interventions related to anxiety. During an interview on 8/7/25 at 3:37 p.m., the MDS Nurse indicated if a resident was taking an anti-anxiety medication, there should be an Anti-anxiety Medication Care Plan. 3.1-35(a)

Based on record review and interview, the facility failed to ensure interventions were attempted prior to administering a PRN (as needed) anti-anxiety medication for 1 of 3 residents reviewed for mood/behavior. (Resident 114)Finding includes:The record for Resident 114 was reviewed on 8/6/25 at 3:03 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, psychotic disorder with delusions, and anxiety disorder. The Significant Change Minimum Data Set (MDS) assessment, dated 7/16/25, indicated the resident was severely cognitively impaired. A Care Plan, updated on 11/8/24, indicated the resident used psychotropic medications related to psychotic disorder, depression, and anxiety.A Physician's Order, dated 7/10/25, indicated lorazepam (Ativan, an anti-anxiety medication) 1 mg (milligram), every 8 hours as needed for anxiety. A Physician's Order, dated 7/7/25, indicated hydroxyzine pamoate (an antihistamine medication also used to treat anxiety) 25 mg every 8 hours as needed for anxiety.The Medication Administration Record (MAR), dated 7/2025, indicated the lorazepam was administered without any prior interventions documented on the following dates and times:-7/11/25 at 10:15 a.m.-7/16/25 at 2:00 a.m., 10:07 a.m., and 6:12 p.m. The Medication Administration Record (MAR), dated 7/2025, indicated the hydroxyzine was administered without any prior interventions documented on the following dates and times:-7/7/25 at 2:27 p.m.-7/11/25 at 6:22 a.m.During an interview on 8/7/25 at 3:29 p.m., the Director of Nursing (DON) indicated she was unable to provide any further documentation. A policy on PRN medication administration was requested.A policy, titled PRN Medications, received from the DON as current, indicated .1. Documentation will be provided in the resident's medical record to show adequate indications for a medication's use and diagnosed condition for which it was prescribed.3. When administering a PRN medication.b. Document the reason voiced by the resident and/or assessment findings that show why the resident needs the medication. Verify the reason is for the prescribed indication for the medication. 3.1-48(a)(4)

Based on observation, record review and interview, the facility failed to ensure a dependent resident received the activities of daily living (ADL) assistance required related to dirty, uncut fingernails for 1 of 5 residents reviewed for ADL care. (Resident 144)Finding includes: On 8/4/25 at 10:21 a.m., Resident 144 was observed lying in his bed. He indicated he wasn't getting his scheduled showers and they hadn't cleaned his fingernails. He held up his hands and there was dark debris observed under his fingernails. On 8/8/25 at 1:32 p.m., the resident was again observed in his bed. He indicated he had received a bath, but they sill had not cleaned or cut his fingernails. His fingernails were slightly long and there was dark debris under his fingernails. The resident's record was reviewed on 8/8/25 at 1:08 p.m. Diagnoses included, but were not limited to, diabetes mellitus, congestive heart failure and osteoarthritis. The admission Minimum Data Set (MDS) assessment, dated 6/15/25, indicated the resident had moderate cognitive impairment and required substantial assistance for bed mobility and was dependent for transfers and toileting. The current ADL Care Plan indicated the resident had a self-care deficit and needed 1-2 person assistance with bathing and 1 person assistance with personal hygiene and oral care as needed, During an interview on 8/8/25 at 1:34 p.m., the MDS Nurse indicated that she would take care of his fingernails. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter collection bag and tubing for a resident with a history of infection was kept off the floor for 1 of 2 residents reviewed for urinary catheters. (Resident 91)Finding includes:On 8/4/25 at 11:40 a.m., Resident 91 was observed lying in bed. The resident's urinary catheter bag was resting on the floor next to the bed.On 8/6/25 at 3:06 p.m., Resident 91 was observed lying in bed. The resident's urinary catheter bag and tubing were resting on the floor next to the bed.Record review for Resident 91 was completed on 8/6/25 at 3:02 p.m. Diagnoses included, but were not limited to, end stage renal disease, neurogenic bladder, and hypertension.The Annual Minimum Data Set (MDS) assessment, dated 5/23/25, indicated the resident was dependent on staff with bed mobility and transfers. The resident had an indwelling urinary catheter. A Care Plan, dated 5/17/24, indicated the resident was incontinent of bowel and had an indwelling catheter present. An intervention included to keep the drainage bag of the catheter below the level of the bladder at all times and off the floor.A Physician's Note, dated 6/6/25 at 4:16 p.m., indicated a wound culture of the resident's suprapubic catheter site had MRSA (methicillin-resistant staphylococcus aureus) infection. The resident was to be started on the antibiotic Bactrim for the infection.During an interview on 8/6/25 at 3:08 p.m., RN 2 indicated the resident's catheter bag and tubing should not have been on the floor and she would fix it.A policy for catheter care was requested but was not provided by the facility.3.1-41(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen administration for 1 of 2 residents reviewed for respiratory care. (Resident 2)Finding includes: On 8/4/25 at 2:26 p.m., Resident 2 was observed sitting in a wheelchair in his room. He had a portable oxygen tank attached to the back of the wheelchair. The oxygen was on via a nasal cannula and set at 4 liters.On 8/6/25 at 10:43 a.m., Resident 2 was observed propelling himself down the hallway. He had a portable oxygen tank attached to the back of his wheelchair. The oxygen was on via a nasal cannula and set at 2 liters. Record review for Resident 2 was completed on 8/6/25 at 10:53 a.m. Diagnoses included, but were not limited to, atrial fibrillation, hypertension, chronic obstructive pulmonary disease and respiratory failure.The Annual Minimum Data Set (MDS) assessment, dated 6/18/25, indicated the resident was cognitively intact. The resident had impairment on both sides of his upper and lower extremities for a functional limitation in range of motion. The resident was dependent on staff for upper body dressing, personal hygiene, bed mobility, and transfers. The resident received oxygen therapy.A Care Plan, dated 11/6/24, indicated the resident had emphysema, chronic obstructive pulmonary disease, and respiratory failure. An intervention included for oxygen via nasal prongs as ordered. A Physician's Order, dated 5/8/25, indicated, may provide oxygen at 3 liters via nasal cannula if oxygen saturations are below 90% every shift.The August 2025 Medication Administration Record (MAR) indicated the oxygen order for 3 liters was checked off as administered for every shift. The residents' oxygen saturation for every shift was documented with percentages above 90%.The record lacked any documentation about how much oxygen the resident was supposed to receive if the oxygen saturation was above 90%.During an interview on 8/6/25 at 11:02 a.m., RN 1 indicated the resident was supposed to be on 3 liters of oxygen. The resident had continuous oxygen therapy, and the order would have to be clarified. During an interview on 8/6/25 at 11:11 a.m., the [NAME] President of Regulatory Compliance (VPRC) indicated the order would have to be clarified with the Physician of how much oxygen the resident was supposed to be on.A Policy titled, Oxygen Administration and received as current from the VPRC, indicated, .1. Oxygen is administered under orders of physician. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a narcotic pain medication was obtained and administered as ordered and PRN (as needed) medications were accurately recorded as dispensed on the Medication Administration Record for 1 of 5 closed records reviewed. (Resident 152)Finding includes: During an interview on 8/5/25 at 3:12 p.m., a family member indicated the resident had stage 4 lung cancer and had pain issues. She indicated all the medications the resident had received were prn (as needed), and the resident had difficulty asking for them. She was concerned he was having pain during his stay. The closed record for Resident 152 was reviewed on 8/8/25 at 1:50 p.m. Diagnoses included, but were not limited to, malignant neoplasm of the left bronchus and Hodgkin's lymphoma. The resident was on hospice services. A General Note dated 7/31/25, indicated the resident had arrived at the facility. He was alert and oriented with some confusion noted. The resident was admitted to the facility on [DATE] for a respite stay. He was discharged back to home on 8/5/25. A Physician's Order, dated 7/31/25, indicated to apply a Fentanyl patch (opioid pain medication), 50 micrograms (mcg) every 72 hours for pain. The August 2025 Medication Administration Record (MAR) indicated the Fentanyl patch was due on 8/2. The patch was not given. A Medication Note indicated the patch was on order. The patch was due again on 8/5 and not given. A Medication Note indicated it was not available. There were no progress notes that indicated the family or the pharmacy had been contacted regarding the missing medication. During an interview on 8/8/25 at 2:40 p.m., the Administrator indicated their pharmacy was located in Indianapolis. If a medication was not available in the facility supply, they could order it stat from the pharmacy and it would be delivered within 4 hours. During an interview on 8/8/25 at 4:15 p.m., the Director of Nursing indicated the family was supposed to bring the medication from home. There was no additional information provided why the family or pharmacy had not been contacted when the medication was unavailable. A Physician's Order, dated 7/31/25, indicated to give morphine sulfate 20 milligrams (mg)/ 1 milliliter (ml), 0.25 ml every 2 hours as needed for pain. A Physician's Order, dated 8/1/25, indicated to give lorazepam (an anti-anxiety medication) 2 mg/1 ml, 0.25 ml every 4 hours as needed. The July 2025 MAR indicated the resident had not received any PRN morphine sulfate. The August 2025 MAR indicated the resident was given morphine sulfate once a day on 8/2, 8/3, 8/4 and 8/5. The Narcotic Reconciliation sheet indicated morphine sulfate had been given on 8/1, 8/2 x 3, 8/3 x 3, 8/4 x 3 and 8/5 x 5. The July 2025 MAR indicated the resident had not received any PRN lorazepam. The August 2025 MAR indicated the resident was given lorazepam 0.25 ml once a day on 8/2, 8/3, 8/4 and 8/5. There was no documentation lorazepam tablets had been ordered or given. The Narcotic Reconciliation sheet indicated nine lorazepam tablets had been delivered on 7/31/25. There were no instructions on the Narcotic Reconciliation sheet related to the medication. They were administered on 8/1, 8/2 x 3, date unreadable x 1 and 8/4 x 2. The Narcotic Reconciliation sheet indicated lorazepam 0.25 ml had been given on 8/4 x 2 and 8/5 x 4. During an interview on 8/8/25 at 3:49 p.m., the Director of Nursing indicated the nurses were only documenting medication use on the reconciliation sheets and should have documented on the MAR. Policies were provided but did not pertain. 3.1-25(a)3.1-25(a)(3)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 8 residents observed during medication administration. Two medication errors were observed during 27 opportunities for error in medication administration. This resulted in a medication error rate of 7.41%. (Resident 41) Finding includes: On 8/6/25 at 9:15 a.m., RN 1 was observed preparing Resident 41's medications. She placed aspirin 81 milligram (mg) enteric coated tablet, Certavite/multivitamin tablet, clopidogrel 75 mg tablet, escitalopram 5 mg tablet, levetiracetam 500 mg tablet, lisinopril 20 mg tablet, and metoprolol succinate extended-release 25 mg tablet into medication bags and crushed the medications. She then administered the crushed medications mixed with applesauce. Resident 41's record was reviewed at 9:20 a.m. The current August 2025 Physician's Order Summary indicated aspirin 81 mg chewable tablet once daily and metoprolol succinate extended release 25 mg once daily. During an interview on 8/6/25 at 10:58 a.m., RN 1 indicated that the aspirin and metoprolol medications should not have been crushed since they were enteric coated and extended-release medications. She indicated the medications were sent from pharmacy and the pharmacy did not take into account what form the resident required the medications to be in, such as crushed, for safe administration. The [NAME] President of Regulatory Compliance was notified of the concern on 8/6/25 at 11:31 a.m. and had no further information to provide. A policy titled, Medication Administration, indicated, .17. Administer medication as ordered in accordance with manufacturer specifications . c. Crush medications as ordered. Do not crush medications with do not crush instructions . 3.1-48(c)(1)

Based on record review, observation, and interview, the facility failed to protect a cognitively impaired resident's rights to be free from physical abuse for 1 of 2 residents reviewed for abuse. (Residents B and C). This deficient practice resulted in Resident B sustaining swelling with discoloration injuries to the bilateral eyes and left wrist, a laceration on the right toe, and a laceration on the right ankle that required six sutures to repair. Finding includes: A Facility-Reported Incident (FRI), dated 12/29/24, indicated the following: .Incident date: 12/29/24 Incident time: 9:30 a.m. Description added -12/29/24 Nurse observed [Resident B] with blood on the foot part of the bed, with an open area noted to right ankle, 2 cm [centimeters] X 0.3 cm, right toe with open area 0.9 cm X 0.3 cm, right eye swollen, left eye discoloration noted, and swelling to left wrist noted upon full assessment. When asked [Resident B], BIM [Brief Interview of Mental Status] 5 [cognitively impaired] was asked what happened he pointed to roommate [Resident C], BIM 15 [cognitively intact]. Assessment completed of [Resident C] denies the allegation but bruising was noted to both of his hands. Action Taken added -- 12/29/2024 Residents put on 1 to 1 [one-to-one] until resident [Resident B] was sent to hospital for evaluation. Full assessment done on both residents, including neuro checks. Both doctors and families were notified . Type of injury added -- 12/29/2024 Injuries noted to [Resident B] as described and [Resident C] noted with bruising to hands upon assessment . Type of preventative measures added -- 12/29/2024 Investigation initiated: 1 to 1 staff initiated with residents. Social services notified. Residents both deny any pain, discomfort and no signs and symptoms of psychosocial distress or changes. Manager on duty notified and follow up in place. Care plans to be updated. Police to be notified due to allegation. Interviews of staff and residents will be conducted. Safety precautions in place A local Police Department Report, dated 12/29/24, indicated the following: The Police Department responded to the facility on [DATE] at 10:38 a.m. for a battery report.Upon arrival I was met by the Nursing Manager [Alzheimer's Unit Director] who advised that they needed to report an attack on a patient [Resident B]. The [Alzheimer's Unit Director] reported that the attack was discovered that morning by [CNA 1] while making rounds. [Resident B] was transported by medics to [Hospital] at least an hour prior to notifying police and not currently on scene. [Resident B] is said to suffer from a stroke and dementia making him nearly nonverbal. [CNA 1] located [Resident B] with a pool of blood under his leg, observed a black eye and swelling to his forehead along with a knot on his wrist. She then observed what appeared to be a puncture wound near his ankle and a small laceration to his toe. Although [Resident B] is nonverbal they asked him who did this causing him to point at his roommate [Resident C]. They advised that [Resident C] claimed that he did not do anything but also did not know what happened. [Resident C] is said to not be able to walk however his bed was on the lowest setting to the floor and they observed what appeared to be bruising and redness to his palms. Although [Resident C] can not [sic] walk they believe that he is able to pull himself from his bed and back again without the use of his legs. The [Alzheimer's Unit Director] advised that she looked through [Resident C's] belongings and the only weapons she located was that of a small [NAME] folding pocket knife [sic] and a pair of scissors; both of which were collected by her and secured in her office before my arrival. Due to the time lapse, the scene was already cleaned up and the sheets were removed from [Resident B's] bed before my arrival. Prior to being transported staff took photographs of [Resident C's] injuries which were forwarded to my department mail and uploaded .I further took photographs of the room, [Resident C], and his hands. [Resident C] claimed he did not know what happened nor did he see anyone enter the room prior to [CNA 1] this morning. He also advised that he has been roommates with [Resident B] for approximately 2 months and only had issues with him being loud but nothing recently. I collected and photographed the knife and scissors from [Alzheimer's Unit Director]. Both were secured and placed in an evidence locker at the police station .I attempted to follow up with [Resident B] at hospital however nursing staff advised that he was medicated at this time and that he was not able to speak with me . The record review for Resident C was completed on 1/2/25 at 3:01 p.m. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), heart failure, anxiety, dementia, and depression. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 12/2/24, indicated the resident was cognitively intact. The resident had no mood problems, behaviors, or indicators of psychosis. The resident had impairment on both sides of his lower extremities with functional limitation in range of motion (ROM). The resident was dependent on staff for transfers from his bed to his wheelchair. A Care Plan, dated 10/22/24 and revised 11/4/24, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to decreased mobility, COPD, dementia, anxiety, heart failure, and major depressive disorder. The resident required assistance with ADL care, transfers, and bed mobility. The resident would often stay in bed and decline to get up. The progress notes, assessments, and care plans, dated September 2024 through 12/29/24, did not include any documentation to indicate Resident C had any prior behaviors or altercations with Resident B. The record review for Resident B was completed on 1/3/25 at 12:04 p.m. Diagnoses included, but were not limited to, paranoid schizophrenia, hemiplegia (partial paralysis on one side of body) following a stroke, altered mental status, and vascular dementia with behavioral disturbance. The Quarterly MDS assessment, dated 9/23/24, indicated the resident was severely cognitively impaired for daily decision making. The resident had difficulty focusing attention, was easily distracted or had difficulty keeping track of what was said. There were no indicators of psychosis. The resident had an impairment on one side of his upper and both sides of his lower extremities with functional limitation in ROM. The resident was dependent for transfers from his bed and required a partial to moderate assistance for bed mobility. The resident had clear speech, was able to make self understood, and a clear comprehension ability to understand others. He had inattention behavior that was continuously present. A Care Plan, dated 10/11/24, indicated the resident had impaired cognitive function related to vascular dementia. An intervention included to ask yes or no questions in order to determine the resident's needs. A Care Plan, dated 10/14/21 and revised 4/10/24, indicated the resident had a physical functioning deficit related to mobility impairment, right dominant side hemiplegia. The resident preferred to stay in bed. The resident required assistance of one to two people for bed mobility and transfer assistance. A Progress Note, dated 12/29/24 at 8:35 a.m., indicated, .Writer was call [sic] into the room by other nurse on shift and CNA. Writer observed resident has a pool of blood by his feet, a cut to his right ankle approximately 2 cm x 0.5 cm, a cut on right foot to the small toe approximately 0.9 cm x 0.3 cm, right eye with some discoloration, left eye swollen with some discoloration, and left wrist warm to touch, discolored, and tender to touch. Resident was asked who did it. Resident pointed to the roommate [Resident C] .911 called, MD notified, PRN pain medication given, resident place on 1:1, Neuro checks implemented. An After Visit Summary from the Emergency Department, dated 12/29/24, indicated Resident B was seen in the emergency room after an assault. The resident had a CT (computed tomography, computerized x-ray) of his head, cervical spine and facial bones. There was no acute fracture or dislocation. The CT facial bones showed possible left periorbital and maxillary cellulitis; however, he had a black eye and no cellulitis. There was an x-ray completed of the left wrist and right hip. The wrist x-ray showed an old navicular fracture. The right hip x-ray did not show an acute fracture or discoloration. The foot x-ray was negative for acute fracture. There was a laceration to his right heel, and it was repaired with 6 sutures. A follow up from the FRI from 12/29/24, dated 1/3/25, indicated the following: . [Resident B] had injuries sustained after an alleged assault from resident [Resident C]. There were no witnesses to the event. The police were called on 12/29/24 and a report was generated. [Resident C] was noted with bruising to his hands but denied the assault allegation. He stated the bruising was from a small chain that he swings around his hand. The [Resident C] is able to move out of bed but there have been no incidents with the [Resident C] that involved any type of abuse of assault. Both residents were sent to the hospital for evaluation and monitored 1:1 until they were moved. Both were put in separate rooms and ultimately [Resident B] was sent to another facility per families [sic] prior request. Witness statements were taken from staff and there were no reported abuse or witnesses from residents. Upon investigation [Resident C] appears to have been the perpetrator of the assault. The State surveyors are currently in the facility and reviewing this incident . During an interview on 1/3/25 at 9:09 a.m., the Administrator indicated she was called on 12/29/24 at 9:37 a.m. and told of Resident B's injuries. The nurse reported to her that Resident B was being sent out to the emergency department. CNA 1 did her rounds around 7:00 a.m., and Resident B was fine. CNA 1 then went back into the room at around 8:30 a.m. and saw Resident B had blood in his bed on his sheets and a had black eye. CNA 1 asked Resident B what happened and Resident B pointed to his roommate, Resident C. The Administrator then interviewed Resident B and asked him if Resident C did this, and Resident B pointed to Resident C. She asked if Resident C had ever touched him before and he shook his head no. She indicated CNA 1 told her the first time she did rounds, Resident C's bed was in a high position. The second time she came back in, Resident C's bed was in a low position. Resident B could not get out of bed by himself, but she believed that Resident C could transfer himself out of his bed and into his wheelchair independently. There were no prior incidents between Resident B and C that were reported to her. The Administrator interviewed Resident C and observed redness to his hands. He told her it was from a beaded chain that he would wrap around his hands. Resident C denied the allegations and said he did not know what happened. She told the resident they were going to have to find a different place for him. The resident told her he wanted to go to a different nursing home. The Administrator indicated an outside entity staff member had also interviewed Resident C. The outside entity staff member told the Administrator that Resident C said he had hit Resident B with a reacher (handheld tool designed to extend your reach allowing to grip objects out of arm's length). The Administrator interviewed other residents in the surrounding areas and no other residents heard or saw anything happen. She believed since the resident's bed was in a low position when CNA 1 came back into the room that Resident C had gotten out of bed and possibly assaulted Resident B since that was what he told the outside entity staff member. She was unsure why Resident C would assault Resident B since there were no prior incidents. There were no residents in the area who had behaviors or would have wandered into the room. Resident B was discharged to a different facility per the family's request and Resident C was on one-to-one supervision until he was discharged to a different facility. During an interview on 1/3/24 at 9:39 a.m., CNA 1 indicated she had made her first rounds around 6:45 a.m. Both Resident B and Resident C were in bed. Resident C's bed was in a high position. Resident C's wheelchair was about three feet away from his bed. She then came back around 8:00 a.m., to deliver the resident's breakfast trays. CNA 1 delivered Resident C's tray first. He was in his bed and awake. She then proceeded to give Resident B his tray. She saw Resident B's face swollen and bruised and blood all over the foot of the bed. Resident B appeared to have been crying. CNA 1 indicated there was so much blood on the bed, and she was unsure where it was coming from. She asked the resident who did this and Resident B then pointed to Resident C. She immediately called the nurse for help. CNA 1 indicated Resident B did not really communicate, he would be able to say yes or no but did not talk much. He mostly made sounds. She had not heard any sounds coming from the room prior to going in. Resident B would not be able to get in and out of bed on his own. Resident C could get out of bed on his own but rarely ever did. CNA 1 did not observe any blood on Resident C or his clothing, but indicated his palms had a blue discoloration. Resident C had a metal fidget [NAME] and plastic reacher with a a metal end on his bedside table. She did not observe any blood on the objects at the time. CNA 1 indicated she was not aware of any previous behavioral issues between the residents prior to the incident. During an interview on 1/3/24 at 9:51 a.m., CNA 2 indicated CNA 1 had called her to come into the room approximately around 8:25 a.m., while she was passing resident breakfast trays. Resident C was in his bed with the curtain closed. She did not observe any discolorations or blood on Resident C. Resident B was observed in bed with a black eye and blood on the bed towards his feet. When Resident B was asked how this happened to him, he pointed towards Resident C. CNA 2 did not work with Resident B or Resident C often and was unaware of any prior behavioral incidents between the two residents. The staff helped clean up Resident B before paramedics arrived. During an interview on 1/3/25 at 10:07 a.m., CNA 3 indicated she was called into the residents' room. CNA 1 was in the room. Resident B was in bed with discolorations on his face and blood on the bed. CNA 1 asked him who did this to him and Resident B pointed to Resident C. Resident C just had a blank face and didn't say anything. She didn't observe any discolorations or blood on Resident C. She indicated Resident C could get out of bed on his own if he wanted to. She was working on the opposite hall on the unit that morning and did not see anyone go into the room. CNA 3 indicated she was not aware of any previous behavioral issues between the residents prior to the incident. During an interview on 1/3/25 at 10:11 a.m., Dietary Aide 1 indicated he had delivered the room cart to the unit that morning. He did not see or hear anything out of the ordinary. During an interview on 1/3/25 at 10:51 a.m., LPN 1 indicated she was passing medications on the unit when she was called into the residents' room by RN 1. Resident B was lying in bed with a pool of blood by his feet. His face was discolored, and his eye was swollen. She indicated the resident didn't communicate and when asked what happened, he then pointed to his roommate Resident C. LPN 1 observed bruising on Resident C's hands but could not recall where on the hands. Resident C had a reacher on his bedside table, but she did not notice any blood on the reacher or on Resident C. LPN 1 had last been in the room at 7:00 a.m., and both residents were in bed. Resident B was asleep, and she could not recall if Resident C was awake or asleep. LPN 1 indicated she was not aware of any previous behavioral incidents with the residents prior to the incident. During an interview on 1/3/25 at 10:58 a.m., RN 1 indicated she was passing medications on a different hallway. She was not the residents' nurse that day, but CNA 1 called her at approximately 8:30 a.m. because LPN 1 was busy with another resident. When she walked into the room, she saw that Resident B had a lot of blood on the bed. He had a discoloration to his eye. She then called LPN 1 to come into the room. They assessed the resident, cleaned him up and asked who hurt him. Resident B then pointed to his roommate Resident C. RN 1 indicated the paramedics also asked Resident B who injured him, and Resident B pointed to Resident C. She asked Resident C what happened, and he indicated he did not know. She asked Resident B if anyone else came into the room and he said he didn't know. Resident C was assessed, and he had bruising observed on the palm side of his hands. RN 1 did not observe any blood on Resident C. She was unaware of any behavioral incidents with the residents prior to the incident. During an interview on 1/3/25 at 12:17 p.m., the Alzheimer's Unit Director ([NAME]) indicated she was the Manager on Duty when the incident occurred. She was made aware of the situation that happened. Resident B had already been sent to the hospital at that time. She asked if any of the staff had searched for any weapons in the room and they told her they had not. She then proceeded in to search the room. She asked Resident C if he had any weapons. He told her he had a pocketknife in his wallet in a drawer to his nightstand. The resident reached over and retrieved the wallet and gave her the knife. She did not observe any blood on the knife. There was also a pair of scissors in a shaving package underneath his television. The [NAME] retrieved them and there was no blood observed on the scissors. She did not observe any discolorations or blood on Resident C. She was in the room when the police arrived and questioned Resident C. The police asked him what happened to his roommate. Resident C said he did not know. The police officer asked him if anyone else came into their room and the resident indicated he didn't see anyone because his curtain was closed. The police officer then went and got pictures from the nurse, came back 15 minutes later and said he needed to take pictures of Resident C's hands because the nurse said he had bruising. The police officer did not say anything to her related to if he saw any bruising. The police officer took the pictures, the pocketknife and the scissors. The [NAME] was unaware of any behavioral problems with the residents prior to the incident. During an interview on 1/3/25 at 12:31 p.m., the Social Services Director (SSD) indicated Resident C was admitted to the facility several years ago. He was living with his sister and mother, and they could no longer provide care for him. He was unable to care for himself. He had been roommates with Resident B since September 2024 and the only problem she heard about was that Resident C was complaining that Resident B's television was too loud. The SSD provided Resident C with headphones and there were no further complaints. Resident C did receive psychiatric services in the past but would often refuse. Resident C indicated he did not like talking with the therapists and had not seen psychiatric services in a long time. The resident did not take any psychotropic medications and was not currently on any behavioral monitoring. There were no prior behavioral incidents of physical aggression that were reported for which precautions would have to be put into place prior to the incident with Resident B. A facility policy titled, Abuse, Neglect and Exploitation and received as current from the Administrator on 1/3/25, indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property .V. Investigation of Alleged Abuse, Neglect and Exploitation . B. Written procedures for investigations include: . 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence) . This citation relates to Complaints IN00450120 and IN00450272. 3.1-27(a)(1)

Based on record review & interview, the facility failed to implement a complete discharge planning process and ensure that the discharge needs of each resident were identified and met related to lack of ongoing Physician follow up for an abnormal wound culture result, indicating an infection, prior to discharge from the facility, for 1 of 3 residents reviewed for skin conditions. (Resident B) The deficient practice was corrected by 7/31/24, prior to the start of the survey, and was therefore past noncompliance. The facility investigated the delay in treatment following the receipt of abnormal wound culture results, completed audits for all wound cultures in the last 90 days, educated all nursing staff on the policy for wound culture tracking and notifications, and implemented a Laboratory Tracking Log. Finding includes: Resident B's closed record was reviewed on 8/1/24 at 10:57 a.m. Diagnoses included, but were not limited to, motor vehicle injury, fracture of upper end of left humerus, fracture of medial condyle of left femur, fracture of left side rib, and insomnia. The Admission Minimum Data Set (MDS) assessment, dated 7/9/24, indicated the resident was cognitively intact for daily decision making. There was an impairment to the upper and lower left extremities. He required substantial assistance for hygiene and transfers. A Care Plan, dated 7/8/24, indicated the resident had altered skin integrity, non-pressure skin conditions related to a traumatic wound to the left medial knee. Interventions included, but were not limited to, conduct weekly skin inspections, monitor for signs and symptoms of infection such as swelling, redness, warmth, discharge, or odor, and notify physician of significant findings. A Nurses' Note, dated 7/8/2024 at 11:48 a.m., indicated the resident had a traumatic wound to the left knee measuring 8 centimeters (cm) by 4.5 cm. A Physician's Order, dated 7/10/24, indicated to obtain a wound culture to the traumatic wound on the resident's left medial knee. A Nurses' Note, dated 7/10/24, indicated the resident had a change of condition. Redness, warmth, and swelling was noted to the left lower extremity surrounding the wound to the left medial knee. The wound was cleansed with wound cleanser, serous drainage was noted from wound, and then sampled with a wound culture swab in a sterile manner. A Nurses' Note, dated 7/16/2024 at 3:12 p.m., indicated the Physician was informed of the wound culture results. No new orders at this time. Awaiting new orders at this time. The resident and the Power of Attorney (POA) were informed. The Wound Culture report, undated with the sample collected on 7/10/24, indicated the left medial knee wound had many enterobacter cloacae (gram-negative bacteria) and many staphylococcus aureus (gram-positive bacteria). There were moderate gram negative bacilli, moderate gram positive cocci, rare white blood cells, and rare epithelial cells. The McGreer's Definitions for Healthcare Associated Infections for Surveillance for Long Term Care Facilities indicated the following criteria: SKIN AND SOFT TISSUE INFECTION Cellulitis/soft tissue/wound infection One of the following criteria must be met: 1. Pus present at a wound, skin, or soft tissue site. (OR) 2. The resident must have four or more of the following signs or symptoms: - fever (>38 C) or worsening mental/functional status; and/or the presence of new or increasing (at the affected site): - heat - redness - swelling - tenderness or pain - serous drainage A Nurses' Note, dated 7/23/24 at 10:45 a.m., indicated the resident was discharged home with family, medications and instructions were received, and the resident and family acknowledged understanding. No concerns were voiced at the time. There was no further follow up regarding the abnormal wound culture results or orders received prior to discharge. A Nurses' Note, dated 7/24/24 at 7:17 a.m., indicated an antibiotic was ordered for discharged Resident B by the Nurse Practitioner (NP) and sent to an outside pharmacy. During an interview on 8/2/24 at 12:30 p.m., the Interim Administrator indicated the nurse who put in the note had a language barrier, which was the reason for the note that said there were no orders and also awaiting orders. The Physician was notified of the wound culture and there were no new orders at the time. The NP sent in an order for the antibiotic to appease the family, as they called the facility the day after the resident's discharge requesting antibiotics. There was no other follow up until the facility received the communication from the family and the facility had since implemented a corrective plan of action related to this incident. An Ad Hoc QAPI, dated 7/31/24, was received on 8/2/24 at 12:45 p.m. from the Director of Nursing, and indicated the identified opportunity for improvement/deficient practice was delay in treatment following receipt of culture results. The facility completed audits for all wound cultures in the last 90 days to check for any outstanding results or follow up that was needed. All nursing staff was educated on the policy for wound culture tracking and notifications. The Laboratory Tracking Log included Resident B, who had a wound culture completed on 7/10/24. The wound culture resulted on 7/14/24 and were abnormal results. The action taken was placing an order sent to an outside pharmacy. A Policy titled, Wound Cultures, indicated .1. A wound will only be cultured in accordance with a physician order, when signs and symptoms of infection are present .6. Notify physician of initial and final culture results. This citation relates to Complaint IN00439994. 3.1-12(a)(19)

Based on record review and interview, the facility failed to ensure medications were managed appropriately related to medications not signed out and given as ordered for 2 of 3 residents reviewed for unnecessary medications. (Residents B and G) Findings include: 1. Resident B's closed record was reviewed on 8/1/24 at 10:57 a.m. Diagnoses included, but were not limited to, motor vehicle injury, fracture of upper end of left humerus, fracture of medial condyle of left femur, fracture of left side rib, and insomnia. The Admission Minimum Data Set (MDS) assessment, dated 7/9/24, indicated the resident was cognitively intact for daily decision making. There was an impairment to the upper and lower left extremities. He required substantial assistance for hygiene and transfers. A Physician's Order, dated 7/3/24 at 9:00 p.m., indicated Xanax (an anti-anxiety medication) extended release 1 milligram oral tablet once daily. The July 2024 Medication Administration Record indicated Xanax was not marked as administered from 7/3/24 thru 7/9/24. A Nurses' Note, dated 7/4/24 at 10:48 a.m., indicated the resident's son stated the resident had not received Xanax during his hospital stay and did not want the resident to take it any longer. A Nurses' Note, dated 7/15/24 at 12:53 p.m., indicated the Nurse Practitioner reviewed the medication list and a new order was received to discontinue Xanax, melatonin, Ambien (a sedative), and hydroxyzine (an antihistamine). During an interview on 8/2/24 at 12:30 p.m., the Interim Administrator indicated the medication was not available, but the family had also requested the medication be discontinued from use. There was no documentation in the resident's record to indicate the NP or Physician was contacted by facility staff regarding discontinuing the Xanax prior to 7/15/24. 2. Resident G's record was reviewed on 8/1/24 at 2:14 p.m. Diagnoses included, but were not limited to, local infection of the skin and subcutaneous tissue, high blood pressure, and type 2 diabetes mellitus. The Admission Minimum Data Set, dated dated [DATE], was still in progress. A Care Plan, dated 7/17/24, indicated the resident had a wound infection. Interventions included, but were not limited to, administer antibiotic therapy as per order until 8/13/24. The July 2024 Physician's Order Summary (POS) indicated the resident received the following antibiotic intravenous medications: - Cefazolin sodium solution reconstituted 2 grams every 8 hours until 8/13/24 - Ceftriaxone sodium solution reconstituted 2 grams once a day for 10 days - Vancomycin solution 1 gram once a day for 10 days The July 2024 Medication Administration Record (MAR) indicated the following medications were not administered as ordered: - Cefazolin was not marked as administered on 7/15/24 at 10:00 p.m. and 7/26/24 at 2:00 p.m. The corresponding Nurses' Note indicated the medication was on order. - Ceftriaxone was not marked as administered on 7/30/24 at 12:00 p.m. The corresponding Nurses' Note indicated the medication was on order. - Vancomycin was not marked as administered on 7/30/24 at 6:00 a.m. The corresponding Nurses' Note indicated the medication was on order. During an interview on 8/2/24 at 1:11 p.m., the Interim Administrator indicated she had no further information related to the antibiotics not signed out as administered. This citation relates to Complaint IN00439994. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to dirty and greasy food equipment, an accumulation of dust on fan blades, food spillage, lack of hair restraints, touching food with gloved hands after touching other items, and the dishwasher gauge not functioning for 1 of 1 kitchen observed. (The Main Kitchen). This had the potential to affect 137 residents who received food from the kitchen. Findings include: 1. During the Kitchen Sanitation Tour on 6/10/24 at 9:10 a.m. with the Dietary Food Manager (DFM), the following was observed: a. A bag of noodles, located in the dry storage room, was not fastened. Loose noodles were observed on the shelves and on top of food boxes. b. The upper shelf located on the oven had an accumulation of crumbs and dust. c. There was an accumulation of dust and dried food spillage on the front of the convection oven. d. A large orange fan, located on a shelf in the dish room, had an accumulation of dust on the fan blades and fan cover. The fan was in use at that time and blowing directly towards clean dishes. e. The dishwasher was identified as being high temperature by the DFM. The final rinse temperature gauge did not move during the rinse cycle and registered at 140 degrees Fahrenheit. There was also no plastic cover over the gauge. The June 2024 Dish Machine Temperature Log indicated the final rinse cycle registered 140 degrees Fahrenheit for the noon and evening meal on 6/9 and the breakfast meal on 6/10/24. During an interview at that time, the DFM indicated he would call someone out to look at the dishwasher. 2. On 6/10/24 at 11:06 a.m., Dietary Employee 1 was observed to donn a pair of clean gloves and proceeded to the walk in refrigerator. He exited the refrigerator with a bag of lettuce. He opened the bag of lettuce and put some on a plate, he then obtained a knife and a boiled egg. He held the boiled egg with his gloved hand while slicing it. He did not change gloves prior to doing this. The Dietary Employee was not wearing a beard guard while preparing the salad. During an interview at that time, the DFM indicated the above was in need of cleaning and the Dietary Employee should have been wearing a beard guard and changed his gloves prior to touching the boiled egg. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a sanitary environment was maintained related to an accumulation of dust and debris on floors, piping, and fan blades, as well as loose and detached base boards for 1 of 1 kitchen areas. (The Main Kitchen) Findings include: During the Kitchen Sanitation Tour on 6/10/24 at 9:10 a.m. with the Dietary Food Manager (DFM), the following was observed: a. The wall located behind the convection oven and the oven had an accumulation of dust and debris along the base of the wall. The white pipes located behind the convection oven and oven had an accumulation of dried food spillage. b. The ceiling vent located in between the steam table and the exit door to the kitchen had an accumulation of dust. c. A fan, anchored to the wall in the dish room, had an accumulation of dust on the fan blades and fan cover. The fan was not in use at the time. d. The base board located underneath the eye wash sink in the dish room was loose in some sections and pulled away from the wall. During an interview at that time, the DFM indicated all of the above was in need of cleaning and/or repair. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure dependent residents received help with Activities of Daily Living (ADLs) related to build up on teeth for 1 of 7 residents reviewed for ADLs. (Resident 54) Finding includes: On 6/10/24 at 10:38 a.m., Resident 54 was observed sitting in bed. The resident's mouth was dry and crusty. His teeth were noted to be discolored and had build up on them. On 6/11/24 at 2:39 p.m., Resident 54 was observed sitting in bed. His mouth was dry and crusty when he opened it. His teeth were discolored and had build up on them. On 6/13/24 at 3:59 p.m., Resident 54 was observed in bed. His mouth was dry and crusty. His teeth were discolored and had build up on them. Resident 54's record was reviewed on 6/11/24 at 3:50 p.m. Diagnoses included, but were not limited to, cerebral infarction and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/19/24, indicated the resident was severely cognitively impaired. He was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. A Care Plan, dated 7/27/23, indicated the resident had an ADL self-care deficit related to weakness, history of a cerebral infarction, chronic respiratory failure, status post tracheostomy removal. Interventions included, but were not limited to, oral care assistance as needed. A Care Plan, dated 5/10/24, indicated the resident was at risk for dental problems related to discolored teeth and the resident was dependent on staff for oral care. Interventions included, but were not limited to, assist with oral care as ordered and as needed. A Physician's Order, dated 5/13/24, indicated oral care every shift. The June 2024 Medication Administration Record (MAR) indicated oral care was signed off as completed every shift. During an interview on 6/13/24 at 3:48 p.m., CNA 1 indicated the resident received oral care by wiping his mouth with a foam swab dipped in mouth wash. She had never brushed his teeth with a toothbrush. During an interview on 6/14/24 at 10:18 a.m., the Nurse Consultant indicated the resident was unable to follow commands to swish water or spit. She had no further information to provide. 3.1-38(a)(3)(C)

Based on record review and interview, the facility failed to ensure residents with impaired vision received the necessary services for 1 of 1 resident reviewed for vision. (Resident 70) Finding includes: During an interview on 6/10/24 at 2:49 p.m., Resident 70 indicated he needed to get his cataracts checked. He had an appointment set up over a year ago, but it was canceled. Resident 70's record was reviewed on 6/12/24 at 8:56 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and hyperlipidemia. The Quarterly Minimum Data Set assessment, dated 3/13/24, indicated the resident was cognitively intact. His vision was listed as adequate with no corrective lenses. A Progress Note, dated 1/27/23, indicated the resident had received a referral for a cataract evaluation from the optometrist. The appointment was scheduled for 2/7/23. A Progress Note, dated 2/3/23, indicated the resident wanted to cancel his scheduled eye appointment due to the cold weather and would like to reschedule when the weather was warmer. A Progress Note, dated 2/6/23, indicated the resident's family had been informed of his choice to cancel his eye appointment and it would be rescheduled for a later date. An optometry note, dated 1/4/24, indicated the resident was referred for removal of right eye cataract but was unable to make the appointment last year. His right eye distance vision was still blurry. The recommendation was to get a consult for a cataract evaluation of the right eye and possible treatment. A written order was given to the charge nurse, who indicated the resident had been scheduled in the past and refused to go. Care plan meeting reviews, dated 2/22/24 and 4/30/24, indicated the resident had last been seen by optometry on 1/4/24. No further information was documented. There was a lack of documentation the facility had attempted to reschedule the appointment or make any further arrangements for the resident to receive the recommended specialty eye care services. During an interview on 6/13/24 at 2:12 p.m., Social Services 1 indicated she was still looking for a traveling eye doctor/specialist who could come see the resident and possibly perform any procedures in the facility because the resident required a stretcher for transportation. If she were to make an outside appointment for him, they would refuse to see him since he could not transfer himself off the stretcher, and the ambulance staff would not assist the resident with transferring once at the appointment. She was unable to provide any documentation she had followed up with the 1/4/24 optometry recommendation and indicated she needed to be better about her documentation. 3.1-39(a)(1)

Based on observation, record review, and interview, the facility failed to ensure a dependent resident was transferred with a Hoyer lift (a full body mechanical lift) as indicated on the Resident Care Sheet for 1 of 1 resident reviewed for accidents. (Resident 113) Finding includes: On 6/11/24 at 8:55 a.m., CNA 2 was observed attempting to transfer Resident 113 from her bed into her wheelchair. The resident was on her bed in a semi-seated position, her left arm was contracted and she had a splint on her right hand. Resident 113 was unable to sit upright on the side of bed by herself and was falling backward. The CNA was leaning forward in front of her, instructing Resident 113 to hold on to her neck as CNA 2 was attempting to hold the resident around her waist. The resident was unable to hold onto the CNA with her right arm only. Her legs were stretched forward and her feet were not securely on the floor. After several minutes, CNA 3 entered the room and indicated to CNA 2 that the resident could not be transferred like that, she needed a sit to stand lift (a device that assists residents from a seated to standing position for transferring). The resident's record was reviewed on 6/11/24 at 1:33 p.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) of the non dominant side, cerebral ischemia and degenerative disease of the nervous system. The Quarterly Minimum Data Set assessment, dated 4/8/24, indicated the resident was cognitively intact and was dependent for transfers, bed mobility and toileting. The Resident Care Sheet indicated the resident was a two person assist with a Hoyer mechanical lift for transfers. During an interview with CNA 2 on 6/11/24 at 9:10 a.m., she indicated she was not familiar with the resident and should have checked the Care Sheet prior to attempting to transfer her. During an interview with the D Unit Manager on 6/11/24 at 11:10 a.m., she indicated the resident needed a Hoyer mechanical lift for transfers and she would begin education with the staff. On 6/12/24 at 11:29 a.m., the resident was observed seated in her wheelchair in the hallway. Her left arm was contracted, she had a splint on her left hand and her left leg was in a foot rest. During an interview on 6/12/24 at 1:26 p.m., CNA 4 indicated he had transferred the resident by himself from the bed that morning by standing and pivoting her to the wheelchair. He was not aware she was supposed to be transferred with a mechanical lift. The policy, Safe Resident Handling/Transfers, indicated, .All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lift are a safer alternative and should be used . and, .Staff members are expected to maintain compliance with safe handling/ transfer practices 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure sores received necessary treatment and services to promote healing, related to treatments and interventions for healing/prevention of pressures sores not completed as ordered, with pressure sore measurements worsening and assessed as deteriorated for a Stage 3 and an Unstageable DTI (Deep Tissue Injury) by the Wound Care Specialist, for 1 of 1 resident with pressure sores observed. (Resident E) Finding includes: The following was observed on 9/24/18: 6:14 p.m., a family member entered the hallway from Resident E's room and informed LPN 1 the resident had a bowel movement and needed care. LPN 1 informed the family member someone would be right there to provide the care. CNA 2 entered the room to assist with the supper meal. The family member indicated the resident needed care due to incontinence of stool. CNA 2 informed the family member it was supper time and was unable to provide incontinence care at this time. CNA 2 went to the back of the head board on the bed and slid the resident up to the head of the bed with the draw sheet, sliding the resident on the bottom sheet on the bed, then sat at the bedside and assisted the resident with the supper meal. 6:58 p.m., CNA 2 entered the resident's room to provide incontinence care. CNA 2 was standing on the right side of the bed, turned the resident on to the left side and removed the soiled brief. The resident had been incontinent of bowel movement. An uncovered open area on the left ischium was observed. A clean brief was applied and CNA 2 went to the left side of the bed, had the resident roll to the right, then pulled the draw sheet, which slid the resident on the linens for positioning. There was a loose dressing on the left heel, not covering the pressure area, with dried bloody drainage noted on the pillow under the heels. The Prevalon Boots (cushioned boots) were not on the resident. 9:20 p.m., the Unit Manager was in the room and indicated there was no dressing on the left heel or the left ischium and both areas should have a dressing, and the Prevalon boots were to be worn at all times. During an observation on 9/28/18 at 9:20 a.m. with the Director of Nursing present, the Prevalon boots were on the chair at the end of the bed. Resident E's record was reviewed on 9/28/18 at 8:40 a.m. The [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, dated 7/30/18, indicated a moderately impaired cognition, no behavior problems, total dependence of two for bed mobility, transfer assistance occurred only once or twice with two person assistance, total dependence of one for dressing, eating, personal hygiene, and bathing, total dependence of two for toileting, and always incontinent of bowel movement, had a urinary catheter, had unhealed pressure ulcers - two stage three ulcers (full thickness skin loss) and three deep tissue injuries. A care plan, dated 11/29/14, indicated there was an actual pressure ulcer and at risk for further pressure ulcers. The interventions included, 8/20/18 Prevalon boots to bilateral heels at all times except for hygiene, and 11/29/14 treatments as ordered. physician's orders [REDACTED].>6/28/18 to 9/13/18 - apply calcium alginate (pressure ulcer treatment) to left ischium every evening after cleansing with normal saline. 9/6/18 to 9/20/18 - apply Santyl ([MEDICATION NAME] agent) and calcium alginate to the left ischium and cover with a dressing every evening and apply calcium alginate and cover with dry dressing every evening. 9/20/18 - cleanse with normal saline 9/13/18 - [MEDICATION NAME] swab sticks to left heel every evening 8/28/17 - Prevalon boots to bilateral heels at all times, may remove for hygiene every shift The Medication Administration/Treatment Administration Record (MARs/TARs), dated 9/2018, indicated the calcium alginate to the left ischium had not been signed out as completed as ordered on [DATE] and 9/10/18. The Santyl and Calcium alginate to the left ischium had not been completed on 9/10/18, 9/14/18, 9/16/18, and 9/19/18. The calcium alginate had not been completed as ordered on [DATE] and 9/22/18. The MAR/TAR, dated 9/2018, indicated the [MEDICATION NAME] to the left heel had not been competed as ordered on [DATE], 9/16/18, 9/19/18, 9/21/18, and 9/22/18. The Wound Specialist Progress Notes, indicated: 8/30/18 - Stage 3 pressure wound to the let ischium, 2 centimeters (cm) by 2.1 cm, unable to measure depth, 50% necrotic tissue and 50 % granulation, and improved. Unstageable (necrotic or slough covering so cannot see the depth) DTI (deep tissue injury) to the left heel, 3.2 cm by 4.0 cm, not ably to measure depth, and had improved. treatment for [REDACTED]. 9/13/18 -Stage 3 pressure wound to the left ischium, 1.5 cm by 1.0 cm by 0.1 cm with 100% granulation, and improved. Unstageable DTI of the left heel, 2.8 cm by 3.6 cm and unable to measure the depth, and improved. treatment of [REDACTED]. 9/20/18 - Stage 3 pressure wound to the left ischium, 1.4 cm x 0.6 cm x 0.1 cm with 100% granulation, and improved. treatment of [REDACTED]. Left heel DTI, 2.8 cm. by 3.6 cm. and unable to measure the depth, no change. Treatment plan, [MEDICATION NAME] apply daily with dry protective dressing. 9/27/18 - Stage 3 pressure wound of the left ischium, 2.8 cm by 1.5 cm by 0.1 cm, 25% slough and 75% granulation tissue, deteriorated. Treatment to alginate calcium daily for 16 days, and Santyl daily for 30 days with dry protective dressing daily. Recommend a fecal collector. Unstageable DTI of left heel, 4.0 cm by 3.6 cm and unable to measure the depth, deteriorated. Treatment plan, [MEDICATION NAME] daily with dry protective dressing. A facility policy, titled, Skin Integrity Guideline, dated 3/1/18 and received from the Administrator as current, indicated, . Positioning devices .can be used to appropriately position .for comfort and pressure relief .Use lifting devices .to move patients/residents who cannot assist during transfers and position changes . 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents, which resulted in a fall with an injury requiring sutures for 1 of 4 residents reviewed for falls in a total sample of 11. (Resident #J). Finding includes: Resident #J's record was reviewed on 03/16/16 at 1:57 p.m. The resident's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, dated 12/24/15, indicated the resident's cognition was severely impaired, required extensive assistance with all activities of daily living (ADL's) except bathing, was dependent for bathing, and had two falls without injury. A Fall Risk assessment, dated 12/24/15, indicated a score of 14 (total score of 10 or above deems the resident at risk) A care plan, initiated on 07/01/15, indicated the resident was a risk for falls due to history of falls and flailing of arms and legs. The interventions included, bed in low position initiated 07/01/15, floor mat next to the bed initiated 07/01/15, floor mat at the foot of the bed initiated on 09/03/15, and full mattress landing mat next to the bed initiated 11/13/15. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Nurses' Note, dated 02/25/16 at 8:45 p.m., indicated the resident fell out of bed and had a history of [REDACTED]. The note indicated the staff had positioned the resident in the bed close to the wall on the resident's left side, then had gone to the resident's bathroom to wet a towel to do the resident's personal care and while in the bathroom the staff heard a, boom, and found the resident lying on the floor on her right side in a fetal position, with blood on the floor and draining from the resident's left eye and the resident was moaning. The note indicated the resident's bed was waist high and the mattress and mat were not on the floor next to the bed. The resident was assessed to have a laceration above the left eye approximately 0.3 centimeters (cm) by 3.5 cm x 0.1 cm with moderate amount of blood draining from the site and the resident was transferred by Emergency Technicians to the emergency room . The Fall Investigation, dated 02/25/16 at 8:45 p.m., indicated the resident was found on the floor in a fetal position, lying on her right side. There was blood on the floor and draining from the resident's left eye and the resident was moaning during the assessment and was moving her body. Pressure was applied to the site and the bleeding would not stop. The resident was transported to the hospital for treatment and evaluation. The Causal/Contributing Factor for the fall, indicated, Staff member was still providing care and had walked to the bathroom while CNA was in bathroom res (resident) fell out of bed. The Summary and Outcome of the investigation indicated, Resident was put into bed by CNA and CNA was getting ready to provide care. Resident fell while CNA was in the bathroom getting ready to complete care. Mattress was not in place due to the same reason staff member still providing care . The Interview Summary of the Fall Investigation indicated, Staff stated when he put resident in bed, he position (sic) her close to the wall and was not aware that she has a history of rolling out of bed. The Possible Causal factor indicated the bed was not at the lowest position. The Hospital History and Physical, dated 02/25/16, indicated the resident had a bleeding laceration on the left forehead and the laceration was sutured and the CT scan of the brain showed no hemorrhage. The resident was admitted to the hospital and placed on stroke protocol. A Hospital Neurological Examination, dated 02/28/16, indicated, .Patient did hit her head and has a laceration above the left eyebrow with no active bleeding .the daughter who states patient has been recently falling out of bed at the nursing home. The daughter also states patient is bed bound and is not able to walk .also admits the patient is restless and is (sic) usually moves around in bed a lot . During an interview on 03/16/16 at 2:55 p.m. the Director of Nursing (DON) indicated the CNA had left the resident's bedside to walk into the bathroom and came back and the resident had fallen out of bed. She indicated the CNA had not put the mattress down beside the bed because the resident's care had not been completed. She indicated the CNA could not stand on the mattress while providing care. The DON indicated the resident had full body movement but could not follow directions for movement. This Federal tag relates to Complaint IN 689. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, related to pressure areas observed without dressings and treatments applied as ordered by the Physician for 2 of 3 residents with pressure ulcers in a total sample of 3. The facility also failed to provide the correct treatment for [REDACTED].#D. Resident #D's pressure wounds increased in numbers and deteriorated. (Residents #C and #D) Findings include: 1. Resident #D was observed on 02/09/16 at 11:21 a.m., while care was being completed by CNA #2 and LPN #3. The resident's coccyx area was pink and the there were two small superficial open areas on the left buttocks. CNA #2 indicated she had just gotten the resident out of bed and the resident had no dressing on the open areas when she got her up. LPN #2 indicated the resident had no order for a dressing on the open areas on the left buttock. LPN #2 applied [MEDICATION NAME] cream (barrier cream) to the resident's left buttocks, coccyx area, and peri-area after CNA #2 provided incontinence care. Resident #D's record was reviewed on 02/10/16 at 11:26 a.m. The resident's [DIAGNOSES REDACTED]. The Physician's Recapitulation Order, dated 01/2016, indicated 01/13/16 an order was received to apply a [MEDICATION NAME] Alginate Dressing Pad (wound dressing) to the left buttock every evening shift. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident was seen at the Wound Clinic on 02/02/16, the measurement of the left buttock wound was 3 centimeters (cm) by 2 cm with a depth of 0.1 cm. Additional Orders included, specialty bed/mattress, turn every 2 hours, and avoid position directing pressure to wound site. The resident was seen at the Wound Clinic on 02/08/16, the measurement to of the left buttock wound was 0.2 cm by 0.2 cm with a depth of 0.1. The status was, Not Healed. Additional orders included, cleanse wound with saline. A Nurses' Progress Note, Change of Condition form, dated 02/10/16 at 3:27 p.m., indicated, .Deterioration of wound to bilateral buttocks. Open area noted to coccyx measures 0.2 (cm) x (by) 0.1 x 0.1, pink in color. Wound to left buttock, red, peeling, denuded (skin gone) area measures 3.0 (cm) x 2.0 x 0.1, with surrounding with redness measuring 5.0 (cm) x 3.0. Wound to rt (right) buttock, red peeling denuded area measures 3.2 (cm) x 1.2 x 0.1 with open area to inner aspect of wound measuring 0.2 (cm) x 0.4 x 0.1. Area is pink .N/O (new order) rec'd (received) for Maxsorb AG (wound dressing) to rt (right) buttock and coccyx . During an interview on 02/10/16 at 1:25 p.m., Unit Manager #4 indicated there were no orders for treatment for [REDACTED]. 2. During an observation on 02/09/16 at 1:32 p.m., CNA #5, CNA #6, and Unit Manager #4, transferred Resident #C from the chair to the bed with the mechanical lift. Resident #C's pressure wounds were observed once the resident was in bed. The resident had a dressing on his left hip/buttock, which was dated 02/02/16. Unit Manager #4 indicated this had to be an incorrect date because the resident had been to the Wound Clinic on 02/09/16 and the Wound Clinic must have misdated the dressing. The left hip/buttock area had pink fresh skin without an open area, when the dressing was removed. CNA #5 and #6 indicated they had not transferred the resident from the bed to the chair, so they were unsure if the resident had a dressing on when he was gotten out of bed. The resident had an open area on his left sacral area. The open area had no dressing covering the area. There was a dressing covering the open area on the right buttock/hip area. LPN #1 indicated there was no treatment ordered for the left sacral open area. Resident #C's physician's orders [REDACTED]. A physician's orders [REDACTED]. The Medication Administration Record, [REDACTED]. The Wound Clinic Progress Note, dated 02/08/16, indicated the left buttock was chronic, not healed and measured 1/2 (cm) by 0.5 cm by 0.1 and was improving with no signs of infection. During a telephone interview, on 02/09/16 at 2:12 p.m., the Wound Physician indicated the resident had an open area in the sacral area found on 01/20/16, which measured 0.5 cm by 0.4 cm by 0.99 cm. The Wound Physician indicated the sacral wound was healed on 01/25/16 and when the resident was seen on 02/08/16 there was no sacral wound. The Physician indicated the right hip wound measured 0.5 (cm) by 1.0 by 1.2 and was undermining up to 2.5 cm and was infected. The Physician indicated the wounds were recurrent and chronic. During an interview with Unit Manager #4, on 02/09/16 at 2:32 p.m., she indicated the measurements on the Wound Clinic Progress Notes on 1/20/16 indicated the resident had pressure areas on his right buttock, left buttock and sacral area, on 01/25/16, the Wound Clinic documented the area on the right buttock and left buttock continues and the sacral area was healed. She indicated the Wound Clinic may have labeled the sacral wound as the left buttock on this dated, since the wound on the left hip/buttock area had been healed. During an interview on 02/10/16 at 9:49 a.m., Unit Manager #4 indicated through an investigation for the open areas, talking with the Wound Clinic, and looking at the pictures of the areas, the Wound Clinic, beginning 01/25/16 identified the area on the left sacral area as the left buttock area. Unit Manager #4 also indicated the dressing on the left hip/buttock area should not have been on. She indicated the wound on the sacral/left buttock had not been identified by the facility prior to the resident going to the Wound Clinic on 01/20/16. She called the Night Shift CNA and Nurse to inquire if a dressing had been placed on the area of the left sacral/buttock area on 02/08-02/09/16 night shift, and they had not called her back. This Federal tag relates to Complaint IN 739. 3.1-40(a)(1)

Based on interview and record review the facility failed to assess a resident who was continent of urine, and became incontinent of urine for potential causes of the incontinence and the need for an individual toileting program and also failed to assess another resident for causes of incontinence and a toileting program for the incontinence, for 2 of 3 residents reviewed for urinary incontinence in a total sample of 4. (Residents #B and #C) Findings include: 1. During an interview on 07/27/15 at 8:55 a.m., LPN #5 indicated Resident #C was alert and oriented to person, place, and time, required assistance with care, and was incontinent of urine. During an interview on 07/27/15 at 8:58 a.m., Resident #C indicated the staff do not check him for incontinence. He indicated he has to use his call light to let them know when he needs to use the toilet or after he has already been incontinent. He indicated he knew when he needed to void. During an interview on 07/27/15 at 11:12 a.m., CNA #4 indicated she would check with Resident #C, but he knows when he is wet. During an interview on 07/28/15 at 9:41 a.m., Resident #C indicated he had been incontinent since he fractured his arm (07/01/15), and the staff placed him in a wheelchair. He indicated he used to use a walker to ambulate and could take himself to the bathroom. He indicated he now wore an incontinent brief. He indicated the staff informed him he could call for assistance to the bathroom, but by the time the staff answer the call light, he had already been incontinent. He indicated he could not wait long for the bathroom. He indicated the staff do not come in before or after meals to ask him if he needed the bathroom. He indicated it had not bothered him to be incontinent, he stated, I adapt. Resident #C's record was reviewed on 07/28/15 at 8:55 a.m. The resident's [DIAGNOSES REDACTED]. A Clinical Health Status form, dated 06/05/15, indicated the resident was continent of urine. A Significant Change Minimum Data Set (MDS) assessment, dated 07/10/15, indicated the resident's cognition was intact, required minimal assistance with transfers, extensive assistance with toileting, and was occasionally incontinent. The Care Area Assessment (CAA), dated 07/10/15, indicated the resident had urinary urgency, became dependent up on staff for assistance with toileting and transfers, was occasionally incontinent of bladder, received a diuretic daily, and the resident was rendered incontinent care daily and as needed. The care plan, dated 01/21/15, indicated the resident had an alteration in elimination of bowel and bladder. The interventions included, call light within in reach and reminders to use as needed, discuss medications with physicians which may be contributing to incontinence, and evaluate frequency/timing of incontinence episodes. The Continence Daily Report, dated 07/01/15 through 07/27/15, indicated the resident was continent on 07/01/15, (the resident was in the hospital from 07/01/15 to 07/06/15), was incontinent at least 2-4 times daily 07/07/15 through 07/27/15, with one continent episode on July 8, 11, 13, 15, and 20, 2015. During an interview on 07/28/15 at 8:25 a.m., CNA #3 indicated when reporting bladder functioning on the Continence Daily Report, they can only document each shift if the resident was incontinent or continent, and they can not document how many times the resident was incontinent. The record indicated the resident's incontinence had not been evaluated for frequency and timing of incontinence, reasons for the increased incontinence, and for an individualized toileting plan. During an interview on 07/28/15 at 1:13 p.m., the ADoN (Assistant Director of Nursing), indicated there had not been an urinary incontinence assessment completed on the resident with the change in bladder function. 2. During an interview on 07/27/15 at 8:55 a.m., LPN #5 indicated Resident #B was alert and oriented to person, place, and time, required assistance with care, and was incontinent of urine. During an interview on 07/27/15 at 8:12 a.m., Resident #B indicated she knew when she was wet and she called for the staff to come change her. She indicated sometimes she was sitting in a wet brief for long periods of time. She indicated she cannot feel the urge to void but she felt the wetness after she voided in her briefs. During an interview on 07/27/15 at 11:12 a.m., CNA #4 indicated Resident #B knew when she was incontinent and used the call light to let the staff know. Resident #B's record was reviewed on 07/27/15 at 11:05 a.m. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS assessment, dated 06/23/15, indicated the resident's cognition was intact, required extensive assistance of two staff for transfers, extensive assistance of one for toileting, and was always incontinent of bladder. There was no bladder assessment located in the resident's medical record. A CAA, dated 04/16/15, indicated the resident had restricted mobility, had urinary urgency and needed assistance in toileting, the resident was frequently incontinent of bowel and bladder, briefs were worn and incontinence care was rendered as needed. The Continence by Day Report, dated 07/01/15 through 07/15/15 and 07/21/15 through 07/27/15, indicated the resident was incontinent multiple times daily. A care plan, dated 04/24/15, indicated the resident had an alteration in elimination of the bladder, the interventions included, call light in reach and reminders to use as needed, check and change as needed, provide assistance to toilet, use of briefs/pads for incontinence protection. During an interview on 07/28/15 at 1:13 p.m., the ADoN indicated a bladder assessment had not been completed for Resident #B. A facility policy, dated 06/09/15, received from the ADoN as current on 07/28/15 at 8:36 a.m., titled, Incontinence Management/Bladder Function Guideline, indicated, .Upon admission (if the resident has a history of incontinence) complete the Bowel and Bladder Tracking Tool. Completed to identify any trends or patterns that the resident may have in relation to incontinence.Complete the Bladder Evaluation Form.Upon completion of this evaluation as well as the Tracking Tool, the toileting/bladder program can be determined. This Federal Tag relates to Complaint IN 623. 3.1-41(a)(1) 3.1-41(a)(2)

Based on observation, record review, and interviews, the facility failed to ensure each resident was free from accidents related to geri sleeves, lying down after breakfast and ensuring the resident's bed was locked and against the wall for a resident who was at risk for falls and sustained a black eye and a dislocated jaw that required surgical intervention for 1 of 3 residents reviewed for accidents in the sample of 3. (Resident #B) Findings include: On 11/7/12 at 9:40 a.m. and at 11:10 a.m., Resident #B was observed sitting in a wheelchair with a tray top attached. The resident was seated in the activity room watching television. At that time, the resident was wearing short sleeves, and there were no geri sleeves observed to her arms. On 11/7/12 at 12:22 p.m., Resident #B was observed being pushed down to the dining room on the D-Wing. The resident was wearing short sleeves and there were no geri sleeves observed on her arms. On 11/7/12 at 1:30 p.m., CNA #1 was observed in the resident's room. She and another CNA had just changed the resident and placed her back up into the chair. At that time, the resident was wearing short sleeves and there were no geri sleeves observed on her arms. During an interview with CNA #1 at that time, indicated the resident stays up after lunch and was supposed to lay down after breakfast. Further interview with the CNA indicated the resident did not lay down today after breakfast. The CNA also indicated she has never seen the resident with geri sleeves on her arms since she had been working with her. She further indicated that staff usually put on shirts with long sleeves or whatever she had in her closet. The record for Resident #B was reviewed on 11/7/12 at 11:20 a.m. The resident was admitted to the facility on [DATE] from another long term care facility. The resident's [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was rarely understood and rarely understands, the resident was at risk for falls with having two or more since the last assessment. The resident was extensive assist with two person physical assist for bed mobility and transfers. Review of the revised 8/7/12 plan of care indicated the resident was at risk for falls. The Nursing approaches were to lay the resident down after breakfast, bed in the lowest position, bed against the wall, and floor mat beside the bed. Review of the revised 9/20/12 plan of care indicated the resident was at risk for injury related to the need for a lap tray and attempts to self transfer herself. The Nursing approach was to place geri sleeves to bilateral arms at all times. Review of the D-Wing CNA Report Sheet on 11/7/12 at 2:17 p.m., indicated the geri sleeves and the information about the resident lying down after breakfast was not on the report sheet. Interview with the D-Wing Unit Manager on 11/7/12 at 2:17 p.m., indicated the CNA report sheet were to be updated every week or when something changes with the resident. She further indicated the resident was suppose to wear the geri sleeves and she was supposed to lay down after breakfast. Review of Nursing Progress Notes dated 10/26/12 at 9:17 p.m., indicated a visitor had found the resident laying on the floor beside her bed inside the resident's room. The resident was observed with a hematoma to the right eye. Review of the Verification of Investigation report completed by the nurse who was at the scene of the accident indicated the resident had redness, swelling and a bruise to the right side of the face. The Physician order [REDACTED]. Review of the Ear Nose and Throat Consultation dated 10/27/12 from the hospital indicated the resident had some hard object strike the right side of her face and she was unable to close her mouth completely since the injury. The resident had ecchymosis and a hematoma of the right upper and lower eyelid. Review of the catscan of the facial bones dated 10/27/12 indicated the resident had an anterior dislocation of the left tempormandibular joint. There was no facial bone fracture. Review of the operative report dated 10/30/12 from the hospital indicated the resident had a closed reduction mandible. Further review of the Verification of Investigation report indicated there was no evidence of any staff interviews documented and conducted at the time of the fall and/or no witness statements as to what happened. Interview with the Assistant Director of Nursing (ADON) on 11/7/12 at 4:15 p.m., indicated she was aware the resident had fallen out of bed, however, she unaware as to what had actually happened. She indicated the resident's right side of the bed was to be against the wall with the floor mat on the left side of the bed. She further indicated witness statements were to be completed and documented at the time of the incident. She was then asked to call the nurse who was working the night the resident was found on the floor. The nurse indicated the resident's bed was unlocked and had been moved away the wall. The nurse further indicated the resident was found on the right side of the bed and had fallen out of bed on the right side in which there was no floor mat. The ADON further indicated she was completely unaware this had happened. This Federal Tag relates to Complaint IN 989 3.1-45(a)

Based on record review and interviews, the facility failed to ensure each resident remained free from accidents related to a transfer using a mechanical lift with only one staff member in which the resident sustained [REDACTED]. (Resident #D) Findings include: The record for Resident #D was reviewed on 12/1/11 at 9:15 a.m. The resident's [DIAGNOSES REDACTED]. Review of Nursing Progress Notes dated 11/15/11 at 10:40 p.m., indicated "CNA was in resident's room attempting to transfer and clean resident. CNA heard resident's arm crack. Once assessed, resident was guarding left arm and not allowing to be touched...." The resident's physician was notified and new order to send the resident to the hospital for an evaluation was obtained. The incident happened at 4:30 p.m. The resident was sent back to the facility at 11:25 p.m., with a left humeral head fracture and her arm was placed in a sling. Review of the Facility Incident Reporting Form dated 11/15/11 at 4:30 p.m., indicated the CNA was preparing the resident for the sit to stand lift. The resident was positioned appropriately in the lift and secured. The CNA initiated incontinent care while the resident was in the standing position. The resident moved left arm from self support position and CNA noticed left arm was not secured by grasp to the lift. The resident changed her vocalization as if in pain and the CNA placed the resident back in the wheelchair. Upon observation the resident was not moving her left arm. The resident was sent to the hospital for further evaluation where she was diagnosed with [REDACTED]. Review of the CNA's witness statement of the actual events of the incident indicated at 4:15 p.m., the CNA prepared to provide incontinent care at the time of the transfer, so he placed a new brief, pants and wipes close by so they would be available. The CNA then indicated he placed the lift in front of himself and locked it because the resident had pushed it away. The CNA indicated he made sure the resident's arms were above and on the pads. The CNA indicated the resident had her arms on top and were holding onto the bars. The CNA then indicated he clipped her in, lifted her up with the lift, holding the lift in the right way and she raised her left arm in the middle of the brace, and her arm was all the way out. The CNA then got in back of her and was putting on her brief. At that time, he heard a cracking sound. The resident then began singing and started saying "yoi, yoi, yoi." The CNA then put her back down to the wheelchair and noticed she could not move her left arm and that it just seemed to hang there. Further review of the CNA's witness statement indicated "I knew it required two people but I went to look for somebody, went down hall, while she was in wheelchair, went to go look for somebody, I have to get my work done, so I then did it by myself." The CNA's witness statement further indicated "I was told by (name) Staff Development Nurse while I was still doing my paperwork to get hired that all lifts had to have two aides. I was told by (name) CNA Mentor there always had to be two people for lifts. Yes, I've done this in the past but always made sure people were safe." Review of the current Policy for the Sit to Stand and Hoyer lifts provided by the Staff Development Nurse on 12/2/11, indicated "The policy for use of the Sit to Stand and Hoyer lifts requires a minimum of two licensed or Certified Care Providers to be present at all times during the lift and transfer process." Interview with the Staff Development Nurse on 12/1/11 at 10:30 a.m., indicated the CNA was supposed to get another CNA or Nurse to assist him with the transfer using the Sit to Stand lift. She further indicated the CNA was terminated for not properly transferring the resident with the Sit to Stand lift. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident's environment was free of accident hazards, related to transferring a resident with a mechanical lift with only one assistant. The resident was assessed to have a deformity of the lower left leg, which was diagnosed at the hospital as a fractured left tibia and fibula (lower leg bones). (Resident #B) Findings include: A, "Facility Incident Reporting Form", with an incident date of 08/24/11 at 4:30 p.m., indicated, "...Resident (Resident #B) presented with bruising that increased with possible fracture to leg...No known fall recently, resident is dependent for mobility and transfers...Conclusion is fracture most likely occurred from positioning of leg in bed to elevate heel. With the movement of the ankle to reposition and the dx (diagnosis) of osteoporosis the gentle repositioning could have resulted in the fracture. Resident showed no signs of distress until positioning of the heel occurred at which time the aide observed the drop in the foot and notified nurse immediately...." The investigation by the facility, date 08/24/11, indicated LPN#1 was interviewed and LPN #1 indicated the resident had been sitting in front of the nurse's station and there was nothing unusual nor calling out by the resident. The facility interviewed CNA #2 (CNA who worked during the day shift on 08/24/11) on 08/26/11. CNA #2 indicated, she had transferred the resident with the "Marisa" lift (mechanical lift) when she got the resident out of bed. She indicated she had used the lift alone. She indicated the resident had not been in any pain and because she was a fall risk, she had taken the resident to sit by the nurses' station. CNA #2 indicated nursing students were in the room during the transfer of the resident with the mechanical lift. The facility interviewed the Instructor of the nursing students on 08/29/11 and the Instructor indicated the students were observing care that day and not assisting. The facility interviewed CNA #3 (CNA who had transferred the resident back to bed on 08/24/11) on 08/25/11. CNA #3 indicated when she arrived on the wing, the resident was in the hallway by the room and the resident had no facial grimaces or pain. She indicated she had transferred the resident to bed and the resident had voiced no complaints. During a telephone interview, on 08/30/11 at 11:40 a.m., CNA #3 indicated she had transferred the resident from her chair to her bed with the mechanical lift. She indicated she had completed the transfer on her own. She indicated no other staff had assisted her with the mechanical lift. She indicated she transferred the resident to bed around 4 p.m., and the resident showed no signs of pain. Resident #B's record was reviewed on 08/30/11 at 10:25 a.m. The resident's [DIAGNOSES REDACTED]. A right hip x-ray, dated 09/23/09, indicated the resident had osteoporosis with osteoarthritis in the right hip. A, "Team Conference/Patient Rounds Form," signed by the physician on 08/05/11, indicated the resident was wheelchair bound, a mechanical lift was used for transfers, and the resident required maximum assistance for activities of daily living. The Annual Minimum Data Set (MDS) Assessment, dated 11/02/10, indicated the resident sometimes understood others and was sometimes understood, had cognitive pattern score of zero (impaired), and was dependent on two or more persons for transfers. The Care Area Assessment, dated 11/03/11, indicated the resident had difficulty maintaining a sitting balance and had impaired balance during transitions. The "Lift/Mobility Assessment for Residents," dated 11/02/10, indicated the resident could not bear weight on at least one leg, was able to follow simple instructions, was not able to grip with at least one hand and weighed less than 350 pounds. The form indicated the resident could be in a semi-reclined position and weighed less than 420 pounds. The form indicated the resident was a candidate for the Marisa lift and not the Sara (stand up) lift. The form indicated the resident required one staff member assistance for transfers. A quarterly clinical health status assessment, dated 07/02/11, the resident had unsteady balance with sitting and standing. A Quarterly MDS Assessment, dated 07/07/11, indicated the resident had a cognition score of 5 (impaired) and required extensive assistance of two or more for transfers. A care plan, dated 07/18/11, indicated the resident was at risk for falls related to a right below the knee amputation, history of falls, and dementia. The interventions included to use a mechanical lift for transfers. The resident's Nurses' Notes indicated: 08/23/11 at 4:48 a.m., "CNA pointed out resident has a large bruise to left lower anterior leg, 13 cm (centimeter) (l) (length) x 4.5 cm (w) (width). Resident des not know how it happened...No swelling noted...." 08/23/11 at 6:26 a.m., "Added note: resident's bruise is purple...." 08/23/11 at 8 p.m., "Resident resting in bed. Calm. Bruise to Left leg unchanged. No signs/symptoms pain to bruised area...." 08/24/11 at 2:06 a.m., "Resident in bed at this time, bruising remains to left anterior calf. No distress noted. No swelling noted to left leg." 08/24/11 at 3:30 p.m., "Resident up in w/c (wheelchair) in dining room...In no apparent distress." 08/24/11 at 4:30 p.m.,"Resident put back to bed...Increased bruising noted to LLE (left lower extremity). Lower left leg elevated on pillow, appears broken in appearance...." 08/24/11 at 5:55 p.m., "Resident transferred...Exhibits Pain to LLE with movement...." Resident #B's hospital records were reviewed on 08/30/11 at 8 a.m. A hospital history and physical, dated 08/24/11 at 9:52 p.m., indicated, "...possible fracture to left lower leg...Sent from the nursing home because of ecchymosis (bruising) and deformity to the leg...Patient is confused and can not give any history...Physical Exam...Ht (height) 5' (feet) 4" (inches)...Wt (weight) 140 lb (pounds)...obese...only looks when her name is called. Does not follow instructions or answer questions...." A hospital left lower leg x-ray, dated 08/24/11, and report completed on 08/25/11, indicated, "...severe bruising and obvious deformity to left lower let. A spiral fracture is noted in the mid shaft through the proximal shaft of the tibia...Osteopenia of the bony structures is noted...Oblique fracture through the proximal shaft of the fibula is noted." During an interview on 08/30/11 at 2:05 p.m., the Administrator indicated the mechanical lift manufacturer's instructions indicated one caregiver could use the lift. During an interview on 08/30/11 at 2:15 p.m., the Director of Nursing (DoN) indicated the mechanical lift instructions indicated one person could use the lift. She indicated the CNA training book indicated there were supposed to be two people assisting with a mechanical lift transfer. A facility policy, titled, "Mechanical Lift, Hydraulic", received from the Administrator on 08/30/11 at 2:30 p.m., indicated, "PLACE THE MANUFACTURER'S INSTRUCTIONS FOR THE FACILITY MECHANICAL LIFT HERE." The Administrator indicated that was the only policy the facility had. The manufacturer's instructions, dated 04/10, indicated, "...Policy on Number of Staff members Required for Patient Transfer. (company name) passive and active series of lifts are designed for safe usage with one caregiver. There are circumstances,...obesity...etc. of the individual that may dictate the need for a two-person transfer. It is the responsibility of each facility or medical professional to determine if a one or two person transfer is more appropriate, based on task...capability, and skill level of the staff members." A professional resource, titled, "Indiana State Department of Health Division of Long Term Care Nurse Aide Training Program July 1998," Topic 22: Transferring, indicated, "...4. A mechanical lift...have at least one co-worker assist when using a mechanical lift...." This federal tag relates to complaints IN 662 and IN 771. 3.1-45(a)(2)

Based on observation, record review and interview the facility failed to ensure supervision was provided and fall interventions were in place and intervention provided were specific and measurable to prevent falls and skin injuries for 4 residents in a sample of 5, related to a resident having multiple falls, resulting in a fractured humerus (Resident #D), resident having multiple falls with fall intervention not in place then a fall with a fracture hip (Resident #B), a resident receiving an injury of unknown origin (Resident #C), and a resident obtaining multiple skin tears and bruises with no interventions in place (Resident #F). Findings include: The Falls Management Clinical Guidelines policy was provided by the Administrator on 1/41/11 at 11:45 a.m. The policy included, but was not limited to, "The interdisciplinary team evaluates the fall prevention plan of care for residents "at risk" for falls. Following a resident's fall: the licensed nurse assesses the resident for injuries and provides necessary treatment and initiates the Change in condition Report-Post Fall/Trauma The physicians and resident's representative is notified. Appropriate interventions are implemented. Care plan is updated." Monitoring Compliance: "The following elements are in place for the center to demonstrate satisfactory compliance with the guide: residents are assessed for fall risk, communication system to identify the residents at risk for falls, care planned with individualized intervention, licensed nurse completes change of condition-post fall/trauma following a resident fall, and IDT assessment is completed on the change of condition report-post fall/trauma." 1. Resident #D was observed on 4/13/11 at 11:50 a.m. She was sitting in her wheelchair in the unit dining room with her left arm in a sling. At 1:35 p.m., the resident was observed in bed sleeping. The bed was in the low position with call light in reach. The resident was covered but there was no sling strap observed over either of the resident's shoulders. On 4/14/11 at 9:10 a.m., Resident #D was observed walking down the hall with her walker. She had a gait belt around her waist and a Therapist was walking beside her. The record for Resident #D was reviewed on 4/14/11 at 9:25 a.m. The resident's [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) Assessment, dated 12/15/10, indicated the resident was understood and usually understands. The resident scored a 7 on the BIMS (Brief Interview for Mental Status), indicating she was severely impaired. She was independent with transfers requiring no physical help. She was independent with walking in room and corridor needing no physical help. The resident no fall since admission or the prior assessment. A fall risk assessment, dated 12/3/10, indicated a score of 17. A score of 10 or above deems the resident at risk. A progress note, dated 1/18/11 at 14:28 ( 2:48 p.m.), indicated "Resident has a purple bruise to right breast measuring 9.5 cm (centimeters) X (by) 3.5 cm. No pain or discomfort noticed to right breast." Staff will continue to monitor. Review of the progress note section from 1/19/11 to 2/1/11, indicated documentation of the bruise to the resident's breast on 1/19/11, 1/20/11, and 1/21/11. A progress note, dated 2/2/11 at 21:53 (9:53 p.m.), indicated received resident in shower room, large purple and green bruise noted to right breast. The resident indicated "I fell last week." The resident indicated she had not told anyone she fell . The resident voiced tenderness to breast. A progress note, dated 2/4/11 at 1:38 a.m., indicated the resident was in bed resting. The room was free of clutter. No acute distress, pain or discomfort noted related to previous fall. Bruise remains to right breast, no lumps or discomfort voiced. Safety maintained. at 14:48 ( 2:48 p.m.) at 11:00 a.m. the resident had active range of motion to all extremities. The bruise to right breast fading, skin intact. The resident denied pain. The resident was up ambulating with walker without difficulty. A progress note, dated 2/5/11 at 2:12 a.m., indicated the resident was asleep in bed at this time. Bruise to right breast is fading, no complaints of pain or discomfort voiced. Will continue to monitor. At 16:37 (4:37 p.m.), the resident was found on the floor on her left side. The resident indicated, "I twisted my ankle." The resident had a history of [REDACTED]. No pain to left ankle. Range of motion with in normal limits to all extremities. The physician and family were notified. Orders received to put ice on ankle, elevate and observe. At 16:48 (4:48 p.m.), the resident was in bed resting vital signs T-97.2, P-70, B/P-124/68, and R-16. The bruise to right breast was fading. No complaints of pain or discomfort. Resident had no injury due to previous fall. Range of motion with in normal limits to all extremities. Staff will continue to monitor. At 20:40 (8:40 p.m.) ice applied to left ankle as ordered. Extremity elevated on pillows in bed. Pedal pulse palpable. The resident was able to rotate left foot without difficulty. No swelling or signs and symptoms of pain noted. Will continue to monitor. A progress note, dated 2/10/11 at 19:21 (6:21 p.m.), indicated The resident was in bed. No signs or symptoms of distress. The resident complained of pain to left shoulder (8 of 10). As need Tylenol (pain medication) was given per orders. Upon on follow up pain related a 6 of 10. The physician was notified and stated to monitor for pain. Staff will continue to monitor. A progress note, dated 2/11/11 at 2:25 a.m., indicated the resident was resting in bed at present time. "Resident has AROM (active range of motion) to bilateral upper extremities. No complaints of pain or discomfort." A progress note, dated 2/11/11 at 6:45 a.m., indicated "late entry for 2/11/11 at 6:45 AM (sic), Upon making morning rounds, midnight CNA (name) in room with resident, res (resident) seated on the toilet with CNA doing patient care. Spoke to CNA and resident, no report given at this time, no c/o (complaint of) voiced, rounds continued." At 13:54 (1:54 p.m.), "8:30 AM, T 98.0, AP 82, B/P 144/80, R 18, Resident noted ambulating with walker with left arm hanging down, pushing walker with right arm. Res (sic) c/o pain to touch. Res (sic) assessed by this writer and Unit Manager. REs (sic) stated that she fell last night in the shower room and the girl picked her up. PROM (passive range of motion) to all other extremities. Res (sic) assisted to bed, res (sic) also noted with 2.0 x (by) 1.4 cm (centimeter) abrasion to right knee, area dry. PRN (as needed) Tylenol given per orders." Nurse Practitioner notified, new order received and noted for STAT x-ray of left arm, CBC (complete blood count), CMP (complete metabolic panel-blood test) and U/A (urinalysis) , C&S (Culture and Sensitivity). Resident and family notified." At 14:02 (2:02 p.m.) "10:00 AM, (name of x-ray company) here to do x-ray left arm. 12:00 PM, received results, res (sic) with fracture left humerus. NP (Nurse Practitioner) notified. (Name of Ambulance Company) called for transport to (name of hospital) ER (emergency room ) report given" At 23:15 (11:15 p.m.) "Resident returned to facility this shift. Orders received to keep left arm in sling at all times. May remove for ADL (activities of daily living) care. Tramadol (pain medication 50 mg (milligrams) every 6 hours as needed for pain." A care plan initiated on 7/8/10, indicated a problem resident at risk for falls related to use of anti-psychotic medications, history of seizures, fatigue related to chronic obstructive pulmonary disease. The goal was for the resident to remain injury free from falls through next review. The interventions included, but were not limited to, report all to physician and family, skilled therapy to evaluate and treat as needed and ordered, obtains labs as ordered, call light in reach, keep frequently used personal items within easy reach, provide rolling walker for ambulation, and if gait unsteady or fatigued guide to chair. The care plan was updated on 1/18/11 instruct resident to ask for assistance, on 2/7/11 instruct resident to be aware of wet floor signs, and fall 2/10/11. A verification of investigation form (DQI form) provided by the DNS on 4/14/11 and reviewed on 4/14/11, indicated the date/time of event: 1/18/11 at 2:00 p.m. Provide a detailed description of event/allegation: "Resident has a purple bruise ti (sic) right breast." "Went in the room to help resident to the shower I noticed the bruise." Assessment of resident/describe injury: "Resident has purple bruise ti (sic) right breast" No apparent injury. Resident interview summary: "She said that it didn't hurt et (and) she fell but doesn't remember when. Witnesses: CNA #1 "I didn't notice it until you nurse showed me. She was dressed when I got here." A verification of investigation form provided by the DNS on 4/14/11 and reviewed on 4/14/11, indicated the date/time of event: 1/18/11 at 2:28 p.m. Provide a detailed description of event/allegation: "Resident stated that she fell . Resident had a purple bruise to right breast." There was no information documented on the witnesses section of the form. A change in condition report -Post fall/trauma, indicated the date and time of 1/18/11 at 2:28 p.m. The location was blank, the resident's explanation box was checked. The box was checked for impaired safety awareness/judgement. "resident has dementia, paranoia, schizophrenia and depressive disorder." The physical assessment had the box check for redness/swelling/bruising. On 1/18/11 at 2:28 p.m., the following occurred: The resident stated that she fell . Resident had a purple bruise to right breast. Injury: No apparent injury. Interventions used prior to fall: was blank. Recommendations and interventions post fall: was blank IDT(interdisciplinary team) review and recommendations: instruct resident to call for assistance. A verification of investigation form was provided by the DNS on 4/14/11 an reviewed on 4/14/11, indicated date/time of event was 2/5/11 at 4:37 p.m. Provide a detailed description of event/allegation: Falls: ambulating-with assistance in resident dining room (Resident observed on floor on left side. Stated, "I twisted by ankle.") Assessment of resident/describe injury: ambulating with assistance, no apparent injury Underlying illness: history of falls. Interventions prior to fall: assistive device within reach, recommendations and intervention post fall: assistive device within reach. The physician and family was notified. The witness section was blank. A change in condition report-post fall/trauma indicated a dated 2/5/11 at 4:37 p.m. There was a check in the box by history of falls. Nurses note intervention: On 2/5/11 at 4:37 p.m. the following occurred: ambulating with assistance in resident dining room (Resident observed on floor on left side. Stated, "I twisted by ankle.") First aid administered in facility, physician and family notified. Interventions used prior to fall: a check was marked by the assistive device within reach. Recommendations and interventions post fall: a check mark was placed in the box assistive device within reach. IDT review and recommendation: therapy to evaluate. The investigation of Resident's #D fractured left humerus was provided by the Administrator on 4/14/11 at 11:45 a.m. The investigation was dated 2/15/11, the information was completed by the Administrator and the DNS (Director of Nursing Services). A written interview with CNA #2, indicated Resident #D "walked to the shower room with her walker, not to stable." "I starting (sic) showering her and she was complaining of pain, her shoulder hurt I was able to lift both arms to wash under her and she stated it hurt but did not cry out in pain. I told her I would let nurse know. I put light on for assessment. I waited 10-15 mins. (minutes) I took her out of the shower room with a gown on, put on with ease, and put in main hall with me so that (name of LPN #2) could see her. I told (name LPN #2) she was complaining of pain in her arm. (Name LPN #2) asked me to take her to the room. When I took her to her room she told me she fell . I didn't think she fell since she was with me the whole time. I should have told the nurse. I told the nurse she had pain." Addition information provided with the investigation indicated CNA #2 "reported she had given (resident's name) a shower the night before and no she had not fallen but that (resident's name) told her that she fell . "she said that she didn't report that to the nurse (nurse's name) all she reported to (nurse's name) was that the resident had pain. She said that (resident's name) was pushing her walker when she left the shower room and she was acting normal. LPN #2 indicated "she had been told about the pain and that she was not told that the resident fell she also said that she did not range her and had not performed any assessment. She gave pains med (sic) and notified NP (Nurse Practitioner)." Review of the Post fall investigation summary indicated IDT review and recommendations: obtain labs CBC, CMP, UA, C & S. Interview with the Administrator and the DNS on 4/14/11 at 11:45 a.m., indicated two staff members had been terminated in regards to the incident involving the fractured left humerus of Resident #D the CNA and LPN #1. It was indicated, the documentation of LPN#1 assessing the resident was not correct. The LPN had not assessed the resident as had been documented and LPN #2 had not assessed the resident when informed about the resident's shoulder pain. It was indicated that interventions had been put into place after falls and felt to be appropriate. Interview with the DNS on 4/14/11 at 4:00 p.m., no further information was provided in regard to the interventions being in place for Resident #D being effect and specific. 2. Resident #B was observed on 4/13/11 at 11:45 am. He was sitting in his wheelchair at the nursing station. He had his lap apron on, long sleeves and no geri sleeves. There was an anti-roll back device on wheelchair. He was not using the apron. The resident was observed on 4/14/11 at 9:15 a.m. In therapy with long sleeves on. There were no geri sleeves observed. He did have on his activity apron. He was not using the apron. The record for Resident #B was reviewed on 4/15/11 at 9:45 a.m. The resident's [DIAGNOSES REDACTED]. A progress note dated 2/9/11 at 15:30 (3:30 p.m.), indicated the resident was found on the floor beside his bed in front of his wheelchair. The resident had dementia that was advanced and the resident made poor choices. The resident had a skin tear to his left lateral forearm. First aid was given. Vital signs were T-97.5, R- 16, P-60 and B/P-110/60, and oxygen saturation was 96% on room air. A progress note dated 2/10/11 at 14:07 ( 2:07 p.m.), indicated a faint very light bruise to left buttocks measuring 3.4 x 3.6 cm in size. The physician and family were notified. Bruise was most likely from fall that occurred the day before. At 12:54 a.m. the resident had a very poor gait and needs wheelchair for mobility with staff assisting. His cognition was very poor and unable to make good decisions. A progress note dated 2/16/11 at 13:59 (1:59 p.m.), indicated IDT (Interdisciplinary Team)-fall. "On 2/9/11 resident fell trying to walk without assist. Skin tear to left arm was sustained d/t (due to ) fall. Resident is currently mobile per wheelchair. The fall team met and decided that the appropriate intervention would be to add an anti-roll back device to wheelchair. Current interventions include: non-skid foot wear; transfer pole; w/c (wheelchair) positioning; bed in lowest position; call light in reach; and safety cues/reinforcement/reminder. Resident remains at risk for falls r/t (related to) history of falls and poor safety awareness. The team will continue to monitor residents safety. A progress note dated 2/18/11 at 18:55 (6:55 p.m.), indicated upon passing resident's room with fell ow resident this writer noted resident standing at the end of his bed walking in his room and then resident slipped and fell to the floor hitting his left arm on the foot board. The resident had just finished dinner and stated to the CNA he was tired and wanted to go to bed. Gait was slow and very unsteady. Range of motion performed to bilateral upper and lower extremities without pain or discomfort. Neurological checks were within normal limit. The resident was assisted to stand with assist from CNA. Placed back in wheelchair without difficulty. VS taken. Previous skin tear re-opened with measurement of 1.2 by 0.2. Area cleansed and dry dressing applied. Physician notified and no orders, family informed. Will continue to have staff monitor. A progress note, dated 3/5/11 at 12:11 a.m., indicated CNA found resident on floor, on his stomach. Nurse called to room by CNA at 11:20 p.m., "alert to self. [DIAGNOSES REDACTED]. Resident on floor on stomach, roled (sic) to side noted st (skin tear) to left elbow, 1/2 cm (centimeter), bruise 10/10 cm to right flank of back, attempted to range of motion, left hip rotated and leg shorter than (sic) right. Resident c/o (complained of ) of pain to hip. Body assessment with no other injury noted. Three man lift to bed, full body assessment (sic) with no other injury noted. B/P 100/62, 82, 97.8, resp 20,98 sat, bs (blood sugar) 207. Call to (physician's name) paged x (times) 2. Call to daughter at 11:34, Dr (doctor) again at 11:35, call to ER at 11:38, ambulance at 11:41, call to supervisor on call at 11:47, ADON ( Assistant Director of Nursing) at 11:38 and DoN (Director of Nursing)at 11:51. Ambulance arrived at 11:55 and left for hosp (hospital) at 12:09 a.m. At 2:24 a.m. a call to ER notified that resident had a fractured left hip. admitted to hospital." A progress note, dated 3/9/11 at 23:59 (11:59 a.m.), indicated resident was readmitted to the unit at 2:15 p.m. A progress note, dated 3/11/11 at 15:02 (3:02 p.m.), indicated IDT fall: on 3/4/11 at 11:20 p.m. resident was observed on the floor on his stomach by CNA. Upon assessment by nurse, resident noted to have skin tear to left elbow, bruising to right flank back, and suspected left hip fracture. The resident was sent to the ER where it was determined that resident had fractured left hip and was admitted for surgery. On 3/9/11, resident readmitted to facility. IDT met 3/10/11 and agreed that PT will evaluate. Follow up to review current interventions and need for further intervention will be discussed in one week. At 15:55 (3:55 p.m.), Resident continued to deny pain even after he was found attempting to get out of bed and had removed dressing from hip. New dry dressing applied. Staff repositioned in bed for comfort. A progress note, dated 3/14/11 at 5:59 a.m., indicated resident in bed. The resident scratched his right arm antecubital area (bend of elbow), causing a skin team measuring 3 x 2 cm. Some bleeding noted. A new order was received. A progress note, dated 3/1/6//11 at 15:39 (3:39 p.m.), indicated resident alert and responsive to care. Treatment in place to right upper arm, dressing dry and intact. Resident has geri sleeves in place per order. orders. All orders noted. A progress note, dated 3/21/11 at 14:07 (2:07 p.m.), indicated follow-up IDT discussion on 3/10/11. On 3/17/11, IDT met to discuss interventions for fall that occurred on 3/4/11. The resident was currently on therapy case load and was agreed that self-release belt be removed as current intervention. A progress note, dated 3/27/11 at 15:00 ( 3:00 p.m.), indicated the resident was found on the floor sitting on buttocks next to bed. He had a history of [REDACTED]. R-18, B/P-95/60, BS-201. Assess resident from head to toe, was advised from CNA resident was toileted at 2:30 p.m., before laying down. No apparent injuries noted. A progress note, dated 3/27/11 at 20:00 (8:00 p.m.), indicated resident found at nurses station sitting on floor next to wheelchair, hands on side of him. The resident was assessed from head to toe. Skin tear found on his left forearm 1.8 x 1 cm. The resident was unable to state what happened. New order received. A progress note, dated 3/28/11 on 12:53 p.m., indicated IDT fall: One 3/27/11 at 8:00 p.m., resident was observed sitting on the floor next to his wheelchair with his hands beside him. The resident obtained a skin tear to his left forearm as a result of this fall. The resident was unable to describe what happened. This resident at risk for falls related to use of anti-depressant medication; poor safety awareness, attempts to self/transfer without assist; history of falls; fractured hip. Prior interventions include: activity programming; call light or personal items on reach; foot wear to prevent slipping; environment free of clutter and well lit; observe for side effects of medication; therapy referral as needed; notify physician and responsible party of any fall; non-skid strips in bathroom; mat at bedside; night light; utilize wheelchair as needed; Dycem to wheelchair; anti- rollback device; assist side rail; currently on therapy caseload; low bed and cushion mat to floor. IDT met and agreed that a lap apron shall be appropriate for this fall. A progress note, dated 4/2/11 at 14:23 ( 2:23 p.m.), indicated The resident had four attempts to get up out of wheelchair. Staff offered snacks, repositioned and laid down. A progress note, dated 4/9/11 at 12:07 p.m., indicated the resident will occasionally stand from sitting position when in wheelchair and redirected by staff. A progress note, dated 4/10/11 at 14:52 (2:52 p.m.), indicated the resident was walking down the hall and was lowered to the floor by staff. The resident stood from wheelchair and began walking down hall. CNA and nurse reached resident but only in time to help him to the floor. The resident began falling and the nurse was unable to help resident regain balance. No injury noted to resident. The resident was without sign or symptom of pain. Resident's typical range of motion intact. Vital signs taken. Physician and family informed. No new orders. A progress note, dated 4/11/11 at 12:35 p.m., indicated IDT fall: On 4/10/11, the resident was observed by the CNA staff walking at the nurses station without assistance. CNA quickly went to resident and was able to lower him gently to the floor. No injuries reported or observed. Prior interventions include: activity programming, call light in reach, foot wear to prevent slipping; environment well lit and free of clutter, observed for side effects of medication, therapy referral as needed; notify physician and family of falls, non-skid strips in bathroom and cushion floor mat at bedside; night light; Dycem to be applied to below wheelchair cushion; anti- rollback device to wheel chair; assist side rails; resident on therapy case load; lap apron and low bed. IDT met and agreed to obtain urinalysis with culture and sensitivity as intervention for purposes of this fall. A Fall risk assessment, dated 12/20/10 indicated a score of 16, on 3/9/11 a score of 14, and on 3/13/11 a score of 18. A score of 10 or greater indicated resident at risk for falls. An annual Minimum Data Set (MDS) Assessment, dated 3/28/11, indicated the resident understood and understands. He had a BIMS (Brief Interview of Mental Status) score of 9, indicated he was moderately impaired cognitively. He was an extensive assist (resident involved in activity, staff provide weight-bearing support with a two plus person physical assist) with transfers. Walking in the room and corridor did not occur during the assessment period. A fall care plan initiated on 10/1/10, indicated at risk for falls related to: use of anti-depressant medication and poor safety awareness, has [DIAGNOSES REDACTED]. On 1/17/11, a bed alarm and night light was added. On 1/24/11, a Dycem to be applied to below and above wheelchair cushion as added. Utilize wheelchair as needed was added with no date. 1/25/11, self release alarm belt was added, On 2/10/11, anti-roll back device to wheelchair was added. On 2/21/11, assist side rails were added. On 3/10/11, PT to evaluate and IDT to address in one week current interventions. On 3/17/11, the resident was added to the therapy case load and the self release alarm belt was discontinued. On 3/27/11, lap apron; low bed, cushion mat to floor was added. On 4/11/11 a urinalysis, culture and sensitivity was to be obtained. A verification of investigation form was provided by the Assistant Director of Nursing (ADoN) and reviewed on 4/15/11. The form indicated the date and time of the event was 2/9/11 at 3:30 p.m. The change in condition report-post fall/trauma was attached. Intervention prior to fall the following were indicated change in footwear, wheelchair positioning, bed in low position, safety cues/reinforcement/reminder, and call light within reach. Recommendations and interventions post fall included: change in foot wear, transfer pole, wheelchair positioning, bed in low position, safety cues/ reinforcement/reminders, call light within reach, psych evaluation. The IDT review and interventions indicated anti-roll back device. A fall safety check list, dated 2/9/11, indicated Please complete and turn in with each fall investigation. Alarm to wheelchair sounding-no, alarm to bed sounding-no, bed in low position-yes, mat to floor at bedside-n/a, did resident have on non skid footwear-yes,was resident attempting to set on chair, bed, or couch-yes back to bed, A verification of investigation form was provided by the ADoN and reviewed on 4/15/11. The form indicated the date and time of the event was 2/18/11 at 6:15 p.m. The resident was standing and ambulating in room by foot of bed. The resident indicated "he slipped." The change in condition report-post fall/trauma was attached. The intervention used prior to fall indicated were bed in low position, safety cues, restrain, call light within reach. The recommendation and intervention post fall indicated bed low, safety cues, restraint, and call light in reach. The IDT review and recommendations indicated assist side rail. A CNA post fall investigation form was attached. It indicated the fall was witnessed in the resident's room at 6:15 p.m. There was injury to the left forearm. The resident was not soiled. The resident had been checked at 6:10 p.m. in bed. The resident could not indicate what he was doing prior to fall. He later indicated "I want to go to bed. The resident detached his seat belt several times and stated he wanted to go to bed. It did indicate he was in the center of the bed. CNA action plan indicated to prevent the fall "put resident to bed right after meal" and the CNA indicated possible one on ones could improve the resident's safety. A fall Safety check list was attached: There was no wheelchair alarm sounding, the bed was in the low position, the mat was to floor at bedside, he was wearing sleepwear and socks. It was indicated "wanted to go to bed after dinner and self ambulated from bed." A verification of investigation form was provided by the ADoN and reviewed on 4/15/11. The date/time of the event was 3/4/11 at 11:20 p.m. The resident was found on the floor on stomach by his bed. There were bruises to left arm and back. On the witness form it was indicated the resident was sent to the hospital. There resident had poor safety awareness, attempts to stand, get up from wheelchair consistently and attempts to ambulate and gait was unsteady. Interventions prior to fall: night light, Dycem to wheelchair, Self release belt, anti-roll back to wheelchair, assist side rails. Intervention post fall: 3/10/11 Therapy to evaluate and IDT to follow up in one week on current interventions. 3/17/11 The resident was on the therapy case load and the self release belt was removed. A verification of investigation form was provided by the ADoN and reviewed on 4/15/11. The form indicated the time of the event was 3/27/11 at 3:00 p.m. The resident was found in his room by CNA on floor next to bed sitting on buttocks. There was no apparent injury. There was no witness of the fall. A change in condition report-post fall/trauma form was attached: The interventions used prior to fall were bed in low position and call light within reach. The recommendation and intervention post fall: bed in low positron, call light in reach toileting schedule and safety cues. IDT review and recommendations: low bed. There was no verification of investigation form provided for the other fall on 3/27/11. A verification of investigation form was provided by the ADoN and reviewed on 4/15/11. The form indicated the event happened on 4/10/11 at 2:15 p.m. The resident was lowered to the floor after standing from wheelchair, walking, losing balance and the nurse lowed the resident to the floor. There was no apparent injury. The resident gave no explanation to what happened. Interventions prior to fall: toileting schedule, assistive device within reach, pain assessment, wheelchair positioning, safety cues. Recommendations and interventions post fall: toileting schedule, assistive device with in reach, pain assessment, wheelchair positioning, safety cures. There were two witnesses to the fall: "Resident got up out of wheelchair and was walking almost fell . Resident caught and lowered to floor." "(Resident's name) was walking by the nursing station. I ran to him to walk him back to the chair. I held him to my arms and (sic) slipped out from my arms and slided (sic) down on my leg." A change in condition report-post fall/trauma form was attached. The only addition information was IDT review and recommendations. These included urinalysis with culture and sensitivity. Interview with the DNS (Director of Nursing Services) on 4/15/11 at 1:20 p.m., indicated the resident's bed alarm was discontinued on 2/4/11. Interview with the DNS on 4/15/11 at 2:45 p.m., indicated there was no way to know if alarm sounded other than to see if it was signed out on the CNA sheets. Some of the interventions such as floor mats and side rails would not be signed out. She indicated what was on the care plan and in the investigation were the interventions put into place. She further indicated the facility was on top of falls and jumped when one happened. She did not give any other intervention other than therapy when the resident returned to the to the facility on [DATE] after falling from his bed and fracturing his hip or any other interventions other than a urinalysis, culture and sensitivity after being lowered to the floor on 4/10/11. She did not indicate where the resident was when he fell on [DATE] or if the self alarming belt was sounding at the times of the falls on 2/9/11 and 2/18/11, or if the assist rails were in place at the time of his fall on 3/4/11. Interview with Unit Manager #2 on 4/15/11 at 3:10 p.m., indicated she could show where the self release belt was signed out as being on the resident. She could not say if the alarming belt was on at the time of his falls on 2/9/11 or 2/18/11. She indicated all interventions should be checked off on the Change in Condition- post fall/trauma form. She then indicated it all interventions were not checked off or list they should have been and they was no system in place to verify if when investigating if all interventions were checked and to see if in place, functioning and effectiveness. 3. The record of Resident #C was re