Every finding on record at Brickyard Healthcare - Valparaiso Care Center

Based on record review and interview, the facility failed to ensure an indication or reason for use was documented prior to administering a PRN (as needed) anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 42)Finding includes:The record for Resident 42 was reviewed on 7/24/25 at 10:59 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, psychotic disorder with delusions, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 6/5/25, indicated the resident was cognitively impaired and received anti-anxiety medications. A Physician's Order, dated 7/14/25, indicated lorazepam (Ativan, an anti-anxiety medication) 2 mg/ml (milligrams/milliliter), give 0.5 ml by mouth every 2 hours as needed for anxiety, insomnia or shortness of breath. A Care Plan, updated on 7/24/25, indicated the resident used anti-anxiety medication. The Medication Administration Record (MAR), dated 7/2025, indicated the lorazepam was administered without any indication or reason for use documented on the following dates and times:-7/19/25 at 3:00 p.m.-7/20/25 at 3:00 p.m.-7/22/25 at 7:20 a.m., 1:00 p.m., and 3:32 p.m.-7/23/25 at 8:25 a.m. and 10:42 a.m. During an interview on 7/25/25 at 10:22 a.m., the Administrator indicated she was unable to provide any further documentation as to why the medication had been administered. A policy, titled PRN Medications, received from the Administrator 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 the Minimum Data Set (MDS) assessment was accurately completed related to wandering behaviors for 1 of 18 MDS assessments reviewed. (Resident 78) Finding includes: On 7/21/25 at 1:08 p.m., Resident 78 was observed wandering in a hallway unaccompanied by any staff. He was headed towards a side entrance door. He was unable to open the door and then continued to enter another resident's room. Resident 78's record was reviewed on 7/23/25 at 3:24 p.m. Diagnoses included, but were not limited to, Alzheimer's Disease with late onset, dementia, and generalized anxiety disorder. The Discharge Minimum Data Set (MDS) assessment, dated 6/25/25, indicated the resident was moderately cognitively impaired and had inattention and disorganized thinking that fluctuated. Over the 7-day look-back period, the resident displayed physical behavioral symptoms for 1-3 days and other behavioral symptoms that were not directed towards others for 4-6 days. The Wandering - Presence and Frequency section indicated the resident had no wandering behaviors. The current care plans indicated the resident had Alzheimer's disease and was an elopement risk and was to wear a Wander Guard (bracelet sensor that alarms when too close to an exit or set perimeter). He had a behavior problem of making sexually inappropriate comments and wandering into other residents' rooms attempting to take personal items. The Progress Notes from the 7-day look-back period indicated the resident was wandering in the hallways on 6/17/25 at 9:33 a.m., 6/18/25 at 1:02 a.m., 6/21/25 at 8:54 a.m., 6/21/25 at 10:52 a.m., and 6/25/25 at 10:49 a.m. During an interview on 7/24/25 at 1:09 p.m., the MDS Coordinator and Administrator indicated the wandering behavior should have been marked on the MDS assessment. 3.1-31(c)(7)

Based on record review and interview, the facility failed to ensure care plans were implemented for 1 of 18 resident care plans reviewed. (Resident 13) Finding includes: Resident 13's record was reviewed on 7/24/25 at 11:35 a.m. Diagnoses included, but were not limited to, paranoid schizophrenia, bipolar disorder, sleep disorder, and generalized anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 6/28/25, indicated the resident was moderately cognitively impaired. He had no behavioral symptoms. He received a scheduled pain medication regimen, antipsychotic, antianxiety, antidepressant, diuretic, antiplatelet, and anticonvulsant medications. A Physician's Order, dated 4/14/25, indicated Depakote (anticonvulsant) sprinkles oral capsule 125 mg, 4 capsules (500 mg) in the morning and 8 capsules (1000 mg) at bedtime. A Physician's Order, dated 6/24/25, indicated risperidone (antipsychotic) 1 milligram (mg) twice daily. The resident's current care plans indicated he was at risk for falls, risk for pain, received antianxiety medications, antidepressant medications, antiplatelet therapy, and had a mood problem related to his diagnosis of paranoid schizophrenia and bipolar disorder. There were no care plans implemented related to the resident receiving antipsychotic or anticonvulsant medications. During an interview on 7/25/25 at 9:25 a.m., the Administrator and Nurse Consultant indicated the care plans should have been in place for the anticonvulsant and antipsychotic medication use. A policy titled, Comprehensive Care Plans, indicated .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished wto attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 3.1-35(c)(1)

Based on record review and interview, the facility failed to ensure physician's orders were followed for a respiratory assessment with administration of an as needed (PRN) nebulizer treatment for 1 of 5 resident's reviewed for unnecessary medications. (Resident 13) Finding includes: Resident 13's record was reviewed on 7/24/25 at 11:35 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 6/28/25, indicated the resident was moderately cognitively impaired. He had no behavioral symptoms. He received a scheduled pain medication regimen, antipsychotic, antianxiety, antidepressant, diuretic, antiplatelet, and anticonvulsant medications. The current July 2025 Physician's Order Summary indicated ipratropium-albuterol solution (nebulizer treatment to help open airways) 0.5-2.5, 3 milligrams/3 milliliters, inhale orally every 6 hours as needed, documentation to be completed after nebulizer treatment: record minutes, document vital signs and lung sounds before the nebulizer treatment. The ipratropium-albuterol nebulizer treatment was administered on 6/14/25 at 1:40 p.m. and 6/15/25 at 9:14 a.m. There was no documentation of the vital signs and lung sounds before the nebulizer treatment was administered. During an interview on 7/25/25 at 9:25 a.m., the Administrator and Nurse Consultant indicated they were unable to find any documentation of an assessment prior to the administration of the treatments. The orders were put in separately, so the nurses were not prompted to do the assessment and fill it out upon administration. A policy titled, Nebulizer Therapy, indicated .6. Obtain resident's vital signs and perform respiratory assessment to establish a baseline .Documentation .record the following information in the resident's medical record .1. Date, time, and duration of therapy 2. Type and amount of medication 3. Oxygen flow if administered 4. Resident vital signs and respiratory assessment 5. Resident's response to treatment 6. Any resident teaching provided and the resident's understanding of the treatment . 3.1-37(a)

Based on record review and interview, the facility failed to obtain prompt diagnostic testing related to a doppler scan (ultrasound) for 1 of 1 resident reviewed for diagnostic testing. (Resident B) Finding includes: Resident B's record was reviewed on 7/22/25 at 1:30 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (weakness and paralysis) following stroke affecting the left non-dominant side, breast and bone cancer, and heart failure. The Discharge Minimum Data Set (MDS) assessment, dated 6/13/25, indicated the resident was moderately cognitively impaired. A Care Plan, initiated 5/12/25, indicated the resident had fluid overload or potential fluid volume overload related to heart failure. A Physiatry Progress Note, dated 5/28/25, indicated the resident was observed to have bilateral lower extremity edema. A Physician's Order, dated 6/6/25, indicated venous doppler to the left lower extremity for diagnosis of edema. A Physician's Note, dated 6/10/25 at 11:39 a.m., indicated the resident had edema to the left lower extremity and the doppler study was negative. The edema was likely positional related. The record lacked documentation of a completed doppler study. During an interview on 7/24/25 at 1:09 p.m., the Administrator indicated the resident did not receive the doppler scan as ordered by the physician and the note on 6/10/25 was charted in error. A policy titled, Diagnostic Testing Services, indicated .The facility will provide the appropriate diagnostic services required to maintain the overall health of its residents and in accordance with State and Federal guidelines .1. Facility will maintain a schedule of diagnostic tests in accordance with the physician's orders. No diagnostic tests will be performed without specific physician orders in accordance with State law to include scope of practice laws. 2. Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering Physician within 72 hours of receipt unless the report results fall outside of clinical reference ranges and require immediate attention at which time the Physician will be notified . This citation relates to Complaint 1321080. 3.1-49(g)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to inaccurate documentation of doppler scan test results for 1 of 1 resident reviewed for diagnostic testing. (Resident B) Finding includes: Resident B's record was reviewed on 7/22/25 at 1:30 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (weakness and paralysis) following stroke affecting the left non-dominant side, breast and bone cancer, and heart failure. The Discharge Minimum Data Set (MDS) assessment, dated 6/13/25, indicated the resident was moderately cognitively impaired. A Care Plan, initiated 5/12/25, indicated the resident had fluid overload or potential fluid volume overload related to heart failure. A Physiatry Progress Note, dated 5/28/25, indicated the resident was observed to have bilateral lower extremity edema. A Physician's Order, dated 6/6/25, indicated venous doppler to the left lower extremity for diagnosis of edema. A Physician's Note, dated 6/10/25 at 11:39 a.m., indicated the resident had edema to the left lower extremity and the doppler study was negative. The edema was likely positional related. A Physician's Note, dated 6/12/25 at 7:50 a.m., indicated the resident said she had not received a doppler scan, however the nurse practitioner indicated the results were negative in the last note she had documented. The resident's legs looked equivalent bilaterally in regard to edema. During an interview on 7/24/25 at 1:09 p.m., the Administrator indicated the resident did not receive the doppler scan as ordered by the physician and the note on 6/10/25 was charted in error. This citation relates to Complaint 1321080. 3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure a resident was informed of resident rights and facility rules upon admission for 1 of 1 resident reviewed for resident rights. (Resident 225) Finding includes: During an interview on 9/30/24 at 10:34 a.m., Resident 225 indicated she was admitted to the facility on [DATE] and had not received any orientation yet. No one had gone over resident rights with her, and she was not aware of any of the rules of the facility. The record for Resident 225 was reviewed on 10/1/24 at 2:59 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, bipolar disorder, and hypertension. The resident was admitted to the facility on [DATE] and was listed as her own responsible party. A Consent to Treatment Form, dated 9/10/24, had been signed by the resident. There was a lack of any documentation that resident rights or the rules of the facility had been discussed with the resident. During an interview on 10/2/24 at 11:39 a.m., the Administrator indicated staff had just gone over the admission paperwork with the resident today, including resident rights. The Admissions Director was on unexpected leave and the staff covering were still trying to catch up. 3.1-4(a)

Based on observation, record review, and interview, the facility failed to notify the physician timely related to ongoing respiratory symptoms and the inability to obtain a sample for ordered laboratory testing for 1 of 1 resident reviewed for respiratory care. (Resident 16) Finding includes: Resident 16 was observed on 10/1/24 at 11:30 a.m. in one of the activity/dining room areas in the Memory Care Unit in a wheelchair at a table with other residents. She was actively coughing. Resident 16's record was reviewed on 10/3/24 at 10:43 a.m. Diagnoses included, but were not limited to chronic obstructive pulmonary disease, vascular dementia with behavioral disturbance, and psychotic disorder with hallucinations. The Quarterly Minimum Data Set assessment, dated 7/18/24, indicated the resident was severely cognitively impaired for daily decision making. A Nurses' Note, dated 9/8/2024 at 3:48 p.m., indicated the resident had a productive cough with some phlegm. The resident was negative for Covid-19 infection and the Physician was notified. A Nurses' Note, dated 9/9/2024 at 7:18 a.m., indicated the Physician ordered a chest x-ray for cough and congestion with diminished lung sounds on lower lobes. A Nurses' Note, dated 9/11/2024 at 9:01 a.m., indicated the resident continued with occasional cough. A Nurses' Note, dated 9/24/2024 at 10:57 p.m., indicated the resident continued with non-productive cough with nasal drainage. A Nurses' Note, dated 9/25/2024 at 11:56 p.m., indicated new orders were received for a urinalysis with culture and sensitivity (UA with C&S) to follow. A Physician's Order, dated 9/25/24, indicated obtain a urinalysis with culture and sensitivity to follow. A Nurses' Note, dated 9/26/2024 at 12:32 a.m., indicated an attempt was made to obtain the UA and C&S per straight catheter, but was unsuccessful as the resident was incontinent of urine. The resident continued to have non-productive cough. A Nurses' Note, dated 9/26/2024 at 2:39 p.m., indicated an attempt was made to obtain a UA and C&S per straight catheter, but was unsuccessful. The resident continued with a non-productive cough with no nasal drainage. There was no documentation available regarding a UA with C&S on 9/27/24. A Nurses' Note, dated 9/28/2024 at 2:20 p.m., indicated the resident continued to have an occasional non-productive cough and staff was unable to get a urine sample from the resident. There was no documentation available regarding a UA with C&S on 9/29/24. A Nurses' Note, dated 9/30/2024 at 2:08 a.m., indicated unable to collect urine specimen at this time related to incontinence. A Nurses' Note, dated 9/30/2024 at 5:37 a.m., indicated the resident had drainage noted to bilateral eyes and the Physician was notified. A Nurses' Note, dated 9/30/2024 at 5:56 a.m., indicated staff was unable to collect a urine specimen at the time related to incontinence. A Nurses' Note, dated 9/30/2024 at 5:25 p.m., indicated staff was unable to collect a urine specimen at the time related to incontinence. A Nurses' Note, dated 10/1/24 at 11:22 p.m., indicated the resident continued with cough and mild nasal drainage. The resident became combative and staff were unable to collect a urine sample. There was no documentation the physician was notified of the continued respiratory symptoms from 9/9/24 when the x-ray was ordered until 9/25/24 when the UA with C&S was ordered. There was no documentation the physician was notified of the inability to obtain a urine sample to send for the UA with C&S from 9/25/24 until 10/2/24, when the order was discontinued. During an interview on 10/4/24 at 8:55 a.m., the Director of Nursing indicated the staff were supposed to get the UA with C&S per the Physician's Order, but were unable to obtain the sample due to incontinence. The order was discontinued on 10/2/24 when the physician was notified it had not been obtained. 3.1-5(a)(3)

Based on observation, record review and interview, the facility failed to ensure residents received medications as ordered related to following blood pressure parameters prior to administration for 1 of 5 residents reviewed for unnecessary medications (Resident 59) and 1 of 2 residents reviewed for pain. (Resident 177) The facility also failed to assess and monitor a skin discoloration for 1 of 3 residents reviewed for non-pressure skin conditions. (Resident 71) Findings include: 1. The record for Resident 59 was reviewed on 10/2/24 at 9:12 a.m. Diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, and diabetes mellitus. The Annual Minimum Data Set assessment, dated 8/7/24, indicated the resident was cognitively intact and received hemodialysis. A Physician's Order, dated 5/17/24, indicated to give midodrine (a medication used to treat low blood pressure) 5 milligrams (mg) three times a day for hypotension (low blood pressure). Hold for systolic (top number) blood pressure (BP) greater than 120 (millimeters of mercury) or diastolic (bottom number) greater than 90. The August and September 2024 Medication Administration Records (MAR) indicated the midodrine was administered outside of the parameters on the following dates and times: 8/2/24 at 1:00 p.m.: BP 128/67 8/10/24 at 1:00 p.m.: BP 126/74 8/30/24 at 1:00 p.m.: BP 133/65 9/24/24 at 1:00 p.m.: BP 124/68 A Physician's Order, dated 6/10/24, indicated to give hydralazine (medication used to treat high blood pressure) 50 mg, three times a day on Tuesday, Thursday, Saturday and Sunday. Hold for systolic BP less than 120 or diastolic BP less than 50. The August 2024 MAR indicated the hydralazine was administered outside of the parameters on the following dates and times: 8/17/24 at 10:00 p.m.: BP 118/58 8/25/24 at 9:00 a.m.: BP 101/62 8/25/24 at 1:00 p.m.: BP 112/68 A Physician's Order, dated 8/27/24, indicated to give hydralazine 50 mg, three times a day on Tuesday, Thursday, Saturday and Sunday. Hold for systolic blood pressure less than 140 or diastolic BP less than 50. The September 2024 MAR indicated the hydralazine was administered outside of the parameters on the following dates and times: 9/7/24 at 9:00 a.m.: BP 125/60 9/7/24 at 10:00 p.m.: BP 121/60 During an interview on 10/3/24 at 9:43 a.m., the Director of Nursing indicated the above medications were given outside of the ordered parameters. 32664 2. Record review for Resident 177 was completed on 10/1/24 at 1:45 p.m. Diagnoses included, but were not limited to, hypertension, hypotension, lymphedema, and depression. The October 2024 Physician's Order Summary indicated an order for midodrine hydrochloride (treats low blood pressure). Give 5 mg (milligrams) by mouth three times a day, hold for a systolic (top number of blood pressure reading) above 120. The September 2024 Medication Administration Record (MAR) indicated the midodrine was administered and not held as ordered on the following dates and times: 9/1/24 at 12:00 p.m., blood pressure (BP) 128/81 9/6/24 at 6:00 a.m., BP 127/69 9/9/24 at 12:00 p.m., BP 131/71 9/12/24 at 6:00 a.m., BP 127/68 9/19/24 at 6:00 p.m., BP 132/77 9/23/24 at 12:00 p.m., BP 128/71 During an interview on 10/1/24 at 3:38 p.m., the Director of Nursing (DON) indicated the midodrine was administered on the above dates and times when the blood pressure was out of parameters. The medication should have been held. 45666 3. On 9/30/24 at 10:08 a.m., Resident 71 was observed self-propelling in a wheelchair down the hall in the locked memory care unit. There was a discoloration approximately the size of a quarter observed above her left elbow. On 10/3/24 at 2:42 p.m., Resident 71 was observed self-propelling in a wheelchair down the hall in the locked unit. There was a discoloration approximately the size of a quarter observed above her left elbow. Resident 71's record was reviewed on 10/2/24 at 10:50 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, psychotic disorder with delusions, and generalized anxiety disorder. The Admission Minimum Data Set assessment, dated 8/10/24, indicated the resident was severely cognitively impaired for daily decision making. A Physician's Order, dated 8/12/24 at 7:00 a.m., indicated a weekly skin review assessment every Monday during day shift. The Weekly Skin Review, dated 9/30/24 at 2:35 p.m., indicated the resident had no new skin issues. During an interview on 10/04/24 at 9:04 a.m., the Director of Nursing indicated she had staff measure the bruised area after notification of the discoloration. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure an indwelling Foley (urinary) catheter tubing and collection bag was kept off the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 276) Finding includes: Resident 276 was observed on 10/2/24 at 10:49 a.m. The resident was lying in her bed, which was lowered to the ground with a fall mat on the left side of the bed. The catheter collection bag was lodged underneath the bed lying directly on the fall mat with the catheter tubing also on the ground. Resident 276's record was reviewed on 10/2/24 at 10:33 a.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder and dementia. The Admission Minimum Data Set assessment, dated 9/26/24, was still in progress. The Baseline Care Plan, dated 9/26/24, indicated the resident was a new admission to the secured unit. She required a Hoyer mechanical lift with 2 person assist, bed in lowest position, bilateral floor mats, and indwelling Foley catheter care every shift. During an interview on 10/2/24 at 11:29 a.m., RN 1 indicated the catheter should not have been on the floor. Someone must have lowered the bed after care and did not place the collection bag in a basin. During an interview on 10/2/24 at 11:48 a.m., the Director of Nursing indicated she had no further information to provide. A policy titled, Catheter Care, and noted as current, indicated .Policy Explanation .10. Ensure drainage bag and catheter tubing are not touching the floor to assist in decreasing risk of UTI. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure the Interim Administrator was notified immediately of a nasal fracture resulting from a resident to resident altercation for 1 of 2 residents reviewed for abuse. (Resident 36) Finding includes: Resident 36's record was reviewed on 12/12/23 at 12:58 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, dementia with behavioral disturbance, major depressive disorder, and fracture of nasal bones. The Quarterly Minimum Data Set (MDS) assessment, dated 11/20/23, indicated the resident was moderately impaired for daily decision making. A Progress Note, dated 12/10/2023 at 7:49 p.m., indicated staff responded immediately to loud voices heard. The resident was observed self-propelling in a wheelchair from his room into the hallway with a moderate amount of bleeding noted from his nose. The resident stated, He hit me. He broke my nose. I'm going to whoop his ass. The resident was assessed immediately by four nurses, noted with bruising to the bony area to the left side of his nose. The Interim Executive Director was notified immediately. The resident was to be placed on 1:1 with staff, to be moved to an open bed on South Unit with a wanderguard in place. The resident was sent to the hospital for evaluation and treatment as indicated per the Director of Nursing. The Physician was notified. Multiple attempts to reach the Power of Attorney (POA) were made. A Progress Note, dated 12/10/2023 at 11:45 p.m., indicated the resident returned from the hospital. The State Reportable related to the incident was reviewed. The incident time was 12/10/23 at 7:30 p.m. The Reportable was submitted on 12/11/23 at 3:24 p.m. The Reportable indicated two residents had appeared to go into the shared bathroom at the same time. Resident 36 was noted to have bleeding from his nose. The residents were immediately separated and placed on 1:1 with staff until both were calm and then they were placed on 15 minute checks. Resident 36 was sent to the hospital immediately. Upon return from the hospital, Resident 36 was diagnosed with a nasal fracture. He was moved to the South Unit for a change in environment. Interview with the Administrator on 12/14/23 at 2:36 p.m., indicated that they in-serviced the staff immediately upon finding out the Interim Administrator was not notified of the nasal fracture upon return from the hospital. They should have reported within 2 hours of return from the hospital as it was a major injury. An in-service was sent via text message on 12/11/23 at 2:09 p.m. to all employees which stated, Any time a resident is involved in a reportable and is sent out to the hospital, the Executive Director must be notified immediately and be notified upon return with an update on status. If they are admitted , the Executive Director must be notified with admitting diagnosis. The Long-Term Care Abuse and Incident Reporting Policy was also attached. 3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure Physician's Orders for lymphedema pumps were documented as completed for 1 of 4 residents reviewed for non-pressure skin conditions. (Resident 29). Finding includes: During an interview on 12/11/23 at 10:35 a.m., Resident 29 indicated she had worn a suit for her lymphedema that helped to reduce the swelling in her legs, but had not worn it for a long time because she had Respiratory Syncytial Virus (RSV) and wasn't feeling up to it. During the interview, her legs were observed to be reddened in color and swollen. Resident 29's record was reviewed on 12/13/23 at 11:15 a.m. Diagnoses included, but were not limited to, lymphedema, heart failure, and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 9/25/23, indicated the resident was cognitively intact for daily decision making. A Physician Order, dated 7/7/23, indicated lymphedema pumps on bilateral lower extremities two times a day for 45 minutes per therapy. A Care Plan, dated 7/27/23, indicated the resident was at risk for fluid and electrolyte imbalance related to having a history of lymphedema and receiving a routine diuretic. Interventions included, but were not limited to, lymphedema pumps to bilateral lower extremities as ordered. There was no documentation related to the use of the lymphedema pumps. Interview with the Nurse Consultant on 12/14/23 at 11:15 a.m., indicated she would change the order so that there would be a check off on the Treatment Administration Record (TAR). 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide the necessary care and treatment for respiratory services related to the improper use of an oxygen delivery mask for 1 of 1 random observations of an oxygen mask. (Resident 10) Finding includes: On 12/11/23 at 12:41 p.m., Resident 10 was observed in her bed. She had an oxygen mask in place with a partially inflated bag attached to the mask. The oxygen concentrator was set on 3 liters per minute (lpm). The resident had her eyes closed and did not respond to voice. At 2:15 p.m., the nursing staff indicated the resident had been sent to the hospital. The resident's record was reviewed on 12/13/23 at 10:38 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, cellulitis and repeated falls. The Significant Change Minimum Data Set assessment, dated 10/25/23, indicated the resident had severe cognitive deficits and required extensive staff assistance for bed mobility and toileting. A Change in Condition Note, dated 12/11/23 at 8:40 a.m., indicated the resident had chills and did not want to get up. When assessed, the resident's temperature was 102.4 degrees, blood pressure 173/77, oxygen saturation was 84%, and a wet, non-productive cough was noted. The nurse applied oxygen via nasal cannula at 2 lpm and the resident's oxygen did not increase. A non-rebreather mask was then applied and the oxygen flow increased to 3 lpm; the oxygen saturation increased to 93%. The nurse then contacted the Physician and received orders for an antibiotic, prednisone (a steroid) and increased diuretic. A General Note, dated 12/11/23 at 2:07 p.m., indicated the family was present and requested the resident be sent to the hospital. A rebreather mask was in use at that time. Interview with the Infection Prevention (IP) Nurse on 12/14/23 at 11:15 a.m., indicated she was taking care of the resident on 12/11/23. When she noted her oxygen saturation was low, she asked staff to bring her a mask and they had brought her the non-rebreather mask. She indicated she was focused on getting the oxygen running and not what type of mask it was. At some point, the mask had been changed to a rebreather mask. The current policy, Oxygen Administration, was received on 12/14/23, indicated, .Non-Rebreather Mask- Oxygen is inhaled from a reservoir bag attached to the mask. Gas exits the mask through a one-way expiratory valve. This delivers concentrations between 60-90%. A minimum flow rate of 10 liters/minute is required for use . The policy did not contain information on rebreather masks. The article Carbon dioxide narcosis due to inappropriate oxygen delivery: a case report, retrieved from www.ncbi.nlm.nih.gov/pmc/articles, indicated, .some oxygen delivery systems such as non-rebreathing face masks with an oxygen reservoir bag require high oxygen flow for adequate oxygenation and to avoid carbon dioxide rebreathing . 3.1-47(a)(6)

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 pass. Seven errors were observed during 30 opportunities for errors during medication administration. This resulted in a medication error rate of 23%. (Resident 36) Finding includes: RN 1 was observed preparing the following medications during medication pass for Resident 36 on 12/13/23 at 4:00 p.m.: - Magnesium oxide tablet 400 milligram (mg) - Memantine tablet 5 mg - Vitamin C tablet 500 mg - Carvedilol tablet 25 mg - Donepezil tablet 5 mg - 2 acetaminophen tablets 325 mg - Ferrous gluconate tablet 324 mg RN 1 sanitized his hands and then placed each of the medications into a medication cup. He placed the medications into a crush bag and proceeded to crush all seven medications together in one bag. He mixed the crushed medications with pudding and administered them to the resident. Resident 36's record was reviewed on 12/12/23 at 12:58 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, dementia with behavioral disturbance, and heart failure. There were no Physician's Orders for crushing of medications. Interview with the Nurse Consultant on 12/14/23 at 1:37 p.m., indicated the order was dropped off when he had left the facility and it was never added back to his orders. 3.1-48(c)(1)

Based on observation and interview, the facility failed to ensure a sanitary kitchen related to staff not wearing hairnets and dirty shelves and carts. This had the potential to affect the 72 of 73 residents who received meals from the kitchen. Findings include: 1. On 11/13/22 at 9:43 a.m., the kitchen was observed during the initial tour. The Cook and Assistant Dietary Manager (ADM) were present, neither was wearing a hair net. Interview with the Cook and the ADM at that time indicated they should be wearing hair nets. They put them on at that time. 2. On 11/13/22 at 9:43 a.m., the kitchen was observed. The shelves below the work area and serving carts had an accumulation of dust, crumbs and spills. On 11/17/22 at 10:51 a.m., the shelves and serving carts had been cleaned. Interview with the Kitchen Manager at that time indicated she was aware of the accumulation of dirt on the shelves, but it had now been cleaned. The staff was to clean all shelves, carts and floors at the end of every shift. 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to develop and implement a care plan for a resident's skin discolorations for 1 of 20 residents reviewed for care plans. (Resident 12) Finding includes: On 11/13/22 at 1:38 p.m., Resident 12 was observed lying in bed. A dark purple discoloration was observed to the top of the left hand/wrist area. On 11/15/22 at 9:07 a.m., Resident 12 was observed lying in bed. A dark purple discoloration was observed to the top of the left hand/wrist area. Record review for Resident 12 was completed on 11/16/22 at 10:05 a.m. Diagnoses included, but were not limited to, anxiety, depression, psychotic disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 10/25/22, indicated the resident was cognitively impaired. The resident required an extensive 2+ person assist with bed mobility, transfers, dressing, toilet use and personal hygiene. The record lacked any documentation the skin discoloration had been assessed. Interview with the Wound Nurse on 11/16/22 at 11:25 a.m., indicated the resident's discoloration was a birthmark. He indicated she had multiple discolorations on her upper body, including a large purple discoloration to her left index finger and the top left hand/wrist, that family had said were birthmarks. He further indicated they did not have the discolorations documented as birthmarks on a care plan and that he would put one in place. Interview with the Director of Nursing (DON) on 11/16/22 at 11:35 a.m., indicated they should have mapped out her birthmarks on her body and put documentation of the birthmarks in a care plan. 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents observed during medication pass. Three errors were observed during 33 opportunities for errors during medication administration. This resulted in a medication error rate of 9%. (Residents 64 and 65) Findings include: 1. On 11/17/22 at 8:40 a.m., LPN 1 was observed preparing medications for Resident 64. She placed all the medications in a cup and indicated there were 10 pills in the cup. There were 10 pills and a medicated patch observed being prepared. She administered the medications to the resident and signed them out on the Medication Administration Record (MAR). The resident's record was reviewed on 11/17/22 at 11:15 a.m. to reconcile the medications given. A Physician's Order, dated 1/13/22, indicated Rosuvastatin Calcium 5 milligram (mg) capsule daily. The November MAR indicated the Rosuvastatin and the 10 additional pills and patch observed above had been given that day during the observed medication pass. The Rosuvastatin had been omitted per the administration observation. Interview with LPN 1 on 11/17/22 at 11:40 a.m., indicated she thought she had given the medication. 2. On Thursday, 11/17/22 at 9:00 a.m., LPN 1 was observed preparing medications for Resident 65. She placed all the medications in a cup and indicated there were 10 pills in the cup. She administered the medications to the resident and signed them out on the MAR. The resident's record was reviewed on 11/17/22 at 11:20 a.m. to reconcile the medications given. A Physician's Order, dated 4/16/22, indicated Finesteride 5 mg tablet daily and Vitamin D 1.25 mg every Thursday. The November MAR indicated the Finesteride, Vitamin D and the 10 additional pills observed above had been given that day during the observed medication pass. The Finesteride and Vitamin D had been omitted per the administration observation. Interview with LPN 1 on 11/17/22 11:40 a.m., indicated she looked in the medication cart, the medications were not there, and she would contact the pharmacy. 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure a resident's skin discolorations were assessed and monitored for 1 of 2 residents reviewed for non-pressure related skin conditions. (Resident 17) Finding includes: On 7/27/21 at 9:22 a.m., Resident 17 was observed lying in bed. There were purple discolorations to the top of her right hand below her 4th/5th knuckles and on her left wrist/forearm area. On 7/28/21 at 2:24 p.m., Resident 17 was observed lying in bed looking out the window. The purple discolorations remained to the top of her right hand below her 4th/5th knuckles and her left wrist/forearm area. The resident did not respond when asked how she obtained the skin discolorations. On 7/29/21 at 9:11 a.m., Resident 17 was observed lying in bed with her eyes closed. The purple discolorations remained to the top of her right hand below her 4th/5th knuckles and her left wrist/forearm area. On 7/30/21 at 2:05 p.m., Resident 17 was observed lying in bed. The purple discolorations remained to the top of her right hand below her 4th/5th knuckles and her left wrist/forearm area. Observation and interview with LPN 2 at that time indicated the areas looked like bruises and she would report them to LPN 1, the resident's nurse. Interview with LPN 1 on 7/30/21 at 2:15 p.m. indicated she had just assessed and measured the skin discolorations and they had not been previously noted. Record review for Resident 17 was completed on 7/29/21 at 1:31 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 5/4/21, indicated the resident's memory was intact and she had modified independence with daily decision making. The resident required an extensive 2 + person assist for dressing, personal hygiene, toilet use, and transfers. The most recent weekly skin reviews, dated 7/19/21and 7/26/21, indicated the resident's skin was intact. There were no areas of bruising or discoloration documented. A facility policy, titled Skin Integrity Guideline, received from the Administrator as current, indicated .Patients/Residents will be observed by the CNA daily for reddened/open areas .Changes will be reported to licensed nurse and documented . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a complete Physician's Order was in place for TPN (total [MEDICATION(S)] nutrition) for 1 of 1 residents reviewed for [MEDICATION(S)] fluids. (Resident 63) Finding includes: On 7/26/21 at 2:14 p.m., Resident 63 was observed sitting in bed. He indicated he was receiving TPN as well as a liquid diet. The bag of TPN was observed to be infusing with the pump set at 65 milliliters (ml) per hour. On 7/28/21 at 10:04 a.m., Resident 63 was observed ambulating in the hallway. He indicated the TPN rate was supposed to be 65 ml/hour. The TPN bag label indicated to infuse at 65 ml/hour, and it was observed to be infusing with the pump set at 65 ml/hour. Record review for Resident 63 was completed on 7/28/21 at 9:19 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment, dated 7/13/21, indicated the resident was cognitively intact and was receiving [MEDICATION(S)]/intravenous nutrition. A Physician's Order, dated 7/26/21, indicated hang TPN every 24 hours at 6 a.m. There was no infusion rate documented in the order. Interview with the Director of Nursing on 7/28/21 at 11:17 a.m., indicated the infusion rate was supposed to be 65 ml/hour per the hospital discharge instructions. She had clarified the TPN order to include the infusion rate. A facility policy, titled Medication Administration [MEDICATION(S)] Nutrition, received from the Director of Nursing as current, indicated .Preparation: 1. A physician's order is necessary for this treatment. The PN order should include the formula or a list of all individual ingredients/nutrients in the base solution, total volume and rate of administration as well as orders for monitoring laboratory results on a routine basis . 3.1-47(a)(2)

Based on observation and interview, the facility failed to ensure medications were properly stored for 2 of 4 medication carts observed. (South 1 Medication Cart and ACU Medication Cart) Findings include: 1. On 7/30/21 at 1:42 p.m., with QMA 1, the South 1 medication cart was observed. There were multiple pills of different sizes and colors that were loose and out of packages throughout the bottoms of the drawers in the cart. The QMA indicated she was unaware of the loose pills in the cart. Interview with LPN 1 on 7/30/21 at 1:44 p.m., indicated the nursing staff was responsible for making sure the medication carts were cleaned out. 2. On 7/30/21 at 1:52 p.m., with LPN 3, the ACU medication cart was observed. There were multiple pills of different sizes and colors that were loose and out of packages throughout the bottoms of the drawers in the cart. The nurse indicated she was unaware of the loose pills in the cart. The nursing staff was responsible for making sure the carts were cleaned and someone from pharmacy also would come to check the medication carts. 3.1-25(j) 3.1-25(o)

Based on record review and interview, the facility failed to notify a Physician by phone in a timely manner related to a change in condition, for which the resident was admitted to the hospital with [REDACTED]. (Resident B) Finding includes: 1. Resident B's record was reviewed on 11/06/17 at 4:50 p.m. [DIAGNOSES REDACTED]. Nurses' Notes indicated: 10/17/17 at 2:41 a.m., the temperature was 100.5. 10/17/17 at 5:28 a.m., the temperature was 100.4. 10/17/17 at 7:26 a.m., the Physician was notified of the temperature and awaiting response. 10/17/17 at 2:36 p.m., Physician was made aware of the elevated temperature at night and a new order for a chest x-ray was obtained. The POA (Power of Attorney) was notified. 10/17/17 at 10:09 p.m., temperature 100.1, blood pressure 89/54, heart rate 119, oxygen saturations 88% on room air. Mucous membranes were dry, scant bleeding to the lips, skin dry, lung sounds diminished, an order was received to send the resident to the emergency room for evaluation and treatment. There were no further Nurses' Notes to indicated the resident was assessed from 2:36 p.m. to 10:09 p.m. A Hospital emergency room indicated the resident presented at the emergency room at 10/17/17 at 8:13 p.m., with altered mental status and fever. The note indicated per the Nursing Home staff, there was more agitation, confusion and less conversation than the resident's baseline, fever and the resident had been biting her lip. A Hospital History and Physical, dated 10/17/17 at 11:02 p.m., indicated, .10/17/17 at 20:12 (8:12 p.m.) .from memory unit .not acting baseline, non comunicative (sic), fever, figety (sic), normally is conversant .critical condition and encephalopathic .yesterday last night patient was found to have slight fevers but she had just been switched to pureed diet because of poor swallowing. Today she was noticed to have altered mental status and [MEDICAL CONDITION] with poor responsiveness and so she was transferred to our emergency room .20:12 (8:12 p.m.) ED (Emergency Department) Temperature 101.6 .ED Pulse Rate 109 .Systolic Blood Pressure 143 .Diastolic Blood Pressure 64 (143/64) .mucous membranes dry .Poor turgor with strong evidence of dehydration .[MEDICAL CONDITION], UTI .severe dehydration, [MEDICAL CONDITION] (high sodium level) . The sodium level was critical at 164 (normal 135-147), BUN (kidney function test) was high at 61 (normal 7-22), and creatinine (kidney function test ) was high at 2.86 (normal 0.55-1.30). During an interview on 11/7/17 at 3:20 p.m., RN 5 indicated on 10/17/17 the resident had not been eating or drinking well and she looked dehydrated. The documentation in the Nurses' Notes was completed after the resident had been transferred, and the resident was transferred before or during the supper meal. (supper meal was served per the Administrator at 5:50 p.m.). By the time I assessed her she looked dehydrated and the family noticed more confusion than normal. When the shift began at 3 p.m., she was informed the resident had been running a temperature. An assessment was completed after report at the first of the shift, the resident had a temperature and looked dehydrated, the Physician's office was still open and a fax was sent. The temperature was 101, and RN 5 was not sure of the time of the assessment. She indicated the Physician's was not called until before or after supper and then the resident was transferred to the emergency room . A facility policy, dated 08/22/17, titled, Notification of Change in Resident Health Status, received from the Administrator as current, indicated, .To ensure that proper notifications are made when a resident has a change in health status .Immediate: As soon as possible no longer than 24 hours .Acute illness or a significant change .Life threatening conditions .immediate .Nursing judgement is an integral part of the skilled care provided in the Living Center;therefore, such judgement must be applied in a case by case basis in keeping with acceptable nursing practice. This Federal tag relates to Complaint IN 721. 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure residents received necessary care and services, related to assessments of residents with condition changes of elevated temperatures, swallowing and chewing problems, altered physical status, and signs of dehydration, for which Resident B was hospitalized for [REDACTED]. (Residents B and C) Findings include: 1. Resident B's record was reviewed on 11/06/17 at 4:50 p.m. [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, dated 08/04/17, indicated impaired cognition, extensive assistance of one for transfers, locomotion, dressing, hygiene and extensive assistance of two for bed mobility and toileting, minimal assistance with eating, and no difficulties with chewing and swallowing. A care plan, dated 07/17/15, indicated inadequate oral intake. Interventions included 03/02/15, diet as ordered and 12/13/16, thickened liquids as ordered. A care plan, dated 01/29/15, indicated a potential for alteration in hydration related to diuretic use. Interventions included, 01/29/15, observe appearance of mucous membranes, skin turgor, observe for mental status changes/mood and behavior changes. physician's orders [REDACTED]. Nurses' Notes indicated: 10/13/17 at 8:21 a.m.: the resident was warm and sweaty in bed with linens on. The temperature was 100 and after the resident was out of bed for 15 minutes, the temperature was 99.5 and denied feeling ill. The next follow-up assessment for the resident's temperature was in a Nurse's Note on 10/13/17 at 10:41 p.m., which indicated a temperature of 99.2, no sweating or coughing during the evening shift. The next follow-up assessment was on 10/14/17 at 6:16 a.m., which there was no temperature checked and the Nurse's Note indicated no coughing during the shift. 10/14/17 at 11:04 a.m., indicated the temperature was 98.7, no distress, and no coughing. There was no assessment or temperature check completed on 10/15/17. 10/16/17 at 6:49 a.m., no coughing this shift. 10/16/17 at 4:24 p.m., no coughing this shift. 10/16/17 at 7:27 p.m., no coughing this shift. Speech Therapy (ST) evaluated and a puree diet ordered. The Physician and Power of Attorney (POA) was notified. A Speech Therapy Plan of Care Note, dated 10/16/17, indicated, .Referral .due to nursing noticing episodes of pocketing and premature spillage from the oral cavity during meals for the last 3 days. Swallowing difficulties are likely caused by declining medical condition . There was no assessment in the Nurses' Notes to indicate any observations which would necessitate a Speech Therapy consult. Nurses' Notes indicated: 10/17/17 at 2:41 a.m., temperature was 100.5, no cough, respirations were even and unlabored, denies pain and no facial grimacing noted. There was no further assessment for possible causes of the elevated temperature and no intervention or reevaluation. 10/17/17 at 3:31 a.m., [MEDICATION NAME] 650 milligrams was given for pain. There was no assessment to indicate where the pain was located or the extent of the pain prior to medication administration, and no timely follow up. 10/17/17 at 5:28 a.m., the [MEDICATION NAME] was effective, no facial grimacing, and the temperature was 100.4. There was no further assessment for possible causes of the continued elevated temperature, despite the administration of [MEDICATION NAME], and no reevaluation of the resident's temperature. 10/17/17 at 7:26 a.m., the Physician was notified of the temperature and awaiting response. 10/17/17 at 2:36 p.m., Physician was made aware of the elevated temperature at night and a new order for a chest x-ray was obtained. The POA was notified. There were no further Nurses' Notes to indicate the resident was assessed, her temperature was rechecked, or the Physician had responded or further notification was attempted between 7:26 a.m. and 2:36 p.m. 10/17/17 at 10:09 p.m., temperature 100.1, blood pressure 89/54, heart rate 119, oxygen saturations 88% on room air. Mucous membranes were dry, scant bleeding to the lips, skin dry, lung sounds diminished, an order was received to send the resident to the emergency room for evaluation and treatment. There were no further Nurses' Notes to indicate the resident was assessed or monitored from 2:36 p.m. until the 10:09 p.m. entry. A Hospital emergency room indicated the resident presented at the emergency room at 10/17/17 at 8:13 p.m., with altered mental status and fever. The note indicated per the Nursing Home staff, there was more agitation, confusion and less conversation than the resident's baseline, fever and the resident had been biting her lip. A Hospital History and Physical, dated 10/17/17 at 11:02 p.m., indicated, .10/17/17 at 20:12 (8:12 p.m.) .from memory unit .not acting baseline, non comunicative (sic), fever, figety (sic), normally is conversant .critical condition and encephalopathic .yesterday last night patient was found to have slight fevers but she had just been switched to pureed diet because of poor swallowing. Today she was noticed to have altered mental status and [MEDICAL CONDITION] with poor responsiveness and so she was transferred to our emergency room .20:12 (8:12 p.m.) ED (Emergency Department) Temperature 101.6 .ED Pulse Rate 109 .Systolic Blood Pressure 143 .Diastolic Blood Pressure 64 (143/64) .mucous membranes dry .Poor turgor with strong evidence of dehydration .[MEDICAL CONDITION], UTI .severe dehydration, [MEDICAL CONDITION] (high sodium level) . Hospital lab results indicated the sodium level was critical at 164 (normal 135-147), BUN (kidney function test) was high at 61 (normal 7-22), and creatinine (kidney function test) was high at 2.86 (normal 0.55-1.30). During an interview on 11/7/17 at 4:15 a.m., LPN 1 indicated the night of 10/13/17 when the resident first started running a temperature, the resident had a lot of covers on, and this was why she was assisted into a wheelchair and the linens were removed. The temperature was place on the change of condition board so other Nurses' could do follow-up on the temperature. LPN 1 indicated on 10/17/17 night shift [MEDICATION NAME] was given and had attempted to call the Physician at the end of the shift, the Physician had not called back and the Day Shift Nurse was informed there was a call out to the Physician. The POA had not been notified due to waiting to hear what the Physician said first. She indicated the resident had no signs or symptoms of dehydration and no coughing. During an interview on 11/7/17 at 12:55 p.m., LPN 2 indicated someone had informed her the resident was coughing at meal time and she had not observed her coughing. She had faxed the Physician about the temperature and had called the POA around 9 a.m. and informed her of the temperature during the night, and the resident now did not have a temperature. The resident was more confused. LPN 2 stated, I didn't document well. The resident required more assistance than normal. She indicated there was no documented assessment or vital signs for the day shift on 10/17/17. She indicated the resident was taking fluids and there was not that much of a change of condition. During an interview on 11/7/17 at 1:25 p.m., CNA 3 indicated no one had tried feeding the resident on 10/17/17 because the family wanted her sent to the emergency room . She had received information the resident had been running a temperature on night shift. The resident looked sick, tired, and pale. The resident was transferred to bed during the shift due to her tiredness, and requests were made to the Nurse to check the resident's temperatures. CNA 3 indicated the resident was on thickened fluids and took a while to swallow. During an interview on 11/7/17 at 1:35 p.m., the Speech Therapist indicated he was working with another resident in the dining room on 10/16/17 when CNA 4 informed him Resident B was not chewing the food, and RN 5 received an order right away for an evaluation. The staff had informed him she had not been feeling well. During an interview on 11/7/17 at 2 p.m., CNA 6 indicated the resident was not acting her normal, there was no yelling out. The family was present and a bite of food was given on 10/17/17 at supper time, she pocketed the food and the bite was removed from her mouth. There was dried blood around the resident's mouth and the RN 5 was informed. Days before the resident had not been her normal self, less talkative, taking fluids but not as much as usual, there had been a decrease in urine output, and she was more sleepy than usual. CNA 6 indicated it happened over 2-3 day time period. During an interview 11/7/17 at 2:05 p.m., CNA 4 indicated on 10/16/17 the resident held food in her mouth and would make a chewing motion, but not chewing the food and was able to swallow the pudding and the night prior to 10/16/17, she was not chewing. She was unsure if she informed the Nurse. During an interview on 11/7/17 at 3:20 p.m., RN 5 indicated an order for [REDACTED]. On 10/17/17 the resident had not been eating or drinking well, she looked dehydrated. The documentation in the Nurses' Notes for 10/16/17 was documented late after the resident had already been transferred, and the resident was transferred before or during the supper meal. (supper meal served per Administrator at 5:50 p.m.). By the time I assessed her she looked dehydrated and the family noticed more confusion than normal. When the shift began at 3 p.m., RN 5 was informed the resident had been running a temperature. An assessment was completed after report at the first of the shift, the resident had an elevated temperature and looked dehydrated, the Physician's office was still open and a fax was sent. The temperature was 101, and was not sure of the time of the assessment. The Physician was then called (before or during supper) and the resident was transferred to the emergency room . She had blood on her lips from her lips being dry. RN 5 indicated the resident's vital signs got worse through out the shift and the first set of vitals, except the temperature, were not documented. The vital signs documented were the vital signs at the time of the transfer to the hospital. 2. Resident C's record was reviewed on 11/7/17 at 5:30 a.m., [DIAGNOSES REDACTED]. A Quarterly MDS assessment, dated 10/09/17, indicated the cognition status was unable to be determined, the resident required limited assistance with eating, and had no swallowing/chewing problems. A Speech Therapy Plan of Care Note, dated 10/16/17, indicated, .nursing staff noticing episodes of pocketing during meals and decreased intake . There were no assessments or observations in the Nurses' Notes, dated 10/1/17 through 10/16/17, to indicate the resident had difficulty with swallowing and chewing food. During an interview on 11/7/17 at 3:05 p.m., the Director of Nursing indicated there was no assessment of the resident's status for swallowing and chewing. This Federal tag relates to Complaint IN 721. 3.1-37(a)

Based on record review and interview, the facility failed to provide adequate supervision for a resident related to an assistive device not in place to prevent an injury which resulted in a hospitalization for a dislocated hip for 1 of 4 residents reviewed for accidents. (Resident #8) Finding includes: Record review for Resident #8 was completed on 1/5/17 at 2:09 p.m. The resident's [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment completed on 11/28/16, indicated the resident had a BIMS (Brief Interview of Mental Status) score of 2 and was severely cognitively impaired. The resident had a fall with a fracture prior to admission to the facility. The resident required an extensive 2+ person assist with bed mobility, transfers, walking, dressing and toileting. A Care Plan initiated on 11/22/16 indicated the resident had a physical functioning deficit related to: mobility impairment due to right hip arthroplasty (total hip replacement). Interventions included an abductor pillow (medical device commonly used to keep the legs stable after hip surgery), assistive devices, inform resident of risks of refusal of care, and to monitor and report changes in physical functioning ability. A Progress Note dated 11/21/16 at 11:33 p.m., indicated the resident arrived to the facility from the hospital with a [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident had an abduction pillow between the legs and had limited mobility and functionality. A Progress Note dated 12/5/16 at 10:45 a.m., indicated the resident was conscious and confused. The resident's legs were not separated using the abduction pillow. The nurse educated the CNA concerning the importance of abducting the legs using the abduction pillow. A Progress Note dated 12/9/16 at 11:36 a.m., indicated the resident's right leg was internally rotated. His legs were not abducted using a pillow. Informed the doctor at 9:45 a.m., and was advised to get a STAT (immediately) X-Ray of the right hip to rule out a dislocation. X-Ray was informed. A Progress Noted dated 12/9/16 at 4:29 p.m., indicated the resident had an X-Ray of the right hip done and was diagnosed with [REDACTED]. Interview with the ED (Executive Director) on 1/6/17 at 9:03 a.m., indicated he was informed by RN #1 the resident had been noncompliant with the pillow and CNA #1 had informed the midnight nurse, therapy and RN #1 the resident's leg was twisted. The doctor was notified to get a STAT X-Ray, then after the results were received, the resident was sent out to the hospital. Interview with CNA #1 on 1/6/17 at 9:16 a.m., indicated she had come on shift on 12/9/16 at 6:00 a.m., and shortly there after went into Resident #8's room. She had pulled the resident's covers back and noticed his leg was twisted. He did not have his abductor pillow in between his legs because he had ripped it to shreds the week before. He also did not have any regular pillow in between his legs. She had informed the midnight nurse of the resident's leg and also therapy because she did not want to move the resident to take him to therapy. She was not sure on the time, but indicated she did not feel the midnight nurse was doing anything about the situation because he had not gone in to check on the resident, so she had informed RN #1 about the situation. She was informed by another CNA a week prior the resident had ripped up his abductor pillow. She was not informed by the nurses to do anything else for the resident, but she thought she should fold up a pillow and put it between his legs. She did not believe any other CNAs were doing this. Interview with RN #1 on 1/6/17 at 9:29 a.m., indicated she had come on shift on 12/9/16 at 7:00 a.m. Around 8:30 a.m., she was assisting residents in the Main Dining Room when CNA #1 informed her of Resident #8's leg. She was unable to assess the resident until around 9:00 a.m., because she could not leave the dining room until all residents were done eating. At around 9:00 a.m., she assessed the resident. He was lying in bed, did not have a pillow in between his legs and his right leg was internally rotated. She paged the doctor and he had returned a phone call at 9:45 a.m., with an order to do a STAT X-Ray. She indicated on two previous days she had came into the resident's room and the resident did not have the abductor pillow in between his legs. She had been informed by a CNA the resident had ripped the pillow up. She had folded up a pillow and placed it in between the resident's legs but she was unaware if the CNAs had been doing this. She did not inform the doctor he had not had the abductor pillow in place nor did she inform therapy the resident had ripped up the abductor pillow prior to the incident on 12/9/16. She ordered the X-Ray at 9:45 a.m., and they are to do the STAT X-Ray within 4 hours. They had not been there within the 4 hours to do the X-Ray, so she had called them and stressed to them the importance of coming soon to do the X-Ray because the resident may have a hip dislocation. She doesn't remember the reason why they said they were late or when they would be able to get there to do it. She did not inform the doctor the X-Ray tech had not been there yet or that she was unsure of when they could get there. She indicated they had arrived around 3:30 p.m., which was 5.75 hours after ordering the X-Ray. The results were received after 4:00 p.m., the doctor was informed of the results and they had sent him out to the hospital at 4:45 p.m. Interview with RPT (Registered Physical Therapist) on 1/6/17 at 10:01 a.m., indicated sometime before breakfast on 12/9/16 he was informed by CNA #1 that Resident #8's leg was twisted. He assessed the resident in front of the therapy office while the resident was in his wheelchair. His leg was twisted so he went and spoke with the RNAC (Registered Nurse Assessment Coordinator) #1 that he recommended an X-Ray. He then transferred the resident back into the bed after breakfast. He spoke with RN #1 later in the day because he was wondering if the X-Ray had been completed, and why he was still in the facility and had not been sent out to the hospital yet. He was unaware the resident had not been using the abductor pillow and, if he had known it was ripped up, then therapy could have ordered a new one. He would have recommended staff used multiple pillows folded up and placed in between the resident's legs until a new abductor pillow was ordered. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the necessary treatment and services were attained to maintain a resident's psychosocial well being related to the administration of an as needed Antipsychotic medication without indications for use or interventions tried first which resulted in a decrease in appetite, a decrease in physical functioning and a fall for 1 of 5 residents reviewed for unnecessary medications. The facility also failed to ensure pain medication was administered on time for a resident who was displaying signs and symptoms of severe pain related to moaning and crying for 1 of 1 residents reviewed for pain and the facility failed to ensure a resident who received [MEDICAL TREATMENT] was assessed and monitored for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. (Residents #57, #68, &, #112) Findings include: 1. On 12/17/15 at 11:16 a.m., Resident #68 was observed in bed. At that time her eyes were closed. The resident was not displaying any behaviors at that time. The record for Resident #68 was reviewed on 12/17/15 at 11:34 a.m. The resident's [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment, dated 9/18/15, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0, indicating she was not alert and oriented and was severely impaired for decision making. The resident displayed physical behavioral symptoms 4 to 6 days during the assessment reference period and some type of verbal behavioral symptoms occurred daily. The behaviors did not interrupt with resident care, however, the resident's behaviors had worsened since the last assessment. The resident needed supervision with one person physical assist with transfers, dressing, eating, toilet use and personal hygiene. The Physician Orders, dated 11/25/15 and on the current 12/2015 recap (recapitulation of medication orders), indicated [MEDICATION NAME] (an Antipsychotic medication) 12.5 milligrams (mg) three times a day. Another Physician Order, dated 9/10/15 and on the current 12/2015 recap, of [MEDICATION NAME] (an Antianxiety medication) 0.25 mg three times a day. An Physician Order, dated 8/5/15 and on the 12/2015 recap, of [MEDICATION NAME] (an Antianxiety medication) 10 mg three times a day. Nursing Progress Notes, dated 8/27/15 at 7:41 a.m., indicated the Nurse was called to the resident's room by staff. The resident was on the floor outside of her bathroom laying on her back. The resident was slow to response, had difficulty talking with slurred speech. The resident resident's skin was cool and clammy and her clothes were wet to touch. Her skin color was pale. The resident refused to stay on the floor, so she was assisted back to bed with staff assist. The resident's Physician was notified and orders were obtained to send her to the hospital. Nursing Progress Notes, dated 8/28/15 at 7:03 p.m., indicated the resident had just returned from the hospital. The resident's family was at the bedside. The resident was alert and combative and was unable to redirect. Nursing Progress Notes, dated 8/28/15 at 9:18 p.m., indicated Hitting staff, yelling at staff and other residents, unable to be redirected. The next documented entry in Nurse's Notes was on 8/29/15 at 12:11 a.m., indicated [MEDICATION NAME] Solution. (an Antipsychotic medication) Inject 2 mg/ml (milliliter) Intramuscularly every 6 hours as needed for Anxiety. Resident in bed resting quietly. PRN Administration was effective. A Physician Order, dated 8/28/15, indicated [MEDICATION NAME] 2 milligrams (mg) IM (Intramuscular) every 6 hours prn (as needed) for Anxiety. A Physician Order, dated 8/29/15 and on the current 12/2015 Physician recap, indicated [MEDICATION NAME] (an Antianxiety medication) 0.25 mg every 8 hours prn Anxiety. Nursing Progress Notes, dated 8/30/15 at 2:28 p.m., indicated the resident was sleeping most of this shift. Her meals were brought to her in the room with staff assisting with eating. The resident's appetite was poor and fluids were encouraged. Resident refused at times. The family was there to visit at lunch and they were unable to get the resident to eat. Snacks were offered and resident refused. The next documented entry in Nurse's Notes was on 8/30/15 at 7:09 p.m., which indicated the resident was noted to be weak and remained in bed most of the shift. The resident was encouraged to drink fluids and ate minimal for dinner, stating she wasn't hungry. Resident was offered snacks throughout shift. An entry in Nurse's Notes on 8/31/15 at 2:52 a.m., indicated the resident was noted to have increased weakness. Nursing Progress Notes, dated 8/31/15 at 10:49 a.m., indicated [MEDICATION NAME] tablet. Give 0.25 mg by mouth every 8 hours as needed for Anxiety. Toileted, redirected, and given breakfast, continues to show anxiety. Nurse's Notes, dated 8/31/15 at 11:00 a.m., indicated resident continues with being agitated, yelling at Doctor and staff. The prn [MEDICATION NAME] was given. Resident shows signs and symptoms of weakness with unsteady gait, stand by assist needed thus far. Nurse's Notes, dated 8/31/15 at 9:06 p.m., resident continues to be unsteady with gait stand by assist needed. The resident had poor safety awareness. The resident's food consumption log was reviewed. The resident's food consumption were not coded on 8/28, 8/29, and 8/30/15. The resident was coded as consuming 50% of breakfast, 25% of lunch and nothing for dinner on 8/31/15. Nurse's Notes, dated 9/1/15 at 12:14 p.m., indicated the resident had slid off the bed to the floor. The CNA was in the doorway and witnessed the fall, but could not get to the resident in time. Resident was confused, weak, pale with clammy skin. The resident indicated she was not feeling good and stated, I am going to die. I am sick. The resident's Physician was notified. Nursing Progress Notes, dated 9/1/15 at 5:28 p.m., indicated Increased anxiety. The next documented entry in Nurse's Notes was on 9/1/15 at 7:00 p.m., which indicated PRN Administration was effective. Nursing Progress Notes, dated 9/3/15 at 4:27 p.m., indicated increased anxiety. The next documented entry in Nurse's Notes was on 9/3/15 at 6:49 p.m., which indicated PRN Administration was effective. Nursing Progress Notes, dated 9/6/15 at 3:53 p.m., indicated give 0.25 mg [MEDICATION NAME] tablet by mouth every 8 hours as needed for anxiety. Resident was administered med for increased anxiety. The next documented entry in Nurse's Notes was on 9/6/15 at 4:47 p.m., indicated PRN Administered was effective. The Medication Administration Record [REDACTED] The Behavior Monthly Flow Sheet, dated 8/2015, indicated the resident was being monitored for agitation, hallucinations/paranoia/delusions, and striking out/hitting. There were no documented behaviors on 8/28, 8/29 and 8/30/15. The Behavior Monthly Flow Sheet, dated 9/2015, indicated the resident was being monitored for agitation, hallucinations/paranoia/delusions, and striking out/hitting. There were no documented behaviors on 9/1, 9/3 and 9/6/15. The current plan of care, updated 12/21/15 with an original date of 7/6/12, indicated the resident displays anxiousness, worries and had repetitive verbalizations and negative statements about death. The resident had short term memory loss and dementia. The Nursing approaches were to redirect resident to an activity of her choice such as reading her religious materials, socializing in small groups, or going outside to the garden and allow the resident to express her feelings and reassure resident through conversation. Interview with the Director of Nursing (DON) on 2/21/15 at 10:52:53 a.m., indicated the order for the [MEDICATION NAME] was obtained from the on call Physician covering for the resident's primary Doctor. She indicated there were no interventions tried first before giving the prn (as needed) [MEDICATION NAME] or [MEDICATION NAME]. 2. On 12/21/15 at 8:40 a.m., Resident #112 was overheard from another room crying and moaning a loud. At that time, the Admissions Coordinator indicated to the resident that she would tell someone about her pain the crying and was observed to walk out of the resident's room. On 12/21/15 at 9:03 a.m., the resident was observed in bed crying. Interview with the resident at that time, indicated she had asked for something for pain a while ago and told some staff member, but she had not come back to give her anything. The resident continued to cry and indicated her legs were so swollen and she was in so much pain. Interview with LPN (Licensed Practical Nurse) #1 on 12/21/15 at 9:10 a.m., indicated she was the nurse taking care of the resident. She further indicated the resident cries all the time and that was nothing new for her. LPN #1 indicated she had not administered the resident any of her pain medications or her routine medications as of yet. When asked if anyone had informed her the resident was crying and in pain, she indicated the Admission Coordinator had informed her another resident was in pain and needed pain medication but did not remember if she had informed her Resident #112 needed pain medication. Interview with the Admission Coordinator on 12/21/15 at 9:12 a.m., indicated the resident had told her she was having pain and she did inform LPN #1 at that time. She further indicated there were two residents who were in pain, and she did inform the nurse. Continued observation on 12/21/15 at 9:17 a.m.(37 minutes later), indicated the resident's medications including the pain medication were administered by LPN #1. Interview with Resident #112 on 12/21/15 at 10:11 a.m. indicated she was comfortable and the pain had subsided. The resident indicated she had no new complaints of pain at that time. The record for Resident #112 was reviewed on 12/21/15 at 10:12 a.m. The resident was newly admitted to facility on 12/3/15 from the hospital. The resident's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 12/10/15, indicated the Brief Interview for Mental Status (BIMS) score was 14, cognitively intact. The resident was interviewed for mood status and indicated she feels down and depressed or hopeless 2-6 days, had trouble falling asleep or staying asleep 7-11 days, feels tired 7-11 days, had poor appetite 7-11 days, feels bad about herself 7-11 days, and had trouble concentrating on things such as reading the paper 7-11 days. The resident needed physical help with extensive assist and 2 person physical assist for bed mobility and toilet use. The resident needed extensive assist with one person physical assist with dressing and personal hygiene. The resident was interviewed for pain. The resident had scheduled pain meds and prn (as needed) pain medication. The resident indicated she had been hurting in the last 5 days, she frequently experienced pain in the last 5 days, had limited the day to day activities over the last 5 days due to pain, and her pain rating score was an 8 (A score of 0 was no pain and a score of 10 was the worst pain you can imagine). The current care plan, dated 12/7/15, indicated Needs pain management and monitoring related [MEDICAL CONDITION] wound and surgical procedure. The Nursing approaches were to administer pain medication as ordered, evaluate need to provide medication prior to treatment or therapy, evaluate what makes the patient's pain worse and repositioning. Physician Orders, dated 12/16/15, indicated [MEDICATION NAME] (a pain medication) 2 milligrams (mg) every 3 hours prn pain. A Physician Order, dated 12/16/15, indicated [MEDICATION NAME] 2 mg every 4 hours while awake scheduled 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. Another Physician Order, dated 12/16/15, indicated Oramorph (a pain medication) 30 mg twice a day, scheduled at 9:00 a.m. and 5:00 p.m. The Medication Administration Record [REDACTED]. The 12/3/15 Clinical health status assessment indicated the resident's pain rating score was a 10. The location of the pain was the resident's sacral/coccyx area that was characterized as being sharp, burning, constant and radiating. The resident's level of pain had impacted the quality of life functioning for the resident. Nursing Progress notes, dated 12/3/15 through 12/21/15, indicated there was no documentation of the resident's pain being a behavior problem. The current 2/9/15 Pain Assessment and Management policy provided by the Director of Nursing on 12/22/15 at 11:10 a.m., indicated it was the facility's policy to promptly assess resident pain levels and provide relief of symptoms whenever feasible, using a resident centered and interdisciplinary approach. Interview with the DON on 12/21/15 at 2:30 p.m., indicated she was aware of the resident's severe pain and they had just increased her pain medication recently, however, she indicated the nurse should have administered her medication timely and assessed the resident for pain at the time of her complaints of pain to ensure the dosage of the medication was adequate. 3. The record for Resident #57 was reviewed on 12/17/15 at 10:44 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE], and was discharged to the hospital on [DATE]. The 11/7/15 Admission Minimum Data Set (MDS) assessment indicated the resident received [MEDICAL TREATMENT] services. A Clinical Health Status Admission Assessment was completed on 10/31/15. The skin conditions section of the assessment indicated the resident had a [MEDICAL TREATMENT] catheter to his right chest. The December 2015 physician's orders [REDACTED]. Review of the November 2015 Treatment Administration Record (TAR) indicated vital signs (weight, blood pressure, temperature, pulse, respirations, and oxygen saturation) were to be recorded on Mondays, Wednesdays and Fridays. The TAR lacked documentation the vital signs were obtained on 11/2/15, 11/4/15, 11/6/15, 11/9/15, 11/16/15, 11/18/15, 11/20/15, 11/23/15, 11/25/15, 11/27/15, and 11/30/15. The TAR lacked documentation the [MEDICAL TREATMENT] catheter site had been assessed on 11/8/15 day shift, 11/13/15 evening shift, 11/15/15 evening shift, 11/18/15 day shift, 11/19/15 evening shift, 11/20/15 day and evening shift, 11/25/15 day and evening shift, 11/26/15 day and evening shift, 11/27/15 evening shift and 11/29/15 evening shift. Review of the December 2015 TAR indicated vital signs (weight, blood pressure, temperature, pulse, respirations, and oxygen saturation) were to be recorded on Mondays, Wednesdays and Fridays. The TAR lacked documentation the vital signs were obtained on 12/2/15, 12/9/15, 12/11/15, and 12/14/15. The TAR lacked documentation the [MEDICAL TREATMENT] catheter site had been assessed on 12/4/15 evening shift, 12/7/15 evening shift, 12/8/15 day shift, 12/9/15 night shift, 12/11/15 day shift, 12/14/15 evening shift, and 12/16/15 night shift. The resident had a care plan for alteration in kidney function evidenced by [MEDICAL TREATMENT]. The nursing interventions included .check access site daily fistula/graft/catheter-signs of infection .observe for post [MEDICAL TREATMENT] hang over-vital signs, mental status, excessive weight gain between treatments, nausea, vomiting, weakness, headache, severe leg cramps Interview with the DON on 12/18/15 at 1:27 p.m. indicated staff should have documented the vital signs on the TAR and she was not sure why they had not. She further indicated the [MEDICAL TREATMENT] should have been checked every shift and documented on the TAR. A facility policy, titled [MEDICAL TREATMENT] Guideline, dated 10/5/15, and received from the DON as current on 12/18/15 at 2:30 p.m., indicated .Post [MEDICAL TREATMENT] Protocol: .blood pressure prn (as needed)/daily or as the physician orders [REDACTED].checks for signs/symptoms of infection daily 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure the timely monitoring, assessing and treating of wounds 3 of 6 residents reviewed for pressure ulcers. This included the development of a Stage 3 pressure ulcer for Resident #47 and Resident #28, an unstageable ulcer for Resident #57. Findings include: 1. On 12/22/15 at 9:22 a.m., the Unit Manager was observed to complete the pressure ulcer treatment for [REDACTED]. The dressing to the left lower buttock was removed. Red tinged drainage was observed on the dressing and packing was removed from the area. The resident was observed with a 1 centimeter (cm) x 1 cm opening to the left lower buttock with depth present. After cleansing the area with normal saline, the LPN (Licensed Practical Nurse) proceeded to pack the wound with an [MEDICATION NAME] packing strip (a medicated strip for open wounds) with the use of a q-tip. The tip of the q-tip was able to be inserted inside the wound. After packing the wound, the pressure ulcer was covered with a clean dressing. Interview with the LPN at the time, indicated the pressure ulcer was a Stage 3 (defined as a wound with full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle are not exposed, slough may be present and may include undermining and tunneling). She indicated the area was found to the resident's left lower buttock on 12/11/15, when they did the house wide sweep and she did not know how long the area had been there. The record for Resident #47 was reviewed on 12/21/15 at 2:07 p.m. The resident's [DIAGNOSES REDACTED]. The Braden Scale (a tool for assessing risk of skin breakdown), dated 12/2014, indicated the resident was at risk for pressure ulcers with a score of 19. A Weekly skin review, dated 10/27/15, indicated the resident's skin was intact. There were no further Weekly skin reviews completed after that date. The 10/30/15 significant change Minimum Data Set (MDS) assessment, indicated the resident was at risk for pressure ulcers. No unhealed pressure ulcers were coded at that time. The plan of care, with a review date of October 2015, indicated the resident was at risk for altered skin integrity related to history of pressure area, excoriation under abdominal fold, the need for some assist with bed mobility at times, frequently incontinent, history of [MEDICAL CONDITION], and [MEDICAL CONDITION] to BLE (Bilateral Lower Extremities), history of noncompliance with treatment and incontinent care. Open area to coccyx and right buttocks (resolved). The interventions included, but were not limited to, conduct weekly skin inspection, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream. On 12/11/15 at 12:46 p.m., a general note was completed indicating the following: Resident skin check. treatment of [REDACTED]. Wound to left ishcial 1.2 cm x 0.7 cm x 0.3 cm tunneling (passage of tissue destruction under the skin surface, with an opening at the level from the edge of the wound). A physician's orders [REDACTED]. A Wound evaluation flow sheet, dated 12/11/15, indicated Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure ulcer to left ischial 1.2 cm x 0.7 cm x 0.3 cm deep. A Wound evaluation flow sheet dated, 12/18/15, indicated Stage 3 pressure ulcer to left ischial 1.1 cm x 0.5 cm x 0.3 cm deep. During an interview on 12/21/15 at 3:09 p.m., the Director of Nursing indicated the resident was found with the Stage 3 pressure area on 12/11/15. 2. The record for Resident #57 was reviewed on 12/17/15 at 10:44 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. A Clinical Health Status Admission Assessment was completed on 10/31/15. The skin conditions section of the assessment indicated the resident had 4 surgical incisions, a PICC (peripherally inserted central catheter) line and a [MEDICAL TREATMENT] catheter. There was no indication in the record that the resident had any pressure ulcers. A Progress Note, dated 11/1/15 at 2:38 a.m., indicated the resident had been admitted at 9:30 p.m. on 10/31/15. The Progress Note indicated the resident had a surgical incision to his mid line chest, a surgical incision to his upper left chest and a surgical incision to his right inner lower leg. There was no indication in the record that the resident had any pressure ulcers. A Progress Note, dated 11/3/15 at 3:28 a.m., indicated .dressing to buttocks and chest C(clean)/D(dry)/I(intact) . A physician's orders [REDACTED]. Review of the November 2015 Treatment Administration Record (TAR) indicated the daily treatments to the left hip and coccyx were started on 11/8/15, on the night shift. There was no indication in the record that any treatment orders had been obtained prior to 11/8/15, or implemented to the coccyx and left hip pressure areas until 11/8/15. The 11/7/15 Admission Minimum Data Set (MDS) assessment indicated the resident was at risk for pressure ulcers and had 1 unstageable pressure ulcer (defined as a full thickness loss in which the base of the ulcer is covered by slough and/or eschar) present on admission due to a non removable dressing or device. A Progress Note, dated 11/18/15 at 1:58 a.m., indicated .Treat (treatment) to coccyc (sic) changed and L (left) hip. Coccyx is 75-80% cover in slough. Surround (surrounding) tissue is pink. Has mod (moderate) amount of serousangious (sic) drainage .L (left) hip is 100% eschar. Surroud (surrounding) tissue is pink. No drainage noted A Progress Note, dated 12/1/15 at 11:12 p.m., indicated .Resident needs to see wound care for coccyx wound. Wound continues to grow. A Progress Note, dated 12/4/15 at 7:52 p.m., indicated .Appointment made for 12/8/15 2pm .wound clinic for areas to coccyx and left hip Wound Center Notes, dated 12/8/15, indicated the resident had an unstageable pressure ulcer to the left trochanter measured at 3.5 x 3.5 x0.1 cm and an unstageable pressure ulcer to the coccyx measured at 16 x 9 x 0.1 cm. A Progress Note, dated 12/11/15 at 4:32 p.m., indicated .Skin check: wound to coccyx 9.2 x (by) 5.2 cm (centimeters) noted with eschar and slough to wound bed, wound edges are irregular with foul odor and purulent drainage. Wound to left ischial is 4 cm x 3 cm with eschar to wound bed and wound edges are irregular with foul odor. Wounds were upon admission and currently had TX (treatment) of santyl cover with dressing daily. Also being seen at wound clinic . An Initial Wound Evaluation Flow Sheet for the coccyx/buttocks was initiated on 12/11/15. The assessment indicated a stage III pressure ulcer was present on the coccyx / buttocks. The Stage III area measured 9.2 x 5.2 x 0 cm, had a moderate amount of purulent exudate and a foul odor. The wound bed was sough and necrotic, the wound margins were irregular, and the surrounding tissue was pink/red. An Initial Wound Evaluation Flow Sheet for the left hip was initiated on 12/11/15. The assessment indicated an unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in ulcer bed.) pressure ulcer was present on the left hip. The unstageable area measured 4 x3x 0 cm, had no exudate and a foul odor. The wound bed was necrotic, the wound margins were irregular and the surrounding tissue was red/pink. There was no indication in the record that any measurements or wound staging of the left hip and coccyx pressure ulcers had been completed prior to 12/11/15. There was no indication in the record that any weekly skin assessments had been completed prior to 12/11/15. During an interview on 12/18/15 at 1:27 p.m., the DON indicated the coccyx and left hip pressure areas were first measured and staged following a skin sweep of all residents in the facility on 12/11/15. She indicated there were no measurements of the wounds, staging of the wounds or weekly skin assessments completed prior to 12/11/15. She further indicated there were no treatment orders obtained for the pressure areas until 11/8/15. She indicated the nurses had told her the resident was admitted with the pressure ulcers but she could not find anywhere where that information was documented. She indicated if the wounds were present on admission they should have been documented on the admission assessment and a wound evaluation flow sheet. 3. On 12/19/15 at 10:01 a.m., Resident #28 was observed self propelling his wheelchair with his feet. The resident had on socks and shoes on both feet. On 12/20/2015 at 8:04 a.m., Resident #28 was self propelling his wheelchair. The resident had on a nonskid sock on the right foot and a sock with a shoe on the left foot. During Resident #28's wound care treatment on 12/21/15 at 1:12 p.m. with LPN #3, the wounds were observed: *the left heel: measured 1 X 1 x 0.4 cm (centimeters), oblong in shape, pale white in the center of the wound, no pink noted, and the wound edges were white and dry. *the right heel: measured 4 X 3.5 X 0.2 cm, white/yellow tissue in the center of the wound and at the edges. Resident #28's record was reviewed on 12/17/15 at 11:21 a.m. The resident was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. Review of the Braden Scale (a pressure ulcer risk assessment), dated 8/25/15, indicated the resident scored a 17, which is at risk for a pressure sore. Review of the resident's pressure ulcer care plan, dated 9/21/15, indicated weekly wound assessments. Review of the Wound Evaluation flow sheets, dated 9/20/15, indicated the right heel was a Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister) pressure ulcer, measuring 2.5 X 2.5 X<0.2 cm (centimeters) with a red/dark center with scan amount of drainage. The left heel was a Stage 2 pressure ulcer, measuring 3 X 3 X<0.2 cm with a dark center with a scant amount of drainage. The next evaluation of the wounds were on 12/11/15 with both wounds had worsened. The right heel was a Stage 3, measuring 3.53 cm with purulent (pus) drainage. The left heel was a Stage 3, measuring 1.3 X 1 cm with moderate purulent drainage and slough. The Nurse notes, from 9/20/15 through 11/12/15, lacked documentation of assessments of the wounds. The Nurse notes, from 9/20/15 through 11/12/15, a lacked documentation of treatments completed from 10/28/15 through 11/12/15. The weekly skin assessments, from 10/3/15 through 12/8/15, indicated the wounds were noted on one day, 11/13/15. The weekly skin assessment, dated 11/13/15, indicated the right heel measured at 3.4 cm, the area was yellowed and calloused and was softer in the center. The wound did not have any slough or eschar (dead tissue) noted. The left heel measured at 2.8 cm X 2.3 cm X less 1 cm, the area was yellowed and calloused area and had a soft calloused center. There was scant amount of seriosanguious (watery blood) drainage to the dressing that was removed. Review of the physician's orders [REDACTED]. Review of the Quarterly MDS (Minimum Data Set) assessment, dated 12/4/15, indicated the resident was at risk for pressure ulcers. During an interview on 12/21/15 at 4:24 p.m., the DON indicated the resident's record lacked weekly wound assessments and there was not an order for [REDACTED]. The policy titled, Skin Integrity Guideline, was provided by the DON (Director of Nursing) on 12/18/15 at 2:30 p.m., and identified as current. The policy indicated, .General Guideline: .Living Center develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings .Wound status is monitored on a weekly basis .Evaluation/Observation is to be completed within the first twenty-four hours of admission/quarterly/significant change of condition .if identified risk present, the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to identify and implement plans of action to correct quality deficiencies related to pressure ulcers for 3 of 5 residents reviewed for pressure ulcers. (Resident #47, #57 and #28) Findings include: The facility failed to ensure residents were being monitored and assessed for pressure ulcers for Residents #47,#57 and #28. During an interview with the Administrator and the Director of Nursing on 12/22/15 at 11:14 a.m., indicated the Quality Assessment and Assurance committee meets monthly and it was not indicated that pressure ulcers were a problem. He further indicated, until the Unit Manager did a full house skin sweep on 12/11/5, we did not know there was a problem. 1. On 12/22/15 at 9:22 a.m., the Unit Manager was observed to complete the pressure ulcer treatment for [REDACTED]. The dressing to the left lower buttock was removed. Red tinged drainage was observed on the dressing and packing was removed from the area. The resident was observed with a 1 centimeter (cm) x 1 cm opening to the left lower buttock with depth present. After cleansing the area with normal saline, the LPN (licensed Practical Nurse) proceeded to pack the wound with an [MEDICATION NAME] packing strip (a medicated strip for open wounds) with the use of a q-tip. The tip of the q-tip was able to be inserted inside the wound. After packing the wound, the pressure ulcer was covered with a clean dressing. Interview with the LPN at the time, indicated the pressure ulcer was a Stage 3 (defined as a wound with full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle are not exposed, slough may be present and may include undermining and tunneling). She indicated the area was found to the resident's left lower buttock on 12/11/15 when they did the house wide sweep and she did not know how long the area had been there. The record for Resident #47 was reviewed on 12/21/15 at 2:07 p.m. The resident's [DIAGNOSES REDACTED]. The 10/30/15 significant change Minimum Data Set (MDS) assessment, indicated the resident was at risk for pressure ulcers. No unhealed pressure ulcers were coded at that time. There was no recent Braden scale (a pressure ulcer determination risk) in the resident's clinical record. The last Braden scale was dated 12/2014 which indicated the resident was at risk for pressure ulcers with a score of 19. The plan of care, dated 2/12/10 and reviewed on October 2015, indicated the resident was at risk for altered skin integrity related to history of pressure area, excoriation under abdominal fold, the need for some assist with bed mobility at times, frequently incontinent, history of [MEDICAL CONDITION], and [MEDICAL CONDITION] to BLE, history of noncompliance with treatment and incontinent care. Open area to coccyx and right buttocks (resolved). The interventions included, but were not limited to, conduct weekly skin inspection, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream. A Weekly skin review, dated 10/27/15, indicated the resident's skin was intact. There were no further Weekly skin reviews completed after that date. On 12/11/15 at 12:46 p.m., a general note was completed indicating the following: Resident skin check. treatment of [REDACTED]. Wound to left ischial 1.2 cm x 0.7 cm x 0.3 cm tunneling. A physician's orders [REDACTED]. A Wound evaluation flow sheet dated 12/11/15, indicated Stage 3 pressure ulcer to left ischial 1.2 cm x 0.7 cm x 0.3 cm deep. A Wound evaluation flow sheet dated 12/18/15, indicated Stage 3 pressure ulcer to left ischial 1.1 cm x 0.5 cm x 0.3 cm deep. Interview with the Director of Nursing (DON) on 12/21/15 at 3:09 p.m., indicated the resident was found with the Stage 3 pressure area on 12/11/15. 2. The record for Resident #57 was reviewed on 12/17/15 at 10:44 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. The 11/7/15 Admission Minimum Data Set (MDS) assessment indicated the resident was at risk for pressure ulcers and had 1 unstageable pressure ulcer present on admission due to a non removable dressing or device. A Clinical Health Status Admission Assessment was completed on 10/31/15. The skin conditions section of the assessment indicated the resident had 4 surgical incisions, a PICC (peripherally inserted central catheter) line, and a [MEDICAL TREATMENT] catheter. There was no indication in the record that the resident had any pressure ulcers. A Progress Note, dated 11/1/15 at 2:38 a.m., indicated the resident had been admitted at 9:30 p.m. on 10/31/15. The Progress Note indicated the resident had a surgical incision to his mid line chest, a surgical incision to his upper left chest and a surgical incision to his right inner lower leg. There was no indication in the record that the resident had any pressure ulcers. A Progress Note, dated 11/3/15 at 3:28 a.m., indicated .dressing to buttocks and chest C(clean)/D(dry)/I(intact) . A physician's orders [REDACTED]. Review of the November 2015 Treatment Administration Record (TAR) indicated the daily treatments to the left hip and coccyx were started on 11/8/15 on the night shift. There was no indication in the record that any treatment orders had been obtained prior to 11/8/15 or implemented to the coccyx and left hip pressure areas until 11/8/15. A Progress Note, dated 11/18/15 at 1:58 a.m., indicated .Treat (treatment) to coccyc (sic) changed and L (left) hip. Coccyx is 75-80% cover in slough. Surround (surrounding) tissue is pink. Has mod (moderate) amount of serousangious (sic) drainage .L (left) hip is 100% eschar. Surroud (surrounding) tissue is pink. No drainage noted . A Progress Note, dated 12/1/15 at 11:12 p.m., indicated .Resident needs to see wound care for coccyx wound. Wound continues to grow. A Progress Note, dated 12/4/15 at 7:52 p.m., indicated .Appointment made for 12/8/15 2pm .wound clinic for areas to coccyx and left hip . Wound Center Notes, dated 12/8/15, indicated the resident had an unstageable pressure ulcer to the left trochanter measured at 3.5 x 3.5 x0.1 cm and an unstageable pressure ulcer to the coccyx measured at 16 x 9 x 0.1 cm. A Progress Note, dated 12/11/15 at 4:32 p.m., indicated .Skin check: wound to coccyx 9.2 x (by) 5.2 cm (centimeters) noted with eschar and slough to wound bed, wound edges are irregular with foul odor and purulent drainage. Wound to left ischial is 4 cm x 3 cm with eschar to wound bed and wound edges are irregular with foul odor. Wounds were upon admission and currently had TX (treatment) of santyl cover with dressing daily. Also being seen at wound clinic . An Initial Wound Evaluation Flow Sheet for the coccyx/buttocks was initiated on 12/11/15. The assessment indicated a stage III pressure ulcer was present on the coccyx/buttocks. The stage III area measured 9.2 x 5.2 x 0 cm, had a moderate amount of purulent exudate and a foul odor. The wound bed was sough and necrotic, the wound margins were irregular, and the surrounding tissue was pink/red. An Initial Wound Evaluation Flow Sheet for the left hip was initiated on 12/11/15. The assessment indicated an unstageable pressure ulcer was present on the left hip. The unstageable (defined as a full thickness loss in which the base of the ulcer is covered by slough and/or eschar) area measured 4 x3x 0 cm, had no exudate and a foul odor. The wound bed was necrotic, the wound margins were irregular, and the surrounding tissue was red/pink. There was no indication in the record that any measurements or wound staging of the left hip and coccyx pressure ulcers had been completed prior to 12/11/15. There was no indication in the record that any weekly skin assessments had been completed prior to 12/11/15. Interview with the DON, on 12/18/15 at 1:27 p.m., indicated the coccyx and left hip pressure areas were first measured and staged following a skin sweep of all residents in the facility on 12/11/15. She indicated there were no measurements of the wounds, staging of the wounds or weekly skin assessments completed prior to 12/11/15. She further indicated there were no treatment orders obtained for the pressure areas until 11/8/15. She indicated the nurses had told her the resident was admitted with the pressure ulcers but she could not find anywhere where that information was documented. She indicated if the wounds were present on admission they should have been documented on the admission assessment and a wound evaluation flow sheet. 3. During Resident #28's wound care treatment on 12/21/15 at 1:12 p.m. with LPN #3, the wounds were observed: *the left heel: measured 1 X 1 x 0.4 cm (centimeters), oblong in shape, pale white in the center of the wound, no pink noted, and the wound edges were white and dry. *the right heel: measured 4 X 3.5 X 0.2 cm, white/yellow tissue in the center of the wound and at the edges. On 12/19/15 at 10:01 a.m., the resident was observed self propelling his wheelchair with his feet. The resident had on socks and shoes on both feet. Another observation of the resident was on 12/20/2015 at 8:04 a.m., he was self propelling his wheelchair. The resident had on a nonskid sock on the right foot and a sock with a shoe on the left foot. Resident #28's record was reviewed on 12/17/15 at 11:21 a.m. The resident was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. Review of the Quarterly MDS (Minimum Data Set) assessment, dated 12/4/15, indicated the resident was at risk for pressure ulcers. Review of the Braden Scale (a pressure ulcer risk assessment), dated 8/25/15, indicated the resident scored a 17, which is at risk for a pressure sore. Review of the resident's pressure ulcer care plan, dated 9/21/15, indicated weekly wound assessments. Review of the Wound Evaluation flow sheets, dated 9/20/15, indicated the right heel was a stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister) pressure ulcer, measuring 2.5 X 2.5 X<0.2 cm (centimeters) with a red/dark center with scan amount of drainage. The left heel was a stage 2 pressure ulcer, measuring 3 X 3 X<0.2 cm with a dark center with a scant amount of drainage. The next evaluation of the wounds were on 12/11/15, with both wounds had worsened. The right heel was a stage 3, measuring 3.53 cm with purulent (pus) drainage. The left heel was a stage 3, measuring 1.3 X 1 cm with moderate purulent drainage and slough. Review of the Nurse notes, from 9/20/15 through 11/12/15, lacked assessments of the wounds. Review of the Nurse notes, from 9/20/15 through 11/12/15, indicated a lack of treatments completed from 10/28/15 through 11/12/15. Review of the weekly skin assessments, from 10/3/15 through 12/8/15, indicated the wounds were noted on one day, 11/13/15. The weekly skin assessment, dated 11/13/15, indicated the right heel measured at 3.4 cm, the area was yellowed and calloused and was softer in the center. The wound did not have any slough or eschar(dead tissue) noted. The left heel measured at 2.8 cm X 2.3 cm X less 1 cm, the area was yellowed and calloused area and had a soft calloused center. There was scant amount of seriosanguious (watery blood) drainage to the dressing that was removed. Review of the physician's orders [REDACTED]. Interview with the DON (Director of Nursing) on 12/21/15 at 4:24 p.m., indicated the resident's record lacked weekly wound assessments and there was not an order for [REDACTED]. 3.1-52(b)(2)

Based on observation, record review, and interview, the facility failed to ensure each resident was free from accidents related to assisting a resident during a transfer with one person rather than two persons which resulted in a fall with a fracture (Resident #B) and leaving a resident with a history of falls on the toilet unsupervised which resulted in a fall (Resident #C) for 2 of 3 residents reviewed for accidents. (Residents #B and #C) Findings include: 1. On 10/7/15 at 8:50 a.m., Resident #B was observed in her room laying in bed. At that time, the resident was observed with a right arm sling in place. The Record for Resident #B was reviewed on 10/7/15 at 10:08 a.m. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 2 indicating the resident's cognition was severely impaired. The resident needed extensive assist with a two person physical assist for transfers. The Fall Risk assessment dated [DATE] indicated the resident was at risk for falls. The current and updated plan of care dated 8/27/15 indicated the resident was at risk for falls related to the need for extensive assist with transfers as well as right sided paralysis. The Nursing approaches included, but were not limited to, two person assist for all transfers. Nursing Progress Notes dated 9/21/15 at 4:27 p.m., indicated the resident was lowered to the floor during a transfer. The verification of an investigation form dated 9/21/15 provided by the Director of Nursing (DON) was reviewed on 10/7/15 at 3:50 p.m. The detailed description of the event indicated the resident was lowered to the floor during a transfer after her leg gave out. The intervention recommended to prevent further occurrence was for the resident to be assisted by two staff at all times. Nursing Progress notes dated 9/22/15 at 10:28 p.m., indicated resident noted to have a bruise to her right upper extremity (RUE) measuring 5 centimeters (cm) by 5 cm purple in color. Continued review indicated the following: -9/23/15 at 8:16 a.m., RUE swollen with bruise -9/23/15 at 8:38 a.m., medication administration due to discomfort -9/23/15 at 2:27 p.m., noted swelling to right upper arm and shoulder area, resident guarding area and would not move arm bruising noted to arm pit area .resident assessed by Medical Doctor (MD) stat x-ray ordered. MD notified of results resident sent to emergency room (ER). -9/23/15 at 9:02 p.m., resident returned from the ER with an immobilizer in place to be worn at all times. The Radiology Report dated 9/23/15 indicated, There was a mildly displaced fracture through the surgical neck of the proximal right humerus (upper arm). Interview with the DON on 10/7/15 at 2:04 p.m., indicated the resident had a fall resulting in a fracture during a one person assisted transfer and the resident was to be transferred by two staff at all times. Interview with CNA #2 on 10/7/15 at 2:55 p.m., indicated the resident was a two person assist with transfers and now requires a Hoyer lift during transfers. Interview with the Physical Therapy Director on 10/7/15 at 2:55 p.m., indicated the resident has always been care planned as a two person assist with transfers. 2. On 10/7/15 at 8:50 a.m., Resident #C was observed sitting in her wheelchair. At that time, the resident was observed with a large scabbed abrasion to the center of her forehead as well as blue/green/yellow bruising around the scabbed area. The resident was also observed with a large skin tear to the left hand surrounded by red and purple bruising. The record for Resident #C was reviewed on 10/7/15 at 9:45 a.m. The resident's [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident was moderately impaired for cognition. The resident needed extensive assist with a two person physical assist for transfers and toilet use. The fall risk assessment dated [DATE] indicated the resident was at risk for falls. The current and updated plan of care dated 8/25/15 indicated the resident was at risk for falls related to difficulty walking and with transfers as well as increased weakness. The Nursing approaches were to position the bed low, keep the call light in reach, wheelchair for mobility and the use of proper footwear. Nursing Progress Notes dated 9/12/15 at 3:15 p.m., indicated the resident was found on the floor by a CNA. The verification of investigation form dated 9/12/15 provided by the Director of Nursing (DON) was reviewed on 10/7/15 at 2:45 p.m. The detailed description of the event indicated the resident fell while transferring herself from her wheelchair to the stationary chair in the dining room. The interventions recommended to prevent further occurrence was for the resident to be encouraged to attend activities or stay in sight of staff when up in the wheelchair. Nursing Progress Notes dated 9/25/15 at 3:59 p.m. indicated the resident was found on the floor on both of her knees in front of her wheelchair. The resident was bleeding from her forehead and sustained a left hand skin tear. The facility called 911 and the resident was sent to the hospital. The resident returned from the hospital at 8:50 p.m. The hospital report indicated the resident had a Cat Scan (CT) of her right hip which indicated a minimally displaced comminuted fracture involving the greater trochanter proximal to the right femur. The verification of investigation form dated 9/25/15 provided by the DON was reviewed on 10/7/15 at 2:45 p.m. The detailed description of the event indicated the resident was found on the floor on her knees. The resident's wheelchair was behind her next to the dining table and window wall. It had appeared the resident was leaning over to reach for something. The interventions recommended to prevent occurrence was for the resident's call light to be in reach and not to lean forward in her wheelchair. Nursing Progress Notes dated 9/26/15 at 7:13 p.m., indicated the resident was found on the floor by nurse. The verification of investigation form dated 9/26/15 provided by the DON was reviewed on 10/7/15 at 2:45 p.m. The detailed description of the event indicated the resident had just finished eating dinner and had asked the CNA to transport her to the restroom. The resident asked the CNA to get her a clean pair of pants out of the closet. When the CNA turned around, the resident fell on the bathroom floor. The interventions recommended to prevent occurrence was for the resident to stay with staff when up in the wheelchair. Interview with CNA #1 on 10/7/15 at 12:23 p.m., indicated the staff were to keep a close watch on the resident but it was hard at times due to the resident was able propel her wheelchair by herself. Interview with LPN #2 on 10/7/15 at 3:40 p.m., indicated the resident self propels herself in the wheelchair, but We try to keep a close eye on her. Interview with the DON on 10/7/15 at 3:00 p.m., indicated the resident had a fall with a fracture on 9/25/15 and fell again the next day on 9/26/15. She indicated on 9/26/15 the CNA had placed the resident on the toilet and left her there to get something for the resident out of the closet. She further indicated the CNA was not in sight of the resident and should not have left the resident on the toilet by herself especially with a history of falls. This Federal tag relates to Complaint IN 681. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure proper supervision and assistance was provided while transferring a resident, resulting in a resident falling and obtaining an ankle fracture for 1 of 5 residents reviewed for falls and a fall with no injury for 1 of 5 residents reviewed for falls. (Resident #B and #C) Findings include: 1. The record for Resident #B was reviewed on 12/30/2014 at 1:15 p.m. [DIAGNOSES REDACTED]. Review of a Progress Note dated 10/10/14 at 10:12 a.m., indicated Resident #B was standing with her walker and 1 therapy staff assist, using a gait belt, when her leg bent & she slid to the floor with staff assist. Review of a Progress Note dated 10/12/14 at 9:14 a.m., indicated Resident #B was lowered to her bed in the low position from standing with her walker and 1 staff assist. The staff reported during this time the resident's right leg buckled "and was basically underneath her." Review of a Progress Note dated 10/12/14 at 1:32 p.m., indicated, the resident was unable to transfer with a 1 person assist, complained of pain to her right calf, ankle and foot, and needed a 2 person maximum assist to transfer to bed. Review of a Progress note dated 10/13/14 at 2:41 p.m., indicated an x-ray was done with "likely malleolar fracture." Review of the physician's orders [REDACTED]. - NWB (non-weight bearing) to RLE (right lower extremity) for Medial Malleolus Fx. (11/18/14) - NWB to RLE in boot at all times except for hygiene - every shift for Medial Malleolus Fx. (10/23/14) - NWB to RLE in boot at all times when up, may remove while in bed if R foot is elevated - every shift for Medial Malleolus Fx. (10/28/14) Review of the Fall care plan indicated: "At risk for falls related to: new environment, hx. (history) of falls, unsteady transfers ...." It was updated to include medial malleolar fracture. Review of the Fall Investigation dated 10/12/14, indicated, "Nurse was attempting to transfer res (resident) 1 person limited assist with walker, res leg started to buckle - nurse lowered bed and helped res back on bed rather than her falling on floor." A staff correction "Teachable Moment" form included in the fall follow-up indicated, "When working as a CNA or assisting residents to transfer, make sure you have your CNA sheet on you at all times and you transfer resident as the CNA sheet indicates." A nursing staff inservice note dated 10/13/14, indicated, "We had an incident where our resident was transferred differently then the CNA INFO sheet stated, which resulted in an injury. CNA must carry Info sheets on them at all times while working the floor ... CNAs and nurse must make sure you are transferring every resident per what is on the CNA INFO sheet. If the resident has had any change in ability to transfer, notify your nurse immediately so the resident can be assessed for change in condition. It takes everybody to keep the resident safe." Interview with the DON on 01/05/2015 11:58 a.m., indicated staff, at the time of Resident #B's fall, should have been using a 2 person assist and only used a 1 person assist. She further indicated falls and transfer status were discussed in daily stand up meetings and it was decided there whether or not to change a status for a resident. Resident #B had been a 1 person assist previously, but had a lowering to the floor incident with therapy 2 days prior to her fall, so the resident was changed to a 2 person assist for staff. Transfer status was on the CNA info sheets and staff were to follow these. Employees were inserviced on the importance of following the CNA sheets after this incident. 2. The record for Resident #C was reviewed on 1/6/15 at 11:00 a.m. [DIAGNOSES REDACTED]. Review of a Progress Note dated 12/11/14 at 7:50 a.m., indicated a CNA was transferring Resident #C from the bed to the wheelchair in the standing position when the resident sat on the edge of the wheelchair and began to slide. The resident was lowered to the floor in the sitting position by the CNA. There was no injury noted. Review of the Fall care plan indicated, "Risk for falls r/t (related to) dx (diagnosis) progressive dementia with psychosis, resident resistive to care at times/ requires two person assist at times, hx of falls, requires staff assist to walk safely." Review of the Fall Investigation dated 12/11/14 indicated, "Description: Resident was being transferred from the bed to the wheelchair by CNA, resident was in the standing position and sat on the wheelchair. When resident sat on the wheelchair, resident began to slide. Resident was lowered to the floor by the CNA. Assessment: head to toe assessment completed, no injuries noted. Interview: Resident does not respond to questions Contributing factors: Resident was transferred one assist, resident is a two assist transfer. Recommendations: CNA instructed to follow the CNA sheet. Wearing shoes at the time of the fall." A staff correction "Teachable Moment" form included in the fall follow-up indicated, "It is mandatory to carry your CNA sheets with you at all times and follow all information in there that pertains to our residents. After education is received, you must follow CNA sheets, If it states a res (resident) is a one assist, it is okay to transfer that resident by yourself if able to do so. If it states "2 assist" you must have another staff member help you with the transfer for not only the safety of our resident but also yourself." Interview with the DON on 01/06/2015 at 12:32 p.m. indicated, the CNA transferred Resident #C with only 1 assist when the resident was supposed to be a 2 assist per the CNA info sheet. She further indicated a "teachable moment" was done for this CNA since she has had no other issues, but if any other incidents of this nature happen with any staff, the staff member will be written up. She has done several inservices which discuss giving care as indicated and following CNA sheets. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure proper supervision and assistance was provided while transferring a resident, resulting in a resident falling and obtaining an ankle fracture for 1 of 5 residents reviewed for falls and a fall with no injury for 1 of 5 residents reviewed for falls. (Resident #B and #C) Findings include: 1. The record for Resident #B was reviewed on 12/30/2014 at 1:15 p.m. [DIAGNOSES REDACTED]. Review of a Progress Note dated 10/10/14 at 10:12 a.m., indicated Resident #B was standing with her walker and 1 therapy staff assist, using a gait belt, when her leg bent & she slid to the floor with staff assist. Review of a Progress Note dated 10/12/14 at 9:14 a.m., indicated Resident #B was lowered to her bed in the low position from standing with her walker and 1 staff assist. The staff reported during this time the resident's right leg buckled "and was basically underneath her." Review of a Progress Note dated 10/12/14 at 1:32 p.m., indicated, the resident was unable to transfer with a 1 person assist, complained of pain to her right calf, ankle and foot, and needed a 2 person maximum assist to transfer to bed. Review of a Progress note dated 10/13/14 at 2:41 p.m., indicated an x-ray was done with "likely malleolar fracture." Review of the physician's orders [REDACTED]. - NWB (non-weight bearing) to RLE (right lower extremity) for Medial Malleolus Fx. (11/18/14) - NWB to RLE in boot at all times except for hygiene - every shift for Medial Malleolus Fx. (10/23/14) - NWB to RLE in boot at all times when up, may remove while in bed if R foot is elevated - every shift for Medial Malleolus Fx. (10/28/14) Review of the Fall care plan indicated: "At risk for falls related to: new environment, hx. (history) of falls, unsteady transfers ...." It was updated to include medial malleolar fracture. Review of the Fall Investigation dated 10/12/14, indicated, "Nurse was attempting to transfer res (resident) 1 person limited assist with walker, res leg started to buckle - nurse lowered bed and helped res back on bed rather than her falling on floor." A staff correction "Teachable Moment" form included in the fall follow-up indicated, "When working as a CNA or assisting residents to transfer, make sure you have your CNA sheet on you at all times and you transfer resident as the CNA sheet indicates." A nursing staff inservice note dated 10/13/14, indicated, "We had an incident where our resident was transferred differently then the CNA INFO sheet stated, which resulted in an injury. CNA must carry Info sheets on them at all times while working the floor ... CNAs and nurse must make sure you are transferring every resident per what is on the CNA INFO sheet. If the resident has had any change in ability to transfer, notify your nurse immediately so the resident can be assessed for change in condition. It takes everybody to keep the resident safe." Interview with the DON on 01/05/2015 11:58 a.m., indicated staff, at the time of Resident #B's fall, should have been using a 2 person assist and only used a 1 person assist. She further indicated falls and transfer status were discussed in daily stand up meetings and it was decided there whether or not to change a status for a resident. Resident #B had been a 1 person assist previously, but had a lowering to the floor incident with therapy 2 days prior to her fall, so the resident was changed to a 2 person assist for staff. Transfer status was on the CNA info sheets and staff were to follow these. Employees were inserviced on the importance of following the CNA sheets after this incident. 2. The record for Resident #C was reviewed on 1/6/15 at 11:00 a.m. [DIAGNOSES REDACTED]. Review of a Progress Note dated 12/11/14 at 7:50 a.m., indicated a CNA was transferring Resident #C from the bed to the wheelchair in the standing position when the resident sat on the edge of the wheelchair and began to slide. The resident was lowered to the floor in the sitting position by the CNA. There was no injury noted. Review of the Fall care plan indicated, "Risk for falls r/t (related to) DX (diagnosis) progressive dementia with psychosis, resident resistive to care at times/ requires two person assist at times, hx of falls, requires staff assist to walk safely." Review of the Fall Investigation dated 12/11/14 indicated, "Description: Resident was being transferred from the bed to the wheelchair by CNA, resident was in the standing position and sat on the wheelchair. When resident sat on the wheelchair, resident began to slide. Resident was lowered to the floor by the CNA. Assessment: head to toe assessment completed, no injuries noted. Interview: Resident does not respond to questions Contributing factors: Resident was transferred one assist, resident is a two assist transfer. Recommendations: CNA instructed to follow the CNA sheet. Wearing shoes at the time of the fall." A staff correction "Teachable Moment" form included in the fall follow-up indicated, "It is mandatory to carry your CNA sheets with you at all times and follow all information in there that pertains to our residents. After education is received, you must follow CNA sheets, If it states a res (resident) is a one assist, it is okay to transfer that resident by yourself if able to do so. If it states "2 assist" you must have another staff member help you with the transfer for not only the safety of our resident but also yourself." Interview with the DON on 01/06/2015 at 12:32 p.m. indicated, the CNA transferred Resident #C with only 1 assist when the resident was supposed to be a 2 assist per the CNA info sheet. She further indicated a "teachable moment" was done for this CNA since she has had no other issues, but if any other incidents of this nature happen with any staff, the staff member will be written up. She has done several inservices which discuss giving care as indicated and following CNA sheets. This Federal tag relates to complaint IN 068. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received assistance to prevent accidents, related to a CNA transferring a resident who required two assistance with transfers with only one assistance, causing a skin tear on the resident's left shin, which required nine sutures to close the skin tear, for 1 of 3 residents reviewed for abrasion and bruises in a total sample of 3. (Resident #B and Terminated CNA #1) Findings include: Resident #B's record was reviewed on 06/04/14 at 8:45 a.m. The resident's [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set Assessment, dated 04/12/14, indicated the resident had poor short and long term memory problems, was extensive assistance with two or more staff for transfers, and required staff assistance to stabilize her with standing. A Resident Care Plan Sheet, dated 05/17/14, indicated the resident required two staff for transfers. A Nurses' Note, dated 05/18/14 at 8 a.m., indicated the resident was transported by ambulance to the hospital due to a open area of the left shin. The Emergency Department notes, dated 05/18/14, at 8:19 a.m., indicated the resident had been transferred from the bed to the wheelchair and the left leg was cut on the wheelchair. The note indicated the left lateral leg had a laceration approximately 5-6 centimeters (cm) over the left shin and the skin was closed with nine sutures. An Incident Report Form, dated 05/19/14, indicated a CNA had transferred the resident from her bed to the wheelchair when the resident caught her leg on the wheelchair and caused a 5.5 cm by 3.3 cm lower left extremity laceration. A typed statement form Terminated CNA #1, dated 05/20/14, indicated Terminated CNA #1 asked another CNA for help and the other CNA indicated she did not have time, Terminated CNA #1 then indicated the Nurse on the unit looked busy, so she had not asked the Nurse for help. Terminated CNA #1 indicated she had decided to transfer the resident by herself and while doing this, the resident's leg slipped and she had to lower the resident to the floor. She indicated the leg rests were not on the wheelchair and she was unsure how the skin tear occurred. During an interview on 06/04/14, the Director of Nursing indicated Terminated CNA #1 had been disciplined and terminated from the facility after the investigation had been completed and all other staff had been inserviced on transferring residents by the care plan. This Federal Tag relates to complaint IN 670. 3.1-45(a)(2)