Every finding on record at Cardinal Nursing and Rehabilitation Center

Based on observation and interview the facility failed to store and prepare food in a sanitary manner in 1 of 1 kitchens and 1 of 2 nourishment pantries. This deficient practice had the potential to affect 58 residents who food from the kitchen and/or pantry. Finding includes: During a tour of the kitchen with [NAME] 2 on 6/9/24 at 9:02 A.M., the following was observed: -Uncovered coffee filters were stored on the lower shelf of a table right next to a trash can for the hand washing sink. -Dead bugs and dirt were noted in the light fixtures in the dry storage area and in the food prep areas of the kitchen. -Metal wire racks in the dry storage area were dusty and had rust and grime on them. -A fan and filter in the walk-in refrigerator were black with dust and dirt. -The knife storage rack was grimy and dusty. -Walls in the food preparation area were dirty with a build up of brown and black grime. During an interview on 6/11/24 at 9:17 A.M., the Dietary Supervisor indicated maintenance was working on replacing the light fixtures covers. She agreed the walls and the knife storage unit were dirty and should be cleaned. During an interview on 6/11/24 at 2:25 P.M., the Executive Director (ED_she indicated the facility did not have a policy regarding kitchen sanitation and cleaning of the kitchen but she did provide a copy of the cleaning schedule. During an observation of the 1st floor nutrition pantry with the Dietary Supervisor on 6/13/24 at 9:13 A.M., there was an employee's purse on the counter. The Dietary Supervisor indicated the purse should not be stored in the nutrition pantry. During an interview on 6/13/24 at 10:56 A.M., the ED indicated they did not have a policy that specifically covered the nutrition kitchen pantry 3.1-21(i)(1)(3)

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of resident's personal refrigerators, for 2 of 3 personal refrigerators that were observed. (Resident 42 & 24) Findings include: 1. An observation of Resident 42's refrigerator was completed on [DATE] at 9:13 A.M and on [DATE] at 11: 16 A.M. with the Director of Nursing (DON). The following was observed: - 7 undated peanut butter and jelly sandwiches without expiration dates - A dark brown, sticky solution covering the bottom of the refrigerator - A heavy amount of ice build-up on freezer compartment During an interview on [DATE] at 9:14 A.M., Resident 42 indicated he used his refrigerator for snacks and drinks. 2. An observation of Resident 24's refrigerator was completed on [DATE] at 10:30 A.M and on [DATE] at 11: 16 A.M. with the DON. The following was observed: - A foul odor was detected when the refrigerator door was opened - A small, clear container labeled ground turkey and with an expiration date of [DATE] - 2 opened diet cokes without opened dates - A thick red substance was inside on the bottom, sides, and condiment holder - Food crumbs throughout the inside of refrigerator and along the seal of the door. - A large amount of ice build up on freezer During an interview with the DON on [DATE] at 11:18 A.M, she indicated there should not be expired food in resident's personal refrigerators and all refrigerators should be clean and maintained without an ice buildup. During an interview on [DATE] at 2:54 P.M., the Housekeeping Supervisor indicated housekeeping was responsible for cleaning personal refrigerators in residential rooms. On [DATE] at 12:52 P.M., the ED (Executive Director) provided a policy, dated ,d+[DATE], titled, Cleaning Refrigerators. The ED identified it as the policy currently used by the facility. The policy indicated, .The refrigerators will be kept clean. Spills and leaks will be wiped up . 2. Remove shelves, drawers and other removable parts. Clean and sanitize. 3. Wash walls and base with warm detergent 3XXX,d+[DATE](f)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for resident rights and dignity, were treated in a manner that respected the resident's dignity, when the resident was photographed without permission by a facility employee (Resident B). Findings include: On 12/12/23 at 12:30 P.M., Resident B was observed in her room sitting in a wheelchair near the bed. The resident was well groomed and in appropriate casual wear. During an interview at that time, Resident B, stood from the wheelchair and transferred herself to her bed without difficulty. The resident indicated that she and Employee 2 had become close friends and that she felt like a granddaughter to her. She indicated sometime in June or July of 2023; she sent a text to Employee 2 requesting that she bring a bag of popcorn to her room from a facility activity. Resident B indicated she fell asleep in her room before Employee 2 delivered the popcorn and that she later sent her a text that showed Resident B sleeping in her bed wearing a night shirt. The resident indicated she was uncovered in the picture and that her legs and upper thighs were exposed. Resident B indicated she did not like the way she looked in the picture and that she did not think the employee should have taken her picture without permission even though they were friends.Resident B indicated she reported the incident to the local Ombudsman around 11/25/23 and gave the Ombudsman permission to notify the facility on 12/4/23. When asked why she did not report the incident to the State Agency, facility Administrator, or Ombudsman earlier, she indicated she didn't know, that the picture did not cause distress, but she didn't like the way she looked in the picture and did not feel Employee 2 should have taken her picture. 12/12/23 at 2:25 P.M., during an interview with the Executive Director, she indicated on 12/04/23 at 1:01 P.M., she was notified by the local Ombudsman that Resident B reported that Employee 2 took a photo of her while she was sleeping in her bed in her room, and without her permission. The Executive Director indicated she immediately notified the State Agency, local police department, Medical Director, began an investigation, and suspended Employee 2 pending an investigation. The Executive Director indicated it was against facility policy for employees to photograph residents without the residents' permission. On 12/13/23 at 10:30 A.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE]. The resident's most resent Minimum Data Set (MDS) was a quarterly assessment, dated 9/26/23. The MDS indicated the resident was cognitively intact, with current diagnosis that included diabetes, hypertension, anemia, and depression. Resident B required limited assistance for transfers, dressing, and personal hygiene. On 12/13/23 at 11:00 A.M., the Executive Director provided Incident #1189. The report indicated on 12/4/23 at 1:01 P.M., the Executive Director was, . made aware that in June 2023, a staff member took a picture of Resident B without her consent .12/4/23 Employee was immediately suspended pending further investigation .12/9/23 Investigation completed .Appropriate disciplinary action rendered to the staff member [Employee 2] On 12/12/23 at 2:46 P.M., the Executive Director provided the current facility policy titled, Resident Rights, dated 7/23. The policy indicated, .All staff members recognize the rights of residents at all times .to enable personal dignity, well being On 12/13/23 at 11:49 A.M., the Executive Director provided an undated document titled,Policy Reminder: Mandatory In-Service ALL LOCATIONS Resident's Rights, Privacy, Photographs, Cell Phone Usage and Investigation Cooperation .Resident Rights Except for photographs or recordings taken with advance written consent of an alert and oriented resident, and as obtained only by the Executive Director (ED) .photographing residents at anytime is a violation of resident's rights and privacy .Residents have rights designed to ensure dignity and self-respect . This concern relates to complaint IN00423238. 3.1-3(a)(u)(3)

Based on interviews and record review the facility failed to notify the attending physician for a change in condition for 1 of 1 resident reviewed for change in condition. (Resident B) Findings include: During a record review, conducted 11/7/2023 at 10:12 A.M., the 5- day Admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had an intact cognition. She was independent for mobility and self-care. Active diagnoses included but were not limited to: chronic obstructive pulmonary disease, anxiety, atrial fibrillation, and cardiac pacemaker. She used oxygen as needed. She took a daily anticoagulant. Physician orders included, but were not limited to: -10/24/2023 Oxygen at l liter per nasal cannula as needed -10/23/2023 Cardizem 180 milligrams (mg) oral once a day -10/20/2023 Eliquis 2.5 mg oral twice a day A care plan problem, dated 10/24/2023, included, but was not limited to: resident is at risk for alteration in cardiac function related to pacemaker. The goal was for the resident to be free from signs of malfunction. Interventions included, but were not limited to, medications as ordered and observe for symptoms of weakness, shortness of breath, cyanosis, and dizziness. A progress note by RN 2, dated 11/5/2023 at 9:47 P.M., included, but was not limited to: resident complaining her heart is going fast. Pulse 112 B/P- 140/68. Resident has had all her scheduled medication at this point. Refused NTG (nitroglycerin) since she denies chest pain. States I don't have anxiety, but clearly trembling. Refused transport to hospital. An investigation interview done by the DON with RN 2, on 11/06/2023 at 12:54 P.M., included, but was not limited to: the resident came to the nurses desk to report that her heart was racing. The RN offered the resident a chair to sit and did an assessment consisting of a biox, pulse, and respirations. The RN offered the resident a nitroglycerin tablet but the res refused. The RN also offered to call for an ambulance but the resident refused. The RN then went to care for another resident's IV and a CNA reported to the RN that the res had sat herself on the floor. The resident then ambulated independently back to her room and offered no other complaints. During an interview with Resident B, on 11/8/2023 at 10:37 A.M., she indicated she walked down to the nurses desk and asked the nurse if she could take her pulse and BP. The nurse did not take her BP or pulse and told her she would be fine its just anxiety. The resident sat down on the floor and the nurse continued to say that it was her anxiety. Then the nurse got up and went down the hall and punched in the code to go on break. Resident continued to sit on the floor for about 45 minutes. After time passed and she felt better she got up without assist and went back to her room. She maintains that the nurse did not do any assessment other than the checking her oxygen level. The nurse did not offer to call an ambulance or her physician. Another resident, that was sitting in the hall during this occurrence, told her she should go to the hospital, but she declined. During a phone interview with RN 2, on 11/9/2023 at 9:35 A.M., she indicated the resident said her heart was beating fast. She went into nurse mode, took vitals, Biox (oxygen level) was 99% but admitted she didn't put it in the note She checked recent meds and what she had that might be effective. Offered an as needed dose of nitroglycerin but the resident stated she was not having chest pain and refused it. Resident B was alert and oriented. Someone else asked Resident B if she wanted to go to the hospital and she denied wanting to go to the hospital. Vitals included pulse, blood pressure (BP) using a manual BP cuff. The resident was sitting in her rollater in front of the nurses station and she was unsure when the resident ended up sitting on the floor. RN 2 indicated that the resident got herself up off of the floor independently. She denied filling out an event or observation form. The RN indicated that she did take the BP contrary to what the resident said. The resident was trembling and seemed anxious but denied feeling anxious. She hesitated to notify the physician. The RN did not take an apical pulse but did a radial and the Biox. It seemed that the resident sitting on the floor was an anxiety type of thing. The RN did not look at all of her diagnoses and so she could not say that it was a change in condition as she did not know the resident well. At the time I thought I was making the correct decision. She did not show any indication that she was having chest pain or an acute cardiac event and did not state she was having chest pain. Offered the nitroglycerin because that was the only cardiac as needed medication ordered and that is when she denied the chest pain. She indicated if there was a resident with any complaint her process would be as follows: I would check the medications to see if there was something to offer, and look at their diagnoses. She would look at their code status. Based on her assessment and if the resident was in pain, she would ask if they wanted to go to the hospital, or anything life threatening especially if they were a full code, she would call the physician. During an interview with DON on 11/9/2023 at 9:54 A.M. indicated if she was the nurse, she would have called the on call provider. A current policy provided by the DON on 11/8/2023 at 2:10 P.M., titled, Resident Change of Condition Policy and revised on 11/2018, included, but was not limited to: .It is the policy of this facility that all changes in resident condition will be communicated to the physician This concern relates to complaint IN00421418. 3.1-5(a)(2)

Based on observation and interview, the facility failed to ensure food items in the freezer were dated/labeled and sealed securely after opening and failed to ensure used by dates on foods. This deficient practice had the potential to affect 62 of 64 residents who received meals out of the kitchen. Findings include: On 6/12/23 at 9:28 A.M., during on observation and kitchen tour with the dietary manager, the following was oberserved: - In the pantry of the main kitchen, graham cracker crumbs were in an open bag with no date on the bag indicating when opened. - In the cooler, an open half gallon of milk and a carton of Half and Half had no open date. - In the freezer, two open tubs of ice cream had no open dates. Italian sausage, pork loin chops, beef cubed patties were found to be undated and unsealed. On 6/15/23 at 12:30 P.M., the Regional Nurse Consultant provided a policy titled, Food Storage, revised 5/23 and indicated the policy was the one currently used by the facility. The policy indicated .frozen foods, should be covered or wrapped tightly, labeled and dated with the date the item is being placed in the freezer. Frozen food items should be used within 1 year of this date to maintain quality dry storage, all foods should be covered or wrapped tightly, labeled and dated refrigerated, ready-to-eat, potentially hazardous foods purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded 3.1-21 (3)

Based on observation, record review and interviews, the facility failed to ensure antibiotic medications were administered as directed by the physician's orders and anti- coagulant medication was resumed timely for 1 of 3 residents reviewed. (Resident C) Findings include: The record for Resident C, reviewed on 6/14/2023 at 11:01 A.M., indicated Resident C was admitted with diagnoses included, but not limited to: acute embolism and thrombosis of right lower extremity, thrombocytopenia, repeated falls, muscle weakness, unsteadiness on feet and osteomyelitis of vertebra -cervical and thoracic region. The resident was hospitalized [DATE] - 4/11/2023 for a septic arthritic left hip joint and on 6/8/2023 for an acute deep vein thrombosis. Review of the hospital discharge records for Resident C, completed on 4/11/2023 indicated the resident was to receive enoxaparin (an anticoagulant) .3 ml (mililiter) via subcutaneous injections every 12 hours for 21 days. In addition, the resident was to receive the antibiotic, Vancomycin 1 gram via intravenous route every 12 hours for 6 weeks. Review of the medication administration record (MAR) for April and May 2023 for Resident C indicated she received the enoxaparin injections from 4/11/2023 through 5/2/2023. The resident had received the Vancomycin infusions but missed one dose on 4/18/2023, 4/19/2023, 4/21/2023, 4/25/2023 and 4/29/2023. The resident missed both doses on 4/20/2023. After 5/2/2023 the resident had no physician's orders for any type of blood thinning medication. During an interview with the Director of Nursing, on 6/19/2023 at 1:46 P.M., she indicated on 4/20/2023 the vancomycin was put on hold due to staff waiting on dosing from the pharmacy based on laboratory results and on 4/25/2023 the resident had been out of building with her family for the morning dose and was given the evening dose when she returned. The Director of Nursing indicated she could not account for the other 4 missing doses. Review of acute care records for Resident C, dated 6/8/2023 indicated the resident presented to the emergency room with overt nonpitting edema to the right lower extremity with associated tenderness below the knee. The resident was diagnosed with an acute DVT (deep vein thrombosis of the deep femoral vein on the right side. The hospital notes emphasized the resident had not been on anticoagulant for several weeks. The resident had reported to the acute care physician she thought the anticoagulation medication had been stopped the first week in May 2023. Review of physician progress notes, dated 5/26/2023 and 6/5/2023, indicated the resident's current medication list included enoxaparin injections, even though the order was discontinued on 5/2/2023. The note also listed Assessment issues including Acute embolism and thrombosis of left femoral vein: continue Xarelto, monitor extremities for changes in color, temperature and peripheral pulse. and Muscle weakness (generalized) Pt (patient) is immobile. Continue Lovenox (brand name for enoxaparin) During an interview with the physician on 6/19/23 at 11:56 A.M., he indicated he used a Scribe system for writing his notes which accounted for the way certain things were typed on the notes. He indicated acute orders from the hospital orthopedic team and/or hospitalists take presidence over routine orders and often resident's blood thinners were held prior to surgical procedures. He indicated while the resident would not be prescribed Lovenox injections at the same time as oral Xarelto medications, she should have been on a blood thinner. He indicated Resident C did have an IVF (intravenous filter) due to her history of blood clots, but she should also have been on Xarelto indefinitely. He indicated the whole clinical team was responsible for reviewing the resident's chart and ensuring her medication regimen was complete and accurate. He indicated no one from the facility had notified him of the need to reorder Xarelto. The facility policy and procedure, titled, Resident Change of Condition provided by the Regional Nurse Consultant on 6/19/2023 at 2:29 P.M., included instructions for reporting Non-urgent Medical Change. The facility policy and procedure, titled, Physician Services provided by the Regional Nurse Consultant on 6/19/2023 at 2:29 P.M., included the following: .The Physician must document a review of the resident's total program of care, including the resident's current condition, progress and problems in maintaining or improving their physical, mental, and psychosocial well-being and decisions about the continues (sic) appropriateness of the resident's current medical regimen This Federal tag relates to complaint IN00407225 and IN00410341. 3.1-37

Based on record review and interview, the facility failed to protect a residents right to be free from verbal abuse for 1 of 1 resident reviewed for abuse. (Resident C) Finding includes: Review of a facility reported incident, on 6/11/2023 indicated Resident C reported a staff person to be verbally abusive to her. The report indicated the identified employee was suspended pending an investigation, alert and oriented residents were interviewed to determine any concerns with staff they might have, the identified employee received Customer service education and the progressive discipline policy was followed. Resident C was to be monitored for any psychosocial concerns regarding the event. There was no specific information regarding the event on the facility reported incident. However, review of the incident investigation, provided upon request on 6/14/2023 indicated the following: On 6/8/2023, two activity aides (Employee 15 and 16) had transported Resident C on the facility bus to an outside physician's office for an appointment. During the bus ride to the appointment, Employee 16 had been driving the bus and Employee 15 was sitting with the resident on the bus. Resident C had been complaining about the bumpy road during the trip. Once the bus arrived at the medical office building, Employee 15 assisted Resident C to the building and discovered they were at the wrong entrance/address. According to Employee 15, Resident C and Employee 16 started speaking to each other, in a raised voice and arguing. Employee 16 then stated to Resident C I brought your a-- to the right place. I'm tired of your f------ yelling at me. Employee 16 also called Resident C a b----. During an interview with Employee 15, on 6/14/2023 at 3:57 P.M. she confirmed the other Act Aide called Resident C a b---- and said also told Resident C that she had brought her a-- to the right place and told the resident she was tired of her f------ yelling at her. Employee 15 indicated she did not do anything immediately as she did not want to get in the middle of it but she did consider it mental abuse and she reported the incident to the Administrator immediately when she returned from the outing. Resident 15 indicated she pushed Resident C into the doctor's office immediately after arriving at the correct entrance and she and Employee 16 drove back to the facility. Employee 15 indicated she had been in-serviced regarding the facility's abuse policy and was able to verbalize the resident was to be removed from any abusive situation and any abuse was to be reported to the Administrator immediately. Review of an Employee Communication Form and interview with the Director of Nursing, on 6/14/2023 at 3:15 P.M. she indicated Employee 16 was terminated for Disruptive Behavior on 6/8/2023. The form indicated the employee used Inappropriate Verbage and her workplace conduct was no in accordance with customer service expectations and she was argumentative with resident. The form was completed on 6/13/2023. The Director of Nursing indicated the employee had some previous disciplinary reports and she was terminated after this incident. The facility's Abuse, Prohibition, Reporting and Investigation policy, provided by the Administrator upon entrance to the facility on [DATE], included the following: .It is the policy of [name of company]to provide each resident with an environment that is free from abuse .[name of company] will not permit residents to be subjected to abuse by anyone, including employees .Verbal Abuse - The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance .This includes any episode of staff to resident .Resident Abuse - Staff member, volunteer, or visitor: 1. The resident (s) involved in the incident will be protected and/or removed from the situation immediately. 2. Any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the chart nurse of the unit, which the resident resides and to the Executive Director (Administrator) This Federal tag relates to complaint IN00407225. 3.1-27(b)

Based on interview and record review, the facility failed to ensure showers were provided for 1 out of 3 Residents reviewed for activities of daily living. (Resident 50) Finding includes: During an interview on 6/13/2023 at 9:11 A.M., Resident 50 indicated he preferred to take a shower but does not get one. During an interview on 6/14/2023 at 1:28 P.M., Resident 50 indicated he did not have a shower this week. During an interview on 6/16/2023 at 1:41 P.M., the resident indicated he had not received a shower this week. A record review was completed on 6/15/2023 at 2:00 P.M. Diagnoses included, but were not limited to: neoplasm of the brain, Diabetes Mellitus, anxiety and depression. A Quarterly Minimum Data Set (MDS) Assessment, dated 5/22/2023, indicated physical help in part of bathing activity. A Preference for Customary Routine and Activities, dated 4/11/2023, indicated he would like twice a week shower in the P.M. and that it was very important to him to choose between tub bath, shower, and bed/sponge bath. A Care Plan, dated 4/9/2023, indicated resident required assistance with activities of daily living (ADL's) with an intervention to assist with bathing as needed per residents' preference. Offer showers two times a week and partial bath in between. During an interview on 6/15/2023 at 3:53 P.M., the Director of Nursing indicated they have a shower schedule posted at the nurse's station, it is the only location where the resident showers are posted. The staff document the showers on the shower sheet and chart in the progress notes of any refusals. She indicated that he was not on the shower schedule, and she could not find any documentation indicating he got a shower or of any refusals. No shower sheets were located for month of May and June. He should have been getting two showers a week per his preference. On 6/16/2023 at 12:00 P.M., the Director of Nursing indicated that they have no policy on showers. 3.1-38(2)(A)

Based on observation, record review and interviews, the facility failed to ensure Activities of daily living assistance was provided for 2 of 4 residents reviewed. (Resident 20 and 53) Findings include: 1. Resident 53 was observed on 6/12/2023, 6/13/2023 and 6/14/2023 dressed in the common areas and/or at an activity. Her hair was observed to be unkept in appearance and greasy. The clinical record for Resident 53, reviewed on 6/19/23 at 9:16 A.M., indicated the resident had diagnoses included but not limited to: hypertension, chronic kidney disease hyperlipidemia, obesity, insomnia, adjustment disorder with depressed mood, dementia, and major depressive disorder, recurrent, The most recent MDS (Minimum Data Set) assessment for Resident 53, completed on 5/11/2023 for a quarterly review, indicated the resident was severely cognitively impaired and required extensive assist of one for toileting, bathing, dressing, and limited assist of one for personal hygiene. The annual MDS assessment, completed on 4/12/2023, indicated it was very important for the resident to choose between a bath/shower/bed bath on the preferences section of the assessment. The current care plan regarding preferences indicated the resident was to be showered twice a week in the mornings. The documentation in the resident's clinical record regarding showering and/or bathing from 5/19/2023 - 6/19/2023, indicated the resident was only documented to have received a shower on 5/31/2023 at 8:37 A.M. The Point of care documentation for bathing from 4/19/2023 - 5/18/2023 indicated the resident only received 3 showers and 1 complete bed bath. Finally, the charting form 4/1/2023 - 4/19/2023 indicated there were no showers documented. Copies of additional Shower Report forms for Resident 53 were provided on 6/14/2023 at 2:00 P.M. by the Administrator. The forms indicated the resident had received a shower on the following dates: 4/3/2023, 4/6/2023, 4/10/2023, 4/13/2023, 4/17/2023, 4/20/2023, 4/27/2023, 5/1/2023, 5/4/2023, 5/8/2023, 5/15/2023, 5/18/2023, 5/25/2023, 5/29/2023, 6/1/2023, and 6/8/2023. The shower form on 4/3/2023 and 4/6/2023 were not signed by the aide or the nurse and did not indicate the time the shower was given and if a shampoo, nail care, was given. The form on 4/10/23, 4/27/2023, 5/4/2023, 5/8/2023, 5/15/2023, 5/18/2023, 5/25/2023, 5/29/2023, 6/1/2023 and 6/8/2023 were all signed by the same nurse, LPN 1, not signed by the aide completing the showering and only indicated shower given, not shampoo. Review of the April 2023 schedule and interview with the Director of Nursing, on 6/19/2023 at 11:40 A.M., indicated on several of the days Employee 1, an LPN, had signed an incomplete shower report, she was not on the working schedule for the day. The Director of Nursing indicated she did know why LPN 1 was not on the schedule on the days she had signed the shower report forms but she was going to look into the discrepancy. She indicated the aides were not good about documenting correctly in the Point of Care electronic record. No further information regarding the showers and/or shower forms was provided during the survey. 44111 2. A record review was completed on 6/14/2023 at 2:40 P.M., for Resident 20. Diagnoses included, but were not limited to: cerebral infarction and hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. During an observation, on 6/13/2023 at 10:17 A.M., Resident 20 was in bed and had long, jagged fingernails with a dark substance under them. During an observation, on 6/14/2023 at 9:04 A.M., the resident was in bed fingernails long, jagged with brown substance under the nails. During an observation, on 6/16/2023 at 2:34 P.M., the resident was in bed and had long, jagged fingernails with brown substance under them. A Quarterly Minimum Data Set (MDS) assessment, dated 5/24/2023, indicated that he is total dependent for bathing with one assist. A Care Plan, dated 2/9/2020, indicated resident requires assistance with activities of daily living (ADL's), assist with dressing, grooming, and hygiene as needed. During an interview, on 6/14/2023 at 3:21 P.M., certified nurse aide (CNA) 5 indicated when she gives a shower she washes the entire body, wash hair, brush residents' teeth, and inspects the skin for redness. During an interview, on 6/15/2023 at 10:17 A.M., CNA 7 indicated when she gives a shower, she will assist with washing the body and their hair, brush the teeth and shave them if needed. During an interview, on 6/15/2023 at 10:21 A.M., CNA 6 indicated when she gives a shower she washes the whole body, hair, shaves them and clips toe and fingernails, dries them off and assist with dressing. On 6/16/2023 at 12:00 P.M. the Director of Nursing indicated she does not have a policy on nail care or showers.

Based on observation, record review and interviews, the facility failed to ensure respiratory equipment was maintained per professional standards for 3 of 3 residents reviewed for respiratory care. (Resident 44, 33 and 1 ) Findings include: 1. Resident 44 was observed on 6/12/2023 during the initial tour of the facility, lying in bed, holding his oxygen tubing and nasal cannula in his hands. The resident's oxygen tubing, which was connected to a concentrator was not dated and there was no plastic storage bag observed in the room. On 6/13/23 at 10:07 A.M., Resident 44 was observed seated in his wheelchair with oxygen per a nasal cannula connected to a portable oxygen tank. The tubing was not dated. On 6/16/23 at 9:30 A.M., Resident 44 was observed lying in bed. The resident was not wearing oxygen at the time. The oxygen tubing was hanging off the back of his wheelchair, connected to a portable oxygen tank. There was no storage bag noted and the oxygen tubing was not dated. A record review was completed on 6/16/23 for Resident 44. Diagnoses included, but not limited to: dementia, Wernicke's encephalopathy, severe protein-calorie malnutrition, chronic obstructive pulmonary disease, lack of coordination, repeated falls, constipation, chronic pain, generalized anxiety disorder, major depressive disorder, hyperkalemia, dysphagia, cognitive communication and alcohol dependence with delirium withdrawal, nicotine dependence, osteoarthritis. During an observation and interview of resident 44, with the DON, on 6/16/2023 at 10:58 A.M., she indicated oxygen tubing and/or a storage bag should have date on it and tubing was to be changed every week. She indicated the nurses usually wrote the date with a permanent marker when they changed the oxygen tubing. 44111 2. During an observation on 6/12/2023 at 12:40 P.M., Resident 33's oxygen concentrator filter was covered with white/gray colored lint. During an observation on 6/13/2023 at 10:04 A.M., the concentrator was covered with white/gray colored lint. During an observation on 6/14/2023 at 8:53 A.M., lint continued to be covering the filter. A record review was completed on 6/14/2023 at 11:55 A.M. Diagnoses included, but were not limited to: acute chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. A Physician Order, dated 4/7/2023, indicated to change the oxygen tubing and humidity, clean concentrator and filter once a day on Monday. During an interview on 6/14/2023 at 1:08 P.M., the Director of Nursing indicated that there was lint on the filter but needed to contact filter company on the maintenance of the filter. On 6/16/2023 at 1:20 P.M., the Regional [NAME] President of Operation (RVPO) provided maintenance on the filter for the concentrator titled, Provider Maintenance, undated. The routine maintenance indicated .The external air intake gross particle filter is located on the back of the unit. You can easily remove it by hand. Instruct the patient to clean this filter weekly On 6/16/2023 at 1:22 P.M. the Regional [NAME] President of Operation (RVPO) indicated that the filter should have been cleaned weekly. On 6/16/2023 at 1:20 P.M. the Regional [NAME] President of Operations provided a policy titled, Oxygen Therapy Devices , undated, and indicated the policy was the one currently used by the facility. The policy indicated . Oxygen Safety 1) No smoking signs need to be affixed to front and back of doors (OSHA regulations), Oxygen Devices 1) Nasal cannula e. Change out weekly and PRN, f. place in a labeled bag when not in use 48054 3. A record review was completed for Resident 1 on 6/14/2023 at 10:00 A.M. The most recent MDS (mimimum data set), assessment, dated 4/4/2023, indicated severe cognitive impairment. Diagnoses included, but not limited to: chronic obstructive pulmonary disease, schizophrenia, palliative care for respiratory failure. Medications included but not limited to: Oxygen at 3 liters per nasal cannula as needed. During an observation on 6/14/2023 at 10:00 A.M., resident was dressed in bed with the head of the bed elevated. Oxygen was on at 3 liters/via nasal cannula. Tubing was not dated; humidification bottle not dated. During an observation on 6/15/2023 at 9:41 A.M., resident was in bed with oxygen on at 3 liter via nasal cannula. The tubing and humidification bottle were not dated. During an interview on 6/15/2023 at 9:57, Employee 1 indicated the resident should have an order to change all oxygen equipment on Sundays. A order for oxygen supply changes was not found in the clinical record. During an observation on 6/16/2023 at 9:18 A.M., Resident was resting in bed with oxygen on at 3 liters via nasal cannula. No oxygen signage was on the door. During a 2nd interview, on 6/16/2023 at 9:18 A.M., with Employee 1 he indicated that tubing and humidification bottles should be dated, and that staff is responsible for chaning oxygen tubing and bottles on Sundays. Hospice managed oxygen therapy for this resident but that staff in the facility should change out oxygen supplies on Sundays as the ordered. She indicated if not directed in the physician order the oxygen supply changes should default to Sundays and there should be signage on the door. On 6/16/2023 at 1:20 P.M., Employee 16 presented a copy of the Oxygen Therapy and Devices policy. The policy indicated .for some people with certain health conditions whose lung function is impaired, the amount of oxygen that is obtained through normal breathing is not enough. Therefore, they require supplemental amounts to maintain normal body function oxygen must be ordered by physician, No smoking signs need to be affixed to front and back of doors per OSHA, practice standard precautions, gather equipment (liquid, cylinder, concentrator and humidity if applicable, apply device at appropriate flow, place oxygen signs and document in patient file .Oxygen nasal cannula to be changed out weekly and as needed and place in labeled bag when not in use 3.1-47(a)(6)

Based on observations and interviews, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents by 1 of 2 medication carts, 1 of 3 treatment carts. Findings include: 1. During a medication observation, on 6/14/2023, at 8:20 A.M., Qualified Medication Aide (QMA) 8 left the medication cart unlocked while she was in a resident's room. The medication cart was not in view of the QMA. QMA 8 indicated she should have locked the cart before entering the resident's room. 2. During a medication observation, on 6/14/2023 at 2:45 P.M., Licensed Practical Nurse (LPN) 9 walked away from the medication cart without locking it. It was not in view of the LPN. LPN 9 indicated he should have locked the medication cart before walking away. 3. On 6/15/2023 at 8:08 A.M., during an observation and interview with QMA 17, the treatment cart was unlocked in the unit's resident lounge with treatment medications and supplies. QMA 17 indicated the cart should be locked. 4. During a medication observation, on 6/15/2023 at 11:56 A.M., Registered Nurse (RN) 11 pre-poured metoclopramide 10 mg 1 tab oral every 6 hours, a medication for Resident 10, and left it in the resident's room on the nightstand while she went back to the nurse's desk. The resident was sitting in his wheelchair in the room at the time. During an interview at the time RN 10 indicated she should not have left the medication in the resident's room unattended. During an interview, on 6/15/2023 at 1:23 P.M., the Director of Nursing indicated medication and treatment carts should be locked when unattended and medications should not be left in a resident's room unattended. A current policy titled, Storage and Expiration Dating of Medication, Biologicals and revised on 7/21/2022, provided by the corporate nurse consultant, on 6/19/2023 at 10:13 A.M. The policy indicated, .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors A current policy titled, General Dose Preparation and Medication Administration and revised on 1/1/2022, was provided by the corporate nurse consultant, on 6/19/2023 at 11:04 A.M. The policy indicated, .Facility staff should not leave medications or chemicals unattended 3.1-25(m)

Based on record review and interview, the facility failed to ensure a notification of change in Medicare covered services was provided for 1 of 3 residents reviewed for Medicare services. (Resident 64) Finding includes: The clinical record for Resident 64 was reviewed on 6/14/2023 at 11:00 A.M. Resident 64 was admitted to the facility on [DATE] and was receiving Medicare Part A Services. Review of the record indicated the resident's last covered Medicare Part A services day was 2/16/2023. The clinical record for Resident 64, reviewed on 6/13/2023 at 1:17 P.M., indicated the resident was admitted to the facility on [DATE] with diagnoses included, but not limited to: hemiparesis and hemiplegia related to subarachnoid hemorrhage, diabetes mellitus, depression, and dysphagia. The resident was receiving Medicare Part A skilled services when she was admitted , and her last covered Medicare day was 2/16/2023. The facility Business office provided documentation that a skilled care ABN (Advanced Beneficiary Notice of Non-Coverage form and a NOMNC (Notice of Medicare Non-Coverage) form were not issued to Resident 64. Resident 64 chose to remain a resident of the facility after 2/16/2023. During an interview with the Business Office Manager (BOM), on 6/13/2023 at 10:30 A.M., she indicated she could not locate the forms for Resident 64 and both forms should have been provided to the resident. The BOM indicated the facility policy was to follow the requirements of both forms per CMS (Centers for Medicare and Medicaid Services). The form instructions for the NOMNC form indicated a completed copy was to be delivered to the resident and/or their representative 2 calendar days prior to Medicare covered services ending. The form instructions for the ABN indicated it was to be issued in advance of a shift from Medicare covered items and/or services to expected non-coverage of items or services. 3.1-4(f)(2)

Based on observation, interview and record review, the facility failed to ensure the signed advance directive was updated in the plan of care and physician order for 1 of 25 residents reviewed for advanced directives. (Resident 20) Finding includes: A record review was completed on 6/14/2023 at 2:40 P.M. Diagnoses included, but were not limited to: cerebral infarction and hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. A Physician Orders For Scope of Treatment (POST), dated 5/12/2023, indicated do not attempt resuscitation. A Physician Order, dated 4/5/2022, indicated full code. A Care Plan, dated 2/19/2020, indicated resident/legal representative prefers a full code status. During an interview on 6/14/2023 at 10:30 A.M., the Director of Nursing indicated they obtain a code status upon admission, readmission, and revisit during a quarterly care conference. The resient was a do not resuscitate and the order and care plan should have been updated when it was changed. 48054 On 6/14/2023 at 10:47 A.M., the Director of Nursing provided a policy titled, Advanced Directives, revised 2/2023, and indicated the policy was the one currently used by the facility. The policy indicated .if a resident has a valid Advanced Directive, the facility's care will reflect the resident's wishes as expressed in the Directive, in accordance with state law .Information about any Advanced Directives already in place will be gathered as part of the admission process. Executed Advanced Directives will be documented in the medical record. Advanced Directives which reflect medical care and treatment will be documented in a physician's order .Advanced Directives will be reviewed quarterly during care plan conference and as needed upon change in condition The POST (physician's orders for scope of treatment) is a physician's order based on resident's individual goals and treatments for medical treatment .the POST will be reviewed by the facility interdisciplinary team during the quarterly care planning conference, anytime there is a significant change in the resident's condition and at anytime the resident or legally recognized health care decision maker requests it .at any time, a resident or legally recognized health care decision making can revoke the POST form or change his/her mind about treatment preferences by verbalizing or given a written advance directive, or after consultation with physician or advanced practice nurse, a new POST form .All discussions about revising or revoking the POST form should be documented in the resident's medical record 3.1-4(5)

Based on observation and record review, the facility failed to ensure physicians orders to prevent the development of pressure ulcers was implemented for 1 of 3 residents reviewed. (Resident 33) Finding includes: A record review was completed on 6/14/2023 at 11:55 A.M. for Resident 33. Diagnoses included, but were not limited to: acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. During an observation, on 6/12/2023 at 12:41 P.M., resident was lying in bed supine with her legs crosses at the ankles, heels not floated, no prevalon boots on or ear protectors on the oxygen tubing. During an observation, on 6/13/2023 at 10:03 A.M., resident was lying supine in bed, heels not floated, no prevalon boots on and no ear protectors on the oxygen tubing. During an observation, on 6/14/2023 resident was lying supine in bed, heels not floated, no prevalon boots on and no ear protectors on the oxygen tubing. A Physician Order, dated 2/24/2023, indicated prevlon [sic] boots to be worn at all times except during patient care. A Physician Order, dated 2/24/2023, indicated to encourage to float heel when in bed. A Physician Order, dated 4/7/2023, indicated ear protectors to oxygen tubing and check placement every shift. A Care Plan, dated 11/11/2022, indicated at risk for skin breakdown with interventions to encourage to float heel and prevlon [sic]boots to be worn at all times except during patient care. During an interview, on 6/14/2023 at 11:16 A.M., the Director of Nursing indicated she is not wearing prevalon boots or ear protectors on the oxygen tubing or floating her heels. She does have orders for them and should have been wearing them. She was unable to find documentation of refusals in the progress notes or the treatment record. She would expect her staff to document refusals and inform management or doctor of refusals and discontinue them. On 6/16/2023 at 12:00 P.M., the Director of Nursing indicated she does not have a policy on physician orders. 3.1-40

Based on observation, interviews and record review, the facility failed to protect a resident's right to be free from physical abuse when a Qualified Medication Aide (QMA) pushed a resident to the ground, resulting in a fracture to the intertrochanter (hip) and radius (arm) for 1 of 3 residents reviewed for abuse. (Resident D) The immediate jeopardy began, on 12/29/22 at 7:30 P.M., when Resident D was observed being pushed to the ground by Qualified Medication Aide T, on the facility's video surveillance system. The Administrator was notified of the immediate jeopardy on 1/25/23 at 4:45 P.M. Finding includes: On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22, of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking. On 1/25/23 at 11:47 A.M., during an interview, conducted with Resident D's responsible party, he indicated Resident D was pushed down real hard by a male nurse. He indicated the facility told him the resident fell and he requested to see a video but was told by the facility they did not have a video of the fall. The Responsible party indicated he was notified of Resident D's fall on 12/30/22 in the morning and was told they were sending the resident to the hospital for pain from a fall. The Responsible Party never notified him there was abuse until after the resident returned to the facility from the hospital. On 1/25/23 at 12:03 P.M., during an interview, conducted with a local police detective, they indicated the facility reported an incident that occurred on 12/29/22 at the facility to the police department and on 12/30/22 at an unknown time, the Detective indicated the facility provided a video related to the incident. The Detective indicated they observed Resident D near the Nurse's Station and was thrown to the ground by QMA T. The resident was sent to the hospital where they discovered a broken hip and arm. On 1/25/23 at 12:30 P.M., during an observation of Resident D, the resident was observed sitting on the edge of his bed eating lunch utilizing the over bed table. Resident D had a brace to his right forearm and 2 healing incisions both approximately 3 cm (centimeters) long to the right hip. In an interview, conducted at that time, the resident indicated he went to the nurses station one evening, he was not able to recall the date, for something more to eat. The resident indicated the nurse pointed back to the refrigerator behind the nurses station so he thought the nurse wanted him to go get a snack from the refrigerator. Resident D indicated when he opened the door the nurse jumped up and took him out of the Nurse's Station and threw him onto the floor and that's when his leg and arm broke. The resident indicated he couldn't move, was crying, and hurt bad while the nurse was telling him to get back to his room. Resident D indicated he could not move, so the nurse got him up and hand hauled him to his room and threw him in his bed. The resident indicated all he could do was cry. On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia. An Admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene. On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated LPN L told her that QMA T indicated he had made a mistake and that was an odd thing to say. The DON indicated she notified the ED on 12/29/22 at about 7:50 P.M., to report the fall and that LPN L had indicated QMA T had made a mistake and told the ED there was something missing in LPN L's report. The DON indicated she asked the ED if she should go to the facility, but was not directed to do so. The DON indicated she did not receive any notifications regarding Resident D until the following morning on 12/30/22 at 6:50 A.M. when the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated she should have gone into the facility when she received the call from LPN L about the resident's fall and the comment made by QMA T indicating he had made a mistake. On 1/25/23 at 3:07 P.M., during an interview, conducted with the ED she indicated she received a call from the DON indicating Resident D had sustained a fall and there was some concern about what had happened. The ED indicated she called the facility and spoke with LPN L and had QMA T removed from the facility pending an investigation. The ED indicated she was notified of Resident D's hip fracture on 12/30/22 at 6:50 A.M., when it was reported to the DON. A Radiology report, dated 12/30/22 at 7:32 A.M., indicated Resident D had a displaced intertrochanteric fracture of the proximal right femur. A Local Police Report, dated 12/30/22 at 4:00 P.M., indicated .viewed the facility video and could see [Resident D] grab the medication cart and start to open the drawers looking for medication. At this time QMA T stood up and walked over and grabbed the cart and told the resident he could not get in the cart. QMA T starts to pull the cart away from the resident and the resident grabbed the cart and pulled it out of the QMA's hands and started going through the drawers again. At this time QMA T is seen putting hands up to stop the resident, but the resident keeps trying to get in the cart. AMA T then grabs [Resident D] by both of his arms and pulls the resident away from the cart at which the resident stumbles to the counter and catches himself. Then [QMA T] is seen to walk over and push the resident causing the resident to fall to the floor. QMA T is seen trying to help the resident back up at which the resident falls again because he can not get his balance. Resident finally gets up with the help of [QMA T] and another nurse comes out after everything happened A emergency room Physician's Report, dated 12/30/22 at 3:03 P.M., indicated .[Resident D] arrived presented to ED [Emergency Department] from [local long term care facility] for evaluation of right hip and right shoulder pain. Patient provides little to no history. Patient states that someone beat his ass .was thrown into a wall. EMS [Emergency Medical Services] state the[ facility] staff state the patient fell at some point yesterday which was unwitnessed between the hours of 2 PM [2:00 P.M.] and 10 PM [10:00 P.M.]. No other history is provided. Patient states that nothing has been tried for relief. When asked to rate his pain he states just put me down man! Knock me out! The ER report further indicated the resident had a right intertrochanteric fracture and an intra-articular right radius fracture. On 1/26/23 at 2:30 P.M., during an interview, conducted with LPN L, he indicated on 12/29/22 around 7:30 P.M., he was working in another area of the building when QMA T came to get him saying he needed some help. LPN L indicated QMA T took him to Resident D's room to have the resident assessed because he had fallen. LPN L indicated when he assessed the resident he was found to be in pain but the remainder of the assessment was negative and the resident stoped complaining of pain within 15 minutes of the assessment. LPN L indicated he asked QMA T what happened and the QMA indicated the resident was reaching for the med cart and he pushed the resident away and he fell . LPN L indicated he attempted to notify the Nurse Practicioner (NP) 4 times but the NP never answered the calls. LPN L indicated he notified the ED and the DON immediately and the ED instructed him to remove QMA T from the facility immediately pending an investigation, which he did. A policy, titled Abuse Prohibition, Reporting, and Investigating dated 1/23 was provided by the DON on 1/24/23 at 11:15 A.M. The policy indicated .It is the policy to provide each resident with an environment that is free from abuse .will not permit residents to be subjected to abuse by anyone, including employees .Physical abuse- A willful act against a resident by .staff member The immediate jeopardy was removed and corrected, on 12/30/23, when the facility staff was; in-serviced regarding their abuse policy and behavior management, an emergency Resident Council meeting was held, resident and staff interviews were completed, a house wide skin sweep was completed for uninterviewable residents, employee files were reviewed for abuse training upon hire, audits were implimented regarding monthly staff abuse policy in-services, and signage regarding staff burn and abuse and how to report to each. This Federal tag relates to complaint IN00399801. 3.1-27(a)(1)

Based on observation, interviews and record review, the facility failed to ensure pain management was in place for a resident who sustained injuries following an altercation with a facility Qualified Medication Aide (QMA) when the resident was pushed to the ground and sustained a fracture to the hip and arm. (Resident D) Finding includes: On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22, of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking. On 1/25/23 at 12:30 P.M., during an observation of Resident D, the resident was observed sitting on the edge of his bed eating lunch utilizing the over bed table. Resident D had a brace to his right forearm and 2 healing incisions both approximately 3 cm (centimeters) long to the right hip. In an interview, conducted at that time, the resident indicated he went to the nurses station one evening, he was not able to recall the date, for something more to eat. The resident indicated the nurse pointed back to the refrigerator behind the nurses station so he thought the nurse wanted him to go get a snack from the refrigerator. Resident D indicated when he opened the door the nurse jumped up and took him out of the Nurse's Station and threw him onto the floor and that's when his leg and arm broke. The resident indicated he couldn't move, was crying, and hurt bad while the nurse was telling him to get back to his room. Resident D indicated he could not move, so the nurse got him up and hand hauled him to his room and threw him in his bed. The resident indicated all he could do was cry. On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included, but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia. An Admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene. Review of Resident D's Progress Notes, indicated on 12/29/22 at 8:57 P.M., .QMA reported resident had a fall with complaints of pain. I [Licence Practical Nurse (LPN) L] assessed resident rang of motion and resident was in intense pain . 12/29/22 at 9:35 P.M., .spoke with resident He complained of pain in his hip. A STAT X RAY was ordered. 12/30/22 at 6:44 A.M., [Resident D] has been in pain, yelling out and on the call light most of the night d/t [due to] right leg having s/s [signs and symptoms] of a fracture from a fall. Noted to be externally rotated, and swollen at the hip ball joint area. Given him PRN [as needed] Butal-Acetam-Caff (primary use to relieve symptoms of tension headaches) at 0030 [10:30 P.M] which did not help much. PRN Loazepam (an antianxiety medication) 0.25 ml given at 0202 [2:02 A.M.] which did help and had been comfortable until [mobile unit X Ray] came to do his x-ray. 12/30/22 at 7:21 A.M., Resident noted with severe pain, calling out in pain. Per report .R [right] leg noted with external rotation, unable to move leg and screaming out when touched and moved . Review of physicians orders indicate Resident D's orders included, but were not limited to: Loazepam 0.25 ml 2 times a day for anxiety disorder, from 7:00 A.M. to 11:00 A.M., and from 7:00 P.M, to 11:00 P.M., dated 12/20/22, Tylenol 650 mg, for pain every 6 hours as needed, dated 12/13/22, Butalbital-acetaminophen-caff 50-300-40 mg for headache every 6 hours as needed, dated 12/20/22. Review of Resident D's Medication Administration Record (MAR) indicated the resident did not received Loazepam 0.25 ml as ordered on 1/29/22 sometime between 7:00 P.M. and 11:00 P.M. Reason/Comments on the MAR indicated the medication was not administered because the medication was unavailable. Resident D received Loazepam 0.5 ml on 1/30/22 at 2:04 A.M. with the Reason/Comment documented as .yelling out d/t pain. The MAR indicated Butalbital-acetaminophen-caff 50-300-40 mg capsule was given one time on 1/30/22 at 12:31 A.M. No documentation for Reason/Comment was noted. No other pain medications or interventions were documented to address the resident's pain. On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated she did not receive any notifications regarding Resident D until the following morning on 12/30/22 at 6:50 A.M. when the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated no one called her about the resident's pain level in the night but that they should have addressed his pain better and the Nurse Practitioner should have been notified of the pain but was not. A policy, titled Pain Management, dated 10/20 was provided by the DON on 1/27/23 at 11:30 A.M. and indicated it was the current facility policy. The policy indicated, .It is the policy .to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being, including pain management .Pain medications will be prescribed and given based upon the intensity of the pain .The physician will be notified [for] unrelieved or worsening pain . This Federal tag relates to complaint IN00399801. 3.1-37(a)

Based on interview, record review, the facility failed to ensure an allegation of abuse that resulted in serious bodily injury was reported to the State Agency (SA) in a timely manner for 1 resident, (Resident D). Finding includes: On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22 at around 7:30 P.M., of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking. On 1/25/23 at 12:03 P.M., during an interview, conducted with a local police detective, they indicated the facility reported an incident that occurred on 12/29/22 at the facility to the police department and on 12/30/22 at an unknown time, the Detective indicated the facility provided a video related to the incident. The Detective indicated they observed Resident D near the Nurse's Station and was thrown to the ground by QMA T. The resident was sent to the hospital where they discovered a broken hip and arm. On 1/25/23 at 12:30 P.M., during an observation of Resident D, the resident was observed sitting on the edge of his bed eating lunch utilizing the over bed table. Resident D had a brace to his right forearm and 2 healing incisions both approximately 3 cm (centimeters) long to the right hip. In an interview, conducted at that time, the resident indicated he went to the nurses station one evening, he was not able to recall the date, for something more to eat. The resident indicated the nurse pointed back to the refrigerator behind the nurses station so he thought the nurse wanted him to go get a snack from the refrigerator. Resident D indicated when he opened the door the nurse jumped up and took him out of the Nurse's Station and threw him onto the floor and that's when his leg and arm broke. The resident indicated he couldn't move, was crying, and hurt bad while the nurse was telling him to get back to his room. Resident D indicated he could not move, so the nurse got him up and hand hauled him to his room and threw him in his bed. The resident indicated all he could do was cry. On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia. An Admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene. A Significant Change Minimum Data Set, dated dated dated [DATE], indicated Resident D was moderately cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required extensive assistance of 2 people with bed mobility, transfers, and toileting, and extensive assistance of 1 person for locomotion on and off the unit, dressing, and personal hygiene. The resident required a wheelchair for mobility. Diagnoses included but were not limited to hip fracture and other fracture (arm). An Incident Report Number: 117, with a report date of 12/30/22 at 8:02 P.M., was provided by the ED on 1/25/23 at 2:09 P.M. The report indicated an incident date of 12/29/22 at 7:30 P.M., indicating, . the resident approached the Nurses Station and Medication Cart demanding medications. As staff member attempted to redirect resident, the resident became increasingly agitated and persistent, pulling med cart and trying to open. Staff member continued to redirect resulting in a physical altercation with resident falling to floor. Staff member contacted Nurse for assessment .Moble X-ray was completed on morning of 12/30 indicating a Right hip fracture . New orders received to send to ER for further evaluation and treatment . On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated LPN L told her that QMA T indicated he had made a mistake and that was an odd thing to say. The DON indicated she notified the ED on 12/29/22 at about 7:50 P.M., to report the fall and that LPN L had indicated QMA T had made a mistake and told the ED there was something missing in LPN L's report. The DON indicated she asked the ED if she should go to the facility, but was not directed to do so. The DON indicated she did not receive any notifications regarding Resident D until the following morning on 12/30/22 at 6:50 A.M. when the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated she should have gone into the facility when she received the call from LPN L about the resident's fall and the comment made by QMA T indicating he had made a mistake. On 1/25/23 at 3:07 P.M., during an interview, conducted with the ED, she indicated she received a call from the DON indicating Resident D had sustained a fall and there was some concern about what had happened. The ED indicated she called the facility and spoke with LPN L and had QMA T removed from the facility pending an investigation. The ED indicated she was notified of Resident D's hip fracture on 12/30/22 at 6:50 A.M., when it was reported to the DON. The ED indicated the State Agency was was notified of the allegation of abuse on 1/30/22 at 8:02 P.M., and that the State Agency should have been notified sooner. A policy, titled Abuse Prohibition, Reporting, and Investigating dated 1/23 was provided by the DON on 1/24/23 at 11:15 A.M. The policy indicated, .Resident Abuse-Staff member .An incident report will be initiated within 2 hours of the allegation, following the guidelines for 'Unusual Occurrence Reporting' via ISDH [Indiana State Department of Health] gateway portal . This Federal tag relates to complaint IN00399801. 3.1-28(c)

Based on interview, and record review, the facility failed to ensure 1 of 3 residents reviewed for Activities of Daily Living and neglect, received showers as scheduled, (Resident B). Findings include: On 1/27/22 at 1:00 P.M., the clinical record for Resident B was reviewed. Resident B was most recently admitted on [DATE] with diagnoses that included, but were not limited to: hemiplegia and hemiparesis following a stroke, chronic obstructive pulmonary disease, diabetes, stage 4 chronic kidney disease, and muscle weakness. Review of the most recent Minimum Data Set (MDS) dated [DATE] for significant change indicated Resident B had moderate cognitive impairment, demonstrated no behaviors, was totally dependent on staff for bathing, and indicated daily preference for choosing between tub bath, shower, bed bath and sponge bath were very important to her. Review of Resident B's Care Plans included but were not limited to; Activites, most recently revised on 10/20/22, that indicated resident preferences while in the facility was to choose between a shower, bed bath, sponge bath, or tub bath, and that the resident prefers to bath more than twice a week in the A.M. ADL (activities of daily living) care, most recently revised on 7/28/21, indicated the resident required assistance with ADLs including assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Review of Resident B's Shower Report Sheet from 8/29/22 to 11/11/22, indicated the resident's documentation regarding showers or baths were as follows: 9/29/22 Refused Shower 9/15/22 Refused Shower 9/26/22 Partial Bed Bath Given 9/27/22 Complete Bed Bath Given 10/20/22 Refused Shower, attempted 2 times 10/25/22 Refused Shower There was no other document regarding Resident B's bathing or showering at the facility. On 1/27/23 at 1:30 P.M., during an interview with the Director of Nursing, she indicated residents at the facility were supposed to be showered 2 times per week or per preference. The Director of Nursing indicated Resident D should have been offered showers more than 2 times weekly due to her preferences and when showers were not given, the reason should have been documented. The Director of Nursing indicated the only records of showers or refusals were provided and noted above. This Federal tag relates to complaint IN00392986. 3.1-38(a)(2)(A)

Based on interview and record review, the facility failed to ensure a resident's responsible party was notified in a timely manor of an allegation of physical abuse and also failed to provide notification in advance of obtaining an X-ray, for 1 of 3 residents reviewed for notification, (Resident D). Finding includes: On 1/24/23 at 4:05 P.M., the Executive Director (ED) provided a recorded video dated 12/29/22 at 7:30 P.M., of the area near and around the first floor 2 E Nurses Station. The Video indicated Resident D was at the Nurses Station attempting to approach the Medication Cart. QMA T was observed talking to the resident and pointing to the medication cart. When Resident D approached the medication cart again, QMA T pushed the resident causing him to fall to the floor. QMA T was then observed getting the resident up to his feet and escorted him back to his room with the aide of a walker, an assessment was not performed at that time. Resident D was observed limping with difficulty walking. On 1/25/23 at 2:00 P.M., the clinical record for Resident D was reviewed. Resident D was admitted on [DATE] with diagnoses included, but not limited to: alcohol withdrawal related seizures, alcohol induced chronic pancreatitis, Wenicke's encephalopathy, diabetes and acute respiratory failure with hypoxia. An Admission Minimum Data Set (MDS) dated [DATE], indicated Resident D was severely cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required limited assistance with bed mobility, was independent with transfers, walking in his room and corridors, locomotion on and off the unit, and dressing. He required supervision with eating and limited assistance with toilet use and personal hygiene. A Significant Change Minimum Data Set, dated dated dated [DATE], indicated Resident D was moderately cognitively impaired and demonstrated verbal behaviors directed at others 1-3 days during the assessment period. Resident D required extensive assistance of 2 people with bed mobility, transfers, and toileting, and extensive assistance of 1 person for locomotion on and off the unit, dressing, and personal hygiene. The resident required a wheelchair for mobility. Diagnoses included but were not limited to hip fracture and other fracture (arm). A review of a Physician's Telephone Order dated 12/29/22 indicated orders for STAT (statim, immediate) X-ray of bilateral hips. A Radiology report, dated 12/30/22 at 7:32 A.M., indicated Resident D had a displaced intertrochanteric fracture of the proximal right femur. Resident D's progress notes indicated on 12/29/23 at 8:57 P.M., QMA reported resident had a fall with complaints of pain. I [Licensed Practical Nurse L] assessed resident .DNS [Director of Nursing Services] was called. ED [Executive Director] was notified. NP [Nurse Practitioner] was notified via voice message. On 12/29/22 at 9:35 P.M., .STAT X RAY was ordered. On 12/30/22 at 7:39 A.M., [Ambulance] arrive to transfer resident to [local] ER [emergency room ] and are currently in route to hosp. [hospital] DNS and resident father informed . On 1/25/23 at 11:47 A.M., during an interview, with Resident D's responsible party, he indicated he was notified in the morning of 1/30/23 that Resident D had a fall the previous evening and that an X-ray was obtained by the facility showing the resident fractured his femur and was being transported to a local hospital. Resident D's responsible party indicated he was not notified of an allegation of abuse until the resident returned to the facility after his hospitalization . On 1/25/23 at 3:00 P.M., during an interview, conducted with the Director of Nursing (DON), she indicated she received a call from Licensed Practical Nurse (LPN) L that Resident D had a fall without injuries but was in intense pain. The DON indicated she notified the ED on 12/29/22 at about 7:50 P.M., to report the fall. The DON indicated on 12/30/22 at 6:50 A.M., the X-Ray technician notified her that Resident D had sustained a fracture to his right hip. The DON indicated the Resident D's responsible party was notified of the fractured hip and transport to the hospital on 1/30/22 at 7:39 A.M. The DON indicated the resident's responsible party should have been notified at the time of the fall and when the order for the X-ray was obtained. A policy titled Resident Change of Condition Policy, dated 11/28 was provided by the DON on 1/24/23 at 11:30 A.M., indicating it was the current policy, indicated, .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party .The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken . This Federal tag relates to complaint IN00399801. 3.1-5(a)(1)(3)

Based on interview and record review, the facility failed to ensure a physician was notified of a significant change for 1 of 3 residents reviewed for significant change, (Resident B). Finding includes: On [DATE] Resident B's Clinical Records were reviewed. The Admission Record indicated the Resident B was originally admitted to the facility on [DATE] and most recently admitted on [DATE], with diagnoses that included, but were not limited to: chronic respiratory failure, congestive heart failure, peripheral vascular disease, chronic non-pressure ulcers of right ankle and right calf, unstagable pressure ulcer to the sacrum, atrial fibrillation, mixed obsessional thought and acts, chronic Cor pulmonale. Resident B's most recent comprehensive Minimum Data Set (MDS), dated [DATE] for Quarterly Assessment, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident B's MDS dated [DATE] for Death in Facility, indicated the resident expired in the facility on [DATE]. Review of Resident B's Nurse's Progress Notes indicated: On [DATE] at 6:04 A.M., the resident was unresponsive to physical stimulation, but would raise eye brows when his name was called. On [DATE] at 12:45 P.M., the resident's responsible party was notified of the resident's condition and was advised to come into facility to spend time with Resident B. The resident continued in a non- responsive state, vital signs remained stable with an elevated pulse rate of 118. On [DATE] at 9:06 P.M., Resident B was observed to have no pulse, no breathing and no heartbeat. Family was at bedside. Director of Nursing and Medical Director were notified to release body. On [DATE] at 12:08 P.M., an interview with Director of Nursing 1, indicated the nursing staff did not notify Resident B's physician regarding the resident's change of condition, and that the physician should have been notified to obtain orders. On [DATE] at 10:34 A.M., an interview with the facility Nurse Practitioner indicated she was not notified of the resident's change of condition until notified by text on [DATE] at 10:27 P.M., when she was notified the resident had expired. Nurse Practitioner indicated the nursing staff should have notified her or the physician of the resident's change of condition so she could have assessed the situation. A policy titled, Resident Change of Condition Policy, dated ,d+[DATE], was provided by the Regional Consultant as the current facility policy on [DATE] at 12:52 P.M., and was reviewed at that time. the policy indicated, .b. The licensed nurse will inform the attending physician .of resident status as soon as possible before, during, or after the change of condition occurs or when resident crisis has been managed, and document the notification This Federal tag relates to complaint IN00391343. 3XXX,d+[DATE](a)(2)

Based on record review, interview and observation, the facility failed to follow CDC guidance during a pandemic and implement an infection control program for timely and accurate assessment of signs and symptoms of COVID-19, continued monitoring of symptoms and ensuring proper isolation requirements and testing were initiated timely to prevent [MEDICAL CONDITION] from spreading, for 15 of 15 residents reviewed for infection control (Residents H, J, D, E, B, C, F, K, L, M, N, Q, S, G, P). As of [DATE], the facility had 39 confirmed COVID-19 cases, including 2 deaths and 2 currently in the hospital. On [DATE], two residents (Residents M and N), who were in close contact with other residents positive for COVID-19, were moved onto another unit into rooms with residents (Q and S) who had no signs or symptoms and no previous known contact with positive COVID-19 cases, Resident N then tested positive for COVID-19 on [DATE], creating the increased risk of further spread of COVID-19 throughout the facility. The immediate jeopardy began on [DATE] when multiple residents were exhibiting symptoms consistent with COVID-19 but were not monitored and/or isolated. The Corporate Nurse, Regional Vice President of Operations, Executive Director, and Director of Nursing were notified of the immediate jeopardy on [DATE] at 1:35 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview, on [DATE] at 1:30 P.M., the ED (Executive Director) indicated the facility had a total of 39 confirmed COVID-19 cases to date, including 2 deaths (one at the local hospital and one in the ambulance outside the facility) and 2 residents currently at the local hospital. She indicated Resident H expired in the ambulance in front of the building and Resident J had expired at the hospital. She indicated the hospital had contacted the facility on [DATE] in regard to Residents H and J with concerns of a COVID-19 outbreak and wanted to complete testing in the facility. The local hospital and the local health department tested all residents on the first floor of the facility (North, East, West and Dementia units) on [DATE]. The ED indicated the COVID-19 positive units were the dementia unit and north hall, and the east and west units were negative for COVID-19. The ED indicated the emergency plan for COVID-19 was implemented in the facility on [DATE] with notification from the hospital that Resident J was positive; he expired on [DATE] at the hospital. Review of the ISDH facility reporting tool as of [DATE] indicated the facility had reported to ISDH the positive COVID-19 result for Resident J on [DATE], but had not reported to ISDH the COVID-19-related deaths of Resident H or Resident J or any other residents positive for COVID-19. Review of an order signed by the State Health Commissioner, dated [DATE], and included in the ISDH LTC (Long Term Care) Newsletter, dated [DATE], included the requirement for COVID-19 reporting for long-term care facilities, prisons, jails, and other congregate housing. Effective Friday, [DATE], long-term care facilities were required to report the following within 24 hours: Any resident who tests positive for COVID-19; Any employee who tests positive for COVID-19; Any confirmed positive COVID-19 related death OR suspected COVID-19 related death of a resident; Any confirmed positive COVID-19 related death OR suspected COVID-19 related death of an employee. Confirmed or suspected deaths should be reported regardless of where the death occurred and within 24 hours of the facilities' knowledge of the death. During an observation, on [DATE] from 1:55 P.M. to 2:15 P.M., the north hall and the dementia unit were observed. The north unit was closed off with fire doors. The doors of residents' rooms were opened, and residents were observed in their rooms. Resident D and Resident F were observed lying in their beds. During this observation, RN 2 indicated all residents on this unit were positive for COVID-19 (total of 10), and there was one resident per room. She indicated Residents D and F were not doing well. The dementia unit was secured with fire doors, residents were observed wandering in the halls and many residents were in their rooms. The majority of the doors were open. Resident E's door was closed. During this observation, RN 3 indicated the staff was not aware of who was positive for COVID-19 and who was not. RN 3 indicated they were to treat everyone as if they were infected. During an interview, on [DATE] at 2:15 P.M., the DON (Director of Nursing) indicated all residents on the dementia unit had tested positive for COVID-19 except for two (Residents M and N) who were being moved off the unit as of this day (24 residents positive with two currently at hospital for a total of 26). 1. The record for Resident M was reviewed on [DATE] at 2:30 P.M. An infectious disease laboratory result, dated [DATE], indicated Resident M had tested negative for COVID-19. A progress note, dated [DATE] at 11:23 A.M., indicated the physician had been notified of the COVID-19 results. During an interview, on [DATE] at 5:00 P.M., the ED (Executive Director) indicated Resident M was one of only two residents who did not test positive for COVID-19 on the dementia unit (all residents on the unit were tested on [DATE]). She indicated Resident M had been moved off the dementia unit and had been placed in a room with a resident who was asymptomatic on a unit with no COVID-19 positive residents on [DATE]. She indicated she had been moved in with Resident Q on the first floor, West unit. Resident M was not isolated for 14 days after being in close contact with other residents who were symptomatic or had confirmed COVID-19. The resident had been exposed to her roommate who tested positive for COVID-19 and other residents on the dementia unit, for three days after being tested , from [DATE] to [DATE], when moved to the other room on another unit. 2. The record for Resident N was reviewed on [DATE] at 2:45 P.M. An infectious disease laboratory result, dated [DATE], indicated Resident N had tested negative for COVID-19. During an interview, on [DATE] at 5:00 P.M., the ED (Executive Director) indicated Resident N was one of the only two residents who did not test positive for COVID-19 on the dementia unit. She indicated Resident N had been moved off the dementia unit and had been placed in a room with a resident who was asymptomatic on a unit with no COVID-19 positive residents on [DATE]. She indicated she had been moved in with Resident S on the first floor, East unit. Resident N was not isolated for 14 days after being in close contact with other residents who were symptomatic or had confirmed COVID-19. The resident had been exposed to her roommate who tested positive for COVID-19 and other residents on the dementia unit, for three days after being tested , from [DATE] to [DATE], when moved to the other room on another unit. Review of an infectious disease laboratory result, dated [DATE], indicated Resident N had tested positive for COVID-19. Resident N had been in the same room with Resident S on a COVID-19 negative unit for two days at this time. During an interview, on [DATE] at 11:28 A.M., the ED indicated additional residents were tested on [DATE], and there were 17 more positive cases in the facility. Resident N was moved back to the dementia unit. During interview, on [DATE] at 1:45 P.M., the ED indicated, after receiving the additional test results, the residents who tested negative on the first floor, but had been in close contact with residents who recently tested positive, were moved upstairs on [DATE] to the third floor into rooms with roommates who were negative and had not been previously exposed. She indicated she did not have time, and they needed off the COVID-19 positive units. ISDH Guidance for out of hospital facilities, dated [DATE] and included in the COVID-19 Toolkit for Long Term Care, which was provided to the facility by an ISDH LTC Surveyor on [DATE], indicated the following: Patients with close contact with a confirmed COVID-19 patient (e.g., roommate or infected staff without wearing PPE) should be isolated and follow 14 day self-monitoring guidelines outline by CDC https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-longterm-care-facilities.html. If they develop symptoms, and are confirmed or suspected to have COVID-19, they should remain in isolation until at least 14 days after illness onset or 72 hours after resolution of fever, without use of antipyretic medication, and improvement in symptoms (e.g., cough) whichever is longer. CDC's Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, included in the COVID-19 Preparedness Checklist for Nursing Homes and other Long Term Care Settings within the COVID-19 Toolkit for Long Term Care, which was provided to the facility on [DATE], was accessed on [DATE] at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html and included the following: Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them. The COVID-19 Toolkit for Long Term Care was updated and distributed again electronically on [DATE], and the above information remained the same. 3. On [DATE] at 4:30 p.m., review of the Surveillance Log of Resident Infections and Antibiotic Use, dated [DATE], indicated Resident B presented with temperature, cough, and congestion with chest x-ray indicating possible pneumonia, and Resident C presented with shortness of breath, decreased oxygenation, labored breathing, and unresponsive. Review of the Surveillance Log of Resident Infections and Antibiotic Use, dated [DATE], indicated Resident D presented with a cough and fever, Resident E presented with a temperature, decreased oxygen saturation and diminished lung sounds, and Resident F presented with complaints of being weak and dizzy, shortness of breath and nonproductive cough. The LTC Respiratory Surveillance Line Listing, dated [DATE] to [DATE], was reviewed at 4:34 P.M. on [DATE]. The line listing indicated 7 residents had presented with respiratory symptoms, myalgia (muscle aches) or fever. Resident P presented with fever, myalgia and labored breathing on [DATE]. Resident B presented with cough on [DATE], per MD not testing for COVID-19. Resident G presented with fever and myalgia on [DATE], with no documentation of testing. Resident C presented with cough and shortness of breath, no date indicated, COVID-19 test negative. Resident D presented with cough on [DATE], per MD not tested for COVID-19. Resident E presented with a fever on [DATE] and shortness of breath, per MD not tested for COVID-19. Resident J had symptom onset on [DATE], but no specific symptoms were indicated. These surveillance listings indicated several residents were presenting with symptoms consistent with COVID-19 between [DATE] and [DATE]. Their records, as well as the records of four additional residents who developed symptoms after [DATE], were reviewed. The record for Resident B was reviewed on [DATE] at 4:35 P.M. The [DIAGNOSES REDACTED]. The resident resided on the first floor, west unit. A progress note, dated [DATE] at 3:10 P.M., indicated Resident B was admitted to the facility from a local hospital. Documentation did not indicate the resident was isolated for 14 days following admission from a hospital. A progress note, dated [DATE] at 11:07 A.M., indicated Resident B presented with a temperature of 99.3 and cough. The physician was notified and an order for [REDACTED].>No documentation was available to indicate the resident was placed in isolation on [DATE]. A progress note, dated [DATE] at 8:36 A.M., indicated Resident B's chest x-ray result was discussed with the physician, and the resident was placed in droplet isolation. A progress note, dated [DATE] at 3:50 P.M., indicated the facility had called the local State Agency epidemiology department at the request of the physician to review Resident B's symptoms. Epidemiology had indicated it was up to the physician to decide if COVID-19 testing should be completed. A progress note, dated [DATE] at 5:44 P.M., indicated Resident B had a new order to discontinue droplet precautions. A progress note, dated [DATE] at 12:33 A.M., indicated Resident B had an occasional cough noted. A progress note, dated [DATE] at 2:49 P.M., indicated Resident B had an occasional dry cough. A progress note, dated [DATE], indicated Resident B had a nonproductive cough noted. A progress note, dated [DATE] at 11:44 A.M., indicated Resident B continued on antibiotic for upper respiratory infection. A progress note, dated [DATE] at 11:25 A.M., indicated Resident B was discharged home. A review of the bed board from [DATE] to [DATE] indicated Resident B was in a room with a roommate. During an interview, on [DATE] at 4:20 P.M., the DON indicated COVID-19 testing had not been completed on residents that presented with symptoms, because the physician had not ordered the testing. During an interview, on [DATE] at 5:00 P.M., the ED indicated she was not aware of any residents who required COVID-19 testing prior to [DATE]. She indicated Resident B was admitted to the facility on [DATE], and the 14-day quarantine on new admissions did not get implemented until [DATE]. During an interview, on [DATE] at 12:36 P.M., the resident's physician, who was also the facility's Medical Director, indicated Resident B had potential symptoms of COVID-19, and he had requested the facility to notify the local state agency. He indicated Resident B was not tested for COVID-19, because he was told residents had to be sent to the hospital for testing. He indicated Resident B was removed from droplet precaution isolation on [DATE] when his chest x-ray indicated pneumonia. CDC guidance, Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19), originally dated [DATE] and last updated [DATE], was accessed at https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html on [DATE] and included the following: Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested . Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Priorities for testing include: .PRIORITY 2 Ensure that those who are at highest risk of complication of infection are rapidly identified and appropriately triaged: Patients in long-term care facilities with symptoms Patients [AGE] years of age and older with symptoms Patients with underlying conditions with symptoms. Review of guidance from CMS, ISDH and CDC included the following: A CMS memo QSO-,[DATE]-NH, dated [DATE], and included in ISDH LTC (Long Term Care) Newsletter, dated [DATE], included, Facility staff should regularly monitor the CDC website for information and resources (links below). They should contact their local health department if they have questions or suspect a resident of a nursing home has COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious residents are essential to prevent unnecessary exposures among residents, healthcare personnel, and visitors at the facility. Therefore, facilities should continue to be vigilant in identifying any possible infected individuals. Facilities should consider frequent monitoring for potential symptoms of respiratory infection as needed throughout the day. The guidance, dated [DATE], also included, Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor, or returning to long-stay original room). Review of the ISDH LTC Newsletter registrants, indicated the facility's corporate Regional Vice President of Operations was registered and receiving the ISDH LTC Newsletters. 4. The record for Resident C was reviewed on [DATE] at 4:45 P.M. The [DIAGNOSES REDACTED]. The resident resided on the first floor, east unit. A progress note, dated [DATE] at 3:22 P.M., indicated Resident C had complained of a sore throat and cough with green sputum noted. A progress note, dated [DATE] at 12:10 A.M., indicated Resident C had an occasional cough noted. There was no documentation available for isolation precautions that were implemented or continued monitoring of these symptoms. A progress note, dated [DATE] at 10:03 A.M., indicated Resident C was noted to have difficulty breathing, difficult to arouse. Her oxygen saturation was less than 90% and she was started on oxygen at 2 liters, lung sounds were diminished to bilateral lower lobes. A progress note, dated [DATE] at 1:08 P.M., indicated Resident C's biox (oxygen saturation) dropped and she presented with [MEDICAL CONDITION] A new order for [MEDICATION NAME] (nebulizer treatment) was received and administered. A progress note, dated [DATE] at 3:04 P.M., indicated Resident C was verbally non-responsive and was on 3 liters of oxygen. A progress note, dated [DATE] at 3:33 P.M., indicated Resident C was sent out to the local hospital. A progress note, dated [DATE] at 12:22 P.M., indicated Resident C was admitted to the local hospital for acute [MEDICAL CONDITION]. A progress note, dated [DATE] at 7:23 P.M., indicated Resident C was admitted back to facility with right lower lobe infiltrate (pneumonia). There were multiple progress notes, dated [DATE] through [DATE], that indicated Resident C was non-compliant with the 14 day quarantine following hospitalization and had to be redirected back to her room multiple times. 5. The record for Resident D was reviewed on [DATE] at 3:00 P.M. The [DIAGNOSES REDACTED]. The resident resided on the North hall on the first floor. A progress note, dated [DATE] at 11:19 A.M., indicated Resident D had received a new order for [MEDICATION NAME] Perle (cough medicine) 100 mg (milligrams) three times daily for 7 days and for [MEDICATION NAME] nasal spray (for nasal congestion). A progress note, dated [DATE] at 8:30 P.M., indicated Resident D had broken the social distancing precaution and sat in the dining room with other residents playing Dominos. He had no signs or symptoms of respiratory infection, no cough or running nose. A progress note, dated [DATE] at 9:34 P.M., indicated Resident D was non-compliant with social distancing and was in the dining room with other residents; none were wearing masks. A progress note, dated [DATE] at 4:19 P.M., indicated [MEDICATION NAME] Perle was administered with positive effects. A nonproductive cough and hoarse voice was noted. A progress note, dated [DATE] at 4:46 P.M., indicated a new order for chest x-ray. A physician order, dated [DATE], indicated Resident D was placed in droplet isolation due to having an active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission related to fever and cough. A progress note, dated [DATE] at 10:12 A.M., indicated Resident D was in droplet isolation precautions and had a temperature of 99.2. A progress note, dated [DATE] at 4:11 P.M., indicated Resident D had elevated temperature and was noted to be perspiring. A progress note, dated [DATE] at 8:28 P.M., indicated Resident D had a temperature of 100.4 and was noncompliant with droplet isolation and social distancing. A progress note, dated [DATE] at 3:31 P.M., indicated a new order for [MEDICATION NAME] twice daily for 10 days for [MEDICAL CONDITION] exacerbation. A progress note, dated [DATE] at 1:55 P.M., indicated Resident D had a temperature of 101.4, and complained of not feeling well with lethargy noted. Lung sounds were diminished on the right and oxygen saturation was ,[DATE]%. An infectious disease lab result, dated [DATE], indicated Resident D had COVID-19 detected. The physician was notified on [DATE] at 7:00 P.M. A progress note, dated [DATE] at 3:40 P.M., indicated Resident D presented with poor appetite and oxygen saturation of 87%. During an interview, on [DATE] at 1:38 P.M., the DON indicated Resident D was not placed in droplet precautions on [DATE] when symptoms of cough and nasal congestion were noted because he did not have a fever. She indicated it was the policy of the facility to inform the physician of signs and symptoms, and it was at the physician's discretion if the residents were placed in isolation. During an observation, on [DATE] at 2:20 P.M., Resident D was lying in bed, asleep, with the door to the room open. A review of the bed board from [DATE] to [DATE] indicated Resident D was in a room with a roommate. The COVID-19 Toolkit for Long Term Care, which was provided to the facility on [DATE], indicated all LTC facilities who have not already done so, need to use the CDC COVID-19 Preparedness Checklist for Nursing Homes and other Long Term Care Settings to prevent the spread of coronavirus in their facilities. This checklist included: Identification and Management of Ill Residents: The facility has a process to identify and manage residents with symptoms of respiratory infection (e.g., cough, fever, sore throat) upon admission and daily during their stay in the facility which include implementation of appropriate Transmission-Based Precautions. The facility has criteria and protocol for initiating active surveillance for respiratory infection among residents and healthcare personnel. On [DATE] at 5:00 P.M., the Corporate Nurse provided the COVID-19 Resident Policy (replaces interim COVID-19 policy), dated [DATE] (revised [DATE], [DATE] & [DATE]), which indicated a resident with suspected or confirmed COVID-19 would be placed on Droplet Precautions and signs would be placed outside of the patient's door. Resident room placement would occur only under the direction of the IDT team and Infection Preventionist. The door should remain shut except when entering and exiting the room. 6. During an interview, on [DATE] at 1:45 P.M., RN (Registered Nurse) 3 indicated Resident E was not doing well. The record for Resident E was reviewed on [DATE] at 3:45 P.M. The [DIAGNOSES REDACTED]. Resident E was documented as a full code. The resident resided on the dementia unit on the first floor. A progress note, dated [DATE] at 10:41 P.M., indicated Resident E had a fever of 102 and chest x ray was ordered. There was no documentation of any isolation precautions at this time. A progress note, dated [DATE] at 12:41 P.M., indicated a new order was received to place Resident E in droplet isolation precautions. A progress note, dated [DATE] at 2:15 P.M., indicated Resident E's chest x-ray results indicated multifocal bilateral [MEDICAL CONDITION] infiltrates. A progress note, dated [DATE] at 5:38 P.M. indicated Resident E was observed on the bedroom floor near bathroom entrance and he was too weak to stand. An Infectious Disease lab result, dated [DATE], indicated Resident E had COVID-19 detected. A progress note, dated [DATE] at 11:14 A.M., indicated Resident E's oxygen saturation was 77% and he was placed on oxygen mask at 6 liters. A progress note, dated [DATE] at 11:17 A.M. indicated Resident E's family was notified on [DATE] that he was positive for COVID-19. A progress note, dated [DATE] at 2:44 P.M., indicated Resident E's pulse was 42 and biox was 77%. Head of bed was elevated and oxygen mask at 10 liters was applied. A progress note, dated [DATE] at 8:35 A.M., indicated Resident E was placed on a non-breather mask at 15 liters and oxygen saturation was ,[DATE]%. A progress note, dated [DATE] at 1:18 P.M., indicated Resident E continued to be restless and oxygen saturation was 84% on 6 liters and resident was non-compliant with rebreather. Physician was notified and resident was send out to local hospital due to being a full code. A history and physical, dated [DATE], indicated Resident E had reportedly had a cough, congestion, and fever up to 102 since [DATE]. He continued to have progressive worsening, [MEDICAL CONDITION] requiring up to 6 liters of oxygen. He continued to have shortness of breath, progressive [MEDICAL CONDITION] and was restless. Upon admission he required 12 liters of oxygen on a non-rebreather mask. The emergency room report, dated [DATE], indicated the physician had spoken with power of attorney and Resident E was changed to a Do Not Resuscitate from a full code. [DIAGNOSES REDACTED]. A discharge summary, dated [DATE], indicated Resident E was admitted for [MEDICAL CONDITION] on [DATE]. He did test positive for COVID-19 and currently resided in nursing facility that had a severe outbreak of [MEDICAL CONDITION]. He was found to have pneumonitis versus possible pneumonia in the setting of COVID infection. Upon observation, patient was breathing very heavily using his abdominal muscles, he was unable to follow any commands and he was not alert. Patient was actively dying. The Discharge summary, dated [DATE], indicated Resident E expired at 11:38 A.M. and primary cause of death was [DIAGNOSES REDACTED]-COv2 (COVID-19) [MEDICAL CONDITION] pneumonia. A review of the bed board from [DATE] indicated Resident E was in a room with a roommate; the other resident was moved out on [DATE]. During an interview, on [DATE] at 4:40 P.M., the resident's physician/Medical Director indicated he had been told the COVID-19 testing was not being completed in the facility, and he just found out that there was a task force that would come do the testing in the facility last week. He indicated if testing had been allowed in the facility, he would have tested Resident B and Resident E for sure. He indicated the facility had told him that residents had to be sent out to the hospital to be tested for COVID-19. During an interview, on [DATE] at 4:50 P.M., the DON indicated that it was the facility's policy to send residents to the hospital for testing; there were no tests completed in the facility prior to [DATE]. Review of the ISDH LTC Newsletter, dated [DATE], included information regarding LTC Strike Teams who would be going to facilities to provide PPE training, communicate risk mitigation strategies with essential staff and do targeted COVID-19 test collection. The ISDH LTC Newsletter, dated [DATE], included a COVID-19 Toolkit for facilities. A copy of this toolkit, as well as information for the LTC Newsletter, was provided to the facility by an ISDH LTC surveyor on [DATE]. This toolkit included information regarding the ISDH teams available to come into facilities to rapidly test residents and staff who are suspected of having COVID-19. It instructed facilities who have residents or providers who are symptomatic and need to be tested , to contact the COVID-19 Outbreak Response Logistics Coordinator and included contact information. The toolkit also included contact information at ISDH if the facility would like to discuss the need for testing at the facility or COVID-19 prevention such as PPE donning and doffing. 7. The record for Resident F was reviewed on [DATE] at 3:50 P.M. The [DIAGNOSES REDACTED]. The resident resided on the North hall on the first floor. A progress note, dated [DATE] at 11:10 A.M., indicated Resident F was weak and dizzy with moist non-productive cough and complained of shortness of breath. His oxygen saturation was 86% and oxygen at 2 liters was applied. There was no documentation of droplet isolation precautions implemented with cough and complaints of shortness of breath. An Infectious Disease lab result, dated [DATE], indicated Resident F had COVID-19 detected. There was no documentation of droplet isolation precautions implementation. A progress note, dated [DATE] at 4:05 P.M., indicated social service had notified a family member of possible room move. A progress note, dated [DATE] at 1:03 P.M., indicated Resident F was on 4 liters of oxygen and complained of shortness of breath with labored breathing. A progress note, dated [DATE] at 6:22 P.M., indicated Resident F had cough and labored breathing noted. He was using accessory muscles to breathe, mouth breathing with slight nasal flare when exhaling and complained of shortness of breath. Biox was 95% on 5 liters of oxygen. Physician was notified with orders to continue to monitor. Family was notified and wanted resident sent out to local emergency room if condition worsened. A progress note, dated [DATE] at 10:02 P.M., indicated Resident F was sent to the local emergency room at 8:00 P.M. Resident had shrill cough and labored breathing noted and indicated he was having trouble breathing, using accessory muscles to breath. Oxygen was at 5 liters per nasal cannula, oxygen saturation was 91% and respirations were 44. A History and Physical, dated [DATE], indicated Resident F had presented with respiratory status over the past 5 days and tested positive for COVID-19 at facility. He was unable to contribute any information as Resident F was breathing hard and not answering questions. Assessment indicated COVID pneumonia and now a health-associated pneumonia. Daughter was notified of prognosis and agreed to a Do Not Resuscitate-Do Not Intubate and that he will likely not have a good outcome. The ER Physician Report, dated [DATE], indicated Resident F presented with breathing difficulty with onset 5 days ago. The course/duration of symptoms was constant. Degree at onset moderate. Degree at present severe. Present to ER with gradually worsening difficulty breathing, had already been diagnosed with [REDACTED]. The daughter was notified that given the situation and diminished likelihood that he would survive on a ventilator, she elected to make him a no code and no intubation. The Discharge summary, dated [DATE], indicated Resident F was found to be COVID positive when he came to the ER, and chest x-ray showed some patchy airspace disease in the mid to lower lungs that was suspicious for infiltrate. Unfortunately, his respiratory status did decline rapidly. He received high-flow oxygen and continued to deteriorate. The decision was made in line with the patient's family wishes that patient be made a DNR and on end of life care, comfort measures. Resident F succumbed to his medical illness and died on [DATE] at 5:15 P.M. Final [DIAGNOSES REDACTED]. A review of the bed board from [DATE] indicated Resident F was in a room with a roommate; the other resident was moved out on [DATE]. 8. The record for Resident H was reviewed on [DATE] (TRUNCATED)

Based on record review and interview, the facility failed to ensure a x-ray was obtained timely after increased complaints of pain for a resident after a fall, and for not notifying the physician timely of an acute [MEDICAL CONDITION], resulting in delay of treatment for [REDACTED]. This deficiency affected 1 of 3 residents reviewed for falls. (Resident B) Finding includes: On 6/25/19 at 11:30 A.M., a clinical review was conducted for Resident B. [DIAGNOSES REDACTED]. A care plan, dated 3/10/2017, indicated Resident B needed assistance with transfers and was to be transferred with a stand up lift (a machine that is designed to raise the resident from a sitting to a standing position with the use of a safety harness). A resident progress note, dated 6/10/19 at 3:47 P.M., indicated .IDT (interdisciplinary team) Fall Review: On 6/7/19 after dinner, resident (B) had an un-witnessed fall. Resident observed lying on floor in large dining room. Resident fully clothed w (with)/socks and shoes on. No c/o (complaints of) pain or discomfort, no injury noted at time of assessment, resident denies hitting head, resident unable to explain how fall occurred, but does have history of throwing self on floor .IDT determined root cause of fall to be poor positioning and discomfort while in wheelchair IDT determined to have resident chair changed to BRODA (a chair that is larger than a wheelchair and is able to be positioned at different angles for resident comfort) chair and therapy to screen During an interview, on 6/25/19 at 1:50 P.M., Nurse 2 indicated she was the nurse who was on duty when Resident B fell on [DATE]. He had fallen in the dining room and was found lying on his right side. She conducted an assessment and he had no indicators of injury at that time. A few days later she was contacted by CNA (Certified Nurses Aide) 1 to assess a red mark to Resident B's left hip. CNA 1 had noted the area when she was giving him a shower. Nurse 2 indicated she assessed Resident B, and could not find a red mark or any other abnormalities. They determined the red mark may have been where he was sitting in his BRODA chair. She indicated they transferred the resident with the sit to stand lift and the resident did not complain of pain. During an interview, on 6/25/19 at 4:33 P.M., CNA 1 indicated she came to work on her usual shift on 6/10/19. CNA 1 had told the nurse that Resident B was complaining of pain and requested she check him out. The nurse did not find anything out of the ordinary when she conducted an assessment on that day and medicated the resident for comfort. CNA 1 indicated the nurse she referenced came back and checked on Resident B several times that shift after she had asked her to assess Resident B. CNA 1 indicated when she came back to work the next day, 6/11/19, he was still complaining of pain and she asked the nurse if Resident B could get an x-ray or something but the nurse didn't have a chance to do it because of another incident that had occurred. CNA 1 indicated she was worried his leg had gotten bumped because he had a bruise on his inner thigh, so when she came back to work on Thursday night, 6/13/19, she asked the nurse on duty if Resident B had had an x-ray, it bothered her because she felt it was a long time for Resident B to be in pain, the nurse she spoke to told her to remind her and she would get one but she ended up leaving early that night so the next day 6/14/19 when she came back to work she asked the nurse on duty to get an x-ray. When CNA 1 came back to work on the following Monday 6/17/19, Resident B was in the hospital and she was told it was due to a [MEDICAL CONDITION]. A resident progress note, dated 6/14/19 at 6:00 A.M., indicated .Resident left thigh noted to be swollen and c/o (complain of) pain, NP (Nurse Practictioner) notified new order given for x-ray A radiology report, dated 6/14/19, indicated .DOS (Date of Service): 06/14/2019 .Patient: (Resident B) .Reason: Pain, Unspecified S/P (status [REDACTED].Results: Acute inter trochanteric fracture A resident progress note, dated 6/16/19 at 11:24 A.M., inidcated .X-ray results recieved and it indicates an acute [MEDICAL CONDITION]. ED (Executive Director), DNS (Director of Nursing Services), and (name of primary physician) notified. New order received to send resident to ER (emergency room ) for eval and tx (evaluation and treatment) A emergency room physician's report, dated 6/17/19, indicated .History of Present illness: Hip Injury - Pain. The patient presents with left and hip injury .The onset was 6 days ago .The course/duration of symptoms is constant .Type of injury: fall .The character of symptoms is pain .The degree at onset was moderate .The degree at present is moderate .The exacerbating factor is movement .the location where the incident occurred was at a nursing home During an interview, on 6/26/19 at 1:00 P.M., the DON (Director of Nursing) indicated Resident B had sustained a fall recently but had not exhibited any symptoms that were out of the ordinary for him inbetween the fall on 6/7/19 and 6/14/19 when it was noted the resident had a swollen left thigh and was x-rayed. Resident B had a history of [REDACTED]. When it was noted that Resident B had a [MEDICAL CONDITION], the facility staff conducted an investigation to determine if the resident had sustained another fall or injury and could not substantiate either. She indicated they interviewed staff who indicated the resident did not complain any more than usual. She indicated the physician should be notified of an abnormal x-ray result timely. A Labs and Diagnostics policy, dated 11/2017, was provided by the Director of Nurses on 6/26/19 at 1:50 P.M. and reviewed on 6/27/19 at 2:00 P.M. The policy indicated .The facility must promptly notify the physician, physician's assistant, nurse practictioner, or other clinical nurse specialist of lab or diagnostic results that fall outside of the clinical reference ranges This Federal tag relates to Complaint IN 902. 3.1-45(a)(2)

Based on record review and interview, the facility failed to follow thier policy related to the assessment and notification of the physician for a resident who was cognitively impaired and sustained a fall which resulted in the resident being hospitalized with an acute impacted and angulated subcaptial fracture of the left femoral neck (left hip fracture). (Resident B) Finding includes: The clinical record for Resident B was reviewed on 8/3/17 at 11:00 A.M. Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) Assessment, with a assessment reference date of 5/9/17 indicated that during the Brief Interview for Mental Status (BIMS) Resident B had 4 or more items coded 0 because Resident B either chose not to answer or gave a nonsensical response. A Resident Progress Note, dated 7/24/17 at 2:49 P.M., indicated .Upon morning assessment this writer noted an 7cm (centimeter) x 3 cm abrasion on this resident's left arm. This writer also noticed a 3 cm x 1 cm hematoma on top of this resident's head. The CNA (Certified Nursing Aide) attempted to assist this resident to his feet. The resident was unable to bare weight on his left leg. This resident grimaced and moaned when this writer touched left hip area. The NP (Nurse Practitioner) was notified and an order to send to (name of local hospital) for and evaluation was given. Family and DNS (Director Nursing Services) notified A Resident Progress Note, dated 7/24/17 at 6:14 P.M., indicated . Spoke with ER (emergency room ) nurse, resident will be admitted with L (left) hip fx (fracture) and surgical repair A Resident Progress Note, dated 7/25/17 at 4:15 P.M., indicated .On 7/24/17 at 1 pm this writer spoke with family/daughter concerning resident's change in status. Daughter was expressed concern about how the injury occurred. This writer assured daughter that a full investigation would ensure. Daughter verbalized understanding A ER Physician Note, dated 07/24/2017 at 05:15 P.M., indicated .Historical Data: .He was found today in his bed, lying on his side with some pain in his left hip. He is on the dementia unit. His wife and sister-in-law are at the bedside when I did the interview. The patient is profoundly demented and is nonverbal at this time. He is always nonverbal. The wife states that they called her and stated that he seemed to be in pain and would not get out of bed. There is no clear story as to what exactly happened. He has an abrasion on his left elbow and some bruising there, but he just seems to have pain in his left hip when you try to move it and wants to lay on his right side A XR (X-Ray) Hips complete final report dated 7/24/17, indicated .Impression: Acute impacted and angulated subcaptial fracture of the left femoral neck. (left hip fracture) During an interview, on 8/3/17 at 12:45 P.M., the DNS indicated that she was notified on 7/24/17 by the day shift nurse that Resident B had an abrasion and some bruising and was favoring his right side. She indicated that a head to toe assessment was initiated and that the residents physician and poa were notified. Resident B was sent to the emergency room for evaluation, she was notified later that Resident B had a left hip fracture. The DNS indicated upon notification and assessment of symptoms she began an internal investigation into the matter and found that Resident B had fallen on 7/23/17 on the evening shift. She indicated the nurse who was working that evening failed to follow the falls policy and notifiy the physician and poa. The DNS indicated the nurse who knew about the fall should have followed the facilities policy for assessment of symptoms and physician and poa notification. During an interview, on 8/4/17 at 12:19 P.M., CNA#1 indicated he worked the night shift on 7/23/17. He indicated he was not given any indication of a change in condition had occurred during shift report. He indicated Resident B was in his bed all night and he did not act any different than he usually did when care was performed. During an interview, on 8/4/17 at 12:40 P.M., Nurse #1 indicated that he had worked the night shift on 7/23/17 and that he had received no report indicating that Resident B had a change in condition. He indicated that Resident B slept all night and that Resident B was a pacer, meaning he walked up and down the hall all night long and that recently he had been prescribed a medication that was supposed to help him relax and sleep. Nurse #1 indicated he thougth the medication was working for this Resident and he was getting a restful sleep. During an interview, on 8/4/17 at 1:00 P.M., CNA#2 indicated that she had worked the evening shift on 7/23/17. She indicated she remembered the nurse running down the hallway with a wheelchair about 8:30 P.M CNA#1 indicated the nurse put Resident B to bed. She indicated she thought it was wierd that the nurse used a wheelchair with Resident B but she did not question it. She indicated the nurse gave no instructions or report on Resident B after she put him to bed and Resident B was visualized lying in his bed, but she had not done a physical check on him after the nurse put him to bed. On 8/4/17 at 1:30 P.M., a Fall Management Program policy with a revision date of 7/2016 and provided by the DNS on 8/3/17 at 12:45 P.M., was reviewed. The policy indicated . Post Fall: 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided .2. If the resident experienced an injury from the fall, contact facility DNS/ED (Executive Director) per facility policy .3. The physician will be contacted immediately, if there are injuries, and orders will be obtained .4. The family will be notified immediately by the charge nurse of falls with injury This Federal tag is related to Complaint IN 451. 3.1-37(a)

Based on interview and record review, the facility failed to transfer a resident in the recommended and ordered mode of transfer which resulted in a right ankle fracture that was undiagnosed for 2 days for 1 of 3 residents. (Resident B) Finding includes: The clinical record for Resident B was reviewed on 4/3/17. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, with an assessment reference date of 3/3/17 indicated Resident B was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and required 2 persons and extensive assistance with transfers. A Therapy Progress Note, dated 3/9/17, indicated a physicians order was obtained and Resident B was to be transferred with a beasy board (A mode of transferring a resident in which a board with a circular seat is placed between where a resident is seated and where they wish to transfer to. The Resident is positioned onto the beasy board and slid into a wheelchair or other designated location. This enables the resident to be transferred in a safe non weight bearing mode). The progress note indicated staff were inserviced on how to transfer a resident on a beasy board. On 4/3/17 at 2:50 P.M., an interview was conducted with Resident B. Resident B indicated she was being transferred to her wheelchair on 3/23/17 and her tennis shoe got caught during the transfer and she heard a pop. Resident B indicated the transfer happened very quickly and there was no time to get her feet positioned correctly in front of her. She indicated she told her CNA's who were assisting her with her transfer and also the nurse on duty that she was experiencing pain to her Right ankle. She indicated no staff came to assess her pain or obtain an x-ray until she asked for an x-ray on 3/25/17. A Resident Progress Note, dated 3/25/17 at 2:12 P.M., indicated .Res C/O (complained of) R (Right) ankle pain requesting x-ray. Received order for x-ray 3 view. Mobile x called to come out ot do x-ray today. Res made aware On 4/3/17 at 2:30 P.M., Unit Manager #1 indicated she was not aware that an incident had occurred until 3/25/17 when she was notified the resident had requested an x-ray of her right ankle. On 4/4/17 at 11:37 A.M., an interview was conducted with the Director of Nurses (DON). The DON indicated she was first notified the resident was experiencing pain to her right ankle on 3/25/17 and that an order was obtained for an x-ray. On 4/4/17 at 2:15 P.M., an interview was conducted with CNA #1. CNA #1 indicated she and CNA #2 had transferred Resident B using a 2 person transfer because Resident B had refused the beasy board transfer. CNA #1 indicated that Resident B told her she was experiencing pain to her to right foot but Resident B .thought it would be ok CNA #1 indicated she went and told the nurse on duty what had happened during the transfer. On 3/25/17, at the request of Resident B, an order was obtained for an x-ray of her right ankle. The Radiology Report, dated 3/25/17, was provided by the Executive Director on 4/3/17at 3: 13 P.M., the report indicated .Results: There is a fracture involving distal fibula with no displacement .Conclusion: Acute ankle fracture as described above On 4/4/17 at 2:44 P.M., the Executive Director indicated if a resident complained of pain the facility would obtain an x-ray to determine the cause of the pain. This Federal tag is related to Complaint IN 754. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to evaluate and analyze causative factors related to falls and develop appropriate interventions to prevent a fall which resulted in a fractured femur (Resident #D) and a subdural hematoma (Resident #F). This deficient practice affected 2 of 5 residents reviewed for falls in a sample of 5. Findings include: 1. Resident #F's closed clinical record was reviewed on 7/28/11 at 5:25 P.M., and indicated [DIAGNOSES REDACTED]. It further indicated she was admitted to the facility on [DATE]. During initial tour of the facility on 7/28/11 at 10:30 A.M., while accompanied by LPN #4, she identified Resident #F as a fall risk who had sustained an injury as a result of a recent fall. A "Fall Risk Assessment," dated 5/20/11, indicated Resident #F had not sustained a fall within the past three months, but was considered a fall risk because of incontinence, impaired gait/balance, impaired vision, non-compliance, and confusion. A Nurse's Note, dated 6/6/11 at 12:30 P.M., indicated, "Resident was observed to be lying on the floor, she was assisted to her w/c (wheel chair) by this unit and CNA. For intervention resident is to be checked every two hours and taken to the bathroom...." A "Fall Circumstance Report," dated 6/6/11 at 12:30 P.M., indicated the fall had taken place in the resident's room. She had been sitting on her bed prior to the fall and was fully clothed with non-skid socks on. It further indicated the call light was in reach and the alarm was sounding. Nurse's Notes, dated 6/11/11, indicated, 10:20 A.M.: "Resident alert and oriented to self only. Confusion noted @ all times. Incontinent of B & B (bowel and bladder). Ambulates with unsteady gait. Mobile via w/c-propels self. No safety awareness. Alarms on bed and w/c to alert staff when rising unassisted.... 11:05 A.M.: "...fell in dining area from w/c. Resident attempting to remove shoe. Was leaning forward and fell out of w/c. Shoe was underneath w/c. Resident landed on left side. Head hit floor. Hematoma above left eye on forehead...." The Nurse's Note indicated the doctor and family had been notified of the fall and family elected not to have resident sent to the ER (emergency room ). An IDT (Interdisciplinary Team) Progress Note, dated 6/13/11, indicated, "IDT review of fall 6/11/11 at 11:05 A.M. ....Gripper socks were immediate intervention. IDT decided staff to ensure shoes on appropriately and continue to observe and F/U (follow up) as needed." A Nurse's Note, dated 6/27/11 at 10:00 P.M., indicated, "...put to bed to sleep and after a while she was found on the floor by her bedside. Bed alarm in place, call light in place. She had a bump on her R (right) forehead...." The "Fall Circumstance Report," dated 6/27/11 at 9:45 P.M., indicated Resident #F had been toileted and put to bed and was later found on the floor in her night gown. It further indicated the floor was dry, without clutter, and the room light was not on. The immediate intervention put in place was a "blue floor mat at the side of the bed (and) non-skid socks on while in bed...." Neither the Nurse's Note or the Fall Circumstance Report indicated the bed alarm was sounding; however, an IDT note, dated 6/28/11, indicated, "Pt. (patient) alarm was sounding." Review of a CT (CAT) Scan Report, dated 6/28/11, indicated, "...Reason for exam: Head Injury...History: Head Injury. Lethargy and confusion...No subarachnoid or other intracranial hemorrhage is evident...." A Nurse's Note, dated 7/18/11 at 9:25 A.M., indicated, "Resident found on dining room floor lying on R side. Alarm sounding...N.O. (new order) received from Dr. (Name) to send Resident to ER for Eval. (evaluation)...." Review of a CT Scan Report, dated 7/18/11, indicated, Reason for exam: ER 24; Head Injury...On today's exam, there is now a left extra-axial hematoma that measures approximately 8 mm (millimeters)...." The "Fall Circumstance Report," dated 7/18/11 at 9:10 A.M., indicated, "...Resident in dining room up in w/c at table...lying on R side...no shoes or socks on @ time of fall...injuries: Middle of forehead near hairline 3 by 3 cm (centimeter) purple raised area, R elbow 1 cm by 1 cm skin tear...Resident [DIAGNOSES REDACTED]." The IDT note, dated 7/19/11, indicated, "...we will offer diversional activities. Will continue to observe and F/U as needed...." RN #3 indicated in an interview on 6/29/11 at 10:15 A.M., that a bed and chair alarm had been placed on 5/22/11, prior to Resident #F sustaining any falls in the facility. Resident #F's Admission Minimum Data Set (MDS) Assessment, dated 5/31/11, indicated she had poor decision-making skills and required cues and supervision. It further indicated she needed extensive physical assistance of two persons for transferring. A Care Plan, dated 6/06/11, indicated, "Problem: Resident is at risk for falls due to: unsteady gait and resident is only able to stabilize with human assistance...Resident has no safety awareness...Approach: ...Non-skid footwear, check and change 2 hrs (hours); (6/13/11) Resident makes attempts to remove foot wear; unable to put back on: ensure shoes are on securely tied; (6/28/11) fall mat; (7/18/11) To observe her-frequent attempts @ standing, leaning over chair: remove res.(resident) from dining room after meals...." The Director of Nursing indicated in an interview on 7/29/11 at 1:30 P.M., that Resident #F had known behaviors prior to coming to the facility. "She has poor safety awareness. Her attention span is 20-30 seconds long. She propels herself into the dining room." During an interview with Occupational Therapist #4 on 7/29/11 at 1:45 P.M., she indicated Resident #F gets tired and then leans in the chair. "When she's awake she sits nice and straight, if she gets fatigued she leans forward. Planned naps would probably benefit her." Social Service Staff #5 indicated in an interview on 7/29/11 at 2:00 P.M., "Resident #F attends activities like music and bingo. Pretty much anything that involves eating or music." During observation of Resident #F on 7/29/11 at 2:20 P.M., she was observed in the dining room, leaning forward in her wheel chair with her elbows barely resting on her arm rests. She was sound asleep and did not respond to her name. Her wheel chair was unlocked. She was not wearing non-skid socks; she was wearing regular white cotton socks and no shoes. She and eight other residents were unsupervised in the dining room. 2. Resident #D's clinical record was reviewed on 7/28/11 at 4:45 P.M., and indicated [DIAGNOSES REDACTED]. A "Fall Circumstance Report," dated 1/6/11, indicated Resident #D sustained an unwitnessed fall on 1/6/11 at 2:00 P.M., and was found "sitting on bottom beside w/c (wheel chair) and next to bed...did not use call light for assist, got himself up out of w/c and lost his balance and landed on his bottom...What intervention (s) was put in to place to prevent another fall? Already has w/c, bed alarms, toilet program after meals. Enc. (encourage) to attend activities, be out of room, join other res. (residents) to talk or watch TV." Review of April, May, June, and July incident reports indicated Resident #D also sustained a fall on 4/28/11, 6/09/11, 6/25/11, and 7/16/11. Resident #D's "Fall Risk Assessments," dated 6/17/10 and 8/4/10, indicated he had a history of [REDACTED]. The most recent "Fall risk Assessment," dated July, 2011, indicated the same. All three assessments indicated Resident #D was non-compliant. An Interdisciplinary Team Progress Note (IDT), dated 6/9/11, indicated, "Fall 6/9/11 at 3:30 A.M. Found on floor in his room. Was in bed sleeping found lying on his left side in night clothes. Laceration to bridge of nose and top of right eyebrow. Immediate intervention 15 minute checks and bed alarm initiated...." Resident #D's Care Plan, initiated 12/09/10, indicated, "Problem: Res (resident) is at risk for falls d/t (due to) poor safety (sic) awareness, hx (history) of falls...doesn't use call lite...Approach: Up in wheel chair with assist... offer to assist to lay down after meals...assist to toilet as needed...chair and bed alarm to alert staff of unassisted transfers...." The Care Plan also indicated hipsters to prevent injury were added on 12/10/10 and chair and bed alarms were discontinued on 5/5/11 and re-initiated again on 6/9/11 as a result of the fall. An untitled investigation report, dated 6/25/11, indicated, "...Nurse called to resident's room found on floor R (right) side. Resident wet, bed soaked. Resident transferred (sic) from bed to chair unassisted. Alarm on w/c and bed working...found pt (patient) lying on right side in room. Pt. was attempting to transfer out of bed unassisted...." An IDT note, dated 6/27/11 (regarding fall on 6/25/11), indicated, "...Pt. was incontinent @ time of fall. Bed alarm was sounding...IDT decided to D/C (discontinue) fall mat...initiate 3 day bowel and bladder. Will continue to observe and F/U (follow up) as needed." Nurse's Notes indicated the following: 7/16/11 at 4:00 P.M.: "Late entry Nurse called to resident's room alarm sounding off resident was lying on L (left) side on floor. Resident had gotten out of bed blood was coming from R (right) elbow skin-tear noted. Vitals were taken WNL (within normal limits)...ROM (range of motion) unchanged after fall. Resident denied any c/o (complaints of) pain at this time." 7/16/11 at 4:16 P.M.: "Resident requested to lay down in bed. Nurse help assist resident to bed. Placed call light within reach asked resident to use call light and to push button showed resident how to use." 7/16/11 at 5:40 P.M.: "Alarm was sounding off resident trying to get out of bed. Nurse and CNA assisted resident to w/c (wheel chair) for dinner. No c/o @ this time." 7/16/11 at 5:45 P.M.; When resident was in dining room he c/o R leg pain...new order to send to ER (emergency room ) for eval (evaluation) treatment." A "Fall Circumstance Report," dated 7/16/11 at 4:00 P.M., indicated, "Resident was in bed prior to fall. Alarm sounding when res. found on floor. Resident was toileted within one hour prior to fall...hipsters on...Resident unable to explain how fall occurred (sic)...." An IDT note, dated 7/18/11, indicated, "IDT review of fall on 7/16/11 at 4 P.M. ...Res. denied pain at time of fall....fall mat was placed at bedside. Will offer Res. diversional activities. Res. c/o R leg pain @ 5:45 P.M. and was sent to ER...Res. was admitted to hospital with R hip fracture...." A hospital History and Physical, dated 7/17/11, indicated, "Elderly male presents with hip fracture and abnormal x-rays that he may have undiagnosed metastatic cancer...He had severe anemia at one point. The patient's family decided at that point to go with comfort measures only. At one point he was in hospice. At this point, however, therefore there are no plans for further aggressive intervention other than trying to stabilize his hip fracture...." During interview with RN #3 on 7/28/11 at 5:15 P.M., she indicated Resident #D was very non-compliant with using the call light. "He didn't seem to understand he had to use the call light for assistance. He would just get up and try to transfer himself." Review of Resident #D's quarterly Minimum Data Set (MDS) Assessment, dated 5/01/11, indicated his cognition was severely impaired with a score of 3 out of 15. It also indicated he needed extensive assistance of one person for physical assistance. A facility policy titled "Fall Management Program," revised March, 2010, indicated, "Policy: It is the policy of American Senior Communities to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls...Fall Risk Interventions:...Equipment interventions: ...low bed with floor mats...personal alarm on chair, personal alarm on bed...proper fitting shoes, gripper socks...Staff interventions: ...Anticipate care needs for confused residents...Lay down for naps between meals. Do not leave unattended in rooms and/or bathrooms if fall risk. Special activity programs for those with behaviors...." This Federal tag relates to complaint IN 796. 3.1-45(a)(2)