Every finding on record at Brickyard Healthcare - Woodlands Care Center

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Floors and equipment were soiled, and food was unlabeled. (Kitchen) Findings include: On 5/12/25 at 8:56 A.M., during observation of the kitchen the following was observed: 1. The top of the dish machine was soiled. 2. The floors in the kitchen area were soiled, debris build up around the edges of the walls, debris under racks and tables with equipment, and under the three compartment sink. 3. Debris build up on a pull down plug hanging above the food prep table, and on a fan hanging on the wall. 4. The walk in freezer had two partially used bags of tater tots in clear bags, one partially used bag of potato wedges in a clear bag, all were unlabeled. On 5/14/25 at 9:18 A.M., the same was observed. On 5/14/25 at 9:25 A.M., the Dietary Manager indicated if food is opened it should be tabled with an open date and a use by date, housekeeping does the deep cleaning of the floors usually once a month, the kitchen staff are supposed to sweep and mop the floors after each shift. On 5/14/25 at 1:08 P.M., the Administrator provided the current policy on freezer storage with a revision date of October 2022. The policy included but was not limited to: .Label and note pull date with use by date on all food items when removing from freezer .All items not stored in original container must be labeled and noted with use by date according to storage chart, used or discarded within allowed days . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to accommodate a resident's choice to participate in an activity for 1 of 1 random observations (Resident 9). A resident was not allowed to participate in the resident council meeting held on May 13, 2025. Finding includes: On 5/13/25 at 9:58 A.M., Resident 9 was observed sitting in her wheelchair in the main dining room. Licensed Practical Nurse (LPN) 3 came to take Resident 9 from the room. Resident 9 indicated she wanted to stay for the resident council meeting. LPN 3 told her that she was not allowed to stay because she wasn't on the list. LPN 3 took Resident 9 from the dining room. The resident council meeting started at 10:09 A.M. and Resident 9 was not in attendance. On 5/15/25 at 10:39 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/15/25, indicated that Resident 9 had mild cognitive impairment and had no behaviors. The most recent care plan conference was held on 3/19/25. Resident 9 was in attendance and the plan of care was reviewed. Activities care plans, dated 12/9/24, included the following interventions: Continue to involve me in out of room activities as desired and able Invite me to my favorite activities (coffee socials, tossing games), and to try new things that I might be interested in An Activity Participation Review, dated 3/7/25, indicated Resident 9 was a regular member of the resident council. The most recent Psychiatry progress note, dated 4/24/25, indicated Resident 9 was oriented to person, place, and situation. On 5/15/25 at 11:24 A.M., the Administrator indicated that anyone could come to resident council meetings. The facility had made a list of residents to attend the meeting held on 5/13/25 and only included those residents who were alert and oriented. She indicated that anyone who was alert and oriented could have attended that meeting even if they were not on the list. On 5/15/25 at 12:50 P.M., LPN 7 indicated that Resident 9 was oriented to person and place, but not always situation. On 5/15/25 at 1:09 P.M., the Resident Council Minutes for January, February, March, and April 2025 were reviewed. Resident 9 was listed as in attendance for the meeting held on 2/5/25 and 4/2/25. On 5/15/25 at 2:15 P.M., the Administrator provided a current Resident Council Meetings policy, dated 2025, that indicated All residents are eligible to participate in the Resident Council and are encouraged by facility staff to participate. On 5/15/25 at 2:15 P.M., the Administrator provided a current Promoting/Maintaining Resident Dignity policy, dated 2024, that indicated Assist residents to participate in activities of choice. 3.1-3(u)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were followed for 1 of 1 resident reviewed for urinary catheter use (Resident 49). A resident's catheter bag was observed on the floor. Finding includes: On 5/12/25 at 10:26 A.M., Resident 49 was observed lying in bed. Her catheter bag was observed on the floor. On 5/15/25 at 10:04 A.M., Resident 49 was observed lying in bed. Her catheter bag was hanging on the bed. The bed was in the lowest position and the catheter bag was touching the floor. On 5/14/25 at 10:09 A.M., Resident 49's clinical record was reviewed. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder and retention of urine. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 2/22/25, indicated Resident 49 was not cognitively intact, was dependent on staff for toileting, had an indwelling catheter, and did not have a urinary tract infection (UTI). Physician orders included, but were not limited to: Sixteen French Foley catheter for urinary retention/neurogenic bladder every shift, dated 4/21/25 The most recent care plan conference was completed on 2/27/25. Care plans were reviewed. A current urinary catheter care plan, dated 11/22/24, included an intervention to keep the drainage bag of the catheter below the level of the bladder at all times and off of the floor. During an interview on 5/15/25 at 10:43 A.M., the Infection Preventionist indicated that catheter bags should not be on the floor. On 5/15/25 at 2:15 P.M., the Administrator provided a current Indwelling Catheter Use and Removal policy, dated 2024, that indicated If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: . Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. 3.18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure EBP (Enhanced Barrier Precautions) were followed during care of an indwelling urinary catheter for 1 of 3 residents reviewed for Foley Catheters. A gown was not used during care. (Resident C) Finding includes: On 10/9/24 at 9:20 a.m., QMA 2 (Qualified Medication Aide) and CNA 3 (Certified Nursing Assistant) were observed to provided Foley Catheter care to Resident C. Both entered the room, performed hand hygiene, donned gloves, cleaned, rinsed, and dried the tubing of the Foley Catheter. Neither staff donned a gown before providing care. Enhanced barrier precaution signage was posted on Resident C's door that indicated a gown was to be worn. On 10/9/24 at 10:51 a.m., Resident C's clinical record was reviewed. Diagnoses included, but was not limited to, unspecified urinary incontinence, frequency of micturition, neuromuscular dysfunction of bladder, retention of urine, unspecified. An annual MDS (Minimum Data Set) assessment dated [DATE], indicated Resident C's cognition was severely impaired, had an indwelling catheter, toileting extensive, assist of two. Care plans included, but were not limited to: Alteration in elimination of bowel and bladder indwelling urinary catheter, retention, neuromuscular dysfunction of bladder, retention of urine, date initiated 11/18/20. Interventions included, but were not limited to: Indwelling catheter care every shift and as needed, Enhanced barrier precautions when providing any Foley Cath care and any high contact Res care activities (see sign on door). Current physician orders for October 2024 were reviewed and included, but were not limited to: Foley Cath care every shift with soap and water every shift related to neuromuscular dysfunction of bladder, unspecified, retention of urine, unspecified, order date 4/13/24. Enhanced barrier precautions when providing any Foley Cath care and any high contact Res care activities (see sign on door) every shift, order date 3/29/24. On 10/9/24 at 1:20 p.m., QMA 2 indicated a gown and gloves should be worn while providing care to a resident with a Foley Catheter who is on enhanced barrier precautions. On 10/9/24 at 1:41 p.m., the Administrator provided the current policy on Enhanced Barrier Precautions with a copyright date of 2024. The policy included, but was not limited to: .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities b. An order for enhanced barrier precautions will be obtained for residents with any of the following: .and/or indwelling medical devices (e.g;central lines, urinary catheters .3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room . This citation relates to Complaint IN00444232. 3.1-18(b) 3.1-41(a)(2)

Based on observation and record review, the facility failed to ensure dignity for 2 of 2 observations of meal service. Staff did not knock or announce themselves before delivering meal trays to resident rooms. (Resident 9, Resident 14, Resident 66, Resident 75, Resident 78, Resident 84, Resident 96) Findings include: On 6/23/24 during observation of the noon meal the following was observed: 1. At 11:34 a.m., CNA 2 entered Resident 96's room to deliver a beverage without knocking or announcing self. 2. At 11:52 a.m., CNA 2 entered Resident 66's room to deliver a beverage without knocking or announcing self. 3. At 11:53 a.m., CNA 3 entered Resident 84's room, walked back out and got a beverage, walked back in the room to deliver the beverage without knocking or announcing self. 4. At 11:55 a.m., CNA 3 entered Resident 75's room to deliver a meal tray, walked back out and got a beverage, walked back in to deliver the beverage without knocking or announcing self. 5. At 11:57 a.m., CNA 2 entered Resident 9's room to deliver a meal tray without knocking or announcing self. 6. At 11:59 a.m., CNA 3 entered Resident 84's room to deliver a beverage without knocking or announcing self. On 6/27/24 during observation of the noon meal the following was observed: 7. At 11:49 a.m., CNA 2 walked in Resident 78's room to deliver a meal tray without knocking or announcing self. 8. At 11:50 a.m., CNA 2 walked in Resident 14's room to deliver a meal tray without knocking or announcing self. On 6/23/24 at 12:00 p.m., CNA 3 indicated when delivering meal trays to a resident's room, staff should knock on the door, tell the resident nursing, let them know why you are there. 48057 9. During a random observation on 6/27/24 at 9:58 A.M., Physician 2 was sitting on the couch in a resident common area, where additional staff, residents, and resident family were present, asking residents medical questions and taking a resident's blood pressure. 38770 10. During a meal observation on 6/26/24 at 7:48 A.M., Licensed Practical Nurse (LPN) 21 was observed to apply clothing protectors to two of four residents at a table on the ACU (Alzheimer's Care Unit). LPN 21 applied the clothing protectors from behind the residents without asking permission, and without explaining what she was doing. On 6/28/24 at 1:46 P.M., LPN 17 indicated staff should ask residents before putting on a clothing protector if they wanted one or not, as well as explain what they were doing. On 6/27/24 at 2:38 p.m., the Regional Nurse Consultant provided the current policy on promoting/maintaining resident dignity with a copyright date of February 2023. The policy included, but was not limited to: It is the practice of this facility to protect and promote resident rights and treat each other with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .12. Maintain resident privacy . 3.1-3(a) 3.1-3(p)(3)

Based on observation and interview the facility failed to provide proper storage of medications in 1 of 1 treatment carts located in the ACU (Alzheimer Care Unit) for 9 of 9 residents reviewed. Unlabeled and undated medications were found in the treatment cart. (Resident 12, Resident 15, Resident 22, Resident 25, Resident 45, Resident 47, Resident 49, Resident 57, Resident 88, Findings include: On 6/26/24 at 12:35 P.M., the locked nightstand/treatment cart was observed to have the following: 1 tub of Curad petroleum jelly lacked a prescription label and an open date 1 tub of petroleum jelly for Resident 45 has prescription label but lacked an open date 1 tube of Diclofenac cream (analgesic cream) lacked a label and an open date 1 glass case with unreadable name and no glasses 1 tube of Volteran cream Resident 47 with a prescription label but lacked an open date 1 tub of Sombra (analgesic cream) Resident 49 with a prescription label but lacked an open date 1 tube of Aspercreme (analgesic cream) Resident 25 with a prescription label but lacked an open date 1 tube of Aspercreme (analgesic cream) Resident 25 with a prescription label but lacked an open date 1 tube of arthritis pain medication Resident 12 with a prescription label but lacked an open date 1 tube of Diclofenac (analgesic cream) Resident 57 with a prescription label but lacked an open date 1 tube of Aspercreme (analgesic cream) lacked a prescription label and an open date 1 bottle of fungal powder with Resident 22 with a prescription label but lacked an open date 2 bottles of fungal powder with Resident 88 with a prescription label but lacked an open date 1 tube of arthritis cream with Resident 57 with a prescription label but lacked an open date 1 tub of Sombra (analgesic cream) Resident 49 with a prescription label but lacked an open date 1 tub of Sombra (analgesic cream) without a prescription label and lacked an open date 1 bottle of Nystatin Powder (fungal powder) Resident 15 with a prescription label but lacked an open date During an interview on 6/26/24 at 12:40 P.M., the DON (Director of Nursing) indicated the medications should not be in the nightstand/ treatment cart and be in the medication room. During an interview on 6/28/24 at 9:26 A.M., LPN (Licensed Practical Nurse) 22 indicated medication are to be labels with a resident name, medical doctor, medication name on the prescription. All medications such as ointments creams, and powders should be dated with open date. On 6/28/24 at 2:38 P. M., the Regional Nurse provided a current, non-dated policy Medication Storage. The policy indicated .it was the policy of this facility to ensure all medications housed on the premises will be stored medication rooms .all drugs and biologicals will be stored in locked compartments . only authorized personal will have access to the keys to the locked compartments . 3.1-25(k) 3.1-25(m)

Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents, staff, and the public for 11 random observations for environment for 3 of 3 days. Food debris on resident wheelchair and dusty and debris found on a mechanical lift and sit to stand in unit hallways. ( Resident 24, Resident 27, 100 Hallway, 300 Hallway, 600 Hallway) Findings include: 1. On 6/26/24 at 2:16 P.M., a sit to stand device on the 600 Hall was observed to have dust on the seat and white residue on the handles. On 6/27/24 at 9:10 A.M., a sit to stand device on the 600 Hall was observed to have dust on seat and white residue on the handles. On 6/27/24 at 10:10 A.M., a mechanical lift on the 100 Hall was observed to have dust, fiber debris, and white spots on the base. On 6/28/24 at 8:45 A.M., a sit to stand device on the 600 Hall was observed to have dust on the seat and white residue on the handles. On 6/28/24 at 8:46 A.M., a sit to stand device on 100 Hall was observed to have dust on the seat. On 6/28/24 at 8:51 A.M., a mechanical lift on the 300 hall was observed to have dust with fiber debris on the seat. 2. On 6/27/24 at 10:12 A.M., Resident 24's wheelchair was observed to have food debris scattered in front of the cushion while the resident was sitting in it. 3. On 6/28/24 at 8:57 A.M., Resident 27's wheelchair was observed to have chocolate milk splattered on the tires. 4. During an interview on 6/27/24 at 11:33 A.M., Resident 30 indicated the staff does not regularly wipe off or clean the wheelchairs. During an interview on 6/28/24 at 9:00 A/M., CNA (Certified Nursing Aide) 10 indicated the wheelchairs are cleaned weekly and as needed. During an interview on 6/28/24 at 9:02 A/M., Resident 74 indicated they did not know if the wheelchair was wiped off. During an interview on 6/28/24 A.M., Housekeeper 32 indicated the night shift CNAs are the ones that will clean the equipment such as mechanical lifts [NAME] spoke with supervisor and the housekeeping staff does not clean the equipment CNA's do. On 6/28/24 at 2:38 P.M., the Regional Nurse provided a current non-dated policy Cleaning and Disinfection of Resident-Care Equipment. The policy indicated .resident-care equipment can be a source of indirect transmission of pathogens .Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include .each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . This citation relates to complaint IN00434672. 3.1-19(f)

Based on observation, record review and interview, the facility failed to develop a care plan for 2 of 5 resident reviewed for care plan intervention. Resident fall interventions and head of bed elevation not being in place. (Resident 24, Resident 351) 35733 1. On 6/24/24 at 2:14 p.m., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, abnormal gait and mobility, displaced supracondylar fracture without intracondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing. A Quarterly MDS (Minimum Data Set) assessment, dated 5/7/24, indicated Resident 24's cognition was moderately impaired, bed mobility extensive, one staff assist, transfer extensive two staff assist. A care plan for falls indicated: At risk for falls related to: History of falls. Use of medication, gout, dementia, osteoarthritis macular degeneration right eye, polymyalgia rheumatic, ulcer, abnormal gait and mobility. HTN (hypertension), muscle weakness. Interventions included, but were not limited to: wedge pillows on sides of recliner to prevent resident from rolling out, date initiated, 6/22/24. A progress note dated 6/22/24 at 7:00 a.m., indicated : .Situation: Resident sleeping in recliner in common area in front of nurses station. Heard resident say oh God damn. Noted resident on floor between the 2 recliners. Background: Hx (history) dementia, repeated falls and decreased safety awareness .Response: [name of physician] triage notified as well as RR (resident representative). Intervention to use pillows on sides of recliner to prevent further rolling out . On 6/27/24 at 9:19 a.m., QMA 2 was observed to transfer Resident 24 from his wheelchair to a recliner, put the foot of the recliner up, walk away and return with a cover and lay across Resident 24. No pillows were placed beside Resident 24. On 6/27/24 at 10:07 a.m., Resident 24 was observed asleep in the recliner, no pillows were beside him. On 6/27/24 at 10:09 a.m., LPN 3 was sitting at the nurses station in front of the common area. She indicated Resident 24 was supposed to have pillows beside him in the recliner to help prevent him from falling out. On 6/27/24 at 10:10 a.m., QMA 2 indicated usually the charge nurse will let staff know of any fall and new fall interventions, it is also on their assignment sheet. QMA 3 indicated she was not sure what Resident 24's fall interventions were, she didn't work with him everyday. 50827 2. On 6/27/24 at 12:13 P.M. RN (Registered Nurse) 3 and LPN (Licensed Practical Nurse) 2 were observed performing a treatment on Resident 351. Resident had slid down in bed, stated could not breathe and needed to sit up. Two minutes passed before LPN 2 and RN 3 used the bed pad under resident to pull up higher in bed. The bed remained flat during treatment. Resident was visualized breathing with pursed lips. Treatment completed at 12:26 P.M. Head of the bed was then raised. On 6/27/24 at 12:13 P.M. Resident 351's clinical record was reviewed. Diagnosis included but was not limited to Chronic Lung Disease. The most recent MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident was cognitively intact, required set up and clean up assistance with eating, substantial or maximum assistance with toileting, substantial or maximum assistance with showering or bathing, and substantial or maximum assistance with bed mobility. Physician orders included but were not limited to head of bed elevated to alleviate/avoid shortness of breath when lying flat every shift related to chronic obstructive pulmonary disease, dated 6/10/24. Care plan for Resident, dated 6/11/24, alteration in respiratory status due to Chronic Obstructive Pulmonary Disease, due to Congestive Heart Failure indicated an intervention but was not limited to elevate head of bed to alleviate/avoid shortness of breath while lying flat. 6/28/24 10:24 A.M. LPN 4 indicated that usually Resident 351 tolerates bed being flat for treatments, but if resident became short of breath or verbalized not being able to breathe staff should stop the treatment so the resident can recover. On 6/28/24 at 2:30 P.M., the Regional Nurse supplied a current, nonrated policy Comprehensive Care Plans. The policy indicated . it was the policy of the facility of develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes .the objectives will be utilized to monitor the resident's progress. Alternative interventions documented, as needed . On 6/28/24 at 2:38 p.m., the Regional Nurse Consultant provided the current accidents and supervision policy with a copyright date of 2023. The policy included, but was not limited to: .Implementation of Interventions- a. Communicate the interventions to all relevant staff, e. Ensuring that the interventions are put into action .Monitoring and Modification- a. Ensuring that interventions are implemented correctly and consistently . 3.1-35(a) 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure care plans were revised in 1 of 2 residents reviewed for care plans. (Resident 45) Findings include: On 6/25/24 at 9:03 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety The most current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was severely cognitively impaired. The resident need supervision for transfer and mobility with substantial help for mobility Current physician orders included but were not limited to: Weekly weights every day shift every Sunday for 4 weeks ordered 6/14/24 Vaseline Pure Ultra [NAME] External Gel (White Petroleum) Apply to right cheek topically every day shift for wound care cleanse facial biopsy site to right cheek with normal saline. Pat dry, apply thin layer of Vaseline to wound bed. Cover with dry dressing dated 6/19/24. There was a current care for a seborrheic lesion to the right cheek dated 8/8/23. Resident had a biopsy done on 6/19/24. The care plan lacked revision of interventions related to wound care. There was a current care plan of nutritional risk for inadequate food/beverage intake with dementia and triggered for 10% weight loss dated 6/17/24. Current interventions indicated monthly weights but lack revision for weekly weights. During an interview on 6/25/24 at 10:07 A.M., MDS RN (Registered Nurse) indicated if a resident had an open area, they would document a care plan and update as needed for surgeries and biopsies On 6/28/24 at 2:30 P.M., the Regional Nurse supplied a current, nondated policy Comprehensive Care Plans. The policy indicated . it was the policy of the facility of develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes .the objectives will be utilized to monitor the resident's progress. Alternative interventions will documented, as needed . 3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to provide care through maintenance of a PICC (peripherally inserted central catheter) line for 1 of 1 residents reviewed for IV therapy. (Resident 302) Findings include: On 6/25/24 at 1:14 P.M., Resident 302's clinical record was reviewed. Resident 302 was admitted on [DATE]. Diagnoses included, but were not limited to, infection of joint prosthesis, anxiety, and hypertension. The Admission MDS (Minimum Data Set) Assessment, dated 6/17/24 was not completed. Current physician orders included, but were not limited to: PICC (peripherally inserted central catheter) line dressing change every Tuesday. Start date 6/18/24. Current care plans included, but were not limited to: I have a PICC line (in my) right arm and have the potential risk of infection at the site. Do not take blood pressure on arm of access site. Encourage patient not to sleep on arm with access site. Date Initiated: 6/12/24. Dressing change as ordered with measurements of the length of the external catheter and the circumference of arm 10 cm above insertion site. Date Initiated: 6/12/24. On 6/28/24 at 9:15 A.M., Resident 302's electronic medication administration record was reviewed. The following dates/times indicated staff obtained a blood pressure reading in Resident 302's restricted limb: 6/26/24 10:34 A.M. sitting right arm 6/24/24 8:18 A.M. lying right arm 6/22/2024 2:25 P.M. lying right arm 6/17/2024 8:24 A.M. sitting right arm 6/16/2024 8:40 A.M. sitting right arm 6/15/2024 8:16 A.M. sitting right arm 6/14/2024 8:29 A.M. lying right arm 6/10/2024 6:25 P.M. lying right arm During an interview on 6/27/24 9:40 A.M., RN 3 indicated she was the nurse covering nursing duties for the 600 hall today and indicated staff should not be taking blood pressure in Resident 302's right arm because of the PICC line and that it was not policy for PICC line measurements, but if there was conflicting information in the policy and care plan, staff should use the care plan since it is specific to each resident. During an observation on 6/27/24 at 3:19 P.M., Resident 302's PICC line dressing was observed. The dressing read 6-11 1555 CD. During an interview on 6/27/24 3:25 P.M., the Director of Nursing indicated there was no documentation of catheter length in Resident 302's clinical record and she doesn't know why Resident 302 was care planned for her PICC line to be measured during dressing changes because the facility doesn't do that. On 6/28/24 at 2:38 P.M., the clinical regional nurse provided a policy titled PICC/Midline/CVAD Dressing Change, dated 2023, that indicated It is the policy of this facility to changes peripherally inserted central catheters (PICC) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. 13. Use sterile measuring tape to measure external length of the catheter from hub too skin entry to ensure that it has not migrated. 3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was receiving oxygen as physician ordered for 1 of 2 residents reviewed for respiratory care. (Resident 39) Finding includes: During an observation on 6/27/24 at 11:36 A.M., Resident 39 was receiving oxygen via nasal cannula from an oxygen concentrator in her room. The oxygen concentrator was set at two liters. RN 3 observed the oxygen concentrator at two liters, checked the resident's orders and confirmed the orders stated three liters, and turned the oxygen up to three liters. On 6/28/24 at 10:09 A.M. Resident 39's clinical record was reviewed. Resident 39 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The most recent Admission MDS (Minimum Data Set) Assessment, dated 6/4/24, indicated resident 39 was cognitively intact, required maximal assistance from staff for toileting, bathing, and transfers, and was receiving oxygen therapy and dialysis therapy. Current physician orders included, but were not limited to: Supplementary oxygen continuously via nasal cannula at 3 L (three liters) every shift for to prevent/relieve hypoxia related to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia. Start date 6/4/24. Check fistula to right arm for bruit and thrill every shift for fistula care. Start date 5/29/24. Current care plans included, but were not limited to: Oxygen as ordered. Date Initiated: 5/29/24. I have a fistula RUE (right upper extremity) and have the potential risk of infection at the site. Date Initiated: 5/29/24. Do not take blood pressure on arm of access site. Encourage patient not to sleep on arm with access site. Date Initiated: 5/29/24. On 6/28/24 at 10:09 A.M., Resident 39's electronic medication administration record was reviewed. The following dates/times indicated staff obtained a blood pressure reading in Resident 39's restricted limb: 6/22/24 12:23 P.M. sitting right arm 6/20/24 11:55 A.M. standing right arm 6/18/24 4:09 P.M. lying right arm 6/16/24 12:22 P.M. standing right arm 6/15/24 9:38 A.M. sitting right arm 6/3/24 4:42 P.M. sitting right arm 6/2/24 12:07 P.M. sitting right arm 6/1/24 10:01 A.M. lying right arm On 6/28/24 at 2:38 P.M., the Regional Clinical Nurse provided a policy titled Oxygen Administration, dated 2024, that indicated Oxygen is administered under orders of a physician. The resident's care plan shall identify the interventions for oxygen therapy, based on resident's assessment and orders, such as, but not limited to: equipment setting for the prescribed flow rate. 3.1-47(a)(2)

Based on record review, interview, and observation, the facility failed to ensure care and services were implemented for 1 of 2 residents reviewed for dialysis. (Resident 75) Findings include: On 6/25/24 at 8:44 A.M., Resident 75's clinical record was reviewed. Resident 75 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/17/24, indicated Resident 75 was moderately cognitively impaired and was dependant on staff for assistance with bathing and transfers, and was receiving dialysis therapy. Current physician orders included, but were not limited to, Dialysis Monday, Wednesday, Friday at 11:20 (A.M.) (arrival time) at (dialysis center) 11: 40 A.M. chair time one time a day every Monday, Wednesday, Friday for dialysis. Start date 5/13/24. Check Bruit and Thrill to fistula to LUE (left upper extremity) every shift for fistula care. Start date 4/15/24. 1800 cc (equivalent to mL) fluid restriction per 24 hours as follows: Nursing to provide a total of 480 cc/24 hr as follows: Days=180 cc Evening=180 cc Nights=120 cc. every shift for fluid restriction. Start date 2/27/23. Current care plans included, but were not limited to: I have a new fistula to LUE (left upper extremity) and have the potential risk of infection at the site. Dated 4/16/24. I have a perma-cath left side of chest and have the potential risk of infection at the site. Dated 5/13/24. Alteration in kidney function evidenced by hendiadys CKD III (chronic kidney disease stage three), acute kidney failure dialysis 3 x a week due to End Stage Renal Disease (ESRD). Date Initiated: 12/4/23. Do not take blood pressure, on arm of access site. Encourage patient not to sleep on arm with access site Date Initiated: 4/16/24. Weights per MD (doctor) order. Date Initiated 7/10/23. The clinical record lacked an order to obtain Resident 75's weight. On 6/25/24 at 8:44 A.M., Resident 75's electronic medication administration record was reviewed. The following dates/times indicated staff obtained a blood pressure reading in Resident 75's restricted limb: 6/21/24 12:21 P.M. sitting left arm 5/24/24 8:07 A.M. sitting left arm 5/19/24 9:19 A.M. sitting left arm During an interview on 6/27/24 2:15 P.M. CNA 6 indicated she was the CNA for the 500 hall today but did not know who was on fluid restrictions. The CNA then went to nurses desk, found CNA assignment sheets and looked for residents who were on fluid restrictions. During an interview on 6/28/24 at 9:35 A.M., LPN 17 indicated nurses and CNA's should be recording fluid amount delivered to residents on fluid restrictions throughout the day and after meals, the nurse then enters the total amount at end of shift, and would expect the CNA's assigned to the hall to know who is on fluid restrictions. On 6/28/24 at 2:38 P.M., the Regional Clinical Nurse provided a policy titled Hemodialysis, dated 2023, that indicated The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to document assessment for symptoms of urinary tract infection for 1 of 1 residents reviewed for IV therapy. (Resident 302) Findings include: On 6/25/24 at 1:14 P.M., Resident 302's clinical record was reviewed. Resident 302 was admitted on [DATE]. Diagnoses included, but were not limited to, infection of joint prosthesis, anxiety, and hypertension. The Admission MDS (Minimum Data Set) Assessment, dated 6/17/24 was not completed. Current care plans included, but were not limited to: Observe for signs and symptoms of UTI (urinary tract infection). Date initiated: 6/11/24. A progress note dated 6/24/24 at 12:23 P.M., indicated Resident 302 complained of lower back pain, received pain medication that was ineffective, peri-area (was) red, blanchable but irritated, barrier cream applied, and (resident) having increased confusion and irritability. Triage (physician phone line) notified and requested urinalysis, awaiting response. The clinical record lacked follow-up of signs and symptoms of a possible urinary tract infection (UTI) or follow up of order request from 6/24/24 at 12:23 P.M. until 6/28/24 at 10:54 A.M. when a progress note was entered that indicated a new order from nurse practitioner for a UA C&S (urinalysis with culture and sensitivity). The record lacked a bowel assessment and need for the administration of Miralax. During an interview on 6/28/24 at 10:20 A.M., the Regional Clinical Nurse indicated the resident received an order for PRN (as needed) Miralax for the possible UTI symptoms. On 6/28/24 at 2:38 P.M., the Regional Clinical Nurse provided a policy titled Documentation in Medical Records, dated 2024, that indicated Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3.1-50(a)

Based on observation, record review, and interview, the facility failed to ensure a resident was on EBP (enhanced barrier precautions) for open wounds, PPE was worn during wound care for a resident who required EBP, and that wound dressings were changed as ordered for 1 of 2 residents observed for wound care and contact precautions . (Resident 352, Resident 45) Findings include: 1. During an observation of wound care on 6/27/24 at 10:37 A.M., RN 3 and LPN 2 entered Resident 352's room. LPN 2 closed Resident 352's door and pulled the privacy curtain. RN 3 and LPN 2 washed their hands and put gloves on. Resident 352 had two dressings on the middle and lower right abdomen dated 6/25/24 and initials (initials of nurse); RN 3 removed the dressings from Resident 352's abdomen. LPN 2 sat up supplies on the bedside table and dated the new dressings 6/27/24. RN 3 cleansed wounds on Resident 352's abdomen, washed her hands, then applied one dressing covering the open wound on the upper middle abdomen, one dressing covering the open wound on the lower middle abdomen, and two dressings covering the open wounds on the lower right abdomen. RN 3 gathered the trash and removed gloves. RN 3 and LPN 2 washed their hands and exited the room. There was not an EBP (enhanced barrier precaution) sign on Resident 352's door. During an interview on 6/27/24 at 10:40 A.M., LPN 2 indicated Resident 352's dressings covering open wounds were ordered to be changed daily. On 6/27/24 at 1:30 P.M., Resident 352's clinical record was reviewed. Resident 352 was admitted on [DATE]. Diagnoses included, but were not limited to, infection following a procedure surgical site, chronic obstructive pulmonary disease, and sepsis. An Admission MDS (Minimum Data Set) Assessment was not complete. Current physician orders included, but were not limited to: Cleanse 2 (two) open lesion on RLQ (right lower quadrant) of abdomen with wound cleanser, pat dry, cover with dry bordered dressing, every day shift for wound care. Start date 6/25/24. Cleanse open lesion to middle lower abdomen with wound cleanser, pat dry, cover with dry bordered dressing every day shift for wound care. Start date 6/24/24. Cleanse navel with wound cleanser, pat dry, apply foam bordered dressing, every day shift for wound care. Start date 6/24/24. Cleanse open lesion on RUQ (right upper quadrant) of abdomen with wound cleanser, pat dry, cover with dry bordered dressing, every day shift for wound care. Start date 6/24/24. Current care plans included, but were not limited to: Altered skin integrity non-pressure related to: 2 (two) JP (Jackson Pratt; a surgical suction drain) drainage to RUQ (right upper quadrant of abdomen) and RLQ (right lower quadrant of abdomen). Resident noted to have eschar (dead skin tissue) from a surgical incision in medial abdominal region. Resident noted to have a previously noted area from JP site removal. Date Initiated: 06/10/24. Enhanced Barrier Precautions when providing any JP drain care and any high contact Resident care activities, See sign on door. Date Initiated: 06/10/24. During an interview on 6/28/24 at 11:47 A.M., RN 12 indicated staff performing high contact activities should wear gown and gloves, and depending on what they are doing should wear masks and goggles if needed with risk of splashes; Resident's with open wounds should have EBP sign posted on their door. 46758 2. On 6/25/24 at 9:22 A.M., a Contact Precautions sign was observed on Resident 45's door. On 6/25/24 at 9:03 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety The most current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 45 was severely cognitively impaired. The resident need supervision for transfer with substantial help for mobility. Current physician orders included but not limited to: Apply skin prep to shingles on pelvic area and keep covered with dry dressing until crusted every day shift for shingles ordered on 6/19/24. Acyclovir HCl Oral Tablet 500 MG (Valacyclovir HCl) (medication for shingles), Give 2 tablets by mouth every 8 hours for Shingles for 7 Days ordered on 6/19/24. Contact Isolation due to shingles every shift ordered 6/18/24. The current care plan lacked a care plan for Contact Precautions. On 6/28/24 at 2:30 P.M., the Regional Nurse supplied a current, nondated policy Comprehensive Care Plans. The policy indicated . it was the policy of the facility of develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes .the objectives will be utilized to monitor the resident's progress. Alternative interventions will documented, as needed On 6/28/24 at 2:38 P.M., the Regional Nurse consultant provided a policy titled Wound Treatment Management, dated 2023, that indicated: Wound treatments will be provided in accordance with physician orders, including method, type of dressing, and frequency of dressing change. On 6/28/24 at 2:38 P.M., the Regional Nurse consultant provided a policy titled Enhanced Barrier Precautions, dated 2024, that indicated: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wound (e.g., (for example) .unhealed surgical wounds .). 3.1-18(b) 3.1-18(j)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19. Staff did not remove gloves after providing care, perform hand hygiene between glove changes, and failed to properly perform hand washing during 3 of 3 observations of care. (Resident C, Resident D, Resident F) Findings include: 1. During an observation on 9/21/23 at 11:30 A.M., LPN 4 used a glucometer to read Resident C's blood sugar level. LPN 4 applied gloves, pricked Resident C's finger, obtained the blood sugar level, then went to the medication cart to dispose of the Lancet and clean the glucometer. LPN 4 removed the gloves, disposed of them, and donned (put on) a new pair of gloves to clean the glucometer without perfoming hand hygiene in between glove changes. 2. During an observation on 9/22/23 at 9:40 A.M., CNA 5 was assisting Resident D to the restroom. CNA 5 donned gloves and assisted Resident D by pulling his pants and brief down and lowering him to the commode. After toileting, CNA 5 provided peri-care, then without changing gloves, assisted Resident D to wash his hands. CNA 5 then removed gloves and washed hands. CNA 5 scrubbed hands for 4 seconds before putting hands under the running water and continued to scrub and rinse for a total of 15 second handwashing time. CNA 5 used her bare hands to comb over the resident's hair with her fingers and then placed her hand on the resident's shoulder as they exited the restroom. CNA 5 pulled the trash bag from the restroom trash can, tied it, and with the trash bag in hand pushed Resident C in a wheelchair out into the hall. CNA 5 stopped at a hall utility room to drop the trash bag, then continued to a common area with Resident C. CNA 5 assisted Resident C back to a relciner in the common area, moved the wheelchair the resident's wheelchair and then left the common area. No hand hygeine was completed. 3. During an observation on 9/22/3 at 11:23 A.M., CNA 5 and CNA 7 were assisting Resident F to the restroom. CNA 5 removed the old brief and handed Resident F a call light prior to stepping out of the restroom to provide privacy. CNA 5 and CNA 7 removed their gloves and did not perform hand hygiene. When Resident F indicated she was ready, CNA 5 donned new gloves and provided peri-care. CNA 5 and CNA 7 assisted the resident back to her wheelchair, then without removing gloves, CNA 5 placed soap into her hand to assist Resident F in handwashing. CNA 5 removed gloves and placed new gloves on without performing hand hygiene. During an interview on 9/22/23 at 11:40 A.M., CNA 9 indicated that staff should change gloves after providing pericare and prior to perfomring a clean task and should perform hand hygeine between each glove change. CNA 9 indicated she sings happy birthday 3 times while washing hands and that staff should scrub hands with soap for 20 seconds prior to rinsing. On 9/22/23 at 12:25 P.M., the IP (Infection Preventionist) supplied a facility policy titled Hand Hygiene, dated 6/2023. The policy included, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Hand hygiene technique when using soap and water: a. Wet hands with water . b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. This Federal tag relates to complaint IN00417150. 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure MDS (minimum data set) Assessments were accurate for 2 of 5 residents reviewed for unnecessary medications and 2 of 2 residents reviewed for resident assessments. (Resident 54, Resident 74, Resident 67, Resident 100) Findings include: 1. On 9/13/22 at 1:20 P.M., Resident 54's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS Assessment, dated 8/3/22, indicated diuretic and opioid use for the previous 7 days. Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] tablet (a diuretic) 20MG (milligrams) by mouth one time a day every other day, started on 6/29/22. [MEDICATION(S)]-acetaminophen tablet (an opioid) 5-325MG 0.5 tablet by mouth every 6 hours as needed, started 7/7/22. Resident 54's MAR (Medication Administration Record) for July and August 2022 indicated resident received [MEDICATION(S)] on 7/29/22, 7/31/22, and 8/2/22. The resident also received [MEDICATION(S)]-acetaminophen on 8/1/22. During an interview on 9/13/22 at 2:39 P.M., MDS Coordinator 1 indicated there were no [MEDICATION(S)]-acetaminophen or [MEDICATION(S)] tablets and 4 (four) [MEDICATION(S)] tablets given in 7 day look back period. She further indicated that the MDS was incorrect. 2. On 9/13/22 at 1:30 P.M., Resident 100's clinical record was reviewed. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent annual MDS Assessment, dated 7/30/22, indicated insulin use for the previous 7 days. Resident 54's MAR for July 2022 indicated resident received [MEDICATION(S)] Solution Pen-injector 0.75 mg/0.5mL (milliliters) on 7/30/22. During an interview on 9/13/22 at 2:39 P.M., MDS Coordinator 1 indicated there was only 1 dose of [MEDICATION(S)] given because it is a weekly injection. She further indicated that the MDS was incorrect. 3. On 9/13/22 at 1:30 P.M., Resident 74's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS Assessment, dated 8/26/22, indicated anticoagulant use for the previous 7 days and opioid use 3 days. Resident 74's MAR for August 2022 indicated the resident did not take an anticoagulant. The resident did receive [MEDICATION(S)]-acetaminophen (an opioid) on 8/22/22. During an interview on 9/13/22 at 2:39 P.M., MDS Coordinator 1 indicated after reviewing the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 4. On 9/13/22 at 11:52 P.M., Resident 67's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS Assessment, dated 8/11/22, indicated antipsychotic use for the previous 7 days. Resident 67's MAR for August 2022 indicated the resident only received [MEDICATION(S)] Suspension Reconstitued ER 12.5mg (an antipsychotic) on 8/6/22. During an interview on 9/13/22 at 2:39 P.M., MDS Coordinator 1 indicated after reviewing the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/13/22 at 3:00 P.M., a current non-dated MDS policy was provided and indicated Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .accurate and standardized assessment of each resident's functional capacity, using the RAI [resident assessment instrument] specified by the state .persons completing part of the assessment must attest to the accuracy . 3.1-31(i)

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment was maintained in resident rooms and restrooms in 2 of 3 units. Resident room floors were not clean, restrooms trash was overflowing, resident personal hygiene items were not covered and labeled in shared restrooms, and a resident restroom sink had come apart from the countertop. (100 unit, 500 unit, Resident 12, 13, 18, 36, 42, 69, 79, 86, 88, 93, 95, 96, 97, 102, 179, Rooms 105, 107, 112, 113, 114, 115, 500, 502) Findings include: 1. During an interview on 9/12/22 at 10:00 A.M., Resident 96 indicated that their room was not cleaned routinely. During an observation on 9/12/22 at 10:02 A.M., Room 105 and room 107's, Resident 96, 95, 12, and 18's shared restroom trashcan was overflowing, and a surgical glove was laying on the floor. 2. During an observation in room 112 on 9/11/22 at 11:07 A.M., a white tablet was on the floor under a chair near the 2nd bed. During an observation in room 112 on, 9/12/22 at 8:25 A.M., a white tablet was on the floor under a chair near the 2nd bed. During an observation in room 112 on 9/12/22 at 11:56 A.M., the restroom (shared with room 114), (Resident 93, 69, 42, and 97) had a gap between the sink and countertop where the caulking appeared to be peeled apart leaving an open space. During an observation on 9/13/22 at 1:20 P.M., the restroom (shared with room 114) had a gap between the sink and countertop where the caulking appeared to be peeled apart leaving an open space. 3. During an observation in room 113 on 9/12/22 at 11:18 P.M., the restroom (shared with room 115), (Resident 86, 13, and 88) did not have a toilet paper roll holder. During an observation in room 113 on 9/13/22 at 1:15 P.M., the restroom (shared with room 115) had overflowing trash on the floor from a full trashcan and no toilet paper roll holder. 4. During an observation in room 500 on 09/11/22 10:30 A.M., a shared restroom for Resident's 102 and 36 had an uncovered bedpan laying on the floor and 2 toothbrushes laying next to the sink uncovered and unlabeled. During an observation on room 500 on 9/13/22 at 1:25 P.M., a shared restroom had 2 toothbrushes laying next to the sink uncovered and unlabeled. 5. During an observation in room 502 on 9/11/22 at 10:45 A.M., a shared restroom for Residents 179 and 39 had a toothbrush was sitting on the countertop unlabeled and uncovered in a shared restroom. During an observation in room 502 on 9/13/22 1:10 P.M. personal items including toothbrushes were uncovered and unlabeled in a shared restroom. 6. During a review of resident council minutes from March 2022 through August 2022, the following was included: July 6, 2022 - Resident council minutes - 4 of 15 residents attending the meeting had concerns with housekeeping not cleaning routinely. June 1, 2022 - Resident council minutes- An unspecified number of residents had concerns that rooms were not getting cleaned thoroughly. Mopping and sweeping was not being done daily. During an interview on 9/13/22 at 1:47 P.M. CNA (Certified Nurse Aide) 29 indicated the CNA's should cover resident personal hygiene items such as toothbrushes by putting them in a plastic bag and should label them with the resident name. During an interview on 9/14/22 at 10:32 A.M., the Housekeeping Supervisor indicated each resident room should be cleaned daily, including sweeping and mopping. On 9/13/22 at 2:00 P.M., Regional Nurse 3 supplied a facility policy titled, Routine Cleaning and Disinfection, dated 07/2019. The policy included, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment . 3.1-19(f) 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 3 residents observed for accidents. (Resident 69) Findings include: On 9/14/22 at 10:27 A.M., Resident 69 was observed sleeping in bed. On the bedside table, 1 medication cup was observed. In the medication cup, was 2 (two) white oblong pills, 1 (one) yellow capsule, and 1 (one) white, small, oblong pill. During an interview on 9/14/22 at 10:30 A.M., LPN (Licensed Practical Nurse) 7 indicated those were her morning pills. She indicated that when she passed medications that morning, the resident took 2 (two) pills and told her she would take the rest. The nurse left the remaining 4 (four) pills with the resident to take later. During an interview on 9/14/22 at 10:33 A.M., LPN 3 indicated that their policy was to watch the residents take all medications during medication pass and not leave them with the resident. During an interview on 09/14/22 at 11:28 A.M., the DON (Director of Nursing) indicated that Resident 69 did not have a self medication administration assessment because she was not one of their residents that self administers her medications. On 9/14/22 at 11:01 P.M., Resident 69's clinical record was reviewed. The most recent annual MDS (minimum data set) Assessment, dated 8/12/22, indicated Resident 69 was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 69's clinical record lacked a self administration of medications assessment. Resident 69's current orders lacked an order to self administer medications. Resident 69's clinical record lacked a care plan to self administer medications. On 9/14/22 at 12:40 A.M., a current non-dated Resident Self-Administration of Medication policy was provided and indicated A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice. Oxygen concentrator filters were not clean for 2 of 3 oxygen concentrators sampled for observation. (Resident 16, Resident 99) Findings include: 1. On 9/12/22 at 12:47 P.M., Resident 16 was observed sitting in her room with oxygen on via nasal cannula. At that time, the filter on the oxygen concentrator was observed with a layer of dust. On 9/13/22 at 2:38 P.M., the same was observed on Resident 16's oxygen concentrator. On 9/14/22 at 9:53 A.M., the same was observed on Resident 16's oxygen concentrator. At that time, the oxygen concentrator was observed with [company name] on the outside of the concentrator with the date 6/22/21. On 9/13/22 at 10:37 A.M., Resident 16's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS (minimum data set) Assessment, dated 7/3/22, indicated Resident 16 was cognitively intact, required extensive assistance of 1 (one) with bed mobility and transfers, and received oxygen while a resident. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] O2 (oxygen) at 3L (liters) as needed, started 9/12/22. A current alteration in respiratory status care plan included, but was not limited to, the following interventions: Administer oxygen as needed per physician order During an interview on 9/14/22 at 10:00 A.M., LPN (Licensed Practical Nurse) 3 indicated oxygen concentrators and filters were serviced by the oxygen company that came in weekly to fill the tanks. She indicated they had been in the facility a week prior looking at the concentrators. 2. On 9/11/22 at 10:18 A.M., Resident 99 was observed lying in bed with oxygen on via nasal cannula. At that time, the filter on the oxygen concentrator was observed with a layer of dust. On 9/13/22 at 2:26 P.M., the same was observed on Resident 99's oxygen concentrator. On 9/14/22 at 10:06 A.M., the same was observed on Resident 99's oxygen concentrator. At that time, the concentrator was observed with [company name] on the outside of it, and the date 9/9/21. On 9/13/22 at 10:22 A.M., Resident 99's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS Assessment, dated 8/31/22, indicated Resident 99 was cognitively intact, required extensive assistance of 2 (two) with bed mobility and transfers, and received oxygen while a resident. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] O2 3L via nasal cannula every shift, started 7/28/21. A current alteration in respiratory status care plan included, but was not limited to, the following interventions: Administer oxygen as needed per physician order, dated 9/12/22. During an interview on 9/14/22 at 10:10 A.M., RN (Registered Nurse) 9 indicated the oxygen company was in the facility weekly to service the oxygen concentrators. During an interview on 9/14/22 at 11:27 A.M., the DON (Director of Nursing) indicated the oxygen servicing company was responsible for cleaning the oxygen concentrator filters as needed, and that the nurses were also able to clean the filters. On 9/14/22 at 12:40 P.M., a current non-dated Oxygen Concentrator policy was provided and indicated Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device The policy lacked information related to oxygen concentrator filters. 3.1-47(a)(6)

Based on observations, record review and interview, the facility failed to adequately supervise and implement specific interventions for 3 of 3 residents who were reviewed for falls. Resident B had multiple falls, Resident C had multiple falls, resulting in a [CONDITION(S)] and hematoma, and Resident D had two falls, with one resulting in a laceration that required sutures. ( Resident B, Resident C, Resident D) Finding include: 1. During a review of Resident B's clinical record on [DATE] at 9:26 a.m., it indicated Resident B was moderately cognitively impaired. Resident B's diagnoses included, but were not limited to, heart failure, hypertension, diabetes, non- Alzheimer's dementia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), and respiratory disease. A Quarterly MDS (minimum data set) assessment, dated [DATE], indicated Resident B required extensive assistance of one assist with toileting, supervision of one assist for bed mobility, transfers, hygiene, and total dependence with bathing. Resident B had 2 or more falls since her admitted . Resident B discharged to the hospital on [DATE], and expired at (local hospice center) on [DATE] at 1:45 p.m. A review of Resident B's care plans indicated, At risk for falls related to diabetes, hypertension, [CONDITION(S)], [CONDITION(S)], polyneuropathy, restless leg syndrome, [CONDITION(S)], unspecified spondylopathy sacral/sacrococcygeal region, history of falls, use of medications. Interventions included, but were not limited to, assess for pain, assess that wheelchair is of appropriate size, call light or personal items available and in easy reach or provide reacher, footwear to prevent slipping, anti-skid strips in front of toilet in bathroom, Dycem in recliner sheet, encourage resident to call for assistance to restroom, gripper socks, house shoes stored in closet, keep environment well-lit and free of clutter, orientation to new room and roommate. Start date [DATE], last revised [DATE]. At risk for falls related to diabetes, hypertension, [CONDITION(S)], [CONDITION(S)], polyneuropathy, restless leg syndrome, [CONDITION(S)], unspecified [CONDITION(S)] spondylopathy sacral/sacrococcygeal region, dorsalgia, PVD (peripheral vascular disease), impaired cognition, poor safety awareness, history of falls, use of medication. Interventions included scoop mattress. Start date [DATE], with no revisions noted. Physical functioning deficit related to mobility impairment, self-care impairment, polyneuropathy, [CONDITION(S)], restless leg syndrome, [CONDITION(S)] with shortness of breath, [CONDITION(S)], hypertension, diabetes, unspecified [CONDITION(S)] spondylopathy sacral/sacrococcygeal region, pain to left hip, and chronic respiratory failure with [CONDITION(S)]. Interventions included, but were not limited to, assist with self-care, assistive devices: walker, wheelchair, bed mobility assistance of supervision staff support of one, call bell within reach, dressing assistance of supervision of one, eating supervision with set up, encourage choices with care, inform resident of risks of refusal of care, may sleep in recliner, mobility chair/bed to chair transfer assistance of supervision or touching, mobility sit to lying and lying to sitting assist of supervision/touching, mobility sit to stand assistance of supervision/touching, mobility with walking assistance of supervision/touching, monitor and report changes in physical functioning ability, personal hygiene assistance of supervision, praise efforts of participation, rehab therapy services as ordered, toileting assistance of extensive with staff support of one, toileting hygiene assist of partial/moderate assistance. Start date [DATE], last revised [DATE]. Impaired cognition status related to dementia other than Alzheimer's disease, BIMS (brief interview for mental status) a 12 (moderately impaired cognition), intermittent confusion that waxes/wanes, impaired safety awareness. Interventions included, but were not limited to, assist in ADLs (activities of daily living) as needed, explain all procedures and reason before performing, medication as ordered, monitor cognitive status, bladder dysfunction, visual disturbance, mental status, and muscular movement for possible sign of disease process-report new occurrences to physician, monitor for pain or increased stiffness, monitor for changes in condition, pleasant interaction with reassures when confused, reality orientation while giving care, rehab as ordered. Start date [DATE], revised [DATE]. During a review of a State Reportable, dated [DATE], indicated Resident B had rolled out of bed and landed on her left side on the floor on [DATE]. Type of injury: 3 cm (centimeter) bruise noted around her left eye after the fall and since expanded to include her nose/face and other eye. Added [DATE]: A CT of her head revealed a subdural hematoma. Immediate action taken: [DATE] Neurological exam was completed at time of fall and was within normal limits. No changes or loss in consciousness. Ice was applied to left eye area. A scoop mattress was placed to assist the resident in identifying bed boundaries. Resident B was seen by the Nurse Practitioner (NP) on [DATE] with no new orders. The physician and resident representative was notified at time of fall. Preventative action taken: [DATE] A scoop mattress was placed to assist the resident in identifying bed boundaries. Care plan was reviewed and updated. Resident continued to participate in therapy. Follow up: [DATE] Resident had rolled out of bed landing on her left side on the floor on [DATE]. A scoop mattress was placed to assist the resident in identifying bed boundaries. No further falls have occurred. Bruising was noted around her left eye after the fall and has since expanded to include her nose/face and other eye. Resident voiced to son that she was reaching for something, did not use her call light, and fell out of bed. She was up daily and participating in therapy. Resident was seen by the NP on [DATE] with no new orders. Resident had a history of mental illness, confusion, hallucinations and altered mental status. Resident was sent to the emergency room for evaluation of ecchymosis/altered mental status on [DATE]. She was admitted to the hospital for continued monitoring. Care plans were reviewed and updated. A review of Resident B's assessment indicated the following, [DATE] Fall risk evaluation Score: 15 at risk [DATE] Post fall evaluation Time of fall: [DATE] 11:25 p.m.- witnessed, toileting with assistance Non-skid shoes/socks, utilizing walker/cane as instructed Legs gave out No medication changes No physical findings [DATE] Post fall assessment Time of fall: [DATE] 1:40 p.m., unwitnessed Res was found sitting on floor in bathroom in front of toilet, indicated was putting on slipper in bathroom standing up, and slipped and fell . Resident was barefoot No call light was activated No injuries noted at time of fall. Notes: Resident ambulates alone and was in bathroom attempting to put slippers on and lost balance and fell , morbidly obese. [DATE] Post fall assessment Time of fall: [DATE] 5:30 p.m., unwitnessed Resident was found on the floor in resident's room. Resident was sitting in bed-side recliner chair on the edge and slipped out and onto the floor. Resident was noted to have improper footwear. No injuries noted at time of fall. Gripper socks were applied. [DATE] Post fall assessment Time of fall: [DATE] 3:00 a.m., unwitnessed In room, sleeping Resident had on non-skid shoes/socks at time of fall Call light was not activated No medication changes No physical changes noted Vital signs WNL (within normal limits), no complaints of pain Environmental factors did not contribute to fall, resident had history of falls No skin issues noted Conclusion: rolled out of bed, scoop mattress in place, resident will also occasionally sleep in her recliner [DATE] Fall risk evaluation Score: 15 at risk Resident B's progress notes indicated, but were not limited to, [DATE] 11:21 p.m.- Late entry [DATE] 11:25 p.m.- Fall was witnessed. Fall occurred in the bathroom. Activity at time of fall: toileting with assistance. Reason for fall was evident. No injury occurred. Contributing factors: legs gave out. Resident was using cane/walker as instructed. Resident morbidly obese with increase in behaviors, history of mental illness, and history of previous falls. [DATE] at 11:25 p.m.- Change of condition. Situation: Fall Diagnoses: Diabetes Mellitus II, history of falls, poor safety awareness, periods of confusion, and gait imbalance. Assessment: Resident found sitting on the bathroom floor facing east beside the toilet with legs in front of her. Gripper socks and gait belt on resident. Resident and staff reported resident's legs gave out when she stood up to transfer to the toilet. Resident was lowered to the floor. Vital signs: BP:,d+[DATE], Temp: 98.2, P78, R18, O2 sat 97% on 3LPM via nasal cannula. ROM (range of motion) WNL (within normal limits). Able to move all extremities without difficulty. No complaints of pain or discomfort voiced at this time. Full body skin assessment completed with no skin concerns observed. Response: Physician updated. No new orders received at this time. Resident and resident representative updated. Will continue to monitor. [DATE] 1:07 p.m.- No complaints of pain or discomfort voiced due to recent fall. ROM WNL. Vital signs WNL. [DATE] 1:50 p.m.- No complaints of pain or discomfort voiced due to recent fall. ROM WNL. Vital signs WNL. [DATE] 1:40 p.m.- Change of Condition. Situation: Called to resident room and resident sitting on floor in bathroom in front of toilet. Resident stated she was putting on slipper in bathroom standing up and slipped and fell . Resident was barefoot. Background: [CONDITION(S)], [CONDITION(S)], hypertension, paranoid [CONDITION(S)], repeated falls. Assessment: Full body assessment completed with no areas noted. Denies pain or discomfort. Vital signs: Temp: 97.5 BP ,d+[DATE] P87 R18, SP02 AT 92% ON 2LPM via nasal cannula. Neuro checks started and WNL. Skin warm/dry to touch. Intervention: Resident to wear gripper socks at all times in room. Response: Physician and son notified. [DATE] 2:19 p.m.- Triage called and said to continue to monitor resident due to fall and report any changes. [DATE] 6:52 p.m.-Follow up to recent fall, very confused this night. Vital signs: Temp: 97.6, P80, R18, BP:,d+[DATE], O2 sat. 97%. [DATE] 10:26 a.m.- Resident on follow up for fall with neuro checks. No injuries. Neuros WNL. Vital signs: Temp: 97.3, BP: ,d+[DATE], P62, R18, SP02 AT 92% ON 3LPM via nasal cannula. Non- skid socks are on. [DATE] 5:30 a.m.- Change of condition. Situation: unassisted fall from bed-side chair. Nurse aide passed by room and saw resident on the floor. Background: fall history, dementia, decreased safety awareness. Assessment: Temp 98.4, P76 , R18, BP ,d+[DATE], and O2 sat. 96% on 3LPM via nasal cannula, neuro checks initiated, denied pain. Assist of 2 staff to return to chair. Response: Physician and family notified. [DATE] 5:31 a.m.- Resident stated she fell earlier due to sitting to close to edge of recliner chair and slid off, gripper socks were applied [DATE] 1:44 p.m.- Vital signs BP ,d+[DATE], Temp 97.0, R18, P86 and 96% ( not noted as on room air or on oxygen). No complaints of pain or discomfort due to recent fall. No signs or symptoms of acute distress observed at this time. Alert, oriented to self with periods of confusion. Call light in reach. Able to make needs known. No change in ROM. Mood pleasant. Cooperative with staff. [DATE] 7:16 a.m.- Follow up to recent fall. Resident stated she hurt all over. Temp 97.6, P72, R18, BP ,d+[DATE], and O2 sat. 97% (not noted as on room air or on oxygen). [DATE] 1:39 p.m.- Skin only evaluation. Skin warm and dry, skin color WNL, mucous membranes moist, turgor normal. Current skin issues: Skin Issue: Bruising. Skin Issue Location: back Length: scattered Width (cm): scattered Skin Issue: Bruising. Skin Issue Location: right buttock Length: scattered Width: scattered Skin Issue: Bruising. Skin Issue Location: LUE Length: scattered Width: scattered Skin Issue: Bruising. Skin Issue Location: RLE Length: scattered Width: scattered Skin Issue: Bruising. Skin Issue Location: LLE Length: scattered Width: scattered Full body post fall skin assessment completed. Scattered bruising observed to the LUE (left upper extremity), back, right buttock and BLE (bilateral lower extremity). Bruising presents with multiple stages of discoloration observed to intact skin. Physician updated. No new orders received. Resident and resident representative updated. Will continue to monitor. [DATE] 6:20 a.m. Legs very swollen. Alert with confusion. [DATE] 10:10 a.m.- Fall follow up with neuros. Neuros within normal limits. BP ,d+[DATE], Temp 98.4, P70, R18, SP02 AT 96% ON 3LPM via nasal cannula. No injuries noted. Transferring well. [DATE] 3:00 a.m.- Change of condition. Situation: Notified via call light per resident roommate. Tech entered and noted resident on floor next to the bed. Background: Resident has a history of falls. Resident has decreased safety awareness. Assessment: BP ,d+[DATE] T 97.4 P 56 R 24 O2 sat 85% Patient cannula out of nose at time of incident. Resident was lying on left side on floor with head toward head of bed and feet toward doorway. Head to toe skin assessment. No skin tears observed. 3 cm hematoma above left eye in eyebrow area. ROM of upper & lower extremities. No outward rotation of lower extremities. Neuro checks initiated. Resident alert with periods of confusion. Not following nurse instructions after advised to leave nasal cannula in place & to leave ice pack on affected area. Patient remained in bed. Previously patient was able to ambulate to bathroom with assist of 2 prior to incident. Response: Physician notified. Son notified .No new orders received. Indicated to follow facility Neuro check policy and to return call with any changes. Bed was already against wall. Call light within patient reach. [DATE] 10:00 a.m.- Post fall evaluation. Time of fall [DATE] 3:00 a.m. Unwitnessed. Fall occurred in resident room. Resident was sleeping at time of all. No physical findings noted. Vital signs WNL. Resident denied pain. Skin color WNL. Resident had history of falls in facility. Conclusion note: Rolled out of bed, scoop mattress placed, resident will also occasionally sleep in her recliner. [DATE] 10:43 a.m.- Resident follow up fall with neuro checks. Neuros WNL. ROM WNL. Vital signs: Temp 97.3 BP ,d+[DATE] P70 R18 SP02 AT 94% ON 2LPM via nasal cannula. Resident resting in bed. Refused ice for left eye. Eye is swollen and purple. [DATE] 9:02 a.m.- Full body post fall skin assessment completed. Hematoma to the left forehead. No longer presents raised. Area extends from the left forehead through the left eye to the bridge of the nose and down to the upper left cheek bone. Skin remains intact with a dark purple discoloration observed to intact skin. No other skin concerns observed at this time. Physician updated. [DATE] 12:19 a.m.- Fall follow up with neuro checks. Neuro checks WNL. No change in ROM. Resident alert, oriented to self with periods of confusion. Bruising continues to Left side of face. Denies pain or discomfort. Mood pleasant. Tolerating oral fluids and medications well. No signs or symptoms of acute distress observed. BP ,d+[DATE], Pulse 60, Resp 20, Temp 97.5, O2 Sat 94% on 3 liters O2 via nasal cannula. [DATE] 9:58 p.m.- Fall follow up. Neuro checks WNL. No complaints voiced. Bruising remains on left side of face. Bed against wall with mattress at bedside. [DATE] 3:38 a.m.- BP ,d+[DATE], P60, T98.1, R20, O2sat 94% on 3L. Resident rested quietly in bed with no complaints this shift. Remains on follow up fall monitoring, neuro checks WNL. Dark purple bruising remains to left side of face, no other injuries observed upon assessment. [DATE] 10:22 a.m.- Fall follow up. Vital signs Temp 97.3 BP ,d+[DATE] P60 R 18 SP02 AT 92% ON 3LPM via nasal cannula. Neuro checks WNL. Resident's left eye purple and swollen. Denied pain or discomfort. No attempts to transfer per self. [DATE] 6:14 p.m.- Resident continues fall monitoring, neuro checks WNL. Dark purple bruising remains to left side of face, no complaints of pain or discomfort voiced. [DATE] at 11:06 a.m.- Nurse Practitioner here to see Resident. Orders reviewed. No new orders received. [DATE] at 12:31 a.m.- Hematoma to the face deteriorated and presents more spread out. Purple discoloration now extends from the left forehead down and around both eyes and the nose, then down the left cheek to the upper portion of the neck. Skin remains intact. Physician updated. No new orders received. [DATE] at 10:30 p.m.- Resident's family called and requested for resident to be sent to [local hospital emergency room ] for evaluation. Triage notified, orders received to send resident to emergency room . Resident and family notified. [DATE] 11:00 p.m.- Ambulance service called to transfer resident. [DATE] 11:20 p.m.- Ambulance service arrived and left with resident. Family notified resident left per their request. [DATE] 10:36 a.m.- Resident was admitted to the hospital on [DATE] [DATE] 10:00 a.m.- Son here this morning and notified facility that resident was admitted to [local hospice center]. He picked up all belongings. A review of Resident B's hospital records on [DATE] at 1:15 p.m. indicated, but were not limited to, Resident B was admitted to the hospital through the emergency roiagnom on [DATE]. She presented to the emergency room with a change in mental status and bruising on the left side of her face. [DATE] CT Maxillofacial without contrast Findings: Mandible is intact. Maxilla is intact. Zygomatic arches are intact. Pterygoid plates are intact. Orbits are intact. Nasal bone is intact. Paranasal sinuses are intact. - Impression - Normal CT of the face with no acute facial bone fracture [DATE] CT Head without contrast Findings: An acute, subdural hematoma is present at the right frontotemporal skull, 8 mm (millimeters) in axial dimension. There is midline shift of 13 mm. Partial effacement of the lateral ventricles is seen. There is complete effacement of the temporal horn of the right lateral ventricle. There is sulcal effacement of the right frontoparietal and temporal regions. Visualized portions of the paranasal sinuses and mastoid air cells are clear. Impression: Acute right subdural hematoma with mass effect. Plan: admit to trauma platelets ordered for correction repeat labs after transfusion neurosurgery consult [MEDICATION(S)] NPO (nothing by mouth) and will likely need speech evaluation patient already a DNR gentle IV fluid hydration bedrest Admit to observation with the potential to be moved to inpatient status if the patient's condition requires it. A surgical discharge note, dated [DATE] indicated, but was not limited to, .Patient admitted to trauma services after a fall at the nursing home. She was found to have the below listed injuries. On arrival, she was significantly [CONDITION(S)] thus hematology was consulted. Neurosurgery followed for her head injury and due to her [CONDITION(S)], she was unable to undergo surgical intervention immediately. She was treated empirically as ITP (immune [CONDITION(S)] purpura) with [MEDICATION(S)] (steroid) and IVIG (intravenous immune [MEDICATION(S)]) She was noted to have an elevated D. Dimer, but was unable to undergo CTA( CT [MEDICATION(S)]) due to agitation nor could she tolerate. Anticoagulant and antiplatelet treatment due to her head injury. US DVT negative. She progressively worsened with increase O2 demands. She was diuresed but still had an increase in O2 demands despite intervention .She was on and off Cardene for blood pressure control. ST (speech therapy) eval (evaluation) and cleared for dysphagia 2 diet, despite her oral intake being extremely poor. She progressively declined despite improvement of [CONDITION(S)]. She remained confused, thus family was present for decision making. Palliative care was consulted and family opted to follow through with comfort measures. She was transitioned to [local hospice center] with comfort measures per palliative recommendations. Final diagnoses: subdural hematoma, [CONDITION(S)], [CONDITION(S)], history of [CONDITION(S)]. Discharge condition: comfort measures. Disposition: discharged to hospice. Resident B was transferred to hospice services on [DATE] where she expired on [DATE]. On [DATE] at 11:04 p.m., the Director of Nursing provided the following information related to new interventions: [DATE]- removed house slippers, changed to gripper socks [DATE]- Dycem placed in recliner, labs drawn ,d+[DATE] and ,d+[DATE], ,d+[DATE] medication change [DATE]- scoop mattress 2. During the initial tour on [DATE] at 9:10 a.m., Resident C was observed on the memory care unit. Resident C was observed in the common area in her wheelchair, near LPN 1. During an observation on [DATE] at 1:53 a.m., Resident C's room was noted to be uncluttered with the bed against the wall. Resident C was observed on the memory care unit in the common area, sitting in her wheelchair next to LPN 1. Resident C indicated she and LPN 1, are buddies. LPN 1 indicated she is kept nearby for increased supervision. During an observation on [DATE] at 9:12 a.m., Resident C's room was noted to be uncluttered with the bed against the wall. Resident C's shoes were on the floor. Resident C was observed on the memory care unit in the common area coming out of the bathroom with a CNA. During an interview with LPN 1 on [DATE] at 9:15 a.m., she indicated Resident C transferred with a walker and an assist of 1. She must be supervised in the bathroom at all times. Resident C does become more anxious in the afternoons due to Sundowner's, but is usually okay during the day. She is weight bearing at this time. During a review of Resident C's clinical record on [DATE] at 10:47 a.m., indicated, but was not limited to, Resident C was moderately cognitively impaired. Resident C's diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)], hypertension, non- Alzheimer's dementia, repeated falls. Resident C's Significant Change MDS, dated [DATE], indicated Resident C required extensive assist of 2 with ADLs and total dependence for bathing. It indicated she had had 1 fall with major injury since admission and had recent surgery to repair a fracture. Resident C's care plans included, but were not limited to, At risk for falls related to history of falls, new environment, use of medications, hypertension, poly [CONDITION(S)], dementia, fracture of left hip, repeated falls. Interventions included, but were not limited to, assess for pain, call light or personal items in easy reach or provide reacher, chair alarm, footwear to prevent slipping, keep environment lit and free of clutter, motion detector alarm at bedside, resident will request privacy with toileting, however staff needs to provide direct supervision, rubber sole shoes, and tabs pull alarm in wheelchair. Start date [DATE], revised [DATE]. Impaired cognition status related to dementia other than Alzheimer's disease, BIMS of 9. Interventions included, but were not limited to, explain all procedures and reason before performing, lab work as ordered, medication as ordered, monitor cognitive status, bladder dysfunction, visual disturbance, mental status, and muscular movement, reality orientation with care, rehab as ordered, and verbal reminders which assist patient in orientation. Start date [DATE], revised [DATE]. Physical functioning deficit related to mobility impairment, self-care impairment, left [CONDITION(S)]. Interventions included, but were not limited to, assist with self-care, assistive devices wheelchair and walker, bed mobility assistance of ,d+[DATE], call bell within reach, dressing assistance, encourage choices with care, inspect skin with care, locomotion assistance of extensive, monitor and report changes in physical functioning, monitor and report changes in ROM. Start date [DATE], no revisions noted. During a review of a State Reportable, dated [DATE], it indicated staff entered the resident's room finding the resident lying on her back beside the a/c unit. Resident was unsure what she was getting up to do. Type of injury added [DATE]: Resident complains of left hip pain. Noted left foot external rotation and shortening. Immediate action taken: Resident left in place. ROM upper extremities WNL. Able to move right leg. Unable to move left leg. No bleeding noted. Unable to roll resident to observe back or hop due to complaints of pain. No new skin areas noted. Resident alert, confused. Speech clear and responding appropriately. Skin pale, warm, and dry. No respiratory distress. Neuro checks completed. Physician and family notified. New orders obtained to send to [local emergency room ]. Did not move until emergency services transferred to cart for transfer to hospital. Preventative measure: Resident sent to emergency room for evaluation. Follow up [DATE]: Investigation complete. As staff entered the resident room she was observed lying on her back beside the a/c unit. Resident has dementia and poor safety awareness. Resident able to ambulate ad lib about the Alzheimer's unit with steady gait. Floor was dry and clear of obstacles. Shoes were on. Resident could not recall what she was getting up to do. Resident complained of left hip pain, and upon assessment, staff noted left foot external rotation and shortening. Resident verbalized pain in left hip. Neuro checks completed. Physician and family notified. New orders obtained to transfer to [local emergency room ]. Resident admitted to hospital for left hip hemi arthroplasty. Care plan reviewed and revised upon return to facility. [DATE] Fall risk assessment Admission Score: 6 no risk noted. [DATE] Fall noted in clinical record. No fall risk assessment or post fall evaluation. [DATE] Fall risk assessment Score: 2, no risk noted. [DATE] Post fall assessment Time of fall: [DATE] 5:55 p.m., Occurred in resident room. Unwitnessed. Contributing factors: dementia No change in medications. No recent physical changes. Vital signs WNL. Pain noted to left hip. Constant. No interventions noted for pain. No skin issues. Conclusion: will assess upon return from emergency room [DATE] Fall risk assessment Score: 10 at risk [DATE] Post fall assessment Time of fall: [DATE] at 11:00 a.m. Unwitnessed. Sitting on toilet in bathroom Injury: 3 cm laceration on top of head leaned too far forward and fell off the floor Resident had on shoes No assistive devices noted in use at time of fall. Call light not activated. Contributing factor: leaned too far on toilet, resident requested privacy and CNA stood at doorway with door cracked No medication changes. Change in behaviors. Active infection. More anxious, possible [CONDITION(S)]. No pain noted. Vital signs WNL. History of falls at home and in facility. Conclusion note: Resident leaned too far forward on toilet and fell forward. Resident B's progress notes included, but were not limited to, [DATE] 1:59 a.m.- Change in condition. Situation: Resident noted sitting on floor in bedroom; struck back of her head; has small to moderate amount bleeding and hematoma. Background: Resident stated she had gotten up to adjust controls on the a/c unit, but my leg gave out. History of dementia. Assessment: BP ,d+[DATE], Temp 98.4, P75, R 16, O2 sat 98% on room air; PERRLA( pupil qualities), grasp and strength equal bilaterally; test for ROM performed; complaints of pain in both arms, but especially right upper arm. Response: Notified physician and obtained new order for X-ay of right arm in morning, monitor for changes in condition, cold compress applied to area on posterior head. [DATE] 11:41 a.m.- Mobile X-ray here to get X-ray of right shoulder and arm. [DATE] 12:44 p.m.- Received report from X-ray. All negative for fracture or dislocation. Resident representative notified. [DATE] 8:42 p.m.- X-ray results received from triage, no new orders. [DATE] 10:59 a.m.- Hematoma to the top of the left scalp improved as evidenced by (aeb) a 60% decrease in surface area. Hematoma continues to present with a purple discoloration observed to intact skin. Skin tear to the right elbow improved aeb an 88% decrease in surface area. Area now presents as pink, intact scar tissue with no drainage or signs of infection present. Bruising to the left hip improved aeb a 22% decrease in surface area. Bruising continues to fade with a green and yellow discoloration observed to intact skin. Skin tear to the right knee improved aeb a 97% decrease in surface area within the wound bed. Wound bed now presents as intact pink scar tissue with no drainage or s/s of infection present. Physician, resident, and resident representative updated. [DATE] 3:55 p.m.- Change of Condition. Situation: Observed resident lying on the floor in her room on her back beside the a/c unit. Background: History of Falls, Dementia, Decreased safety awareness. Assessment: BP ,d+[DATE] T98.7 P92 R18 02 sat 94% on room air. Resident lying on her back beside the a/c unit in her room. Resident was unsure of what she was getting up to do. Resident complained of left hip pain, Noted left foot external rotation and shortening. Resident complained of severe pain in left hip. Resident left in place. ROM upper extremity normal. Able to move right leg. Unable to move left leg. No bleeding noted. Unable to roll resident to observe back or hip due to complaints of pain and symptoms. No new skin areas noted. Resident alert, confused. Speech clear and responding appropriately. Skin pale, warm and dry. No respiratory distress. Response: Physician and family notified. New orders obtained to transfer resident to [local emergency room ]. Neuro checks completed. Did not move resident until emergency service transferred resident to cart for transfer to the hospital. [DATE] 6:05 p.m.- Fall reported to triage with symptoms and resident complained of left hip pain. Orders received to send to emergency room . [DATE] 6:18 p.m.- Call placed to 911 to transfer resident to emergency room . [DATE] 6:40 p.m.-Resident transferred per cart with ambulance service. Resident alert, continued to complain of left hip pain. [DATE] 9:00 a.m.- Post fall evaluation. Time of fall [DATE] 5:55 p.m. Fall was not witnessed. Fall occurred in the resident's room. Vital signs WNL. Resident complains of generalized pain. Pain Description: Left hip. Reports that pain is constant. Skin color is WNL. Mucous membranes moist. Skin Note: no skin issues. Conclusion Note: will assess upon return from emergency room . [DATE] 9:34 p.m.- Spoke to charge nurse at hospital, resident to have left hip Hemi arthroplasty, due to [CONDITION(S)] at 8:00 a.m. in the morning. [DATE] 5:45 p.m.- Resident returned from hospital per stretcher. Alert with confusion. Speech clear and responding appropriately. BP ,d+[DATE] T97.6 P102 R16 02 sat 96% on room air. Transferred to bed with assist of 4. [MEDICATION(S)] dressing dry and intact on left hip, are to leave in place until visit with physician on ,d+[DATE]. Noted dressing on left elbow. Bruising noted on left shoulder as per report. Neuros and VS WNL. Bowel sounds present in all 4 quads. Lungs clear to auscultation. No SOB or dyspnea. Skin pale, warm and dry. To have CBC with auto diff in morning. Incontinence pad dry at this time. No cough or SOB. Pedal pulses palpated in bilateral feet. Abdomen soft and tender. Able to make needs known. [DATE] 7:00 p.m.- Resident continues to be anxious and needing constant attention and supervision from staff. Resident called [TRUNCATED]

Based on observation, interview, and record review, the facility failed to thoroughly assess the nutritional preferences, implement interventions and provide selected menu items to prevent weight loss for 1 of 4 residents reviewed for weight loss in a sample of 5. (Resident I) Findings include: A Resident Census provided by the HFA (Health Facilities Administrator) on 08/14/13 at 11:15 a.m. indicated Resident I was interviewable. During an observation on 08/15/13 at 8:05 a.m. Resident I was observed to be sitting in her room in a wheelchair with a food tray on a table in front of her. During an interview at that time, Resident I indicated she was not going to eat anymore of the food on the tray and stated, "No wonder I lost 10 pounds, I told them I don't like eggs, but they keep sending them...I don't order cream of wheat or milk, they just send it to me." The breakfast tray was observed at that time, to include, but was not limited to, scrambled eggs, cream of wheat cereal, and milk. The clinical record of Resident I was reviewed on 08/15/13 at 9:30 a.m. The clinical record indicated Resident I was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Admission MDS (Minimum Data Set Assessment) dated 07/24/13 indicated Resident I experienced moderate cognitive impairment, was able to express wants, and experienced no concerns with nutrition. A Psychosocial Assessment/Progress note dated 07/31/13 indicated, "Is able to make accurate statements regarding...condition and circumstances..." The Admission Physician order [REDACTED]. The Admission Nursing assessment dated [DATE] indicated Resident I weighed 117 pounds. The weight was identified as within her ideal body weight status. The Weight Summary Record dated 07/30/13 indicated Resident I weighed 108 pounds. (9.23% weight loss in 13 days.) A Care Plan for Nutrition dated 07/24/13 indicated, "...Potential for weight loss r/t (related to) inadequate oral food/beverage intake..." with interventions which included, but were not limited to, "...diet as ordered... obtain and update food/beverage preferences...whole milk with meals..." A Nursing note dated 07/30/13 at 8:37 a.m. indicated, "Pt. (Patient) current wt (weight) is 108 which is down 9 (nine) pounds in one week. Average meal consumption is 29% ...currently receiving...whole milk with meals..." A Care Conference note dated 08/01/13 indicated, "...Dietary: Appetite poor 28%, cont (continue) to have weight loss..." An undated Food Preference Form provided by the DM (Dietary Manager) indicated, "...offer select menus...". The form lacked any documentation related to Resident I's dislike of eggs, cream of wheat, or milk. A Dietary progress note dated 08/02/13 at 16:07 (4:07 p.m.) indicated, "...Select menus were provided to the family to fill out..." A Dietary progress note dated 08/07/13 at 10:23 a.m. indicated, "Weight variance meeting...receives...whole milk with meals..." On 08/15/13 at 10:44 a.m., the DM provided a copy of the completed selective breakfast menu for 08/15/13 for Resident I. The menu indicated eggs, cream of wheat, and milk had not been selected. During an interview on 08/15/13 at 10:10 a.m., a family member indicated they had assisted Resident I with the Selective menu choice for the breakfast meal on 08/25/13 and had not selected eggs, cream of wheat, or milk because Resident I had never liked any of them and would not eat the items. The family member further indicated, at that time, Resident I frequently did not receive the meals as they had been selected. The policy and procedure for Selective Menu provided by the HFA on 08/15/13 at 3:50 p.m. indicated "...2. Patients receive the next week's menus on Monday...Completed menus are picked up by and assigned Dining Services employee on Wed (Wednesday)-Thur (Thursday)-Fri (Friday) Dining Services and nursing..." During an interview on 08/15/13 at 10:45 a.m., the HFA indicated Resident I should have received the selected menu options for breakfast on 08/15/13, but did not, because the chosen selective menu options had not been entered into the system. This Federal tag relates to Complaint IN 977. 3.1-46(a)(1)