Every finding on record at Brownsburg Meadows

Based on observation, interview, and record review, the facility failed to honor a resident's right to dignity when she was kissed by a facility bus driver for 1 of 3 residents reviewed for resident abuse (Resident B). Findings include:A facility reported incident (FRI), dated 2/24/26 at 4:01 p.m., indicated Resident B reported a bus driver placed an unwanted kiss her on the forehead during transport. Bus Driver 5 was suspended pending investigation then later brought back with education. The resident care plan and profile were reviewed and updated, and the resident would be transported by third-party vendor to future appointments. Resident B's clinical record was reviewed on 4/15/26 at 11:32 a.m. Resident B was admitted on [DATE] with diagnoses that included spinal stenosis with fusion of the lumbosacral spine and admission for orthopedic aftercare. An admission Minimum Data Set (MDS) assessment, completed on 2/3/26, assessed Resident B as being cognitively intact with no documentation of behaviors or rejection of care. The resident required partial/moderate assistance with transfers to and from a wheelchair (WC), and ambulation of short distances. The resident utilized a manual WC for mobility. A late entry nursing progress note, effective date 2/23/26 at 2:40 p.m., created on 2/25/26 at 2:41 p.m., indicated Resident B continued to be seen by the wound care center in a nearby town. An Event (incident) tab in the electronic medical record, dated 2/24/26 at 4:58 p.m., indicated monitor for psychosocial distress related to any complaints while on appointment transfer. A progress note by the Social Service Director (SSD), dated 2/26/26 at 8:58 a.m., indicated she had gone to speak with Resident B for psychosocial follow-up. The resident stated that she did not want to talk to her and was only comfortable talking to the Executive Director (ED). A progress note by the former ED, dated 2/26/26 at 1:02 p.m., indicated he had met with Resident B. The resident and ED discussed forms the resident refused to sign for the Social Security Director (SSD), and the resident report of having upcoming appointments the following Monday. The resident's progress notes lacked documentation the SSD had followed the resident for psychosocial distress more than 1 day following the incident on 2/24/26. The Director of Nursing Services (DNS) indicated Resident B had not wanted to speak with the SSD, and the hot charting event meant nursing staff had been prompted and would have documented psychosocial distress if any had been observed. The resident record lacked documentation Resident B's care plan or profile had been updated to reflect that the resident was upset with Bus Driver 5 or that she would be transported by third-party vendor to future appointments. During an interview on 4/5/26 at 12:20 p.m., Resident B indicated that on 2/23/26 she had been taken to and picked up from an outside appointment on the facility bus. While she was being strapped onto the bus for transport back to the facility she had been upset at having to wait for the bus. Bus Driver 5 was talking to her, moving his feet like he was dancing, singing a silly song about getting a kiss to make it better, and while he stood in front he leaned forward and kissed her on the forehead. Resident B indicated she had not asked to be kissed, he did not apologize for it, and she was upset about the situation. There had been a female bus driver standing beside the resident at the time and she said nothing to Bus Driver 5 which the resident found weird. Resident B indicated she felt the male bus driver's actions were offensive and the situation had been uncalled for. Resident B indicated she had reported the indicated, and it took 2 days for the Executive Director (ED) to get back with her. A Concern/Grievance Form filed by the former ED, dated 2/24/26, indicated Resident B complained of not being notified of an upcoming appointment until transportation came in and told her they needed to go. The Transportation Coordinator (TC) responded, on 2/23/26 the resident had an 11:00 a.m. wound care appointment and needed to leave at 9:00 a.m. with another appointment out. When the TC knocked on the resident's door and greeted her and stated you have an appointment, the resident was still in bed asleep and not ready to leave. A Witness Statement written by Bus Driver 5 on 2/24/26, incident, dated 2/23/26, indicated, I explain to the lady why I was late and I apologize to her and I listened to what she was saying because she was very frustrated about me being very late, so I listened to her and she went on talking then I asked her jokingly would it be okay if I kiss her on the forehead and her respond was I don't care it don't matter what you say to me then she went on still complaining.she did mention the next time this will not happen again. Because she will call 911 and let the police know to pick her up so I proceeded to put her on the bus and fasten her down in the wheelchair. So I started driving about two miles down the road then she switched the conversation. A Witness Statement written by the former ED, dated 2/24/26, incident date 2/23/26, indicated Bus Driver 5 had indicated he had been almost an hour late picking up Resident B from an appointment due to securing the resident on the bus. The bus driver had tried to smooth things over, stating things like it's going to be alright and sorry for being late. The resident stated she did not care and she knew it would not happen again as she would call the police. Bus Driver 5 indicated he did not know when, but thought after they were ready to take off, he pecked the resident on the forehead. About 2 miles down the road, the resident requested something to eat from a fast-food restaurant, and even though he knew he was not supposed to and trying to do the right thing to smooth the being late out for her, he stopped at the restuarant. An Employee Communication Form, dated 2/24/26, indicated Bus Driver 5 was suspended from 2/22/26 - 2/27/26, when he returned to work. It was reported that the bus driver had kissed a resident on the forehead during transport. The employee was suspended pending investigation and then returned. The employee was educated on expectations as it results in contact with or comforting residents. The employee received a final written warning for this incident of workplace misconduct. An In-Service sign-in log, dated 3/11/26, indicated 26 staff members had signed as having attended the all-staff meeting and receiving information to include abuse training. Bus Driver 5 had not signed as having attended the meeting. The Director of Nursing Services (DNS) indicated Bus Driver 5 had completed on-line abuse training on 1/5/26 and his file lacked documentation of having completed abuse or resident rights training after the incident on 2/23/26. Bus Driver 5 was on vacation during the survey process and was unavailable for interview. The ED on record in February 2026 no longer worked in the facility and did not respond to a call with request for an interview. During an interview on 4/15/26 at 9:38 a.m., the Assistant Director of Nursing Services (ADNS) indicated when there were reports of abuse, staff were to immediately assure the resident was safe, then notify the ED as that person was the abuse coordinator. Abuse training was offered upon employee hire, then presented at least annually on the computerized training site, and more often as needed. During an interview on 4/15/26 at 10:43 a.m., Registered Nurse (RN) 8 indicated she had not had any residents complain of abuse in recent months. If so, she would have reported the information. During an interview on 4/16/26 at 9:43 a.m., Bus Driver 9 indicated on 2/23/26, she had been on the bus with Bus Driver 5 and assisting residents for transport, but once the bus was ready to leave the facility, she had left for a personal appointment. Bus Driver 9 indicated she had not witnessed any inappropriate interaction between Bus Driver 5 and Resident B, and she did not have any details to share. During an interview on 4/16/26 at 10:03 a.m., the DNS indicated that Resident B had unspecified complaints, so the prior ED had gone to speak with her. Resident B told the ED that Bus Driver 5 had kissed her on the forehead when on the bus. The resident had already been unhappy about being late for her appointment that day. The resident did not think the incident was anything sexual, but she did not like it. An investigation had been conducted and residents that used the bus had been interviewed with no new concerns regarding Bus Driver 5. The bus driver had indicated he was just trying to smooth things over and make things right as the resident was upset, and he did not think he'd done anything wrong as the resident did not say anything. During an interview on 4/16/26 at 10:30 a.m., the ADNS indicated the day of the incident, Resident B had told an aide on the floor she wanted to speak with the ED in the next 5 minutes, or she was calling the Ombudsman. The resident did not specify what she wanted to speak to the ED about, but she wanted to speak only to him. Within minutes before the ED got down to speak with Resident B, 3 town policemen entered the facility. The resident had been mad as she had to wait for the bus driver to pick her up from an appointment but not mad enough that she hadn't requested to stop at a fast-food restaurant on the way back for a burger, and the driver complied. During an interview on 4/16/26 at 11:32 a.m., the SSD indicated she had gone to speak to Resident B on 2/26/26 regarding psychosocial related to her being upset with the bus driver, but the resident only wanted to speak with the ED. The SSD indicated she had not gone back to follow up psychosocial that incident but had spoken with the resident multiple times during her stay, mostly regarding her discharge planning. Any documentation she might have done could be found in the progress notes. On 4/16/26 at 12:44 p.m., the ED provided a Resident Rights policy, revised 7/2023, and indicated the policy was the one currently being used by the facility. The policy indicated, Facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.All staff members recognize the rights of residents at all times and residents assume their responsibility to enable personal dignity, wellbeing, and proper delivery of care. This citation relates to Incident 2788928. 410 IAC (Indiana Administrative Code) 16.2 - 3.1-3(a)

Based on interview, and record review, the facility failed to ensure residents' narcotic medications were protected from diversion resulting in 21 missing Oxycodone (a Schedule II narcotic medication) tablets, for 1 of 3 residents reviewed for misappropriation (Resident B). This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past Noncompliance.Findings include:A Facility Reported Incident (FRI), dated 9/19/25 at 3:59 p.m., indicated a medication discrepancy was found with Resident B's pain medication from the pharmacy. The Executive Director (ED), Director of Nursing Services (DNS), Physician (MD), Power of Attorney (POA), pharmacy, police department, and Adult Protective Services (APS) were notified, and a consumer complaint was filed. Registered Nurse (RN) 6 was suspended pending investigation and subsequently terminated. Resident B's clinical record was reviewed 10/16/25 at 10:45 a.m. Diagnoses on Resident B's profile included traumatic subdural hemorrhage with loss of consciousness (brain bleed), and chronic obstructive pulmonary disease.A physician's order for Resident B, dated 9/10/25, Oxycodone 5 milligrams (mg) give 1 tablet every 4 hours PRN (as wanted or needed) for pain. A Controlled Substance Record for Resident B indicated Registered Nurse (RN) 6 signed as having destroyed 21 Oxycodone 5 mg tablets on 9/17. The photocopied record was crumpled and had a rip and piece of the form missing through the destruction information section. There was no second witness signature, only an O visible on the signature line. A documented timeline related to narcotic diversion, dated 9/17/25 - 10/2/25, included, a. On 9/17/25, RN 7 identified Resident B was missing a card of Oxycodone 5 mg tablets. RN 6 was contacted at home and indicated she had destroyed the medication by mistake. b. On 9/18/25, the DNS contacted RN 6, who indicated she had destroyed the Oxycodone by mistake, and Qualified Medication Aide (QMA) 8 had witnessed her destroying the medication. RN 6 indicated she had the Controlled Substance Record (narcotic count sheet) on her person at home. c. On 9/18/25, QMA 8 was contacted to verify destruction of Resident B's Oxycodone the prior evening. QMA 8 indicated she had observed RN 6 administer flu vaccines to residents where she was working on the secured memory care unit, hallway 100, but she had not spoken with RN 6 on 9/17/25, nor had she witnessed any drug destruction. d. On 9/18/25, RN 6 was suspended pending investigation, and the local police department was notified. e. On 9/22/25, the Assistant Director of Nursing Services (ADNS) performed a record sweep searching for narcotic destruction sheets for 3 additional residents who had recently had their narcotic medications discontinued. One (1) of the 3 residents' records could not be located, leaving an additional 24 Oxycodone tablets unaccounted for. f. On 9/23/25, the Regional Director of Clinical Services began a narcotic audit, specifically looking for discrepancies of Oxycodone, with a date range of 7/1/25 - 9/23/25. g. On 9/26/25, a Record of Facility Inservice indicated 36 nursing staff signed as having received education regarding a new narcotic card removal sheet. h. On 9/29/25, 2 nurses from the facility pharmacy conducted a narcotic audit, with a date range of 8/22/25 - 9/22/25. Review of RN 6's employee file indicated on 12/5/19 she had signed as having received education on Resident Abuse, Resident Rights, and the Elder Justice Act. An Employee Communication Form, dated 9/29/25, indicated RN 6 had been suspended on 9/17/25 and terminated on 9/29/25. Details of the incident/performance/workplace conduct/policy violation, indicated, Employee suspended pending investigation for narcotic discrepancy 9/17/25 with resident in facility. It is substantiated that employee falsified/altered narcotic count sheet. It is found that staff member has misappropriated or taken resident narcotic medications. It is found that employee stated destroying medications with staff that report never destroying medications with employee. Employee returned 9/18/25 and resuspended due to new and updated information on 9/19/25. Employee sent attached notification via email or wish to resign. Communicated to employee that investigation will be ongoing. Employee to be terminated for this occurrence. A Plan of Action document, dated 9/26/25, indicated there had been alleged diversion of narcotics by a licensed nurse. The goal was to have no diversion of medications. Preventative actions included a 100% audit of narcotic count sheets for all residents with routine and PRN narcotic medications. Nurses were re-educated on medication destruction policy/procedure along with accurate counts for narcotics. A new form was initiated for adding/removal of narcotic cards. The DNS or ADNS was to be involved in all narcotic destruction. Preventative actions included audit of narcotic count sheets for all resident with routine and PRN narcotic medications utilizing pharmacy delivery manifests to be completed upon the following schedule: 5 times/week for 8 weeks, 3 times/week for 4 weeks, and weekly for 4 weeks. Spot audits were to be completed monthly x 6 months and PRN thereafter, with results presented in QAPI meetings overseen by the Executive Director (ED).During an interview on 10/16/25 at 2:05 p.m., the Assistant Director of Nursing Services (ADNS) indicated, on Wednesday 9/17/25 RN 6 was scheduled per her normal routine, she was administering flu shots on the 200 hallway and was going to be there later to supervise dining at dinner time. Somewhere between 5:00 p.m. - 6:00 p.m., RN 9 asked RN 6 to take over her hallway as her replacement was not scheduled to arrive for another hour, and she needed to leave. RN 6 and RN 9 counted the medication cart, and both nurses signed as the narcotic medication and narcotic card count were correct at that time. At 6:00 p.m., RN 7 arrived to assume nursing duties on the 200 hallway, and RN 7 and RN 6 counted the medication cart and documented the counts as being correct. RN 7 did not know at that time Resident B's card of Oxycodone and the count sheet had been removed from the cart. Around 8:30 p.m., Resident B requested an Oxycodone tablet for pain, and she had no Oxycodone available. RN 7 assumed at that time the resident had run out of the medication, so she called the pharmacy to re-order the medication, and to get an authorization code to take a dose of Oxycodone from the emergency drug kit (EDK). A pharmacy representative indicated, the Oxycodone had been filled 2 days prior (30 tablets had been dispensed), and the patient should have plenty in her supply. RN 7 reached out to RN 6 via text message and asked where Resident B's card of Oxycodone was, and RN 6 replied via text, I pulled the wrong person's medication and destroyed it. RN 7 called the DNS and left a voice mail of the medication having been destroyed. During an interview on 10/16/25 at 2:05 p.m., the DNS indicated, on 9/18/25 she reached out to RN 6 via phone and had to leave a message. Later the same day RN 6 called back and when questioned regarding Resident B's Oxycodone, indicated she had destroyed the medication by mistake. RN 6 indicated she had pulled the Oxycodone from the medication cart and the declining narcotic sheet from the binder and placed them in an unsecured cart she was using to roll around the facility and administer flu shots to residents. RN 6 indicated she had taken the medication off the 200 hallway to the secured memory care unit to give a couple of flu shots and have QMA 8 witness destruction of the medication. When asked where the declining narcotic sheet was, RN 6 indicated she had the sheet at home and would send a picture. The DNS received a picture of a crumpled up narcotic sheet with a tear and a missing piece of paper over the signature section where the QMA's signature would have been. The DNS called QMA 8 who indicated she had seen RN 6 administer a few flu vaccines and leave the unit, but RN 6 had not requested her keys to access the medication room where the drug buster was stored and had not asked her to witness a drug destruction. QMA 8 indicated she had not signed as having witnessed Resident B's medication being destroyed. The DNS indicated RN 6 had been observed on camera while in the facility but was not observed interacting with QMA 8 or seen destroying medications. The DNS indicated RN 6 did not explain why she had taken the card of Oxycodone from the 200 hallway to destroy versus having RN 7 who was working on the 200 hallway witness the destruction. During an interview on 10/16/25 at 2:05 p.m., the ADNS indicated the Regional Director of Clinical Services conducted a narcotic audit, specifically looking for discrepancies of Oxycodone, with a date range of 7/1/25 - 9/23/25. Upon conclusion of the audit, there were at least 7 more residents found with discrepancies regarding their Oxycodone and around 348 tablets unaccounted for. The medication cards and narcotic sheets for discharged residents were missing. On 10/16/25 at 4:15 p.m., the ADNS provided a Controlled Substances: Storage, Documentation, Inventory and Destruction policy, revised 10/25, and indicated the policy was the one currently being used by the facility. The policy indicated, Purpose of the Policy: To prevent diversion, improper use and accidents related to controlled substances. Policy: It is the policy of this facility that all controlled substances will be stored, recorded, accounted for, and destroyed by state regulation.When the resident's physician discontinues a controlled substance, all unused medication will be destroyed by the Director of Nursing or ADNS and a witnessing licensed nurse or QMA.This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included monitoring delivery, storage and counting of narcotic medications, staff education regarding accurate narcotic counts and policy and procedures for medication destruction, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). This citation relates to Intake 2623477.3.1-28(e)(3)3.1-28(o)

Based on interview, and record review, the facility failed to maintain a system for the reconciliation of controlled medications, resulting in diversion of at least 369 Oxycodone (a Schedule II narcotic medication) tablets from 4 of 4 hallways reviewed for diversion of narcotics (100, 200, 300, and 400 hallways). This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past NoncomplianceFindings include:A Facility Reported Incident (FRI), dated 9/19/25 at 3:59 p.m., indicated a medication discrepancy was found with Resident B's pain medication from the pharmacy. The Executive Director (ED), Director of Nursing Services (DNS), Physician (MD), Power of Attorney (POA), pharmacy, police department, and Adult Protective Services (APS) were notified, and a consumer complaint was filed. Registered Nurse (RN) 6 was suspended pending investigation and subsequently terminated.A Controlled Medication Reconciliation pharmacy audit report dated 8/22/25 - 9/22/25, documented 14 residents having been audited for narcotic medications. The audit indicated that 7 of the 14 residents did not have 2 nursing signatures present on Transfer/Destruction sheets, and 8 of the 14 residents were missing Reconciliation Forms from the narcotic logs. During an interview on 10/16/25 at 2:05 p.m., the ADNS indicated, the Regional Director of Clinical Services conducted a narcotic audit, specifically looking for discrepancies of Oxycodone, with a date range of 7/1/25 - 9/23/25. Upon conclusion of the audit, there were at least 7 additional residents found with discrepancies regarding their Oxycodone and around 348 tablets unaccounted for. The medication cards and narcotic sheets for discharged residents were missing. A list of the additional resident found with discrepancies and the exact count of Oxycodone tablets missing was not provided during the survey process. A Plan of Action document, dated 9/26/25, indicated there had been alleged diversion of narcotics by a licensed nurse. The goal was to have no diversion of medications. Preventative actions included a 100% audit of narcotic count sheets for all residents with routine and PRN narcotic medications. Nurses were re-educated on medication destruction policy/procedure along with accurate counts for narcotics. A new form was initiated for adding/removal of narcotic cards. The DNS or ADNS was to be involved in all narcotic destruction. Preventative actions included audit of narcotic count sheets for all resident with routine and PRN narcotic medications utilizing pharmacy delivery manifests to be completed upon the following schedule: 5 times/week for 8 weeks, 3 times/week for 4 weeks, and weekly for 4 weeks. Spot audits were to be completed monthly x 6 months and PRN thereafter, with results presented in QAPI meetings overseen by the Executive Director.On 10/16/25 at 4:15 p.m., the ADNS provided a Controlled Substances: Storage, Documentation, Inventory and Destruction policy, revised 10/25, and indicated the policy was the one currently being used by the facility. The policy indicated, It is the policy of this facility that all controlled substances will be stored, recorded, accounted for, and destroyed by state regulation.1. Facility will utilize the Shift Change Verification of Controlled Substances form to count all controlled substances for each medication cart in the facility. 2. The incoming nurse or QMA will count all controlled substances being stored at the facility while the outgoing nurse or QMA watches the process. Both staff members sign that the count sheets and verification have been completed with no discrepancies.Destruction: 1. When the resident's physician discontinues a controlled substance, all unused medication will be destroyed by the Director of Nursing or ADNS and a witnessing licensed nurse or QMA. a. Destruction will be documented on the residents' Controlled Substance Record. b. Copies of the records will be scanned into the resident's EMR [electronic medical record] . This deficient practice was corrected by 9/29/25 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included monitoring delivery, storage and counting of narcotic medications, staff education regarding accurate narcotic counts and policy and procedures for medication destruction, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI).Cross reference F602. This citation relates to Intake 2623477.3.1-25(e)(2)3.1-25(e)(3) 3.1-25(s)

Based on observation, interview, and record review, the facility failed to ensure a resident was mechanically transferred using proper technique, resulting in harm when a resident had a fall resulting in an avulsion fracture at the tip of the distal fibula for 1 of 3 residents reviewed for falls with injury (Resident D). Findings include: A Facility Reported Incident (FRI), dated 8/30/25 at 4:39 p.m., indicated on 8/29/25 Resident D was being assisted with a transfer out of her wheelchair by Certified Nursing Assistant (CNA) 10 when the resident began to experience pain in her right foot. The resident was gently lowered to the floor. On 8/31/25 Resident D was diagnosed with a probable subacute nondisplaced demineralized medial cuneiform (bones between the toes and ankle) fracture. The resident's activity level was upgraded to include non-weight bearing on the right lower extremity (RLE), and total mechanical lift for all transfers. On 9/3/25 at 2:28 p.m., Resident D was observed in a wheelchair (WC) at bedside, wearing a controlled ankle motion boot (CAM boot - a specialized walking boot designed for injuries to the foot, ankle and lower leg) on her right foot that extended to her knee, and her call light had been activated. The resident indicated she was waiting for staff to come and help change her brief. An unidentified staff member was observed entering the resident's room with a Hoyer lift (a mechanical device with a sling used to lift and transfer a resident from one surface to another) and indicated she would return with help. On 9/3/25 at 2:35 p.m., Resident D indicated, on 8/29/25, CNA 10 who was a new CNA and who had not been assigned to her care before, had responded to her call light for assistance. During the process of hooking the resident to a standup mechanical lift, the CNA had not properly strapped the resident to the lift, and ultimately the resident had been on the floor with pain in her right foot. Resident D had been to an orthopedic appointment on 9/3/25, and the orthopedic physician had confirmed she had a fractured bone located on the outside of her right foot. The physician had explained, when her foot had been twisted and bent at an odd angle, the ligaments had stretched so far that the bone was pulled away from the other bone. Resident D's clinical record was reviewed on 9/3/25 at 2:30 p.m. Diagnoses on Resident D's profile included osteopenia (low bone mineral density), osteoporosis (decreased bone mass and density), paraparesis (partial loss of motor function in both lower legs), monoplegia (paralysis or weakness) of the right lower limb, dependence on a wheelchair, and obesity (body mass index [BMI] over 33.0). A quarterly Minimum Data Set (MDS) assessment, completed on 6/11/25, assessed the resident as being cognitively intact. The resident required substantial/maximum assistance for bed mobility, was dependent on staff for transfers, and did not walk. A WC was used for mobility. There was no documentation of falls in the six months prior to the assessment. A care plan, dated 3/19/23, indicated Resident D required assistance with activities of daily living (ADLs) to include bed mobility and transfers. An approach, dated 9/28/23, indicated two people assist with transfers with use of a stand-up lift. A physical therapy (PT) discharge note, dated 2/12/25, indicated Resident D had multiple long-term goals to include, but not limited to: to safely perform WC to bed or WC to toilet transfers using assistive equipment with minimum assistance of one person, safely transition from supine to sitting position with minimum assistance of one person, and to improve bed mobility from supine to sitting position with maximum assistance of one person. These goals were not achieved due to the resident reaching maximum rehab potential. The clinical impression indicated PT services were discontinued due to the resident reaching her maximum rehab potential and would require maximum assistance of one to two people for bed mobility and stand up lift. A nursing progress note, dated 8/29/25 at 4:42 p.m., indicated the nurse was called to Resident D's room by CNA 10, and when she entered the resident's room, she observed the resident on the floor. CNA 10 stated that she was transferring the resident but had to lower her to the floor when Resident D started complaining about her leg hurting. A care plan for resident falls was updated on 8/29/25 to include resident to use passive mechanical lift for all transfers. A physician's order for activity level, dated 8/30/25, indicated up ad lib (as wanted or requested) with total mechanical lift with assistance of two members to wheelchair, and non- weight bearing (NWB) to the right foot. Mobile x-ray diagnostics reports included,a. On 8/29/25 at 7:33 p.m., concern for a nondisplaced medial cuneiform fracture.b. On 8/30/25 at 3:26 p.m., an addendum was added to include, there was a minimally displaced fracture of the first cuneiform bone.c. On 8/30/25 at 4:39 p.m., an addendum was added to include, there was a slight step off medial aspect cuneiform, margins not sharp. Subacute fracture cannot be excluded. Stress type injury cannot be excluded.d. On 9/2/25 at 1:03 a.m., images of the right foot demonstrate normal osseous alignment. No definite fracture, including the medial cuneiform. An orthopedic physician report, dated 9/3/25, indicated Resident D presented today for evaluation of her right foot and ankle. Last Friday, the resident was in a standing hoyer (sic) lift which got tangled around her foot and ankle causing pain and discomfort. She had a fairly significant amount of swelling, and she was then placed in a CAM boot which had made her ankle feel better and she had noted significant improvement in the swelling. Resident D was assessed for a nondisplaced distal avulsion fracture (a bone injury that occurs when a strong force pulls a tendon or ligament away from the bone, taking a small piece of bone with it) of the right fibula. Findings indicated radiographs of the right foot and ankle were obtained on 9/3/25 and reviewed. Review of these radiographs revealed a small avulsion fracture at the tip of the distal fibula that was nondisplaced. Also noted, a healed distal fibula fracture in anatomic alignment. The plan indicated the physician discussed the etiology of her pain and treatment plan, continued use of a CAM boot that would likely be required for 2 to 4 weeks, 2 daily skin checks around the foot and ankle for any breakdown, and return to the physician as needed. A pain specialist progress note, dated 9/4/25 at 2:18 p.m., indicated Resident D had been seen on rounds that day after a fall that resulted in right foot/ankle pain, and right shoulder pain. The resident indicated she had a fall on 8/29/25 and was seen at the orthopedic clinic where imaging demonstrated an avulsion fracture, and ortho was managing the resident conservatively with a CAM boot. Additionally, the resident reported exacerbation of right shoulder pain after a failed hoyer (sic) transfer. The plan indicated RTC tendinopathy (rotator cuff tissue connecting muscle to bone had become inflamed) as well as biceps tendonitis which was new. The physician would re-order diclofenac gel (used to decrease inflammation) and a lidocaine patch (used to relieve nerve pain) for the right shoulder/bicep tendon. Orders would also be placed for Resident D to have a repeat injection at the next visit pending further progress. CNA 10's job specific orientation record indicated she was hired on 7/30/25. Validation skills for day 2 that included mechanical lift and stand-up lift, were signed by the Staff Development Coordinator (SDC) as completed on 8/10/25. A handwritten note indicated the employee was a little timid and was instructed on ways to ask for help, and to never do anything she was nervous about. A Mechanical Lift/Hoyer Lift Safety protocol, signed by CNA 10 on 7/30/25, indicated, .1. I understand that all mechanical lifts, including hoyer lifts require the use of 2 trained people to operate safely.3. I understand that if I operate a mechanical lift by myself, I am subject to disciplinary action up to and including termination. 4. I understand that if I operate a mechanical lift by myself and an injury to a resident occurs, I may be reported to the nurse aide registry, Attorney General, and/or law enforcement for investigation of negligent care.8. I understand that I must follow the manufacturer's guidelines for the specific mechanical lift that is utilized. During an interview on 9/3/25 at 10:49 a.m., the Assistant Director of Nursing Services (ADNS) indicated Resident D was alert and oriented to person, place, and time. The resident required a mechanical lift for transfers to an electric WC, where she drove herself around the facility ad lib. On 8/29/25 around 4:30 p.m., Resident D was being transferred from her bed into her chair with the assistance of CNA 10, and when maneuvering the resident's body, the resident began complaining of pain and she told the aide to put her down. The lift only lowered a resident down far enough to be in a sitting position, so the aide had to manually lower the resident the rest of the way onto the floor. The transfer with only one new CNA had somehow gone wrong and resulted in the resident having a fracture. Nurse Practitioner (NP) 13 ordered x-rays for 8/29/25, 8/30/25, and 9/2/25 that were completed with differing results, and an orthopedic consult was scheduled for 9/3/25. During an interview on 9/3/25 at 2:35 p.m., Resident D indicated she had been utilizing a stand-up lift for transfers since her admission 2 years ago. On 8/29/25, CNA 10 had responded to her need to have her brief changed. The entire process was not done correctly, from not making sure the torso belt was tight enough to support her, the CNA seemed flustered when told she'd have to hurry as the resident was slipping and the CNA hit the wrong control button, and the CNA attempted to transfer the resident by herself instead of getting assistance due to the resident being a big girl and the CNA being a tiny little thing who had difficulty maneuvering the resident in the lift. Resident D indicated x-rays had been taken in-house three times after the incident, all with different results. CNA 10 was new to the facility, very sweet, and was just attempting to help, but due to not having a second CNA as a spotter like she was supposed to, the resident ultimately ended up with a fractured foot. The resident indicated she had little strength in her right leg/foot and hoped being NWB would not cause her to lose what strength she had in her left leg that allowed for her to use the stand-up lift versus a Hoyer lift. During an interview on 9/4/25 at 3:20 p.m., Resident D indicated on 8/29/25 CNA 10 had come to change the resident's brief. The resident explained the process of utilizing the stand-up lift so the resident could be stood up, and while standing within the straps of the lift, her brief could be changed. CNA 10 made mistakes when she did not have the torso belt/strap tight enough, and she did not strap the resident's legs so her feet would remain in position on the lift platform. When the CNA stood the resident, the torso belt/strap started slipping and ended up under the resident's armpits. The resident then prompted CNA 10 to hurry up the process as the resident was slipping. Instead of pushing the button to raise the resident up higher so she could sit back onto the seat of the WC, the CNA accidentally pushed the wrong button and the lift went down. The resident ended up in a crouched position with her right foot off the platform and bent at an odd angle under her. At that point, the resident could not reach the handgrips and could not stand herself back up. CNA 10 swung the resident around with the intent of placing her onto the bed, but the resident had slipped too far down to sit onto the bed. At that point the resident told the CNA she had to go get help. The CNA went to the doorway to summon help, and other staff came immediately. The resident could not stand back up and staff had to put her onto the floor. The resident indicated she saw the pain physician 9/4/25 for her right shoulder that hurt, and he told her she potentially had messed up her rotator cuff when suspended by the belt/straps under her arms, and he would be ordering occupational therapy (OT) for the shoulder. A physical therapy (PT) evaluation had been ordered to assess her legs, more specifically to help retain her ability to stand and bear weight on her left leg. During an interview on 9/4/25 at 11:00 a.m., the Director of Nursing Services (DNS) indicated in her opinion Resident D had not been injured with a mechanical lift or during the lift process, she had already been standing when the safety belt slipped, and she complained of foot pain. The manufacturer's general information for the mechanical lift indicated the lift could be used with one staff member, although it was the facility protocol to use two staff members when transferring residents with mechanical lifts. During an interview on 9/4/25 at 1:19 p.m., a representative from the Orthopedic physician's office indicated Resident D had been seen by the Orthopedic physician on the day prior and diagnosed with a newly acquired acute avulsion fracture (a break in the bone that occurred when a piece of bone was pulled away from the main part of the bone by a strong force from a ligament or tendon) at the tip of the distal fibula, that was nondisplaced. This was a separate finding from a prior healed distal fibula fracture in anatomic alignment that was also viewed on the x-ray. On 9/4/25 at 11:00 a.m., the DNS provided a printout of the manufacturer's general information for the stand-up mechanical lift, undated. The information indicated passive and active series lifts were designed for safe usage with one caregiver. There were circumstances such as obesity of the patient that may dictate the need for a two-person transfer. It was the responsibility of each facility and medical professional to determine if a one or two-person transfer was more appropriate, based on the task, patient load, environment, capability, and skill level of the staff member. On 9/4/25 at 2:56 p.m., the ADNS provided a Fall Management Policy, dated 6/25, and indicated the policy was the one currently being used by the facility. The policy indicated, A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level.3. A care plan will be developed at the time of new move-ins with care plan interventions to address the resident specific fall risk factors.5. The resident specific fall risk factors will be communicated to the assigned caregiver utilizing the resident profile or the CNA assignment sheet. This citation relates to Intakes 2566173, 2603419, and 2606522. 3.1-45(a)(2)

A. Based on record review and interview, the facility failed to obtain resident weights as ordered for 2 of 2 residents reviewed for weights (Resident 74 and 107). B. Based on observations, interview and record review, the facility failed to ensure a newly admitted resident, (Resident C) had physician's orders in place and treatments rendered for a new surgical wound upon his admission for 1 of 5 residents reviewed for quality of care. C. Based on record review and interview the facility failed to ensure a resident's (Resident B) physician's ordered were followed to apply and remove a transdermal medication patch for 1 of 5 residents reviewed for quality of care. Findings include: A1. On [DATE] at 11:04 a.m., a record review was completed for Resident 74. She had the following diagnoses which included but were not limited to dementia, hyperlipidemia (high cholesterol), depression, and insomnia. She had an order, dated [DATE], to obtain her weight weekly on Monday. Her weight was not obtained on [DATE], [DATE] and [DATE]. She had a care plan dated [DATE] that indicated she was at risk for unintentional weight loss related to dementia. The goal indicated she would be free from significant weight changes. A2. On [DATE] at 10:30 a.m., a record review was completed for Resident 107. He had the following diagnoses which included type 2 diabetes mellitus, congestive heart failure (CHF), hyperlipidemia, mild cognitive impairment, and difficulty in walking. Resident 107 had an order, dated [DATE], to obtain daily weight for CHF daily and to notify the physician if there was a weight gain of 3 pounds a day or 5 pounds in a week. Resident's [DATE] medication administration record (MAR) was reviewed. He was missing weights for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Resident's [DATE] MAR was reviewed. He was missing the following weights: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 1:45 p.m. the Regional Nurse Consultant (RCS) provided an updated MAR for Resident 107. The MAR was complete with indications that he refused his weight. This was added after the weight concerns had been brought to her attention. He had a care plan dated [DATE] which indicated he had the potential for impaired gas exchange related to respiratory failure, his head of bed is elevated while lying, CHF, oxygen use. On [DATE] his care plan was updated indicating he refuses to be weighed at times. This information was added after weights were brought to management's attention. On [DATE] at 2:00 p.m., during an interview with the Director of Nursing (DON), she indicated they need to do a better job at recording refusals. She wanted to continue with daily weights because Resident 107 had a new diagnosis of CHF. A policy titled, Resident Weight Monitoring with a date of ,d+[DATE] was provided by the DON on [DATE] at 9:29 a.m. It indicated, .It is the policy of this facility to weigh residents no less than monthly or per physician orders. Residents may exercise their right to refuse to be weighed . 38768 B. On [DATE] at 9:50 a.m. Resident C's wife was observed as she left the hall and stopped a nurse to ask about her husband's leg. She indicated to the unidentified nurse that his leg was still bleeding and had gotten all over his sheets. On [DATE] at 10:32 a.m., Resident C was observed as he laid in bed. He had a left below the knee amputation (BKA) which was wrapped up however, he had bleed through the dressing and bandage. A folded sheet had been placed under his soiled dressing and there was a moderate amount of bright red stains on the white sheet as well. Residnet C indicated, he admitted to the facility on Friday the 18th. Everything had been find at the hospital after his amputation, but shortly after he arrived to the facility, he noticed he started bleeding through the bandage. He and his wife, (who was also a resident) had talked to several staff member, but he still had not had a dressing change. On [DATE] at 10:44 a.m., Registered Nurse (RN) 12 indicated, he had not seen Resident C yet, but had been alerted that his bandage had bled through, so he was going to put a PRN (as needed) dressing in place since his bandage was soaked through. On [DATE] at 10:47 a.m., Resident C's physician's orders were reviewed and revealed no dressing/treatment orders schedule or as needed for his left BKA. On [DATE] at 8:55 a.m., Resident C was observed. He remained in bed and his dressing was observed soiled with bright red drainage. He indicated, he bled through his dressing and it seemed that the wound would not stop bleeding. On [DATE] at 1:33 p.m., Resident C was observed. He had a new bandage which appeared to be dry and intact. Resident C indicated, it seemed like it was under control now. On [DATE] at 9:15 a.m., Resident C was observed. His bandage remained dry and intact, and he indicated he had not needed it changed since the bleeding seemed to have stopped. On [DATE] at 8:50 a.m. Resident C's medical record was reviewed. He was a newly admitted resident for aftercare following a left BKA with a history of atherosclerosis of native arteries of extremities with gangrene, (a condition where hardened plaque buildup in the arteries of the legs and feet leads to poor blood flow and tissue death [gangrene]). and peripheral vascular disease ([PVD] a condition where blood flow to the extremities, primarily legs and feet, is restricted due to narrowed or blocked blood vessels). On [DATE] at 12:26 p.m., the Infection Preventionist (IP) provided a copy of Resident C's hospital discharge summary and instructions. The hospital record was dated [DATE] and indicated, continue daily dressing changes, wash with soap/water and pat dry. May leave open to air if no drainage and clean environment versus dry dressing. Staples to remain ,d+[DATE] weeks A physician's order for treatment and dressing to his left BKA was not placed in the order set until [DATE]. Resident C's Treatment Administration Record (TAR) was reviewed from his admission on [DATE] until [DATE] and revealed no treatments or wound dressings had been administered over the weekend after his admission. A late nursing progress note was added to his record on [DATE] at 3:16 p.m., (dated effective for [DATE] at 3:04 p.m.) which indicated, .changed wound dressing to resident's left BKA with a pressure wrap. His wound was bleeding out from the previous dressing onto his bed sheets. Wound has some staples still remaining, the oozing of blood was coming from one of the staples On [DATE] at 10:22 a.m., the Infection Preventionist (IP) provided a copy of current facility policy titled, Nursing Admission/Return Admission Policy and Procedure), revised ,d+[DATE]. The policy indicated, .Upon admission, physician orders must be obtained. Transcribe the admission orders from the original orders sent from the hospital or physician's office C. A confidential interview during the survey indicated Resident B was taken to the hospital were they found two Nitroglycerin (ointment or skin patch is used to prevent angina [chest pain] caused by coronary artery disease [CAD]) patches on the resident. On [DATE] at 1:38 p.m., Resident B's medical record was reviewed. She had been a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, Alzheimer's disease (an irreversible and degenerative brain disease which affects memory and cognition) hypertension (high blood pressure) and heart failure. She was discharged to the hospital on [DATE] and did not return to the facility. A nursing progress note, dated [DATE] at 1:10 p.m., indicated, Resident B's family requested she be sent to the ER for assessment and evaluation after a fall earlier that morning. Resident B was transferred to the hospital, but returned the same day with no major injuries or infections. On [DATE] at 11:35 a.m., the Director of Nursing (DON) provided a copy of a hospital emergency room (ER) summary from [DATE]. The ER summary indicated, .she did have 2 nitroglycerin patches on, one of them was expired At the time of her hospitalization on [DATE] she had an order for the following, nitroglycerin patch 24 hour; 0.2 mg/hr; Amount to Administer: 0.2 mg/ hr; transdermal every 12 hours. The order included specific instructions to place ON 12 hours during the day (y) OFF 12 hours at night A nursing progress note dated [DATE] at 3:23 p.m., indicated, Resident B had a Nitro patch on her left shoulder from yesterday. It was removed and replaced with a new patch on left shoulder. The note lacked documentation the physician had been notified. The physician's order active for her Nitro patch on [DATE] indicated specific instructions to remove the old patch at bedtime. Resident B's comprehensive care plan was reviewed and lacked implementation and/or revision to include person-centered goals and interventions related to her heart failure and the use of a nitro transdermal patch. On [DATE] at 9:50 a.m., the Director of Nursing (DON) provided a copy of a nursing in-service. The DON indicated that Resident B's family was upset when she returned to the facility and told the administrator (ADM) that two Nitro patches were on her back. The ADM told the DON, and the DON conducted an in-service and audit to correct the issue. The DON indicated they conducted the in-service and audits at the time they were made aware on [DATE]. The DON indicated, there was no specific policy, but it was basic nursing standards of care to follow physician's orders as written and to update the care plans with interventions as needed. The in-service material and audit tools were reviewed but had not been initiated until [DATE]. On [DATE] at 10:40 a.m., the Regional Nurse Consultant (RNC) provided a copy of current facility policy titled, IDT Comprehensive Care Plan Policy, revised ,d+[DATE]. The policy indicated, It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on the Resident Assessment Instrument (RAI) process. The care plan must include measurable goals and resident specific interventions based on the resident's needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being . care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MSDS assessment This citation relates to Complaint IN00456348. 3XXX,d+[DATE]

Based on observations and interviews, the facility failed to date insulin and eye drops when opened and failed to remove expired tuberculin serum and insulin from the refrigerator for 3 of 6 medication carts and 2 of 4 medication rooms. Findings include: On [DATE] at 1:03 p.m., 200 hall medication cart was observed. Resident 282 had an insulin pen dated [DATE]. Resident 281 had a vial of folic acid inside the refrigerator on 200-hall that was undated. The 300-hall medication cart was observed. Resident 25 had a NovoLog insulin pen undated, and glargine insulin pen undated. Resident 86 had an insulin pen Semglee with no date to indicate when it was opened. Resident 38 had a bottle of brimodine 0.2% with no date to indicate when it was opened. The 300-hall medication room was observed. Inside the refrigerator was a vial of tuberculin serum that had a date of [DATE] on it. The 400-hall back medication cart was observed. Resident 1 had a insulin pen glargine with no date to indicate when it was opened. On [DATE] at 11:32 a.m., during an interview with the Director of Nursing (DON), she indicated they had been auditing the carts to ensure items had dates on them. A policy titled Storage and Expiration Dating of Medications and Biologicals was provided by the Assistant Director of Nursing (ADON) on [DATE] at 1:35 p.m. It indicated, .Facility should ensure medications and biologicals that 1) have an expired date on the label .Once any medication or biological package is opened, the facility should follow manufacturer/suppliers guidelines with respect to open dates for opened medications . 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](n)

Based on observations, interviews, and record review, the facility failed to ensure a safe and orderly discharge from the facility for 1 of 1 residents (Resident 118) reviewed for transfers and discharges. Findings include: On 4/21/25 at 9:58 a.m. Resident 118 was observed as she lay in bed. There was a catheter drainage bag hanging on the side of the bed, with a small amount of dark yellow urine in the tubing. Resident 118 indicated that she was unhappy with her stay at the facility, and she wanted to leave. She did not know why she had a catheter, and she complained of being constipated for a week. On 4/24/25 11:04 a.m. Resident 118's medical record was reviewed. She was a rehabilitation resident whose diagnoses included but were not limited to malignant neoplasm of the larynx (throat cancer), constipation, and urinary tract infection (UTI). A progress note, dated 4/21/25 at 1:38 p.m., indicated an unidentified staff member was walking past the nurses' station when Resident 118 and her family member walked by with a couple of bags with them. They indicated Resident 118 was going on a leave of absence (LOA), to go to CVS pharmacy to pick up her prescriptions that someone called in for her. The resident's family member signed her out in the LOA binder and said he was bringing her back after they were done. The note indicated the resident then mouthed to the unidentified staff member I'm leaving this place! A progress note, dated 4/21/25 at 9:55 p.m., indicated an unidentified staff member received report that Resident 118 was on LOA with her family member and had not returned at that time. A progress note, dated 4/22/25 at 12:14 a.m., indicated Resident 118 remained LOA at that time. According to the LOA book, Resident 118 signed out on 4/21/25 at 12:00 p.m. A progress note, dated 4/22/25 at 5:54 a.m., indicated Resident 118 remained LOA, though the Residents' personal vehicle remained in the facility parking lot. A progress note, dated 4/22/25 at 2:52 p.m., indicated Resident 118 remained out on LOA. The facility had attempted to contact Resident 118 and the resident's family member twice with no success, but voicemails were left. Resident 118 had a Brief Interview for Mental Status (BIMS) score of 15 (indicating her cognitive function was intact). The note indicated the facility left a voice mail with Anthem Medicaid (the resident's insurance) to make them aware that the resident had been out for more than 24 hours. The note indicated Resident 118 was to be discharged from the facility Against Medical Advice (AMA) at that time. The record lacked any additional information related to the resident's discharge, her belongings, or the disposition of her medications. During an interview on 4/24/25 at 1:35 p.m. the Assistant Director of Nursing (ADON) indicated Resident 118 went LOA on 4/21/25 and ultimately left AMA on 4/24/25 at 12:00 p.m. The ADON indicated she saw the resident return to the facility to get her belongings and leave but did not pay enough attention to see whether Resident 118 still had her catheter in or not. During an interview on 4/25/25 at 12:45 p.m., the Executive Director (ED) indicated a few staff members saw Resident 118 get her belongings, get in her car, and leave the facility. He indicated no AMA or discharge paperwork was signed and he was unsure if anyone attempted to talk to her or if she had her catheter in or not. During an interview on 4/25/25 at 1:00 p.m. the Director of Nursing (DON) indicated she called Resident 118's family member during the facilities morning meeting on 4/22/25, she indicated she talked to him and begged him to bring the resident back so they could care for her. The resident's family member indicated he would figure things out but never called the DON back. The DON indicated Registered Nurse (RN) 13, the unit manager for the unit Resident 118 was residing on, gave the resident discharge information and education on her catheter as the resident was walking out the door. During an interview on 4/25/25 at 1:15 p.m. RN 13 indicated Resident 118 showed up to the facility, saying she's getting out of here. She indicated the resident went into her room and gathered her things with her family member. At that point RN 13 indicated upper management was supposed to take over and handle discharge and education. RN 13 indicated even if a resident discharged AMA they should have still given that resident discharge instructions and education on catheter care. On 4/24/25 at 1:35 p.m. the ADON provided a copy of a current facility policy titled, Discharge Against Medical Advice dated 10/2022. This policy indicated, .documentation in the medical record should indicate the facility staff attempted to provide other options to the resident and inform the resident of potential risks of leaving AMA .4. Facility staff will document in the medical record the options offered risks explained and information given to the resident/representative. Documentation will be completed on the discharge against medical advice observation in matrix .5. Every effort should be made to give the resident/representative as much information as possible to assist in a safe transition .6. The discharge against medical advice observation and accompanying information should be reviewed with the resident/representative. If the resident/representative refuse the review, that must be noted on the observation. The resident/representative will also sign the observation indicating their understanding of the information 3.1-12(a)(21)

Based on observations, interviews and record reviews, the facility failed to ensure a newly admitted resident, (Resident C) had a baseline care plan in place to address his immediate medical needs for a new surgical wound upon his admission for 1 of 3 new admission records reviewed. Findings include: 1. On 4/21/25 at 9:50 a.m. Resident C's wife was observed as she left the hall and stopped a nurse to ask about her husband's leg. She indicated to the unidentified nurse that his leg was still bleeding and had gotten all over his sheets. On 4/21/25 at 10:32 a.m., Resident C was observed as he laid in bed. He had a left below the knee amputation (BKA) which was wrapped up however, he had bleed through the dressing and bandage. A folded sheet had been placed under his soiled dressing and there was a moderate amount of bright red stains on the white sheet as well. Resident C indicated, he admitted to the facility on Friday the 18th. Everything had been find at the hospital after his amputation, but shortly after he arrived to the facility, he noticed he started bleeding through the bandage. He and his wife, (who was also a resident) had talked to several staff member, but he still had not had a dressing change. On 4/23/25 at 9:15 a.m., Resident C was observed. His bandage remained dry and intact, and he indicated he had not needed it changed since the bleeding seemed to have stopped. On 4/23/25 at 8:50 a.m. Resident C's medical record was reviewed. He was a newly admitted resident for aftercare following a left BKA with a history of atherosclerosis of native arteries of extremities with gangrene, (a condition where hardened plaque buildup in the arteries of the legs and feet leads to poor blood flow and tissue death [gangrene]). and peripheral vascular disease ([PVD] a condition where blood flow to the extremities, primarily legs and feet, is restricted due to narrowed or blocked blood vessels). The record lacked a baseline care plan for his immediate medical needs related to his left BKA. On 4/24/25 at 10:40 a.m., the Regional Nurse Consultant (RNC) provided a copy of current facility policy titled, IDT Baseline Care Plans, revised 4/2018, and indicated, baseline care plans should be added to the Care Plans upon admission to provide orders and interventions which were critical for the first 48 hours after admission. The policy indicated, It is the policy of this facility that each resident will have an interdisciplinary baseline care plan developed within 48 hours of admission the baseline care plan will be developed in collaboration with the resident, family and/or representative and direct care staff to incorporate findings based on the admission assessment, observations, interviews, and resident preferences. The baseline care plan will include resident centered goals and interventions relative to resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychosocial needs procedure: baseline care plans will be opened in matrix and initiated within 48 hours of admission to the facility by the admitting nurse in collaboration with the interdisciplinary team the baseline care plan will include but is not limited to the following colon the residents initial goals for care instructions . the Baseline Care Plan will include, but not limited to the following . the resident's immediate health and safety needs, physician's orders

Based on observation, interview and record review, the facility failed to ensure a resident (Resident 87) received care plan revisions to implement new goals and/or approaches to address her diabetic management for 1 of 5 residents reviewed for unnecessary medications. Findings include: On 4/22/25 at 9:00 a.m., Resident 87 was observed in bed. A over-bed table with a breakfast tray was observed in front of her, but Resident 87 indicated she did not want to eat her breakfast. Resident 87 indicated she did not like the food and because of her diabetes, there were certain things she could or could not eat. On 4/23/25 at 10:16 a.m., Resident 87's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to diabetes mellitus type II (a blood sugar disorder) and kidney failure. A nursing progress note, dated 2/21/25 at 10:14 p.m., indicated, Resident 87 had refused all evening medications and refused to have her blood glucose checked. She was asked three separate times but remained adamant about her refusal. An interdisciplinary team (IDT) progress note, dated 3/4/25 at 9:20 a.m., reviewed Resident 87's recent refusals of evening medications and blood sugar checks. Her refusal was attributed to delusions of contracting an illness due to sharing a room. She was provided assurance and staff showed her infection prevention tasks. A nursing progress note, dated 4/6/25 at 9:04 p.m., indicated, Resident 87 refused insulin that shift. She stated she felt she did not need to take medication. Resident 87 continued to refuse her insulin but took her oral medication. A nursing progress note, dated 4/15/25 at 11:51 p.m., indicated, Resident 87 had received her scheduled insulin, but refused to eat her dinner and refused to eat any snacks. Her blood sugar level was taken and was 152. A nursing progress note, dated 4/19/25 at 5:18 a.m., indicated, Resident 87 refused to have her blood sugar checked and refused her scheduled insulin. She stated, she didn't need to have her blood sugar checked and she felt like she didn't need any insulin. The resident was reminded of the importance of taking her insulin and getting her blood sugars checked. She had a care plan dated 8/21/24 which indicated, she was at risk for adverse effects of hyperglycemia/hypoglycemia (high/low blood sugar) related to use of glucose lowering medication and/or diagnosis of diabetes mellitus. This care plan, and her full care plan set, lacked revision to include her history of behaviors for refusing her medications, insulin and meal schedules for her diabetic management On 4/24/25 at 10:40 a.m., the Regional Nurse Consultant (RNC) provided a copy of current facility policy titled, IDT Comprehensive Care Plan Policy, revised 8/2023. The policy indicated, It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on the Resident Assessment Instrument (RAI) process. The care plan must include measurable goals and resident specific interventions based on the resident's needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being . care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MSDS assessment 3.1-35(d)

Based on observation and interview, the facility failed to prevent the potential for accidents when medications were left bedside with residents without self-administration assessments for 2 of 2 random observations (Residents 78 and 118), and when a nurse was observed leaving medications unattended on top of the medication cart during a medication pass observation which had the potential to affect 2 of 2 residents in the hallway when the medication was unattended. Findings include: 1. On 4/20/25 at 9:46 a.m. Resident 78 was observed sitting up in his wheelchair. On his bedside table was a clear cup and inside there were 7 pills ranging in color and size. Resident 78 indicated he had not taken them yet because he had an upset stomach. He indicated the nurse left them there for him to take. A record review was completed. Resident 78 had the following diagnoses which included but were not limited to cerebral infarction (stroke), type 2 diabetes, difficulty swallowing, hyperlipidemia, and hypertension. On 4/23/25 at 1:30 p.m., the Director of Nursing (DON) indicated Resident 78 lacked a self-administration assessment and the nurse should not have left the medications at bedside. 2. On 4/21/25 at 9:58 a.m., Resident 118 was observed as she laid in bed. As the resident explained that she had been constipated for the last week, she pulled a bottle of Dulcolax (an over the counter stool softener) out of her purse. On 4/24/25 at 11:04 a.m., Resident 118's medical record was reviewed. She was a rehabilitation resident whose diagnoses included but were not limited to malignant neoplasm of the larynx (throat cancer), constipation and Urinary Tract Infection (UTI). On 4/24/25 at 10:30 a.m., the Assistant Director of Nursing (ADON) indicated Resident 118 did not have a self-administration assessment and should not have any medications at bedside. 3. On 4/24/25 at 8:15 a.m., Registered Nurse (RN) 6 was observed as she passed medications. When preparing medications for a resident she separated the residents blood pressure medication from all the other medications and put it in its own medication cup. When taking the medications to the resident RN 6 left the medication cup with the blood pressure medication in it on top of the medication cart unattended. At the time the medication was left unattended there were two unidentified residents in the hallway. A policy titled, Storage and Expiration Dating of Medications and Biologicals was provided by the Assistant Director of Nursing (ADON) on 4/24/25 at 1:35 p.m. It indicated, .Facility should not administer/provide bedside medications or biologicals without a physician/prescriber order and approval by the interdisciplinary team and facility administration . 3.1-45(a)

Based on observations, interviews and record review the facility failed to ensure the medical record reflected accurate documentation of a pressure injury for a resident for 1 of 25 residents reviewed for accurate documentation (Resident 16). Findings include: On 4/22/25 at 10:15 a.m., Resident 16 was observed as he lay in bed. He was pleasantly confused at times, but he could answer most questions appropriately. He had a pressure-relieving boot on his right heel and another pressure-relieving boot was on the floor at the foot of the bed. On 4/24/25 at 1:35 p.m., Resident 16's medical record was reviewed. He was a long-term care resident whose diagnoses included but were not limited to Type 2 Diabetes and Urinary Tract Infections (UTI). A progress note, dated 11/15/24 at 10:35 p.m., indicated Resident 16 arrived at the facility in a wheelchair with bilateral edema in his lower extremities and a pressure ulcer on his right heel. A progress note, dated 3/16/25 9:59 p.m., indicated Resident 16 had a dressing changed to his right heel ulcer. An admission assessment, dated 11/15/24, indicated Resident 16 had a pressure ulcer on his right heel. A weekly skin assessment, dated 11/26/24, indicated Resident 16 had open areas on his left foot. A weekly skin assessment, dated 12/3/24, indicated Resident 16 had open areas on his left foot with eschar (a hardened crust of black or brown dead tissue, that forms over a wound). A weekly skin assessment, dated 12/10/24, indicated Resident 16 had open areas on his left heel. A weekly skin assessment, dated 12/24/24, indicated Resident 16 had open areas on his heel, it did not specify which heel. A weekly skin assessment, dated 12/31/24, indicated Resident 16 had open areas on his heel, it did not specify which heel. A weekly skin assessment, dated 1/14/25, indicated Resident 16 had open areas on his heel, it did not specify which heel. A weekly skin assessment, dated 1/28/25, indicated Resident 16 had open areas on his left heel. A weekly skin assessment, dated 3/4/25, indicated Resident 16 had open areas on his left, it did not specify where the open areas were located. An admission assessment, dated 3/13/24, indicated Resident 16 had a pressure ulcer on his right heel. In an interview on 4/24/25 at 12:00 p.m., Registered Nurse (RN) 11 indicated Resident 16 has a pressure ulcer on his right heel only. In an interview on 4/25/25 at 11:00 a.m., the Director of Nursing (DON) indicated Resident 16 did not have open areas anywhere but his right heel. She indicated that the skin assessments that say he had a wound on his left heel were incorrectly charted and she was going to have the nurses who charted incorrectly fix the mistakes. On 4/24/25 at 1:35 p.m. the Assistant Director of Nursing (ADON) provided a copy of a current facility policy titled, Documentation Guidelines for Nursing dated 7/2024. The policy indicated, .Purpose: to accurately document in an organized manner all information related to the resident in the medical record 3.1-50(f)

Based on observation, interview, and record review, the facility failed to manage Peripherally Inserted Central Catheter (PICC) line dressing changes for a resident receiving intravenous (IV) antibiotics to treat extradural and subdural abscesses for 1 of 2 residents reviewed for PICC line dressing changes (Resident C). Findings include: During an interview on 1/22/25 at 10:41 a.m., a resident representative indicated Resident C had been admitted to the facility from a local hospital on 10/29/24 with orders to change his PICC line dressing weekly, but the facility did not have his PICC line dressing changed until close to discharge over 3 weeks later. The resident representative indicated they had repeatedly taken their concerns to the Infection Preventionist nurse and floor nurses. They had even brought up their concerns during a care plan meeting on 11/19/24 with a picture of his dressing dated 10/28/24 from the hospital and the PICC dressing coming loose around the edges as proof, but the facility did not change the residents dressing until 11/25/24. Resident C's record was reviewed on 1/21/25 at 1:45 p.m. Diagnoses on Resident C's profile included, but not limited to, external and subdural abscess (pus collections located outside the body and between the outer layer and middle layer of meninges surrounding the brain), osteomyelitis of vertebra of the lumbosacral region (rare spinal infection that can cause severe back pain, fever, and bone death), and elevated white blood count (indicative of an infection). An admission MDS (Minimum Data Set) assessment, completed on 11/4/24, assessed Resident C as having the ability to make himself understood and to understand others. A BIMS (brief interview for mental status) score 15 out of 15 indicated he was cognitively intact. The resident had open lesions other than ulcers, rashes, or cuts, had IV access to include a PICC, and was receiving IV antibiotics. A local hospital PICC line insertion procedure report, dated 10/28/24 at 9:30 a.m., indicated a PICC line was inserted by RN 12 with a transparent occlusive dressing applied. Physician orders, dated 10/30/24, indicated a. The nurse was to initial every shift the PICC/midline site was free of warmth, redness, or swelling b. Vancomycin (anti-infective/antibacterial agent) recon solution (reconstituted with sodium chloride solution) infuse 1.5 gram piggyback IV once daily. A physician's order, dated 10/31/24, indicated change the PICC/Midline dressing every 7 days with transparent dressing. The MAR (medication administration record), dated October 2024, indicated the dressing change scheduled for 10/31/24 had no documentation the PICC/Midline dressing had been changed. On 11/1/24 LPN (Licensed Practical Nurse) 9 documented not administered, last changed on 10/28/24, will reschedule. The resident record lacked documentation the PICC line dressing was changed within the following 13 days, or that the physician was notified of the missed order. A physician's order dated 11/13/24, indicated change the PICC/Midline dressing every 7 days with transparent dressing. The dressing changes were scheduled for 11/13/24 and 11/20/24. A MAR, dated November 2024, indicated, a. On 11/13/24 LPN 10 documented as having changed the PICC dressing. b. On 11/20/24 LPN 11 documented as not having changed the PICC dressing as it was changed earlier that day. The resident record lacked documentation the dressing had been changed earlier that day. A nursing progress note, dated 10/29/24 at 10:54 p.m., indicated Resident C was admitted to the facility after having been treated for a complicated abscess related to an epidural. A care plan dated 10/30/24, indicated Resident C had a PICC line and was at risk for infection and complications. The goal was for the resident to be free from complications associated with the IV access. Approaches dated 11/19/24 included changing the dressing as ordered, and keeping the site clean and dry. During an interview with the Infection Preventionist nurse, on 1/22/25 at 12:05 p.m., she indicated Resident C was admitted to the facility on [DATE] with orders to change his PICC line dressing weekly. Upon review of the resident record, she indicated the PICC line dressing was first documented as having been changed on 11/13/24 and again on 11/19/24, there was no documentation the dressing was changed within the first 2 weeks of admission. On 11/1/24 LPN 9 documented the dressing had been changed in the hospital before discharge therefore she had not changed the dressing as ordered on 10/30/24 and she would write new orders. LPN 9 wrote a new order for the PICC line dressing change but wrote the order wrong with the start date as 11/13/24. The Infection Preventionist nurse indicated, on 11/19/24, the resident representative texted her at home voicing concerns about the resident's dressing having peeled back on the edge and thought it needed changed. The Infection Preventionist nurse contacted the charge nurse at the facility and the dressing was changed. She was not sure if the PICC line dressing had been changed again before the resident was discharged to home. During an interview on 1/24/25 the ADNS (Assistant Director of Nursing Services) indicated the night shift nurses were responsible for changing IV/PICC line dressings. In the situation with Resident C, the nurse just forgot to re-write the order when the resident was admitted . On 1/22/25 at 12:05 p.m., the Infection Preventionist provided a Peripherally Inserted Central Catheter (PICC) management nurse policy and procedure-skills validation form, dated 9/2012, and indicated the form was the one currently being used by the facility. The nurse policy and procedure - validation form indicated, All PICCs are maintained by nursing associates trained in the care and management .Dressing and securement device is to be changed every 7 days or PRN [pro re nata -as the situation arises] using sterile technique .PICC insertion site should be assessed every eight hours for signs of redness, edema, pain, drainage or venous cord [red or hard outline of vein tracing upward on upper arm] . This citation relates to Complaint IN00449240. 3.1-47(a)

Based on interview, observation, and record review, the facility failed to ensure residents' rooms and bathrooms were cleaned daily and the residents' shower rooms were kept clean and uncluttered for 3 of 4 shower rooms observed. This had the potential to affect 136 of 136 residents who resided in the facility. Findings include: During an interview Resident B's family member, on 7/9/24 at 10:36 a.m., indicated housekeeping services were not provided on a regular basis. On 7/10/24 at 10:17 a.m., Resident F's family member indicated she visited her husband daily. The resident's room and bathroom were not cleaned routinely. She had complained about the uncleaned room and bathroom previously, in March 2024, during a care plan meeting and had filed a grievance, on 6/3/2024, about the cleanliness of the resident's room. The next day, on 6/4/24, the room and bathroom were cleaned. Now, on the floor, there was dirt, dust, debris and the toilet in the bathroom was also dirty. Resident F and his roommate, Resident H, were bedridden and did not use the toilet, but occasionally the residents' wives used the toilet. It had been a couple of weeks since the room and bathroom had been cleaned. The resident's bed had food crumbs and dirt debris underneath his bed and on the floor throughout the resident's room and bathroom. The daily routine cleaning of the resident's room and bathroom would be nice. On 7/10/24 at 11:10 a.m., the Executive Director (ED) was observed mopping the 300-hallway. The ED indicated his floor technician had called in sick today and the ED had seen the 300-hallway had dust and debris on it, so he decided to mop it himself. The residents' rooms and bathrooms should be cleaned daily. Resident F's and Resident H's room and bathroom, on 7/10/24 at 11:59 a.m., were observed with paper debris and dust on the floor and under the beds and the toilet was not cleaned. On 7/10/24 at 12:32 p.m., Resident H and his wife were observed in the main dining room for the lunch meal. Resident H's wife indicated she visited with her husband daily and the resident's room and bathroom were not cleaned daily. During an interview with the Housekeeping Supervisor, on 7/10/24 at 2:55 p.m., she indicated housekeeping staff had no set schedule for cleaning, but each housekeeper had room assignments for every day. All the residents' rooms and bathrooms should be cleaned daily, but she did not have enough staff, with one housekeeper on vacation and two others had quit about three weeks ago. She had three new housekeepers coming on, but one just had started yesterday and the other two were still in processing. All the residents' rooms and bathrooms should be cleaned daily. On 7/1/24, she had spoken to the housekeeper for Resident F's and Resident H's room and there had been a miscommunication between the staff and the residents' room got missed for a couple of weeks and did not get cleaned. During an environmental tour with the Housekeeping Supervisor, on 7/10/24 at 3:15 p.m., the 200 front-hall shower room was observed crowded with 13 wheelchairs, a rolling walker, a bariatric toilet riser chair, a standard size toilet riser, soiled towels, and soiled wash cloths, with paper debris, dirt, soap suds, and standing water on the floor. The Housekeeping Supervisor indicated she was unsure why the shower room was so crowded with equipment. The night shift staff were supposed to clean and store the equipment appropriately and not store all the equipment in the shower room. Staff were supposed to take the soiled towels and washcloths to the soiled utility room after completing a resident's shower. The shower room should be cleaned, including swept and mopped daily. During an environmental tour with the Housekeeping Supervisor, on 7/10/24 at 3:24 p.m., the 200 back-hall shower room was observed messy with a used drinking cup at the sink, a dirty toilet, an overflowing trash container, paper debris and dirt on the floor throughout the shower room, a 2 oz bottle of shampoo, a container of clinical prevent silicone cream, a soiled towel, and a used soiled shower chair. The Housekeeping Supervisor indicated staff were supposed to clean the shower room daily, clean the shower chairs after each use, and should have bagged the used bath towel and placed the bag in the linen barrel container. On 7/10/24 at 3:32 p.m., during the environmental tour with the Housekeeping Supervisor, the 300-hall shower room was observed with paper debris and dirt on the shower room floor, a soiled with stool bariatric shower chair, a shower chair placed over the toilet, a soiled mirror, and 2 bottles of shampoo/body wash. The Housekeeping Supervisor indicated staff should have cleaned the shower chairs after every use and the floor should have been swept and mopped. She had deep-cleaned this shower room and the 200-hall back shower room herself, on 7/8/24. The shower room floor and shower stall were dirty and should have been cleaned, swept, and mopped daily. During the environmental tour with the Housekeeping Supervisor, on 7/10/24 at 3:41 p.m., the 400-hall shower room was observed with paper debris and dirt on the floor and an uncleaned toilet with brown smears on the toilet seat. The Housekeeping Supervisor indicated the housekeeping staff had not gotten to the 400-hall shower room today. On 7/10/24 at 3:56 p.m., during the environmental tour with the Housekeeping Supervisor, the 100-hall shower room was observed with a soiled and broken shower seat chair and was soiled with dirt and grime buildup around and on the toilet. The Housekeeping Supervisor, on 7/10/24 at 4:15 p.m., indicated she did not have a deep cleaning schedule for the shower rooms, but the housekeeping staff were assigned to clean daily the shower room along with their assigned residents' rooms listed on the daily hall cleaning assignment sheets. On 7/10/24 at 4:55 p.m., the ED indicated if a resident or family member had a concern, they could complete a grievance form, which are located at the front desk, at the nurses' stations, or tell a staff member who would complete a grievance form for them and share the concern with the Interdisciplinary leadership team (IDT). When the ED and IDT received a concern, they discussed the concern in the daily morning meetings and figured out a plan to resolve the concern and put a system in place to prevent the reoccurrence of the concern. During an interview, on 7/10/24 at 5:25 p.m., Resident J indicated the facility's shower rooms on the 200-hall were filthy dirty. She had been at the facility for three weeks and had been taking sink baths in her bathroom, because the shower rooms were so dirty and with dirty shower chairs, dirty floors. The shower rooms were unkept and not cleaned. Resident J was admitted to the facility with open wounds on her feet and did not want to risk an infection from the uncleaned shower rooms. A couple weeks ago, she was with the ED and told him how unkept and filthy the shower room was. Her room nor bathroom had not been cleaned in a couple of weeks. On 7/10/24 at 4:10 p.m., the Housekeeping Supervisor provided and identified an undated document as a current facility policy, titled Cleaning Guideline (And other pertinent guidelines). The policy indicated, .Daily Resident Rooms: .Clean and disinfect restroom, replenish soap paper towels and toilet tissue, clean/disinfect horizontal surfaces including commonly touch items, clean over bed light and bedside table, remove refuse/clean container/replace liner, sweep and mop floor vacuum carpet if applicable .(Each hall housekeeper should do a minimum of one resident room deep clean including disinfection of mattresses and bed frame per day to assure that all rooms have been deep cleaned each month. Quality control inspection checklist must be filled out and turned into supervisor. Missed rooms will be scheduled for the next day or as assigned) .Daily extra duties for resident rooms and all common areas: .Monday: High dust room including bathroom, wall hangings, TV's, and ceilings .Tuesday: Wipe down walls where apparent dirt, food debris, etc. is apparent, clean lower doors, clean refuse cans .Wednesday: Clean shelves and furniture (chairs) .Thursday: Wipe down cove base, edging and corner where accessible .Friday: Window treatments including window blinds, and clean/dust windowsill and heating a/c unit, dust personal effects .Monthly: Verify that all rooms have been deep cleaned .Bi-annually: All privacy curtains washed (or as visually soiled or after isolation precautions have ended). A log sheet should be made to validate completion This citation relates to complaint IN00438334. 3.1-9(a) 3.1-19(f)

Based on observation, interview, and record review, the facility failed to identify bruising timely and failed to accurately document a new skin area on her chest for 1 of 1 residents reviewed for hospice and end of life services (Resident 4). Findings include: On 2/19/24 at 11:50 a.m., Resident 4 was initially observed. There was a large irregularly shaped bruise on the middle of her left upper arm. It was dark purple and green, with a raised bump in the middle of the bruise. A second more faded bruise was observed on her upper left shoulder as well. Resident 4 indicated she did not know what happened, and it was a little tender as she touched the area. During an interview on 2/21/24 at 1:26 p.m., Unit Manager (UM) 28 indicated, any new skin issues, open areas or bruises should be documented in the Resident's record as a new skin event, and followed up with a progress note and wound referral. At that time, UM 28 reviewed Resident 4's record skin events and progress notes but indicated there was no documentation related to a bruise on her left arm. On 2/21/24 at 1:30 p.m., Resident 4 was observed with UM 28. Upon observation, UM 28 indicated she was not aware of the bruised area, and suspected it was from Resident 4 having leaned against her side rail. UM 28 indicated she would open a new skin event and have the Wound Nurse assess the area. On 2/21/24 at 1:34 a.m., Certified Nursing Aide (CNA) 32 entered Resident 4's room. CNA 32 indicated the resident had the bruise for several days and the Hospice nurse was in the day before and had noticed it too, but they did not know how Resident 4 got it. A hospice note dated 2/20/24 indicated, RN [Registered Nurse] assessment, hypotensive [low blood pressure] not eating, sleeping majority day, comfort meds order put in . The note lacked documentation of the bruised area to the resident's arm. Hospice notes from the previous visits on the 14th, 8th and 6th also lacked documentation of the bruised area on her arm. On 2/26/24 at 8:30 a.m., Resident 4 was observed with CNA 31. At that time, a new skin issue was noted on the middle of her chest. Resident 4 indicated her chest hurt from where she scratched it. The area was observed to be irregularly shaped, scratched raw and the wound edges were patchy and red. During an interview on 2/27/24 at 9:00 a.m., LPN 29 indicated she was not aware of a new skin issue on her back, just the raw area on her chest and preventative foam on her coccyx. On 2/27/24 at 9:03 a.m., a new skin event was reviewed with UM 28 indicated. The event indicated a new area to Resident 4's upper back. UM 28 indicated she had not seen the area, but it might have come from when the aides were turning or repositioning her. With Resident 4's permission her upper back was observed with UM 28. There were no skin issues noted. UM 28 indicated, the skin even must have been incorrectly documented and meant to have been an assessment of her chest. On 2/21/24 at 11:51 a.m., Resident 4's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, acute on chronic diastolic (congestive) heart failure, chronic respiratory failure with hypoxia (shortness of breath), permanent atrial fibrillation (irregular heart beat), occlusion and stenosis of right carotid artery, Bifascicular block (a bifascicular block delays or stops electrical signals between the left and right bundle branches of the heart (fascicles) which affects the heart's lower pumping chambers (ventricles), and causes it to pump too slowly or out of rhythm (arrhythmia), and pulmonary hypertension (high blood pressure). The most recent comprehensive Minimum Data Set (MDS) assessment was a significant change MDS dated [DATE]. The MDS indicated, Resident 4 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15. A review of Resident 4's Hospice binder, scanned in Hospice notes, Events, Observations and nursing progress notes, lacked documentation of the bruise to her left arm and shoulder. A new skin event dated, 2/26/24 at 8:18 p.m., indicated, cleanse skin tear to right upper back with normal saline, pat dry and apply xeroform and cover with bordered gauze dressing. On 2/22/24 at 9:15 a.m., the Executive Director (ED) provided a copy of current facility policy titled, Skin Management Program, revised 2/2022. The policy indicated, It is the policy of American Senior Communities to ensure that each resident receives care, consistent with professional standards of practice . procedure for wound prevention . Any skin alteration noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin altercations by the direct caregivers on the shift reported . the wound nurse/designee will be notified of altercations in skin integrity . the wound nurse/designee will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day 3.1-37(a)

Based on observation and interview, the facility failed to properly label medications with dates when they were opened and failed to dispose of expired insulin for 3 of 5 medication room observed and 3 of 6 medication carts observed. Findings include: 1. On [DATE] 10:01 a.m., RN 27 provided an escort to check medication rooms and medication carts for labeling and dating of medications. Upon observation of the 200 Front medication room, a bottle of tuberculin serum was found rolling around in the door of the refrigerator. The multi-dose vial lacked a date to indicate when it was opened. 2. On [DATE] at 10:12 a.m., the 300-medication cart was observed. a. Resident 17 had a bottle of refresh eye drops (a lubricant for the eyes). The bottle was not opened and a label on the bottle indicated to refrigerate. b. Resident 96 had a bottle of ipratropium 0.3% spray for the nose (used for runny and nasal stuffiness) lacked a date when opened. c. Resident 72 had a bottle of fluticasone prop 50 mcg spray (used for allergies). It lacked a date to indicate when it was opened. d. Resident 52 had a bottle of erythromycin 0.5% eye drops (an antibiotic for the eye). It lacked a date to indicate when it was opened. e. Resident 25 had a bottle of prednisolone ac 1% eye drops (used for inflammation of the eye). It lacked a date to indicate when it was opened. 3. On [DATE] at 10:30 a.m., the 200 back-hall-medication cart was observed. a. Resident 117 had an insulin pen, glargine-yfg 100 unit/ml (used for diabetes). It was dated [DATE] and was in use longer than the expiration date. b. Resident 61 had an inhaler, anoro ellipta, 62XXX,d+[DATE]mcg 700SE (used for breathing problems) on the medication cart with no dated to indicate when it was opened. c. Resident 74 had an albuterol suf hfa 90mcg inhaler (used for breathing problems lacked a date to indicate when it was opened. d. Resident 28 had trelegy ellipta ,d+[DATE]XXX,d+[DATE] inhaler (used was present and lacked a date to indicate when it was opened. 4. On [DATE] at 10:50 a.m., the 400 B hall-medication cart was observed. a. Resident 23 had anor ellipta 62XXX,d+[DATE]mcg inhaler on the medication cart. It lacked a date to indicate when it was opened. b. Resident 2 had albuterol suf hfa 90mcg on the medication cart. It lacked a date to indicate when it was opened. A policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, was provided by the RCS (Regional Clinical Support) on [DATE] at 10:50 a.m. The policy indicated, .Once any medication or biological package it opened, facility should follow manufacturer/supplier guidelines with respect to expiration dated for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](n)

Based on observation, interview, and record review, the facility failed to ensure medications and wound cleanser were secure and not found in an unlocked memory care (MC) linen closet for 18 of 28 residents who resided in the MC unit. The facility failed to ensure medications were not found in resident's rooms without self-administration assessments for 4 of 4 residents reviewed for self-administration assessments (Resident 27, 68, 190, and 88). Findings include: 1 On 2/19/24 at 10:34 a.m., the MC linen closet was observed to be unlocked. Unlabeled and opened containers of nystatin topical powder (treats fungal skin infections), Calmoseptine (barrier skin cream), and an almost full 8 ounce bottle of wound cleanser were found in the room. On 2/19/24 at 11:00 a.m., Licensed Practical Nurse (LPN) 9 indicated the MC linen closet should have been locked. She indicated the nystatin powder, Calmoseptine, and wound cleanser should have been locked up because a memory care resident could have come in the linen closet and ingest it. She indicated they should have been thrown away because they were not labeled with resident's name. On 2/21/24 at 10:51 a.m., Resident 84 and Resident 76 were observed to be wandering in the MC unit. On 2/21/24 at 12:00 p.m., the MCSS provided care plans for MC residents who wander. The intrusively wandering care plans included: Residents 105, 56, 84, 69, 89, 42, and 76. The residents with wandering care plans included: Residents 43, 132, 71, 114, 116, 147, 130, 26, 44, 83, and 112. On 2/22/24 at 11:17 a.m., the Memory Care Support Specialist (MCSS) indicated he did not know for whom the nystatin powder and Calmoseptine was ordered. He indicated every door with a key pad should have been locked, including the linen closet. The current resident's hygiene bins were kept in the supply room in the spa. A month ago, hygiene bins were reorganized. On 2/23/24 at 1:40 p.m., the Director of Nursing (DON) indicated the expectation was for the doors to be locked in MC. 2. On 2/23/24 10:54 a.m., Resident 27's and Resident 68's prescription medications were observed in Resident 27's room on a table against the wall. Resident 27's prescription medication was a zinc oxide paste skin protectant, with no resident name, label, or pharmacy information. Resident 68's prescription medication, dated 1/22/24, was hydrophilic wound dressing. The prescription label indicated it was Triad Wound Dressing Paste. The tube was observed to be almost empty. Her orders were reviewed. Barrier cream to buttocks every shift, as needed. Her skin care assessment indicated there were no wound types identified. On 2/23/24 at 11:12 a.m., Resident 68 indicated she was admitted on [DATE]. She indicated she had no skin treatments or skin conditions. She was not aware of a prescription for Triad wound care paste. Her orders were reviewed: Triad Wound Dressing, apply a thin layer to the buttocks, every shift. Her skin care assessment indicated there were no wound types identified. On 2/23/24 at 11:26 a.m., Licensed Practical Nurse (LPN) and Certified Wound Care nurse (WCC) 10 indicated the house barrier cream was zinc oxide paste and should have had Resident 27's name on it. She indicated the Triad Wound cream for Resident 68 should not have been in Resident 27's room. She indicated she was confused because Resident 68 was not on Triad Wound cream. On 2/23/24 at 11:29 a.m., WCC 10 indicated Resident 27's Triad Wound cream was discontinued on 2/15/24 and started on barrier cream. The Triad cream should not have been in her room. She would order for Resident 68 a tube of Triad Wound cream since it was physician ordered. She would get a new container of barrier cream for Resident 27. On 2/23/24 at 11:39 a.m., Registered Nurse (RN) 24 indicated he did not apply any cream found in her room to Resident 27 and both creams should have been locked up in the treatment cart. On 2/23/24 at 1:41 p.m., the Director of Nursing (DON) the medications should have been kept in a secure location. 3 On 2/19/24 at 2:29 p.m., two eye medications were observed in Resident 190's room. She indicated the print was so small she was unable to read the labels. The bottles were observed to be shaped differently. The eye drop medications were BromSite (for treatment of inflammation and prevention of pain in patients undergoing cataract surgery) and Systane (treats dry, irritated eyes). Her medical record was reviewed. She had a physician's order for Systane, one drop in both eyes daily. She did not have an order for BromSite. She did not have a self-administration assessment or care plan for BromSite or Systane. On 2/22/24 at 10:35 a.m., BromSite and Systane were observed to still be in her room. On 2/22/24 10:36 a.m., the Regional Clinical Support indicated she did not know Resident 190 had medications in her room. The resident did not have an order for BromSite or a self-administration assessment for either medication. She would go into her room and collect the medications. On 2/26/24 at 12:13 p.m., Resident 190 record was reviewed. A physician's order, dated 2/22/24, BromSite, give 1 drop in each eye daily. A care plan, dated 2/22/24, indicated Resident 190 chose to self-administer BromSite eye drops with a goal for her a safely self-administer the medication. A self-administration assessment, dated 2/22/24, indicated it was safe for her to administer BromSite and systane. On 2/23/24 at 1:41 p.m., the DON indicated the staff should be following the self-administration policy. 49890 4. On 2/19/24 at 10:43 a.m., Resident 88's room was observed through the open door. A bottle of 3 milligram (mg) Melatonin tablets (used to treat insomnia) were observed on the Resident's bedside table, unsecured and unsupervised. On 2/19/24 at 11:15 a.m., Resident 88's room was observed. The bottle of Melatonin remained unattended at bedside. On 2/19/24 at 11:00 a.m., Resident 88's medical record was reviewed. Resident 88 was a long-term care resident who had diagnoses which included, but were not limited to, myasthenia gravis (an autoimmune disorder resulting in muscle weakness), Parkinson's disease (a nervous system disorder resulting in tremors and weakness), and insomnia. Resident 88's comprehensive care plans were reviewed and lacked provisions to include his preference and/or ability to store his own medications at bedside. Resident 88 did not have a current physician order to store and/or administer his own medication. The record lacked documentation of a self-medication administration assessment. During an interview on 2/19/24 at 11:33 a.m., the Director of Nursing (DON) indicated, Resident 88 should not have a bottle of Melatonin at his bedside and the Melatonin bottle had been removed by a licensed staff member. A current policy, titled, Storage and Expiration Dating of Medications, Biologicals, dated 7/21/22, was provided by the Executive Director (ED), on 2/23/24 at 8:55 a.m. A review of the policy indicated, Facility should ensure that only authorized Facility staff .should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas . On 2/23/24 at 8:55 a.m., the Executive Director (ED) provided a copy of the current facility policy titled, 5.3 Storage and Expiration Dating of Medications and Biologicals, revised 7/21/22. The policy indicated, Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. The facility should store bedside medications or biologicals in a locked compartment within the resident's room. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident, (Resident 70) who had recent medication adjustments and fluctuating blood pressures, received timely documentation from his Dialysis center after treatment sessions to ensure continuity of and to prevent the potential for complications related to post-Dialysis change of condition for 1 of 1 resident reviewed for Dialysis. Findings include: On 2/22/24 at 10:12 a.m., Resident 70's medical record was reviewed. He was a long-term care resident who had diagnoses which included, but were not limited to, end-stage renal disease and was dependent on renal dialysis and hypertensive heart disease. Resident 70's nursing progress notes were reviewed and revealed recurrent fluctuating blood pressures and the need for administration of as needed medications (PRN), which included, but were not limited to: a. 1/10/24 at 3:25 a.m., Resident BP checked and was at 179/106. PRN clonidine administered. Writer re-checked BP later and was 154/96. Resident stable and resting at this time. Will continue to monitor progress b. 1/15/24 at 3:26 a.m., Resident BP checked was at 168/105, Clonidine 0.1 mg was administered to good effect, same re-checked was at 147/85, resident is resting in his room c. 1/26/24 at 10:36 p.m., This evening's blood pressure reading was 126 / 82 d. 1/31/24 at 10:24 p.m., This evening Blood Pressure: 93 / 58 e. 2/2/24 at 6:09 a.m., the Qualified Medication Aide [QMA] called writer due to Resident's blood pressure [BP] was 195/116, writer reassessed Resident and noted BP to be lower but still high, PRN clonidine administered. BP re-checked an hour later and BP back down to 147 / 67 f. 2/3/24 at 12:05 a.m., BP was 195/92. Administered clonidine as ordered PRN and effective for reducing BP to 142/86 g. 2/6/24 at 10:26 p.m., The Resident continues care with continuous blood pressure monitoring after clonidine 0.1 milligram [mg] administration, close vitals are measured every hour, the initial blood pressure was 182/94, dropped to 172/96 . The recent blood pressure is 143/100. The Resident is stable and does not show any concern h. 2/21/24at 9:27 a.m., The Resident's vital signs were taken for his dialysis appt and was at 195/105 on his right arm, he was sitting and at rest at 9:05 a.m., PRN Clonidine 0.1 mg was given per PRN orders. BP rechecked at 9:17 a.m. and was 182/99. No chest pain, SOB, dizziness, headaches A nursing progress note, dated 7/19/23 at 8:34 p.m., indicated, .Resident returned from dialysis center at 5 p.m. with his communication binder not filled out. Informed the Unit Manager about this and she will reach out tomorrow to the center During an interview on 2/22/24 at 10:41 a.m., Registered Nurse (RN) 35 indicated, facility staff should contact the dialysis center if Resident 70 returned without his log filled out, then follow up with a progress note. Resident 70's Dialysis Event Logs was reviewed for the month of February and revealed the following: An Event was opened on the 5th but lacked documentation of a return assessment. The record lacked documentation of Dialysis Event assessments for the following days; the 2nd, 7th, 9th, 14th, 16th, and 21st. Resident 70's Dialysis binder was reviewed for the month of February and revealed, the Communication Tool had not filled out upon the completion of his Dialysis session by the Dialysis Nurse for the following dates: the 2nd, 5th, 12th, 14th and the 21st. The record lacked documentation that the facility's receiving nurse contacted the Dialysis center for follow up. During an interview on 2/22/24 at 1:03 p.m., the Director of Nursing (DON) indicated they had been having trouble getting the Dialysis center to fill out his post Dialysis logs. At that time, the Medical Record Coordinator (MRC) just called about once a week, or at the end of the month to request a copy of his full Run-Sheets to be faxed over and scanned in. Resident 70's scanned in Run-Sheets were reviewed. There were no scanned in Run-Sheets for the month of February. The latest set of Run-Sheets was from the month of January and included the following out of range observations: On 1/3/24 an out-of-range pre-BP was recorded at 189/104, his post weight was recorded out-of-range at 73.4 Kilograms (KG) and an out-of-range Interdialytic weight gain (IDWG- the result of salt and water intake between hemodialysis sessions). On 1/5/23 an out-of-range post-BP was recorded at 162/94. On 1/8/24 an out-of-range pre-BP was 182/106 and his post-BP was out-of-range at 162/91. On 1/10/24 an out-of-range pre-BP was 185/106. On 1/17/24 his post-weight was out-of-range at 71.0 KG. On 1/19/24 an out-of-range pre-BP was recorded at 196/97 and his post-BP was 177/93. On 2/22/24 at 2:45 p.m., the DON provided a copy of current facility policy titled, Dialysis Care, revised 11/2017. The policy indicated, .ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility . ongoing assessment and oversight of the resident before, during and after dialysis treatments for complications . ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . A dialysis even will be initiated in EMR [electronic medical record] to include time of transfer and completed on return to the unit . the nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide appropriate hand hygiene while assisting residents with eating for 2 of 2 days of dining observations. (Resident 44, 89, 42, 76, 110, 84, 42, and 56). Findings include: On 2/19/24 at 12:33 p.m., Qualified Medication Aide (QMA) 14 was observed to cut up Resident 95's food, did not wash or gel her hands and provided food for Resident 44. On 2/19/24 at 12:35 p.m., the Memory Care Support Specialist (MCSS) was observed to move a dining room chair with his bare hands, did not wash or gel his hands, and provided food and cut-up food for Resident 89. On 2/19/24 at 12:36 p.m., QMA 14 provided Resident 42's food, she did not wash or gel her hands, and provided food for Resident 76, and without washing or gelling her hands, provided food for Resident 110. On 2/19/24 at 12:46 p.m., Licensed Practical Nursing (LPN) 16 pulled up a dining room chair with her bare hands, did not wash or gel her hands, then assisted Resident 84 with eating. On 2/19/24 at 12:51 p.m., QMA 14 left the dining room table while assisting Resident 42 with eating. When she returned to the table, she pulled the dining room chair up to the table with her bare hands, did not wash or gel and continued to assist Resident 42 with eating. On 2/19/24 at 12:57 p.m., Certified Nursing Aide (CNA) 15 left the dining room table while assisting Resident76 with eating. When she returned to the table, she pulled the dining room chair up to the table with her bare hands, did not wash or gel and continued to assist Resident 76 with eating, On 2/19/24 at 1:01 p.m., LPN 16 completed assisting Resident 84 with eating, she did not wash or gel, then provided a drink to Resident 56. On 2/20/24 at 12:33 p.m., QMA 17 was observed to pull up a dining room chair to the table with her bare hands. She did not wash or gel her hands before assisting Resident 110 with eating. She left the table and returned with two straws, she put one straw in an unidentified resident's drink and provided one for Resident 110. On 2/22/24 at 11:20 a.m., the MCSS indicated his expectation was for the staff to keep their hands clean. They should use their foot to pull the chair up to the table. On 2/23/24 at 1:45 p.m., the Director of Nursing (DON) indicated if the staff contaminated their hands, they should perform hand hygiene. A current policy, titled, Hand Hygiene Policy, dated 12/2021, was provided by the Executive Director (ED), on 2/23/24 at 8:55 a.m. A review of the policy indicated, .to provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees .Healthcare personnel should sue an alcohol-based hand rub or wash with soap and water for the following clinical indications .immediately before touching a resident .after touching a resident or the resident's immediate environment 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure all mechanical equipment was kept in safe operating condition for 1 of 1 observation of the laundry service area. Findings include: On 2/23/24 at 11:00 a.m., during a routine observation of the laundry service area, soiled linen was in an uncovered barrel. Housekeeping Supervisor acknowledged all soiled linen was to be covered. Clean clothes were bagged and lying on the floor in the soiled linen area. The Housekeeping Supervisor indicated the items were clothes which had been placed there by the nurse aides and the clothing needed to be labeled. She indicated it was ok for the linen to be on the floor because it was in bags. A laundry rack containing clean unbagged linens was uncovered. Observation of the dryer lint traps indicated dryer number 3 had a minimal amount of lint. Dryers number 1 and 2 contained a large amount of lint in the lint traps. Review of the lint trap cleaning log dated, February 2024, lacked documentation of cleaning from 1am to time of observation. The housekeeping Supervisor acknowledged the documentation log was not completed for 2/23/24. Housekeeping aide 22 indicated the laundry personnel cleaned dryer vents every hour. Housekeeper 23 indicated she had cleaned the dryer vents at 6:00 a.m. on 2/23/24 and acknowledged she had not signed the log as being completed. On 2/23/2024 at 12:16 p.m., the Infection Preventionist Nurse (IP Nurse) provided a document titled, Laundry/Linen, dated 2/2012, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .To ensure the proper care and handling of linen and laundry to prevent the spread of infection, in resident -care areas and in the laundry facility .3. Laundry area: General .e. Scheduled daily cleaning (laundry staff) and routine cleaning (housekeeping) .4. Laundry area: Soiled linen .b. Keep soiled linen covered in container until ready to load into machine .Cover clean linen carts/racks On 2/23/2024 at 12:17 p.m., the IP Nurse provided a document, titled, Safety -Dryer Operation dated 8/17 and revised on 12/21, and indicated it was the policy currently being used by the facility. The policy indicated, .Lint screens must be cleaned after EVERY load, or hourly, under normal shift operation. Lint trap logs filled out accordingly and retained by supervisor 3.1-19(bb)

A. Based on observation, interview, and record review, the facility failed to ensure a resident was assessed prior to being moved after a fall and failed to ensure appropriate first aide after an accident on the facility bus for 1 for 3 residents reviewed for falls (Resident B). B. Based on interview and record review, the facility failed to get an x-ray in a timely manner for 1 for 3 residents reviewed for falls (Resident D). Findings include: A. On [DATE] at 10:03 a.m., Resident B's record was reviewed. His diagnoses included, but were not limited to, complication of vascular prosthetic device, presence of artificial heart valve, myocardial infarction (heart attack), chronic kidney disease, chronic osteomyelitis (bone infection), cirrhosis of liver (progressive liver disease), tobacco use, and hypertension (high blood pressure). His anticoagulant medications included aspirin 81 milligrams (mg) daily due to vascular prosthetic device, clopidogrel 75 mg tablet daily due to presence of prosthetic heart valve, and enoxaparin 40 mg daily injection. A fall care plan goal, target dated [DATE], indicated the goal would be for Resident B's fall risk factors to be reduced in an attempt to avoid significant fall related injury. The facility Medical Director note, dated [DATE], indicated Resident B had a complex medical history prior to coming to the facility. He was on IV antibiotics due to a post-surgical infection acquired in the hospital. A nursing progress note, on [DATE] at 2:15 p.m., the Wound Care Coordinator (WCC) 5 indicated Resident B was in route to the facility from a physician's appointment. Resident B fell forward out of the wheelchair and landed on his hands and knees on the bus floor. The fall was witnessed by the bus driver. Resident B and Bus Driver 7 both indicated he did not hit his head. First aide was provided, and Resident B was assisted getting back into his wheelchair. The WCC 5 assessed Resident B upon his arrival to the facility He was alert and oriented x 3 (person, place, and time). He was able to provide a verbal statement of the incident. He sustained the following injuries: hematoma with skin tears to the left elbow, skin tear to his left pinky finger, skin tear with bruising to his right thumb, skin tear with bruising to right posterior forearm, and bruising to the right elbow. Resident B voiced discomfort to his left elbow, he stated pain was from the bruising. An elbow sling was provided to his left arm as a precaution. He continued to move his left arm despite being educated to keep it immobile. First aide was provided on the facility bus after the incident by the bus driver. WCC 5 removed the dressings placed by the bus driver and cleansed the skin tears. Steri-strips were applied and wrapped with kerlix and secured in place. The family was notified of the incident and requested Resident B be sent to the emergency room (ER) for evaluation. He was transported by a local ambulance company. His physician was notified. An Interdisciplinary Team (IDT) note, dated [DATE] at 1:05 p.m., was written by the Assistant Director of Nursing (ADON). She indicated Resident B had new wound/skin injury on his right elbow with bruising and skin tear 3 centimeters (cm) by (x) 3 cm. Skin tear to his right posterior forearm of 5 cm x 2 cm. A skin tear to his right thumb 5 cm x 2.5 cm. His left pinky finger was 2 cm x 1.5 cm. A skin tear with hematoma (bruise) to his left elbow of 12 cm x 8 cm. His left elbow was swollen, and he was in pain. She indicated his seat belt was applied per facility staff on the bus. The IDT determination was Resident B removed his seat belt while he was being transported on the bus. He fell forward from his wheelchair when the bus came to a stop. Resident B was educated on not removing his seat belt mid-transfer. First aide was administered at the time of his injuries, then Resident B was sent to the ER for evaluation and treatment per family request. The resident, his family members, and his physician/nurse practitioner were notified. A second IDT note with further information, dated [DATE] at 2:00 p.m., indicated Resident B was admitted to the hospital. Resident B's hospital records, dated [DATE], were reviewed. ER documents indicated Resident B arrived with multiple abrasions and skin tears throughout bilateral forearms and fingers. Resident had a S4 sacral fracture and a forearm laceration. The ER documents indicated a laceration repair, location not indicated, on [DATE] at 11:55 a.m., where an 8 cm simple, macerated (softened skin tissue due to a dressing) wound was reapproximated (brought together) with 7 sutures. During an interview, on [DATE] at 10:30 a.m., the Transportation Coordinator indicated she scheduled all resident's needs for transportation. She indicated her office was right behind the receptionist area. When the receptionist received a call about Resident B being injured on the bus due to a fall after a sudden stop, she told Bus Driver 7 to call 911 immediately. Bus Driver 7 should have called 911 and waited for them to arrive, then the resident could have refused care from EMS. The Transportation Coordinator indicated she was CPR (cardiopulmonary resuscitation) and First Aide certified and her knowledge was to call 911 and not to move the resident. She indicated Resident B refused emergency services, and asked Bus Driver 7 to not call 911. Bus Driver 7 indicated Resident B was bleeding. Again, Resident B refused 911 services. She told Bus Driver 7 to get the first aid kit and wrap him up the best you can, bring him back to the facility, and the wound nurse would be on standby to receive him. The Transportation Coordinator observed Resident B was in his locked and anchored wheelchair with his safety belt on his waist and across his chest. Resident B was bleeding from his arms. Resident B appeared relaxed, he did not moan or groan, the only thing he said was he wanted off the bus. The Wound Care Coordinator (WCC) 5 did not come on the bus to assess the resident before Bus Driver 7 and the Transportation Coordinator moved him into the facility. Resident B was asking for his phone. It was found on the floor of the bus. Resident B was moved into the facility as WCC 5 was arriving at the front of the building. The Transportation Coordinator indicated she probably should have left Resident B in place on the bus and let the WCC 5 nurse enter the van to access him. She indicated that after Resident B was being taken care of by WCC 5. She went out with Bus Driver 7 to clean up the bus. There was a lot of blood. Resident B had quite a few wounds. During an interview, on [DATE] at 11:42 a.m., WCC 5 indicated she was notified by the Director of Nursing (DON) that a resident was injured on the facility bus. She grabbed immediate items she would need to care for his wounds: 4 x 4 gauze, kerlix, saline, wound cleanser, skin prep, and steri-strips. Resident B met her at the front door. She did not know the resident had had a fall, the DON indicated the resident was injured on the bus and wound need wound care. She immediately accessed him at the entrance. She was alerted the resident fell out of the wheelchair. The most of his injuries were on the left arm. She removed the gauze and kerlix dressings. She didn't know how many dressings were removed. His wounds were measured on his bilateral (both) arms, cleansed, and she applied steri-strips and dry dressings. A hematoma on his left arm was in the elbow region. He had other bruising, mostly on his bilateral arms, but had some bruising on a hand. He was provided a left arm sling and probably needed an x-ray. Once she was finished with the dressings. She did a full assessment of his range of motion (ROM) and a neurological assessment. During an interview, on [DATE] at 12:20 p.m., Bus Driver 7 indicated he was the only bus driver on [DATE]. The Bus Driver 7 indicated he had a green light and had to make a sudden stop because just before an ambulance entered the intersection, it flipped on its red lights and sirens. He made an abrupt stop and swerved. He heard something go boom. He immediately turned around and Resident B was on the floor of the bus. He rushed back to him and said he was going to call 911. Resident B refused the offer of 911 twice. He observed blood on Resident B. The resident indicated to just let me lay here because it took 2 staff members to move him. Bus Driver 7 indicated to the resident he was strong enough to lift him. The resident used his legs, and they took baby steps to get to the wheelchair. He moved the resident into the wheelchair and the chair did not move at all. After the resident was in the wheelchair, Bus Driver 7 called his boss, Activity Director (AD) 11. She indicated for him to call 911 and get the resident to the hospital. Bus Driver 7 asked the resident if he could take him directly to the ER since he did not want an ambulance because he needed checked out. He offered to take him to the hospital twice. Resident B refused all attempts at EMS and ER care. Bus Driver 7 indicated there was a lot of blood. The resident had a lot of blood on himself and Bus Driver 7. Resident B indicated he was okay. The resident's main focus was to get him back to the facility. Bus Driver 7 managed Resident B's wounds by using the gauze from the first aid kit. He covered the wounds to stop the bleeding. He indicated he had the first aid classes. His main thought was to stop the bleeding. He was nervous but saw no bruises on Resident B's face and didn't feel like he needed to call 911. He put the dressings on Resident B while he was down on the bus floor because he was bleeding furiously. During an interview, on [DATE] at 2:50 p.m., the DON indicated the Executive Director (ED) called her to indicate Resident B had an accident on the bus. He was refusing to go to the hospital He had injures on his arms and skin tears. The facility bus was bringing him back here to the facility. In general terms, he was okay and was talking. The DON called WCC 5 and had her meet the resident up at the front of the facility. She called the family members but was unable to reach either of them. During an interview, on [DATE] at 8:38 a.m., Licensed Practical Nurse (LPN) 9 indicated Resident B was non-compliant. On [DATE], WCC 5 rolled Resident B to the nurses' station. He was still bleeding from the elbow. He had blood on his clothes and elbow. He was on a video call with his family. He told his family he was in an accident and the family wanted him to go to the ER. The resident was only on the unit for about 5 minutes, in that time LPN 9 gave him an oxycodone 5 mg tablet because he said he was in pain. He indicated he was aching all over and in excruciating pain. During a second interview, [DATE] at 11:13 a.m., Bus Driver 7 indicated to lift the Resident he got behind him and put his arms under Resident B's arms and wrapped them around his shoulders. Bus Driver 7 indicated he sat in the wheelchair first, asked the resident to raise his legs up, and told him to push up. Bus Driver 7 pivoted and was able to get Resident B into the chair. It took three attempts to get him in the chair. He buckled him because he knew the wheelchair was stable. Bus Driver 7 indicated he did not remember all of the transportation policy. On [DATE] at 9:49 a.m., the ED provided Bus Driver 7's First Aid CPR AED certification. The certificate indicated it expired ,d+[DATE]. The ED indicated the First Aid did not expire. Bus Driver 7 was CPR and First Aide trained prior to coming to the facility. During an interview, on [DATE] at 10:16 a.m., the AD 11 indicated bus drivers were shown how to use the First Aid kit. She told them to get gauze out, and always elevate the wounds. Bus Driver 7 called her and told her Resident B slid out of his wheelchair. Bus Driver 7 indicated he did not want 911. She told him to get the first aid kit, apply pressure to the area of the arm. Bus Driver 7 indicated he had spoken with Receptionist 10, and he needed nursing at the front of the building. The WCC 5 texted her and indicated she was going to take care of it. She indicated she did not keep up with CPR and First Aide certification for bus drivers. On [DATE] at 11:02 a.m., the AD 11 provided more information regarding the first aide training she provided for the bus drivers. It indicated the location of the first aid kit. Items inside and how to use them, like sterile bandages for applying pressure and the Stop the Bleed kit, with the instructions inside the kit. On [DATE] at 11:20 a.m., a bus driver job description was provided by the ED. It indicated, .The Bus Driver has a primary responsibility with ensuring the health, safety and welfare of the residents while transporting to and from activities outside the community .CPR and First Aide certification preferred On [DATE] at 3:08 p.m., the DON indicated if there was an injured on the facility bus, they should be directed to seek EMS, in conjunction with and honoring the resident's rights. A current policy, titled, ASC Facility Bus/Van Transportation Guidelines, dated ,d+[DATE], was provided by the ADON, on [DATE] at 9:04 a.m. A review of the document indicated, .Seat belt are required to be worn by driver and passenger(s) .911 must be called immediately for any resident requiring medical attention .Any injury must be reported to the facility ED/DNS immediately A current policy, titled, Resident Rights, dated ,d+[DATE], was provided by the ADON, on [DATE] at 9:04 a.m. A review of the document indicated, .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, wellbeing, and proper delivery of care B. On [DATE] at 10:53 a.m., Resident D's record was reviewed. Her diagnoses included, but were not limited to, Alzheimer's disease (degeneration of the brain), dementia (persistent loss of intellectual function), and hypertension (high blood pressure). Her Brief Interview of Mental Status (BIMS) score indicated she had severely impaired cognition. A fall care plan, dated [DATE], indicated Resident D was at risk for falls due to a history of falls, age, and high risk medication use. The interventions were reviewed. No new intervention was added after the [DATE] fall with left femur (thigh bone) fracture as advised by the IDT progress note, dated [DATE] at 2:09 p.m. A hospice care plan, dated [DATE], indicated Resident D required hospice and would experience death with dignity and physical comfort as the disease allowed. A nursing progress note, dated [DATE] at 12:06 p.m., indicated at approximately 8:20 a.m., Resident D was noted to be lying on her left side on the floor yelling out for help. The resident had been trying to self-transfer from her bed to her wheelchair. Resident D immediately complained of left hip pain. Pain was noted with passive range of motion, no bruising was noted. Skin tears observed to left pinky finger and ring finger knuckle. The Director of Nursing (DON) and hospice made aware. The resident's family was made aware. A new order for Morphine 20 mg/mL (milligram per milliliter) oral concentrate indicated to give 0.25 milliliters (mL) by mouth every 4 hours as needed for pain or shortness of breath. An x-ray was ordered by hospice for her left upper leg and hip. Her x-ray was not performed during this shift. Scheduled Tylenol was administered. A nursing progress note, dated [DATE] at 11:40 a.m., indicated her left upper leg and hip x-ray had not been performed during this shift. Per hospice they used their own radiologist who would perform the imaging. A nursing progress note, dated [DATE] at 10:45 p.m., more than 38 hours after Resident D's fall, indicated the x-ray technician came in for the hip film. The interpretation was still pending. An Interdisciplinary Team (IDT) progress note, dated [DATE] at 2:09 p.m., indicated the x-ray results were received and showed an acute left femoral fracture. The physician and family were notified. The resident was not sent to the ER for evaluation and treatment. Short term interventions were put in place at the time of the fall: Assist resident with a.m. care, position for comfort, and offer and assist resident to get up before the breakfast meal was served. Orders and care plan updated. A nursing progress note, dated [DATE] at 2:06 a.m., indicated the fall intervention were in place per plan of care. A nursing progress note, dated [DATE] at 1:46 p.m., indicated the hospice nurse gave a new order for Norco (narcotic pain reliever) ,d+[DATE] mg scheduled every 6 hours. On [DATE] at 9:59 a.m., the DON indicated Resident D did not get her care plan updated because after her fall, the risk factor of why she fell were eliminated. After her fall on [DATE], she became bedfast (confine to bed) because of the femur fracture. At an unknown date and time, the Assistant Director of Nursing (ADON) indicated, regarding the delay in Resident D's x-ray, the facility had made a procedural change. The facility was to get their own x-rays. Hospice could get their own x-ray too. A current policy, titled, IDT Comprehensive Care Plan Policy, dated ,d+[DATE], was provided by the ADON, on [DATE] at 10:33 a.m. A review of the document indicated, .Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input A current policy, titled, Fall management Policy, dated ,d+[DATE], was provided by the ADON, on [DATE] at 10:33 a.m. A review of the document indicated, .A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate intervention This Federal tag related to Complaint IN00410354. 3XXX,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to assess, notify of change of conditions, and ensure emergency medical attention was provided for 2 residents with significant head injuries after falls resulting in altered mental status, pain, change of conditions, and death for 2 of 3 residents reviewed for quality of care (Resident E and Resident B). The immediate jeopardy began on [DATE], when Resident E fell and sustained immediate injuries of a laceration and hematoma to his forehead, skin tears on his knees, and pain in his neck. Resident E was moved to his bed after the fall, and later transferred a second time to go outside for a visit and then back to his bed. The record lacked documentation of both a skin assessment and pain assessment after his fall. The record lacked documentation the physician had been notified when Resident E began to have trouble swallowing and made choking/gurgling sounds on [DATE]. He was not transferred for emergency medical treatment until [DATE] when his family insisted 911 be called to treat his uncontrolled neck pain and he had become unresponsive and only groaned in pain. EMS (emergency medical services) arrived at 1:17 p.m. and determined his injuries required upgraded services and he was rerouted to the nearest trauma hospital. Resident E had agonal breathing (reflexive breathing when the brain was not getting enough oxygen and usually indicated when someone was close to death) upon arrival to the hospital triage department and died at 2:06 p.m. as a result of the injuries sustained from the fall. A CT scan indicated he had sustained a severe hyperextension neck fracture at his C4-Cervical Spine. On [DATE] at 4:30 a.m., Resident B rolled off the bed during care and sustained a large laceration on the forehead which continued to bleed significantly. When a hospice nurse arrived at 10:56 a.m., the bleeding continued and did not stop after 20 minutes of pressure. Resident B had a change in neurological condition and went from being able to speak in sentences to only ,d+[DATE]-word answers. EMS was called to send her to the ER (emergency room ), but the facility indicated bleeding had stopped, and it was not necessary for her to be sent out. Resident B, who had previously been on hospice, but not actively dying transitioned to active death beginning on [DATE] and died on [DATE]. The Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) were notified of the Immediate jeopardy at 1:25 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During the survey a confidential interview indicated Resident E had been admitted to the facility for strengthening and rehabilitation after a recent hospital stay for an infection. He had only been at the facility a few days and was doing well, but he and his family were a little nervous about him getting in and out of bed because he was weak and unsteady on his feet. The family requested bed rails but had been told by the facility they could not put bed rails up because they would be considered a restraint. The family asked a second time about bed rails but was told they could only offer a mobility bar. On [DATE] the family was notified, Resident E had fallen that morning around 7:30 a.m., and bumped his head. Other than some bruises, he was fine and had been put to bed and rested comfortably. The family arrived around 1:00 p.m. and were surprised at the extent of his injuries. They asked him what happened. Resident E said he tried to get out of bed to go to the bathroom. He had a large bandage on his forehead, and his face was black and blue, but at that time, Resident E was responsive. He got out of bed and went to the front of the facility to sit outside for the visit. During the family visit, Resident E complained of his head and neck hurting, but the family had been assured by the Assistant Director of Nursing Services (ADNS), they would be able to control his pain at the facility. They gave him Tylenol and ordered some cream to rub on his neck. The family was unsure about leaving him overnight and stayed until visiting hours were over. Throughout the day he seemed to get more and more tired, and continued to complain of pain in his head and neck, but the ADNS continued to assure the family, the Medical Doctor (MD) was aware of his condition and would be in to see Resident E. The next morning, on [DATE], the family returned to visit Resident E around 11:00 a.m., and were shocked at his apparent decline. He no longer responded to questions, he kept holding his head, and moaned in pain, he would not eat or drink anything. The family insisted he be sent to the emergency room (ER) for pain control to keep him comfortable, but the ADNS insisted they should keep him in the facility, and he could get COVID if he went to the hospital. The family told the nurse to call 911. Even though Resident E had a Do Not Resuscitate (DNR) order, the family had chosen not to sign a do not send to hospital order so if something emergent happened he could be sent out for emergency medical attention. A confidential written statement, received during the survey, indicated they visited Resident E the day of, but after his fall. They brought him outside in the wheelchair to get some fresh air. He was in so much pain he kept holding his head and neck. You could also hear fluid in his lungs as well. I got him a milkshake which he loves, and he barely had any of it. I asked the nurse if it was normal for him to sound this way and she told me, 'Tell him he just needs to cough harder, and he'll feel better.' No matter how hard he tried to cough, it was not making anything better. As I sat with him outside, he hunched over, and to be honest I thought he had passed away then. I went in to get the nurse [ADNS] and she said, 'he's fine let's get him back into his room and lay him down.' When he came back-to, a few seconds later, he was very disoriented and drooling. I asked her if it was normal for his pupils to be so small as well. And she said they looked fine as well. We got him back to his room. The blood-stained sheets were still on his bed and blood was still on the floor and had not been cleaned up. This is when I asked them to get him stronger meds because the Tylenol was not working. She promised she would do so and obviously that was not the case During an interview, on [DATE] at 3:00 p.m., Certified Nursing Assistant (CNA) 18 indicated she was the first staff member who found Resident E after the fall. It was early in the morning, staff had just come on for the morning shift, nurses were giving report and the CNAs began their morning rounds. Resident E was at the end of the hall, but his call light was blinking so she went to him first. She walked in the room and found him lying on the floor on his side and faced his roommate's bed. His call light was observed hanging off the edge of the bed. CNA 18 indicated it would have been within his reach when he was in bed, but from where he was on the floor it was out of his reach. There was a pool of blood around him. She called for help. She asked Resident E what happened, and he indicated he was trying to get something off his table when he fell and hit his head. Registered Nurse (RN) 19 was the first nurse to respond, then the ADNS came in too. The nurses began their assessments while he laid on the floor and elevated his feet on a nearby chair. After they finished, she and another CNA got Resident E up into bed to clean him up. He had been incontinent of a small bowel movement (BM). CNA 18 indicated she did not think it was a good idea for him to go outside for a visit since he had a fall that morning. He did not complain of pain until he came back inside. He rubbed his neck and asked, can you rub my neck? CNA 18 indicated she gave him a couple neck rubs. A Corresponding written statement from CNA 18 was provided by the ADNS on [DATE] at 10:40 a.m. Her statement, dated [DATE], indicated .[On [DATE]] I helped [Resident E] up into his chair to go outside with his family. I asked him if he was sure he wanted to get up and go outside. He said he was fine and wanted to go outside with his family .he drank a milkshake and played with his great-grand kids .he sat outside for about an hour and came back inside. Later I went into the room to check on him and he told me he was ok. He told me that his neck hurt a little and that the boss said I have to give him neck rubs. I rolled a towel and placed in behind his neck. He Laid down and went to sleep During an interview, on [DATE] at 11:21 a.m., RN 19 indicated she was the first nurse who entered Resident E's room after CNA 18 alerted her, he had fallen. RN 19 indicated she observed him lying on his back on his floor with blood on the floor. The ADNS came into the room, and they assessed him initially laying on the floor, then assisted him to a seated position. He had an open wound in the center of his forehead about the size of a half dollar, and a formed hematoma. His blood pressure was low, but that was normal for him. He did complain of a little pain on the back of his neck, but said he had chronic pain. He moved everything normally and range of motion was fine. RN 19 indicated she was a little worried about the neck pain, but the ADNS took over from there. When RN 19 left the building later that day she observed him sitting in a wheelchair outside with his family. During an interview, on [DATE] at 12:00 p.m., the Nurse Practitioner (NP) indicated Resident E had only been at the facility for about a week, and she was still getting to know him at that time. He was ill and fragile when he came to the facility and the labs, he had from the hospital were not great. Families often want their loved ones to go to rehabilitation to see how they do, so that was her understanding of what Resident E's goals were. He had come to the facility after being in the hospital for strengthening. He had chronic low blood pressure, so they treated him for that by adding a new medication. The ADNS reported the fall to the NP later that day, and the NP indicated she did not want to give stronger pain medication for someone after a fall, especially if the Tylenol and BioFreeze (an organic [MEDICATION(S)] medication used to control pain) were working, as the ADNS indicated they were. During an interview, on [DATE] at 2:50 p.m., the ADNS indicated she was working as a nurse on the floor the morning of Resident E's fall. She was alerted to the fall by other staff members and immediately went to his room. She observed him lying on the floor, she checked his vital signs which were normal and applied first aid to the hematoma and skin tears. Then she helped to assist Resident E back into bed. There was some bleeding, but it was under control. The ADNS notified the family of the fall, and the on-call NP (Nurse Practitioner) gave orders for STAT (urgent/rush) labs. Throughout the day, he complained of pain in his neck, but Resident E and his family both indicated that was baseline for him because of a history of a neck fusion. The ADNS provided Tylenol and the NP ordered some BioFreeze gel which controlled his pain. His family came that day and sat with him outside for a visit and he had a milkshake. The next morning, I was told a family member told the nurse they wanted him sent to the hospital to get something more effective for his pain. The ADNS put a heat pack and BioFreeze on his neck and told CNA 18 to check on him. The ADNS indicated at some point, she had been notified Resident E was having difficulty swallowing but that was not new for him either. A Corresponding written statement from the ADNS was provided by the ADNS on [DATE] at 10:40 a.m. Her statement, dated [DATE], indicated .At 7:22 a.m. on [DATE] I was notified that [Resident E] was on the floor. Upon arrival to the unit, resident was laying on his back on the floor, he was responsive and able to state that he was trying to get to his call light, which was attached to his shirt .Resident had [a] hematoma with skin tear to center of forehead and 2 small skin tears to his right leg. Resident not complaining of difficulty or pain with moving extremities, stated that his neck hurt but that it always hurts. Resident's vitals and neuro checks were at his baseline. Resident assisted per 3 staff into bed. Resident given Tylenol for neck pain .NP aware of fall and medical condition including low platelets and hemoglobin, NP gave orders for STAT labs and to monitor resident .[family] came in to visit and writer let them know again that he fell and that he had facial injuries but that his vitals and neuros were stable. [Family] went to room to see resident. Resident stated that he wanted to go to the hospital for 'faster services .' Resident repositioned in bed for comfort and fluids offered. Resident had slight difficulty swallowing fluids from straw .Resident got out of bed and went outside for family visit .Resident had a short period of confusion and family stated that it has been happening for a while. Resident was outside for about 45 minutes and then requested to go to bed due to neck pain .At 4:09 p.m. [more than eight hours after the fall] I called [NP] since she knows the resident and his history better than the on call. I relayed the situation and she advised that there was not an indication that he needed to be sent out due to his overall prognosis and health status .Family had requested muscle relaxers or stronger pain medication for his neck. [NP] stated that due to his recent fall and confusion, it was not appropriate to give him stronger medication, and to continue to use BioFreeze and Tylenol for pain management as they are currently effective .At 6:26 p.m. I called resident's [family member] to discuss prognosis and treatment plan. I explained that resident was still stable with vitals and neuros at his baseline, explained that his pain was being managed with BioFreeze and Tylenol and warm towel A third written witness statement from the incoming nurse, RN 20, was provided by the ADNS on [DATE] at 10:40 a.m. Her statement, dated [DATE], indicated .I, [RN 20] took care of [Resident E] on [DATE]-[DATE] on evening and night shift. Resident was on follow up fall documentation and neuro checks from previous fall on day shift. Upon start of my shift around 7:30 p.m. resident had his call light on requesting another blanket because he was cold .around 11:15 p.m., resident placed call light on, and CNA answered it. Resident requested Tylenol for a headache. Writer administered 2 Tylenol around 11:20 p.m. Resident did get one Tylenol stuck under his tongue and requested several drinks of water to get it to go down but did so with no issue. Around 2:00 a.m., CNA came to get writer due to bleeding from skin tear on arm. Writer assessed resident and noted that he had picked at skin tear on left lateral forearm due to part of the steri-strips [thin adhesive bandage] were off and resident had fresh blood under nails. Area was cleansed and dressing placed on area for protection. Resident has also removed ABD pad that was on skin tear to mid forehead. Protective dressing placed on that area also .Resident did show slight confusion as he was looking for his wife because he thought she was at facility .Writer assisted CNA with turning and repositioning of resident and providing incontinent care. When turned, resident did state, ouch, when writer asked if something hurt, he stated, just body aches . During an interview, on [DATE] at 10:47 a.m., the Therapy Director indicated Resident E had participated in Physical Therapy and Occupational Therapy. He only attended 2 of the 3 sessions and missed his therapy sessions on [DATE] due to medical complications. Resident E was alert and oriented. He was very friendly, polite and motivated to get stronger so he could discharge back home. On [DATE] at 10:00 a.m., Resident E's medical record was reviewed. A comprehensive nursing admission assessment, dated [DATE] at 6:09 p.m., indicated the resident answered the questions and was alert and oriented to person, place, time and situation. He indicated he was in good health, had problems with his bowels and incontinence of the bowel, he had balance problems and was unsteady on his feet, he had weakness, reported no pain and had weakness. He had current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Pain Assessment, dated [DATE] at 6:33 p.m., indicated a total score of 0 of 10 and no reported pain in the last 5 days. A second Pain Assessment, dated [DATE] at 2:52 a.m., indicated a total score of 0 of 10 and no reported pain in the last 5 days. An admission Fall Risk Assessment, dated [DATE] at 6:32 p.m., indicated Resident E was considered a high fall risk with a score of 17, where 13 or more points indicated a high fall risk. An admission Bowel Assessment, dated [DATE] at 9:34 a.m., had been opened, but not completed. All fields were left blank. A comprehensive care plan, initiated [DATE], indicated Resident E was at risk for falls. The intervention in place at that time was for him to wear non-skid socks. A CNA assignment sheet, dated [DATE], indicated Resident E needed assistance with bathing and ambulation as needed but did not indicate he was a high fall risk or list any fall interventions which should be in place. A comprehensive care plan, initiated [DATE], indicated Resident E was at risk for constipation. Interventions for this plan of care included but were not limited to; Notify MD if no BM after 3rd day and Abdominal assessment if no BM times 4 days, notify MD of findings. Resident E's nursing progress notes were reviewed. There were no nursing progress notes which indicated Resident E reported any pain from the time of his admission on [DATE] at 5:07 p.m., until after his fall on [DATE]. A Hot Charting event tool, dated [DATE] at 8:25 a.m., indicated Resident E had not had a bowel movement in 3 days. The physician had not been notified. A Hot Charting event tool, dated [DATE] at 8:23 a.m., indicated Resident E had still not had a bowel movement in more than 3 days. The physician had not been notified. Resident E's bowel elimination record was reviewed on the vitals report and indicated he had not had a bowel movement for the last 4 days. A nursing progress note, dated [DATE] at 6:32 p.m., indicated Resident E had bright red blood in his urine, but no complaint of pain or discomfort. The MD was notified with no new orders since recent labs had already been sent to oncology. A nursing progress note, dated [DATE] at 11:12 p.m., indicated Resident E had blood in his urine, and the MD was notified. No new orders were placed. A nursing progress note, dated [DATE] at 7:49 a.m., indicated Resident E had an unwitnessed fall from his bed. He was noted to have a hematoma with an abrasion on his forehead and was disoriented at the time of his fall and complained of pain in his posterior neck. The On-call NP was notified and new orders for STAT labs were placed. Resident E was offered ice for his forehead and given Tylenol for neck pain. A Fall Event tool was opened, on [DATE] at 7:49 a.m., and indicated Resident E had an unwitnessed fall with injuries which included: A 5 centimeter (cm) round hematoma with 3 cm long by 1 cm wide abrasion in the center of his forehead, A 2 cm long, by 1 cm wide, and 1 cm long by 1 cm wide abrasions on his right leg and, A 3 cm long skin tear on his left forearm. Immediate interventions put into place at the time of the fall was to complete a review of medication and labs. The record lacked documentation a full skin check was completed on or after the fall event. The record lacked documentation a full pain assessment for the new injuries and neck pain sustained from the fall had been completed on or after the fall event. A nursing progress note, dated [DATE] at 7:23 p.m., indicated Resident E's family was reassured the facility would do everything possible to ensure the resident was comfortable and well taken care of .the NP gave a new order for BioFreeze for neck pain. A physician order, dated [DATE] at 2:00 p.m., prescribed BioFreeze ([MEDICATION(S)] 5% gel) to apply as needed to the back of the neck for pain and stiffness. Resident E's MAR (medication administration record) was reviewed. BioFreeze was not documented on the MAR as having been administered and there were no additional pain monitoring orders on the MAR. A nursing progress note, dated [DATE] at 4:50 a.m., indicated Resident E had received medication earlier that shift for a headache and had been using his call light appropriately. He asked to be repositioned several times due to inability to find a comfortable position. A Nursing to Therapy Referral event was opened on [DATE] at 11:58 a.m. The referral indicated Resident E was choking and sounded like he was gargling when he took a drink of water and when he took his medicine. Resident E also stated he was having trouble swallowing. The referral indicated family was notified, but the physician was not notified. A nursing progress note, dated [DATE] at 1:25 p.m., indicated Resident E continued to complain of neck pain and had difficulty swallowing. Resident stated his pain was unbearable and asked for Tylenol. His family asked if he could have something stronger for pain. The On-call was notified and wanted to obtained STAT x-rays before prescribing pain medication. The family was notified and agreed at that time, but when the nurse went to place order for the x-ray, the family changed their mind and stated they wanted Resident E to be sent to the hospital for his neck to be looked at. 911 was called. A nursing progress note, dated [DATE] at 1:28 p.m., indicated 911 arrived and took the resident via stretcher. Before the ambulance left, EMT (emergency medical technician) came back in and told the nurse they would take him to a different hospital due to the level of trauma that he was. The most recent comprehensive assessment was a 5-Day MDS (minimum data set) assessment dated [DATE]. The MDS indicated Resident E was moderately cognitively impaired and required extensive assistance for most of his ADLS (activities of daily living) from at least ,d+[DATE] staff members. An EMS Run Report, dated [DATE], indicated the local fire department responded to the call for a neck injury. At 1:16 the report indicated the first set of vital signs. They were unable to obtain a blood pressure, his respirations were 5 (per minute) and his oxygen saturation was 88%. 11 minutes later at 1:27 p.m., his vitals were re-taken. His blood pressure was ,d+[DATE], his respirations increased to 13 (per minute) and his oxygen saturation level rose to 98 with oxygen canula in place. His skin was noted to have multiple large, purple bruises, including on his back with tenderness. The Run Report narrative indicated .dispatched 911 and responded immediately to an ECF [extended care facility] for a sick person .advised the facility had reported the [patient] was an elderly male with neck pain and trouble swallowing . presented as an alert and oriented 93 [year old white male] laying semi fowlers [laying on back, angled between 30 degrees and 45 degrees] in bed .family present. There were no staff members present and [EMS responder] went to locate the patient's nurse for report and collect paperwork. Patient had significant bruising noted to the face and arms. There was a large bandage on the patient's forehead over an abrasion. Patient had significant dark purple bruising and swelling around both eyes. Patient complained of severe neck pain and was holding the back of his neck. Family reported the patient fell sometime yesterday and he was not taken to the hospital. Family claimed the facility staff had told them the patient did not need to go to the hospital for his injuries yesterday. Family had pressed facility staff to send the patient to the hospital today when he began to complain of severe neck pain. Staff had previously administered acetaminophen for pain management without improvement. Patient was immediately placed in a cervical collar. Staff nurse came to the patient's room and reported he had fallen sometime yesterday and claimed she had no knowledge of any of the details pertaining to the fall and also claimed there was no documentation about the fall in the patient's chart. Staff did not report any assessment or vital signs. Staff nurse reported the patient had not been evaluated by a physician and had no knowledge of why the patient was not transported to the ED [emergency department] for evaluation of his injuries. Patient was noted to have bleeding skin tears on the right lower leg and some blood on his sheets. When questioned about these injuries, the staff nurse claimed they were old and from a previous fall despite EMS pointing out they were actively bleeding. The staff nurse commented she was a new employee and she did not typically care for this patient. Patient to cot via draw sheet with manual C-Spine precautions. Patient was secured in a semi fowlers position of comfort. Cot to ambulance without incident .Patient had extensive purple bruising primarily to the RUE [right upper extremities], face, and back. The extent of the bruising to the back was not investigated due to the patient's severe neck pain and limited room for maneuvering in the ambulance .EMS was unable to palpate or auscultate [examine a patient by listening to sounds] a BP. Patient had weak, irregular radial pulses. 12 Lead ECG [Electrocardiograms, sometimes referred to as ECGs, capture the electrical activity of the heart and transfer it to graphed paper] showed arrhythmia [a problem with the rate or rhythm of your heartbeat] .he had an initial oxygen saturation of 98% but quickly experienced difficulty breathing and desaturation to 87%. Pt became tachypneic [rapid breathing] with subcostal retractions [when the belly pulls in beneath the rib cage]. Applied oxygen at 12 lpm [liters per minute] .Patient had a wristband with 'DNR' printed on it and ECF paperwork that said 'DNR' . Patient very clearly stated he did not want anything done and just wanted to die when it was his time A hospital report summary, dated [DATE], indicated Resident E arrived as a trauma 2, but was upgraded to a trauma 1 after a fall at ECF. His family reported they asked the facility to call EMS as they noted Resident E was not acting right. He was brought to the ED with agonal breathing and O2 (oxygen) saturations in the 80s. His eyes were open spontaneously but he did not regard faces or respond to his name. Attempted to go to CT scanner for imaging, however patient did code in scanner, time of death at 2:06 p.m. Injuries noted on the patient upon arrival included, 1. Scalp bruising 2. Periorbital Ecchymosis (or raccoon eye was commonly seen in surgical emergency and results from accidental injuries to the base of the skull) 3. Significant Ecchymosis (Blood or bleeding under the skin due to trauma of any kind) of abdominal region and 4. Right hip Ecchymosis. Cause of death listed: fall, acute hypoxic [CONDITION(S)], [CONDITION(S)]. The postmortem CT scan indicated Resident E sustained a severe hyperextension teardrop-type fracture at the C4 with 3 column involvement, suggesting significant mechanism of injury in the setting of complete fracture through hyperostotic osteophyte and vertebral body. 2. During an interview, on [DATE] at 9:50 a.m., Resident B's son and Power of Attorney (POA) indicated the facility did not call when his mother fell or when she died . He knew from the hospice nurse she fell about 4:00 a.m. and she was bleeding all over the place. Paramedics were called to stop the bleeding. Her head wound was on her upper left forehead, across to the middle. It was pressure wrapped. Hospice indicated she would not come out of this, and it would lead to her passing. The Director of Nursing talked to him and indicated there was one person changing her brief, there should have been 2 staff members to change her brief, and she fell off the bed. His mother lay in her bed for a week in pain and she finally stopped breathing. Hospice provided a low dose of [MEDICATION(S)], but when staff would come in to turn her or pull her up in bed she would scream and yell. Hospice increased the dose from 4 doses a day to 6 doses a day. He indicated he believed she was not close to death prior to the fall from the bed, and the fall brought about her death. Resident B's record was reviewed on [DATE] at 4:15 p.m. Resident B's code status was DNR (do not resuscitate). Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She started with Hospice on [DATE]. A progress note, on [DATE] at 11:37 a.m., indicated Resident B was stable and all vital signs were stable. No complaints of pain. A progress note, on [DATE] at 2:15 p.m., indicated Resident B's vitals were stable, continued on hospice, no changes in her condition have been noted at this time. A progress note, on [DATE] at 4:30 a.m., indicated the resident was laying on her back after a fall from the bed. There was a 3 centimeter (cm) by (x) 0.5 cm laceration to the left side of her forehead. Pressure and ice was applied to area and the area stopped bleeding. Steri-strips (adhesive approximation dressing) were applied with a dry dressing. An abrasion was noted on her mid-back. PRN (as needed) pain medication was provided. Staff were unable to get an accurate blood pressure because the resident was yelling out. Three staff members assisted her back to bed with a sheet. A neurological assessment was completed and within normal limits. A Certified Nursing Assistant (CNA) was providing incontinent care, when she turned the resident on her left side, Resident B fell from the bed. She hit her head on the bedside table. The resident was on an air mattress. The physician and the Director of Nursing Services (DNS) were notified. Hospice was notified and the hospice company would notify the family. Hospice would be out to assess Resident B in the morning. A progress note, on [DATE] at 6:30 a.m., nursing charted Resident B's heart rate was accelerated to 110 with respirations at 24. Her oxygen saturation was 86%. Oxygen was applied and increased it to 96%. Hospice notified. A progress note, on [DATE] at 11:30 a.m., indicated Resident B was responding to verbal stimuli. Her pupils were responding to light and vital signs were stable at this time. A hematoma (clotted swelling of solid blood within the tissues) was present to the forehead. The laceration was approximately with steri-strips, with bleeding noted to the forehead laceration. Pressure was applied and the bleeding stopped. Dressing was applied and son was notified. A progress note, on [DATE] at 5:46 p.m., indicated Resident B's son and POA arrived for a visit post-fall. Resident B was able to communicate with yes and no answers. The son indicated his mother would not want to ride in an ambulance and go to the hospital. Comfort care continued. A progress note, on [DATE] at 11:46 p.m., indicated Resident B's vitals were stable while on 3L (liters) of oxygen. Resident had new bleeding from the wound sustained from a fall earlier today. The head dressing was changed. The resident did not respond to verbal stimuli and did not open eyes throughout the evening shift. Resident B's neurological assessment, on [DATE] at 10:55 a.m., LPN 17 charted Resident B's bilateral (both eyes) pupil size had changed from 3 mm to 2 mm. LPN 17's 1:00 p.m. neuro charting indication Resident B's consciousness was no longer oriented. The next neuro charting due at 8:00 p.m. was incomplete. It indicated

Based on interview and record review, the facility failed to ensure Resident B had adequate staff present to prevent her from rolling off her bed, hitting her head, notifying the family at the time of the fall, notifying the physician with a change of condition resulting in altered mental status, pain, change of condition and death for 1 of 3 residents reviewed for accidents (Resident B). Finding includes: During an interview, on [DATE] at 9:50 a.m., Resident B's son and Power of Attorney (POA) indicated the facility did not call when his mother fell or when she died . He knew from the hospice nurse she fell about 4:00 a.m. and she was bleeding all over the place. Paramedics were called to stop the bleeding. Her head wound was on her upper left forehead, across to the middle. It was pressure wrapped. Hospice indicated she would not come out of this, and it would lead to her passing. The Director of Nursing talked to him and indicated there was one person changing her brief, there should have been 2 staff members to change her brief, and she fell off the bed. His mother lay in her bed for a week in pain and she finally stopped breathing. Hospice provided a low dose of [MEDICATION(S)], but when staff would come in to turn her or pull her up in bed she would scream and yell. Hospice increased the dose from 4 doses a day to 6 doses a day. He indicated he believed she was not close to death prior to the fall from the bed, and the fall brought about her death. Resident B's record was reviewed on [DATE] at 4:15 p.m. Resident B's code status was DNR (do not resuscitate). Her diagnoses included, but were not limited to, heart failure, [CONDITION(S)], and need for assistance with personal care. She started with Hospice on [DATE]. A progress note, on [DATE] at 11:37 a.m., indicated Resident B was stable and all vital signs were stable. No complaints of pain. A progress note, on [DATE] at 2:15 p.m., indicated Resident B's vitals were stable, continued on hospice, no changes in her condition have been noted at this time. A progress note, on [DATE] at 4:30 a.m., indicated the resident was laying on her back after a fall from the bed. There was a 3 centimeter (cm) by (x) 0.5 cm laceration to the left side of her forehead. Pressure and ice was applied to area and the area stopped bleeding. Steri-strips (adhesive approximation dressing) were applied with a dry dressing. An abrasion was noted on her mid-back. PRN (as needed) pain medication was provided. Staff were unable to get an accurate blood pressure because the resident was yelling out. Three staff members assisted her back to bed with a sheet. A neurological assessment was completed and within normal limits. A Certified Nursing Assistant (CNA) was providing incontinent care, when she turned the resident on her left side, Resident B fell from the bed. She hit her head on the bedside table. The resident was on an air mattress. The physician and the Director of Nursing Services (DNS) were notified. Hospice was notified and the hospice company would notify the family. Hospice would be out to assess Resident B in the morning. A progress note, on [DATE] at 6:30 a.m., nursing charted Resident B's heart rate was accelerated to 110 with respirations at 24. Her oxygen saturation was 86%. Oxygen was applied and increased it to 96%. Hospice notified. A progress note, on [DATE] at 11:30 a.m., indicated Resident B was responding to verbal stimuli. Her pupils were responding to light and vital signs were stable at this time. A hematoma (clotted swelling of solid blood within the tissues) was present to the forehead. The laceration was approximately with steri-strips, with bleeding noted to the forehead laceration. Pressure was applied and the bleeding stopped. Dressing was applied and son was notified. A progress note, on [DATE] at 5:46 p.m., indicated Resident B's son and POA arrived for a visit post-fall. Resident B was able to communicate with yes and no answers. The son indicated his mother would not want to ride in an ambulance and go to the hospital. Comfort care continued. A progress note, on [DATE] at 11:46 p.m., indicated Resident B's vitals were stable while on 3L (liters) of oxygen. Resident had new bleeding from the wound sustained from a fall earlier today. The head dressing was changed. The resident did not respond to verbal stimuli and did not open eyes throughout the evening shift. Resident B's neurological assessment, on [DATE] at 10:55 a.m., LPN 17 charted Resident B's bilateral (both eyes) pupil size had changed from 3 mm to 2 mm. LPN 17's 1:00 p.m. neuro charting indication Resident B's consciousness was no longer oriented. The next neuro charting due at 8:00 p.m. was incomplete. It indicated the right pupil was 2 mm, with no measurement for the left pupil. A progress note, on [DATE] at 1:05 a.m., indicated the resident was responsive to name and touch. Lung sounds were diminished. Neurological signs and vitals were within normal limits. Resident took a few sips of water. A Fall Review note, dated [DATE] at 8:32 a.m., indicated Resident B was on a low air loss mattress. One staff member was assisting the resident with her soiled brief. She turned the resident to be changed and resident rolled, and the bed deflated on one side, the resident hit her head on the bedside table, and slid off the bed. The resident received a laceration to her forehead. The determined root cause of the fall was the staff member who turned the resident on the low air loss mattress did so without the mattress being on the Firm setting. The new intervention put into place was two staff members on bed mobility for Resident B. A fall care plan, revised [DATE], indicated Resident B was at risk for falls due to decreased mobility and strength, [CONDITION(S)], [CONDITION(S)], daily diuretic use, over age 80, decreased balance, needs assist with mobility, history of falls, use of high-risk medications, diagnosis of [CONDITION(S)], utilizes glasses, incontinent, restless leg syndrome and receiving hospice services. New approaches, dated [DATE], were use 2 staff members to assist for bed mobility and incontinent care and to use bolsters with the low air loss mattress. On [DATE] at 2:56 a.m., Resident B was responsive to touch. Lungs sounds were diminished. On [DATE] at 11:55 a.m., Resident B's lung sounds were diminished. Resident B was not drinking any fluids. On [DATE] at 10:34 p.m., the resident was responsive to touch and voice. Lung sounds diminished. On [DATE] at 5:17 a.m., the resident had no signs or symptoms of shortness of breath, but wheezing was noted. On [DATE] at 1:52 p.m., the resident was not able to swallow anything. On [DATE] at 1:44 p.m., the resident was not able to swallow anything, continued on 3L oxygen and was responsive to name and touch. On [DATE] at 9:37 p.m., Resident B was responsive to pain and voice this afternoon. Scheduled [MEDICATION(S)] was given. The resident was found unresponsive at 9:15 p.m. Verified with another nurse. Hospice nurse informed and she would contact the resident's family. On [DATE] at 12:15 p.m., the MDS (Minimum Data Set) Coordinator Assistant provided information for the most recent quarterly assessment, dated [DATE]. Resident B's assessment indicated she was a 2 person assist for bed mobility, this included being turned to her side and toileting. She was always incontinent of bladder and bowel. During an interview, on [DATE] at 2:56 p.m., the Assistance Director of Nursing Services (ADNS) indicated only CNA 5 was in Resident B's room during the check and change of her soiled brief on [DATE] at 4:30 a.m. On [DATE] at 9:35 a.m., an observation of Resident B's previous room indicated she had used an AdvaCare Rhythm Multi bed. During an interview, on [DATE] at 11:15 a.m., an AdvaCare Customer Service representative indicated the bed should have been on the Firm setting for assisting the resident with care. When the resident was turned on her side the air-fields were not filled on that setting. During an interview, on [DATE] at 1:16 p.m., CNA 5 indicated she went into Resident B's room for a check and change of her soiled brief. She was putting the resident on her side after cleaning her up, to put the new brief on, and that was when she fell . The resident slid off the bed to the floor. There was a flat sheet on the bed and the flat sheet fell with her. Resident B's head hit the bedside table. CNA 5 was the only person in the room when the resident fell . She knew she should have had 2 staff people to assist with toileting the resident, but the facility was short of staff. One aide to each hallway and the nurse was busy with another resident. There was no one else to help. CNA 5 immediately went to the resident and lifted her head up. She put pressure on the bleeding wound and then lower her head to the floor to get Licensed Practical Nurse (LPN) 6. There was no room for the Hoyer Lift, so the staff used the sheet to lift the resident back into bed. The resident's vital signs were checked. The resident was saying, My head, My head. LPN 6 cleaned up the head wound and put a dressing on it. The resident indicated, Am I going to die? Am I going to die? LPN 6 indicated she was going to be ok; you are not going to die. You are going to be ok. Her blood pressure was really elevated. The resident passed away on Sunday, [DATE] about 9:15 p.m. During an interview, on [DATE] at 1:54 p.m., the Hospice Registered Nurse (RN) indicated when the facility called the hospice company after hours, they called the on-call service at 4:30 a.m., after Resident B's fall. It always depended on the findings from the facility whether they call hospice staff. The facility indicated it was fine with the hospice nurse waiting until morning to come in. Resident B was the first resident of the day, the Hospice RN arrived at 10:56 a.m., to do an assessment. The resident's head wound was covered with kerlix (gauze wrapping), it was saturated with blood and the resident was moaning. The Hospice RN removed the dressing and found the left side of the forehead had ,d+[DATE] steri-strips, and the wound was about 2 ½ inches wide. Blood was still trickling out between the saturated steri-strips. She put pressure on the head wound and it was still soaking through the gauze. The Hospice RN indicated, The bleeding was pretty bad. Prior to the fall, Resident B was completely immobile and was totally unable to move herself. All her movement had to be done by aides. She could only move her head a bit. She could speak in complete sentences and say her name. After the fall, she could only blink her eyes and say please, please. She was laying on her right side and the right side of her face and hair were saturated with blood. The Hospice RN was worried about the amount of blood loss. She wanted to know why the facility didn't send her out because she needed stitches. The Hospice RN held pressure for ,d+[DATE] minutes and the wound was still saturating the gauze with blood. The Hospice RN called the Resident's son and asked if the facility had told him about the seriousness of the wound his mother sustained. He indicated no. He wanted his mother to go to the ER for stitches. Before the emergency services personnel could leave with her. The DNS indicated to the paramedics to not transport her because she just talked to the son again and the son said since the bleeding had stopped, he thought the trip to the hospital would be too traumatic for his mother's body. The paramedics wanted to know why she wasn't being transported. They called their chief and the Hospice RN had to explain to him why the Resident was not being transported. The Hospice RN indicated RN 17 informed her the facility had changed the dressing 5 times before the Hospice RN arrived. So, her dressing change was the sixth dressing change since 4:30 a.m. At this time, the resident was still actively bleeding. The DNS talked to the hospice nurse and indicated the son didn't want you to send her out. The DNS indicated to the son the wound had stopped bleeding. On [DATE], the Hospice RN arrived at 9:06 a.m., she observed Resident B's head was still wrapped with gauze. The was no visible blood. The Aides were trying to give her water with a straw and the water would trickle right back out of her mouth. The resident did not eat anything. She was just staring straight ahead. She was in pain. Her pupils were not the same size, the left pupil was 5 mm (millimeters), and the right pupil was 2 mm. The Hospice RN called Resident B's son to give an update on her condition. She informed him Resident B was found with uneven pupils and no longer able to speak or swallow. She educated him the resident's neurological decline was consistent with head trauma and due to her decline, she was likely transitioning. Anew Hospice would be monitoring her daily. On [DATE], the Hospice LPN arrived. She indicated the steri-strips were gone and there was powder on the wound. On [DATE] at 11:15 a.m., the Hospice RN arrived. The son and his spouse were at Resident B's bedside. They asked about pain, Hospice RN responded the pain could be intra-cranial pressure. All the resident's limbs were contracted, including bilateral knees, shoulders, and elbows prior to the fall. Their discussion included x-rays and with the need to move the limbs to get x-rays, the family declined the x-rays. The Hospice RN indicated, after Resident B's fall, you would have needed the family's permission to give [MEDICATION(S)]. The first scheduled [MEDICATION(S)] dose was given on [DATE] as 0.25 mL (milliliters) every 6 hours. The Hospice RN believed the resident was in pain because she was moaning, increased vital signs, and body language. On [DATE], the [MEDICATION(S)] was increased in frequency to 0.25 mL every 4 hours. Resident B's pupils were back to the same size, but the right eye was drifting, and her mouth could no longer form words. The Hospice RN asked Resident B if she was in pain and her left eye wound blink several times. Her son indicated his mother was moaning when they changed her and turned her. On [DATE] at 4:15 p.m., Resident B's chart was reviewed. An area of nursing information, called Documentation Guidelines/Hot Charting, filled out by LPN 4 indicated there was a hematoma and laceration to the forehead. The Physician or NP (Nurse Practitioner)/PA (Physician's Assistant) was notified on [DATE] at 4:41 p.m. On [DATE] at 4:33 p.m., Hospice provided nursing notes regarding Resident B's care after her fall. The [DATE] documentation indicated the problem to be altered neurological status. Level of Consciousness: Stupor/Semi-Coma .Clinical Findings: Head wound from fall. Orientation to person, place and time: Severely impaired. Alertness: Severely impaired. Type of accident: Fall with injury. Circumstances surrounding the accident: Patient was being toileted in bed and was dropped off the side of the bed. Treatment received as result of accident: Minor treatment by caregiver. Type of injury: Bruises/contusions, cut/laceration. Narrative Notes: Resident in bed with eyes closed. Had a witnessed fall earlier this morning. Has a kerlix bandage dressing wrapped around her head, with a significant amount of sanguineous saturation. Hair on right side of head completely saturated, mainly due to positioning, wound is on left forehead. Patient is contracted and can't move on her own .[RN 17] indicated she was accidentally dropped off the side of the bed. Was unable to see the wound due to the amount of active bleeding. Counted ,d+[DATE] steri-strips in place on left forehead, which covered the wound and they were saturated with blood seeping out around the strips. The right forehead had significant swelling and bruising. The Hospice RN applied pressure for approximately 20 minutes to active bleed and was unable to get the wound clotted off. RN 17 and Hospice RN applied more gauze and kerlix. Patient was moaning and saying, 'please,' during care. Notified Hospice supervisor. Also, phoned patient's son to see if he wanted her sent to ER for treatment, possibly sutures, to stop the bleeding. He stated that he would like to have her sent out. By the time the paramedics arrived her dressing was saturated again. Once the paramedics arrived at her room, the facility DNS stopped them and stated that the son did not want her send out after all, due to the fact that they had the bleeding under control. She stated it was clotted off and slowing down. The Hospice RN called the son again and he clarified he wanted her to stay at the facility for now but if she continued to bleed uncontrollably then he wanted her sent out. The Hospice RN indicated she was questioned by the paramedics as to the change of mind, explained that the son declined due to information received from the facility and it was decided by him and facility on whether or not to send her out for treatment. Before leaving the Hospice RN was asked to explain the situation to the paramedics chief On [DATE], the Hospice notes continued to indicate the resident's level of consciousness was stupor/semi-coma, unequal pupils, and multiple bruises and swelling across entire forehead. The left pupil was measured at 5 mm and the right pupil was 2 mm. The resident's baseline had decreased dramatically and believed to be transitioning. She would no long open her mouth to be fed. Staff was giving her water though a straw, but the patient wouldn't swallow, and the water just ran back out of her mouth. [MEDICATION(S)] scheduled to be given every 6 hours. On [DATE], the Hospice notes indicated the level of consciousness was unresponsive with pupils unequal. Forehead swollen and bruised from trauma wound from the fall. Patient without any intake since the fall. Patient pupils are unequal. Patient moaned out in pain when touched or moved. PRN pain medication was given by the facility nurse. Patient appeared to be transitioning. Unit manager indicated patient was saying yes and no to questions earlier but unable to at this time. On [DATE], the Hospice notes indicates the level of consciousness was unresponsive and pupils were unequal. Patient had a flat affect. Patient without any intake since the fall. Patient pupils were unequal. Patient moans out in pain when touched or moved. PRN pain medication given by the facility nurse. Urine output diminished with sluggish bowel sounds. On [DATE], the Hospice notes continued. Arrival time 11:15 a.m. Resident B's level of consciousness was stupor/semi-coma. Patient staring straight ahead with right eye drifting outward. Pupils appeared to be equal. Patient had pain upon touch or movement. Had no intake of food or water since [DATE]. Orders received to increase frequency of [MEDICATION(S)]. During an interview, on [DATE] at 8:45 a.m., LPN 6 indicated CNA 5 was providing care for Resident B. She stepped out in the hallway and called her name. She went to the room, and saw the resident was on floor. Resident B's head was bleeding. She immediately did an assessment. Someone got towels and pressure was applied to the wound. She looked for other areas of injury. Another aide came in, LPN 6 was still applying pressure to her head. The staff in the room grabbed the sheet, and hoisted her on her bed, Then, she was able to observe an abrasion to the resident's back. Someone went to get ice. LPN 6 indicated she did neuro checks (neurological assessment). After some time, the forehead wound stopped bleeding, but as with a head wound it continued to seep out more blood. She measured the wound size, applied steri-strips, and a dry dressing. All head wounds seep out more blood. When she came back that night for her next shift, Resident B had a different dressing. At first the resident was moaning, so she gave her PRN (as needed) [MEDICATION(S)] concentrate - immediate release solution ([MEDICATION(S)]). It was effective for pain. The neuro checks started at 4:30 a.m. The new shift came in at 6:00 a.m. On [DATE] at 10:13 a.m., the DNS indicated it was the policy of the facility to notify the family or other responsible party. LPN 6 had stopped Resident B's bleeding forehead wound and it started bleeding again. We were able to stop it from bleeding again. The DNS indicated she believed the Hospice RN did not talk to the family before she called 911. During an interview, on [DATE] at 10:29 a.m., Resident B's son indicated he did agree to have his mother go to get stitches. The Hospice RN called him back and said the bleeding was under control. So, she was not sent out. He never actually spoke to the DNS. Within 24 hours of the fall, his mother was in transition, and the family decided to let her pass in comfort. He believed it was a wrongful death, she did not fall out of bed, she was dropped by the aide, and this started the transition to death. His mother was a two person assist for toileting, and only one person did the check and change resulting in her being dropped to the floor. Her forehead wound was about the size of 2 golf balls. He saw the DNS around 3:,d+[DATE]:00 p.m., on the same day as the fall. He asked the DNS you aren't going to tell me she just fell . He indicated the DNS told him, 'No, we messed up. We messed up.' During an interview, on [DATE] at 11:20 a.m., the DNS indicated another Hospice staff person was at the facility. She was the Hospice Supervisor. She had worked at this facility for years, and still saw residents there. The Hospice Supervisor talked to the son and told him the bleeding was under control. She was in a different part of the building and came over when the EMS services arrived. The DNS told the Hospice RN the facility staff had gotten the bleeding under control again. The DNS indicated the Hospice RN thought Resident B needed stitches, but she didn't. The ADNS, LPN 4, and the DNS got the forehead wound to stop bleeding by applying a large amount of collagen powder. The DNS indicated the forehead wound was approximately 5 cm long. During an interview, on [DATE] at 1:27 p.m., the ADNS indicated the steri-strips were removed because they were no longer effective because they were saturated with blood. They were not adhering to her skin anymore. The collagen was not a physician's order, it was a nursing measure. The hospice doctor was called by the on-call service. During an interview, on ,d+[DATE] 21 at 11:54 a.m., the Hospice Clinical Director indicated their afterhours on-call services indicated the first call from the facility was from LPN 6 at 6:17 a.m. and a second call from LPN 6 was at 7:08 a.m. The Hospice Clinical Director indicated the afterhours on-call service did not notify the physician. On [DATE] at 2:54 p.m., the Hospice Supervisor emailed the over-night information to the Hospice Administrator and the Hospice Administrator provided information via email of their afterhours on-call services transcripts. At 6:17 a.m., received a call from LPN 6 at Brownsburg Meadows regarding Resident B. Resident with a fall that morning at 4:20 a.m., fell out of bed. Three cm laceration to left forehead, pressure and ice applied, bandaged. Neuro checks were within normal limits, PRN pain medications were given. Abrasion to center of her back. The resident was comfortable and sleeping. The family had not yet been called. Hospice Supervisor indicated she updated Resident B's son, he expressed understanding. The facility was okay with a visit later this morning. The second call was at 7:09 a.m., the call received was again from LPN 6 at Brownsburg Meadows regarding Resident B with vitals: Respirations 24, Pulse 110, Oxygen saturation at 86% on room air, with oxygen applied via nasal cannula was 96%. [MEDICATION(S)] was given. A current policy, titled Fall Management Program, dated ,d+[DATE], was provided by the DNS on [DATE] at 2:26 p.m. A review of the document indicated .to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .The resident specific care requirement will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet .If the resident experience an injury from the fall, contact facility DNS/ED (Executive Director) per facility policy. The physician will be contacted immediately, if there are injuries, and orders will be obtained .The family will be notified immediately by the charge nurse of falls with injury A current policy, titled Resident Change of Condition Policy, dated ,d+[DATE], was provided by the ADNS on [DATE] at 10:38 a.m. A review of the document indicated .all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .All nursing actions, physician contacts, and resident assessment information will be documented in the medical record .Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communication to the physician .The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken .All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly .the nurse in charge is responsible for notification of physician and family/responsible party prior to end of assigned shift when a significant change in the residents' condition is noted .Document resident change of condition and response in the medical record. Documentation will include time and family/physician response This Federal tag relates to Complaints IN 839 and IN 490. 3.,d+[DATE](a)

Based on observation, interview, and record review, the facility failed prevent the development of pressure ulcers for 1 of 5 residents reviewed for pressure ulcers resulting in harm when the resident developed abrasions to her right and left gluteal folds (the crease of the upper limit of the thigh from the lower limit of the buttock) from the use of ill-fitting briefs, that worsened to a stage 3 (full thickness tissue loss, fat may be visible but bone, tendon or muscle are not exposed) pressure ulcer (Resident 78). Findings include: During an initial interview on 7/8/19 at 11:18 a.m., Resident 78 was observed sitting up in her wheelchair in her room. Resident 78 indicated she had pressure sores on her feet and bottom. She did not remember when they developed but suspected the wounds had gotten so bad from sitting in her chair a lot. Resident 78 indicated she did not like to lay down in bed, but understood the importance of off-loading the pressure from her bottom. Resident 78 and her daughter indicated staff would sometimes remind her to lay down, but never pushed the issue, so it did not seem like a big deal. On 7/8/19 at 2:57 p.m., Resident 78 was observed in her room sitting in her wheelchair beside her bed. Her eyes were closed, and her head rested in her hands. Her daughter indicated Resident 78 was sleeping, but should be in bed. On 7/10/19 at 1:19 p.m. Resident 78 was observed sitting in her wheelchair beside her bed. During an interview on 7/15/19 at 11:25 a.m., Resident 78 indicated most of her wounds had healed. She was still slightly concerned about her bottom, and understood why it was important to lay in bed and take the pressure off, so she did not mind lying down for an hour or two at a time. But often if she agreed to lay down, it was hard to get staff to come get her back up. She wished there was something more they could do then keeping her in bed all the time. Also, she did not like having her treatments done so early in the morning. A lot of times they would come as early at 4:00 a.m. and it always seemed like they forgot something, or didn't have everything they needed for the treatment. A comprehensive review of Resident 78's medical record was completed on 7/10/19 at 11:41 a.m. The most recent comprehensive assessment was a significant change Minimum Data Set (MDS) assessment dated [DATE]. The MDS indicated Resident 78 was cognitively intact, and had not exhibited any new or worsening behaviors (such as rejection of care/treatments) which could have had put her at risk for significant risk for physical illness or injury. Resident 78 required extensive assistance from at least one staff member to complete activities of daily living (ADLS) which included but were not limited to: bed mobility, transfers, walking, toilet use, and personal hygiene. The MDS indicated Resident 78 had impaired skin integrity and pressure wounds which included but were not limited to, 3 stage 3 pressure ulcers, 2 of which were facility acquired. During an interview on 7/15/19 at 11:42 a.m., the MDS Assistant indicated Resident 78 required a significant change MDS due to her worsening condition related to her pressure ulcer areas. Resident 78 had current care plans which included but were not limited to: a plan of care started on 4/7/19 which indicated, Resident has impaired skin integrity as of 5/2/19 stage III R (right) gluteal fold (4/8/19 wound classified as unstageable) previously a stage III and unstageable to L (left) gluteal as of 5/30/19 area was a stage III L gluteal (area reclassified from abrasion to pressure ulcer 4/4/19 per WCS (Wound Care Specialist)) approach/interventions: . offer continued encouragement and praise to off load to promote wound healing . treatments as ordered Resident 78 had current physician orders [REDACTED]. Cleanse R gluteal fold with wound cleanser, pat dry, pack with alginate rope, (a wound dressing used to pack into the depth of pressure ulcer to maintain moisture and prevent the wound from drying and worsening) cover with ABD (a large absorbent pad used for wound treatment), and secure with tape .treatments to be done daily, and as needed should the dressing become dislodged. On 7/12/19 at 11:44 a.m., a wound observation was completed with the observation: Assistant Director of Nursing Services (ADNS), Licensed Practical Nurse (LPN) 20, and Director of Nursing Services (DNS). With extensive assistance, Resident 78 was rolled to her right side. The dressing was removed from Resident 78's left gluteal fold wound and the wound was observed to be approximately the size of a quarter, with clean round white edges, minimal depth with a small circular wound bed, approximately the size of a pencil eraser. The skin which surrounded the wound was observed to be darker in color like a bruise. The wound was cleansed with normal saline, pat dry, and santyl (a medicated ointment used to treat wound and burns) was applied to the wound bed. The wound was covered with an ABD and secured with tape. With extensive assistance, Resident 78 rolled to her left side so that her right gluteal fold wound could be treated. When the bandage was removed, no packing was observed in the wound or observed to be pulled out with the removal of the dressing. The dressing which was removed was clean white, with no noted signs of drainage or blood. The wound was observed to be approximately as large as, and as deep as a golf ball. At this time the wound was not measured, and the ADNS indicated, due to the technique and positioning which the wound doctor used, the current measurements were different then how the wound appeared during the dressing change observation. The ADNS indicated the wounds started as little slits from the Resident's briefs which were too tight, and had turned into these current wounds. The ADNS sprayed wound cleanser into the wound, saturating the inside and edges of the wound, then she removed alginate rope and began packing the wound with several inches of packing. When asked if packing should have been visible upon the removal of the dressing, the ADNS indicated the dressing had been soiled earlier that morning and replaced by the nurse. On 7/15/19 at 1:21 p.m., a copy of the Treatment Administration Record (TAR) for the past week was provided by the ADNS. The TAR did not indicated any PRN (as needed) treatments to Resident 78's right gluteal fold wound had been applied on 7/12/19. During an interview and review of Resident 78's Electronic Health Record, on 7/15/19 at 10:12 a.m., the ADNS indicated Resident 78's left gluteal fold wound was opened on 1/10/19 and noted to be a pink area with no drainage. The first skin event to the right gluteal fold was opened on 1/24/19, which indicated redness to the right side. On 2/13/19 the skin event for the right gluteal fold wound had worsened to an abrasion with partial thickness and measured 2 cm (centimeters) by 2 cm by 0.1 cm, and had a small amount of serosanguinous drainage. At this time, Resident 78's briefs were determined to be ill-fitted, so her large size briefs were replaced with extra large briefs. The ADNS indicated orders to treat the wounds were changed many times to try new approaches for healing, but indicated Resident 78 was non-complaint with offloading, had fluctuating [MEDICAL CONDITION], and low [MEDICATION NAME] levels at 2.6 ([MEDICATION NAME], a type of protein, normal range 3.4-5.4). On 7/15/19 at 1:21 p.m., copies of Resident 78's Weekly Wound Review and Non-Ulcer Skin Event documentation was provided by the ADON: An initial wound review, dated 2/6/19, indicated Resident 78 admitted with wound to her left and right heels, and coccyx. A new non-ulcer skin event, dated 2/13/19, indicated an abrasion to the right gluteal fold which measured 2 cm by 2 cm by 0.1 cm (Length, by Width, by Depth). A weekly skin update event, dated 2/14/19, indicated the right gluteal fold, and maintained measurements of 2 cm by 2 cm by 0.1 cm. A weekly skin update event, dated 3/14/19, indicated the right gluteal fold measured 1.1 cm by 4 cm by 0.2 cm. Accompanying nurses notes attached to this event document ranged in dated from 3/13/19-3/21/19 indicated lower extremity [MEDICAL CONDITION] A weekly skin event, dated 3/21/19, indicated the right gluteal fold measured 2 cm by 4 cm by 0.1 cm. Accompanying nurses notes attached to this event document ranged in dated from 3/22/19-3/27/19 indicated lower extremity [MEDICAL CONDITION]. A weekly skin event dated 3/28/19 indicated the right gluteal fold measured 1.2 cm by 3.2 cm by 0.2 cm. Accompanying nurse's notes attached to this event indicated, 4/16/19 . foul smelling serosanguinous drainage (fluid that contains both blood and the liquid part of blood, serum) from the right gluteal fold 4/24/19 . Resident tolerated resting in bed A weekly skin event dated 4/4/19 indicated, IDT (interdisciplinary Team) review of worsening wound. Wound to L (left) and R (right) gluteal folds have worsened On 7/15/19 at 1:21 p.m., a progress note from the Wound Doctor, dated 4/4/19, and indicated, . gluteal areas are due to abrasion from brief but now also aggravated by pressure associated signs and symptoms: Buttocks painful During an interview on 7/15/19 at 3:09 p.m., the ADM indicated she and ADNS discussed the concern regarding Resident 78's wound dressing observation, and wanted to clarify the treatment that was in place at the time, calcium alginate, would have dissolved, and may not have been visible upon the dressing change, and the ADNS would come to discuss in more detail. During an interview on 7/15/19 at 3:13 p.m., the ADNS and LPN 20 indicated there had been packing in the wound when the dressing was removed. On 7/15/19 at 1:50 p.m., the ADNS provided a copy of current facility policy titled, Skin Management Program dated 4/2018. The policy indicated, . it is the policy of (company name) to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical conditions demonstrates that they were unavoidable; and a resident with pressure ulcer receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing definitions: avoidable pressure ulcer/injury: means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate 3.1-40(a)(2)