Every finding on record at Cathedral Health Care Center

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 5 residents reviewed for unnecessary medications. The clinical record lacked a plan of care for resident's taking anticonvulsant and diuretic medications. (Resident 2, Resident 7, Resident 59)Findings include: 1. On 7/22/25 at 10:56 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, paranoid schizophrenia, bipolar disorder, and Parkinson's disease. The most recent quarterly Minimum Data Set (MDS) assessment, dated 6/24/25, indicated Resident 2's cognition was severely impaired and received an antipsychotic medication. Current physician's orders included, but were not limited to, the following:Gabapentin (anticonvulsant) 400 milligram (mg), give one capsule by mouth three times a day for pain, ordered 6/2/25 Lasix 40 mg, give one tablet orally two times a day for edema, ordered 6/12/25 The clinical record lacked a care plan for diuretic and anticonvulsant use. The July 2025 Medication Administration Record (MAR) indicated resident was currently taking both medications routinely. 2. On 7/22/25 at 1:40 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, stroke, diabetes mellitus type II, and heart failure. The most recent quarterly MDS assessment, dated 6/2/25 indicated resident 7's cognition was severely impaired and received an anticoagulant medication. Current Physician's Orders included, but were not limited to, the following:Xarelto (anticoagulant) 10 mg, give 1 orally once daily for personal history of stroke, ordered 5/24/25The clinical record lacked a care plan for anticoagulant use.The July 2025 MAR indicated Resident 7 was currently taking the medication routinely. 3. On 7/23/25 at 8:34 A.M., Resident 59's clinical record was reviewed. Diagnoses included, but were not limited to, bipolar disorder, dementia with psychotic disturbances, and chronic cystitis. The most recent quarterly MDS assessment, dated 7/2/25, indicated Resident 59's cognition was severely impaired and received a diuretic medication. Current Physician's Orders included, but were not limited to, the following:Lasix (diuretic) 20 mg, give one tablet orally daily for chronic cystitis, ordered 10/16/24. The clinical record lacked a care plan for diuretic use. During an interview on 7/23/25 at 1:55 P.M., the Administrator indicated the resident's were currently on those medications but she was unable to provide a care plan for them. She would expect a care plan to have been added by the nursing staff, Director of Nursing (DON), or herself. She was unsure why these were missed. On 7/23/25 at 3:23 P.M., a current Care Plan Policy, last revised December 2016, was provided by the Administrator and indicated, A comprehensive, person-centered care plan . is developed and implemented for each resident . The comprehensive, person-centered care plan is to be completed within 21 days from admission to the facility . 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for 2 of 5 residents observed for care, and 2 of 10 residents reviewed for medication administration. Staff did not wash hands with at least a 20 second lather, did not change gloves and perform hand sanitization from dirty to clean tasks, did not wear gloves when administering an injection, and touched resident pills with bare hands. (Resident 34, Resident 37, Resident 20, Resident 9) Findings included: 1. On 9/9/24 at 7:27 A.M., RN (Registered Nurse) 15 was observed during a medication administration to Resident 20. RN 15 came out of the pantry room upstairs with a drink for the resident. She proceeded to prepare her medications without performing hand hygiene. She opened the medication cart, opened the narcotic box, popped out the resident's clonazepam (anxiety medication) tablet into her bare hand, and then placed it into the medication cup. After preparing all of the medications, RN 15 administered them to Resident 20. 2. On 9/10/24 at 10:57 A.M., RN 23 was observed using a glucometer to check Resident 37's blood sugar. After she was done, she took the used supplies out of the room to the medication cart. RN 23 took off her gloves, washed her hands with a 6 second lather of soap, went to computer to look up the insulin dose, and indicated he needed 10 units of Humalog (insulin). She grabbed the syringe and insulin vial from the medication cart, wiped the top of insulin vial with an alcohol wipe, drew back air then pushed it into the vial. She drew up 10 units of insulin, wiped Resident 37's left lower abdomen with an alcohol swab, and administered 10 units of Humalog to his left lower abdomen without putting on gloves. During an interview on 9/13/24 at 11:42 A.M., the DON (Director of Nursing) indicated medications should not be touched with a bare hand and administered. Staff should be popping the medication directly into the medication cup. Staff should wear gloves while administering insulin and staff should wash hands, lathering with soap at least 20 seconds, or using hand sanitizer between tasks. 45933 3. During an observation of care on 9/13/24 at 11:10 A.M., LPN (Licensed Practical Nurse) 14 washed her hands with an 8 second hand lather and donned gloves to clean a wound on Resident 9's neck. LPN 14 cleaned the wound with soap and water on a washrag, removed gloves, and washed hands with an 8 second lather. At that time, she donned new gloves and placed the bandage on Resident 9's neck, then removed an empty trashbag from the trash can and placed the soiled linens in the bag and removed her gloves, and an 11 second hand lather was performed. 38770 4. On 9/13/24 at 11:34 A.M., Certified Nurse Aide (CNA) 7 was observed to transfer Resident 34 from the bed into a wheelchair. CNA 7 placed a gait belt on the resident, assisted out of bed to a standing position, then assisted the resident to pivot and sit in the wheelchair. CNA 7 washed their hands in the resident's sink. Hands were lathered for five seconds with soap then rinsed. On 9/13/24 at 11:42 A.M., the Director of Nursing indicated staff should be washing their hands with a lather of at least 20 seconds. On 9/9/24 at 10:00 A.M., a current Handwashing/Hand Hygiene Policy, dated January 2019, was provided by the Administrator and indicated This facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Single-use disposable gloves should be used: . when anticipating contact with blood or body fluids . vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) . 3.1-18(l) 3.1-18(b)

Based on interview and record review, the facility failed to ensure accuracy of MDS (Minimum Data Set) Assessments for 1 of 1 resident assessments reviewed and 2 of 5 unnecessary medications reviewed. A resident's traumatic brain injury, a resident's injections, and a resident's insulin use were not marked on the MDS Assessments. A resident's bed rail was marked incorrectly as a restraint on the MDS. (Resident 8, Resident 5, Resident 27) Findings included: 1. On 9/11/24 at 8:42 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia on right dominant side, dementia, epilepsy, and TBI (Traumatic Brain Injury). The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 8/6/24, indicated Resident 5's cognition was moderately impaired, an extensive assist of 2 staff for bed mobility, transfers, toileting, and the active diagnosis of TBI was marked no. 2. On 9/10/24 at 10:39 A.M., Resident 27's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's and Rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood and can damage kidneys). The most recent Quarterly MDS Assessment, dated 6/28/24, indicated Resident 27's cognition was severely impaired, an extensive assist of 2 staff for bed mobility, transfers, toileting, and used a bed rail as a restraint daily. During an interview on 9/12/24 at 9:09 A.M., the MDS Coordinator indicated Resident 5 did have a TBI and the question was answered incorrectly. It should have been marked yes. Resident 27 does not use the mobility bar as a restraint. The question was answered incorrectly and should have been marked no restraints were used. 45933 3. On 9/13/24 at 12:15 P.M., Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, type 2 diabetes mellitus. The most recent State Optional and Quarterly MDS (Minimum Data Set) Assessment, dated 6/11/24, indicated Resident 8 had a severe cognitive impairment and did not receive insulin or injections during the assessment period. Physicians Orders during the assessment period included, but was not limited to: Humalog mix 75/25 (Insulin Lispro Protamine and Lispro) subcutaneous suspension 100 Unit/ML (milliliter). Inject 15 units once a day subcutaneously related to type 2 diabetes mellitus, dated 4/20/24. Humalog mix 75/25 (Insulin Lispro Protamine and Lispro) subcutaneous suspension 100 Unit/ML (milliliter). Inject 40 units once a day subcutaneously related to type 2 diabetes mellitus, dated 4/20/24. Resident 8's MAR (Medication Administration Review) for June 2024 indicated Humalog was administered during the assessment period for the 6/11/24 MDS. During an interview on 9/13/24 at 12:20 P.M., the MDS Coordinator indicated the 6/11/24 should have indicated Resident 8 received insulin and injections, and it was coded in error. On 9/12/24 at 9:09 A.M., the MDS Coordinator indicated they did not have a policy for filling out an MDS Assessment, but they would use the RAI (Resident Assessment Instrument) manual.

Based on interview and record review, the facility failed to ensure comprehensive assessments were completed for 1 of 12 residents reviewed with diabetes. A follow up assessment was not completed after a low blood sugar reading as indicated. (Resident 8) Finding includes: On 9/10/24 at 10:26 A.M., Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 6/11/24, indicated a severe cognitive impairment, and a requirement of setup with supervision for bed mobility and transfers. Physician orders included, but were not limited to: Accu check four times a day for diabetes, dated 2/17/24. Blood sugar 70 or below and able to swallow - Give 4 ounces orange juice or 6 ounces soda and repeat blood sugar after 15 minutes. Repeat if necessary and follow up with cheese crackers, milk and fruit or sandwich as needed for hypoglycemia, dated 12/18/24. A current diabetes mellitus care plan included, but was not limited to, the following interventions: Obtain and monitor lab and /or diagnostic work as ordered. Repeat results to physician and follow up as indicated, dated 1/14/19. A nurse's note, dated 8/16/24 at 5:00 A.M. indicated Resident 8's fasting blood sugar was 48. The Registered Nurse (RN) gave the resident a chocolate ensure and an oatmeal cream pie, and would recheck the blood sugar in 15 minutes per physician's order. Resident was alert and eating the snack. A nurse's note, dated 8/16/24 at 5:22 A.M. indicated Resident 8's blood sugar was rechecked and was 68. The resident woke for the accu check and went back to sleep. Resident indicated he was feeling ok. Resident 8's Medication Administration Record (MAR) for August 2024 indicated the following blood sugar readings on 8/26/24: 5:30 A.M. 48 12:00 P.M. not recorded (leave of absence) 4:00 P.M. 155 8:00 P.M. 175 Resident 8's August 2024 MAR lacked documentation that an as needed blood sugar was checked for a blood sugar below 70. On 9/12/24 at 1:15 P.M., the Director of Nursing (DON) indicated she had been the nurse on duty on 8/16/24 when Resident 8's blood sugar had read below 70 twice. She indicated she had not rechecked it after it read 68 although the physician's order should have been followed. On 9/12/24 at 2:20 P.M., the Administrator provided a current, non-dated, Staff Nurse job description. She indicated at that time that the information would serve as a facility policy. The form indicated Documents accurately in resident chart any significant changes in care . Responsible for interpretation and execution of physician's orders and call physician as indicated . Is responsible for accurate observation, evaluation, and reporting of residents 3.1-37(a) 46882

Based on observation, interview and record review, the facility failed to ensure comprehensive assessments were completed appropriately for 2 of 5 residents reviewed for accidents. Fall risk assessments were not thorough and complete, and 72 hour follow up for a fall was not initiated immediately after the fall. (Resident 20, Resident 8) Findings include: 1. On 9/12/24 at 9:01 A.M., Resident 20 was propelling self down the hall in a wheelchair when she stood up and pushed wheelchair to room. LPN 6 was walking down the hall, came up beside Resident 20 and reminded her she had a walker to use if she didn't want to use the wheelchair. On 9/10/24 at 11:27 A.M., Resident 20's clinical records were reviewed. Diagnosis included, but were not limited to schizoaffective disorder, bipolar type, type II diabetes mellitus, repeated falls, extrapyramidal and movement disorder, anxiety disorder, and borderline personality disorder. The most current Quarterly MDS (Minimum Data Set) assessment, dated 8/2/24, indicated Resident 20 was severely cognitively impaired, required supervision with bed mobility and eating, limited assistance of one for transfers and extensive assistance of one for toilet use, had one fall with no injury and one fall with injury. Nursing Note 5/23/2024 10:00 Note Text: Resident fell in her room. She was found lying on her side. Resident was able to move all extremities. She was assisted to get up. Resident went to the bathroom. Resident was moaning and complaining about her roommate's chair. Resident walked without difficulties. No bruised or injury noted. Resident in on neurological checks. Family, DON (Director of Nursing), and NP (Nurse Practitioner) notified. After a fall in Resident 20's room on 5/23/24, the care plan failed to be updated. After a fall on 7/5/24, the fall risk assessment indicated Resident 20 did not have any falls in the previous three months when the resident had a fall on 5/23/24. During an interview on 9/12/24 at 2:45 P.M., Administrator indicated the fall risk assessment completed on 7/5/24 should have been marked 1-2 falls in the last 3 months. During an interview on 9/13/24 at 8:21 A.M., Administrator indicated fall risk assessments were done per regulation and included in the quarterly nurse evaluations. During an interview on 9/13/24 at 8:28 A.M., Administrator indicated care plans were updated after every fall. During an interview on 9/13/24 at 9:31 A.M., Social Services indicated the care plan should be updated after each fall. She indicated she could not find an updated care plan for the 5/23/24 fall. 2. On 9/10/24 at 10:26 A.M., Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, other abnormalities of gait and mobility, unsteadiness on feet, other lack of coordination, and unspecified lack of coordination. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 6/11/24, indicated a severe cognitive impairment, and a requirement of setup with supervision for bed mobility and transfers. A current falls care plan indicated cognitive impairment, lack of coordination, unsteadiness on feet, weakness, and abnormal gait, initiated 1/15/19 and revised 8/22/24. Resident 8 experienced four falls from December 2023 through September 2024 on 12/4/23, 12/5/23, 2/4/24 and 8/25/24. A fall risk evaluation, dated 2/4/24, indicated no falls in the past 3 months and no noted drop in blood pressure between lying and standing. Resident 8's fall score was 6 (a score of 10 or more indicated high risk for falls). A fall risk evaluation, dated 8/25/24, indicated no falls in the past 3 months and no noted drop in blood pressure between lying and standing. Resident 8's fall score was 8. On 8/29/24, an order was placed for a 72 hour follow up charting every shift for the fall on 8/25/24 to document in progress notes for 3 days. An Interdisciplinary (IDT) note, dated 9/3/24, indicated Resident 8 had fallen and the care plan had been updated. On 9/10/24 at 3:03 P.M., the leave of absence binder was reviewed and lacked documentation that Resident 8 had been LOA on 8/16/24. On 9/12/24 at 1:15 P.M., the Director of Nursing (DON) indicated falls were typically reviewed from the previous day at the morning meetings. If a fall occurred over the weekend, it was reviewed on Monday morning. She indicated she learned Resident 8 may have had a fall on 8/29/24, and at that time reached out to the nurse to see if anything had been initiated and apparently had not. It was then when the 72 hour post fall follow up had been put in, although it had already been 72 hours post fall. She indicated when filling out fall risk evaluations, the fall that occurred that same day should be counted in the history of falls, and that staff would need to be inserviced on that. She further indicated the nurses that filled out the fall risk evaluations on 2/4/24 and 8/25/24 and marked no drop in blood pressure from lying to standing did not actually check the blood pressure at the time the forms were filled out. She indicated normally for the resident's lying to standing blood pressure to be checked, there needed to be a physician's order and they didn't get many of those. On 9/12/24 at 2:20 P.M., the Administrator provided a current Fall Risk Assessment policy, dated 3/2018, that indicated The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions . that may predispose to falls On 9/12/24 at 2:20 P.M., the Administrator provided a current Falls policy, dated 3/2018, that indicated For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall On 9/12/24 at 2:20 P.M., the Administrator provided a current, non-dated, Staff Nurse job description. She indicated at that time that the information would serve as a facility policy. The form indicated Documents accurately in resident chart any significant changes in care . Responsible for interpretation and execution of physician's orders and call physician as indicated . Is responsible for accurate observation, evaluation, and reporting of residents 3.1-45(a)

Based on record review and interview, the facility failed to monitor for side-effects related to antipsychotic drug use for 1 of 1 resident reviewed for psychotropic drug use. (Resident 63) Findings included: Resident 63's clinical record was reviewed on 9/13/24 at 1:02 P.M. An annual MDS (Minimum Data Set) Assessment, dated 6/20/24 indicated Resident had some cognitive impairment, no behaviors noted, required anywhere from supervision to extensive assist with mobility and transfers. Diagnoses in Resident 63's chart included but were not limited to paranoid schizophrenia. Physician orders in Resident 63's chart included but were not limited to, clozapine 100 mg (milligrams) 3 tablets a day, dated 5/11/23. Another order for clozapine 100 mg 1.5 tablets daily was found, dated 4/2/234. The Resident was being given a total of 450 mg a day of clozapine. Clozapine is an antipsychotic medication used for treatment resistant schizophrenia. An order was also placed on 3/15/23 to monitor for side effects of antipsychotic medications, listing many side effects for nursing staff to monitor every shift, if side effects present, document in progress notes. When reviewing Resident 63's clinical record on 9/13/24 at 2:00 P.M., it was found that in the treatment administration record there were many dates where nursing staff indicated y (yes), that Resident had side effects but failed to put in a progress note to follow with information on what side effects the resident was experiencing. The following dates are dates with y indicated on record but no progress note: May 2, 6, 7, 9, 13, 14, 16, 17, 20, 21, 28, 30 of 2024. June 5, 6, 10, 11, 13, 17, 18, 20, 27 of 2024. July 1, 2, 9, 15, 18, 22, 25, 27, 29, 30 of 2024. August 1, 6, 8 of 2024. On 9/13/24 at 9:46 A.M., the DON (Director of Nursing) indicated that sometimes the orders to monitor side effects will have a key for staff to use to show what side effect was present instead of staff giving a yes or no answer, that she would have to look into it. LPN (Licensed Practical Nurse) 6, on 9/13/24 at 10:05 A.M., indicated that when charting in the treatment administration record for side effects, when it is marked yes it means the resident was monitored for side effects. LPN also indicated if she were to observe side effects during her shift that she puts in a progress note regarding them. On 9/13/24 at 10:50 A.M., the DON indicated that she called the nursing staff who had been marking y in the treatment administration record for side effects. This nursing staff indicated that she was under the impression that she should have been marking y, meaning yes she was monitoring the resident for side effects. On 9/12/24 at 2:20 P.M., the Administrator provided a current, non-dated, Staff Nurse job description. She indicated at that time that the information would serve as a facility policy. The form indicated Documents accurately in resident chart any significant changes in care . Responsible for interpretation and execution of physician's orders and call physician as indicated . Is responsible for accurate observation, evaluation, and reporting of residents 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 1 residents reviewed for notification of change. A resident received a dose of the wrong insulin. (Resident 8) Finding includes: On 9/10/24 at 10:26 A.M., Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 6/11/24, indicated a severe cognitive impairment, and a requirement of setup with supervision for bed mobility and transfers. Current physician orders included, but were not limited to: NovoLOG Mix 70/30 FlexPen (a mixture of insulin aspart protamine, an intermediate-acting human insulin, and insulin aspart, a rapid-acting insulin) subcutaneous suspension pen-injector (70/30) 100 unit/ml (milliliter), inject 20 units one time a day, dated 7/24/24. NovoLOG Mix 70/30 FlexPen subcutaneous suspension pen-injector (70/30) 100 unit/ml (milliliter), inject 50 units one time a day, dated 7/24/24. Resident 8 did not have a physician's order for Novolin R (insulin regular - a short-acting insulin) or Novolin N (insulin isophane - an intermediate-acting insulin). A current diabetes mellitus with history of longterm use of insulin care plan indicated, but was not limited to, the following intervention: Administer my medications as ordered, dated 1/14/19. A nurse's note on 9/8/24 at 8:15 A.M. indicated Resident rec'd [received] incorrect insulin for AM dose. MD notified et [and] stated to monitor resident. A nurse's note on 9/9/24 at 11:00 A.M. indicated the physician rounded with the resident. Resident 8 had received Novolin R instead of Novolin. One was short acting and one was intermediate acting. No new orders were given. On 9/10/24 at 1:02 P.M., the Director of Nursing (DON) indicated the Unit Manager had called her over the weekend to tell her that an agency nurse had given Resident 8 Novolin R instead of Novolin N, but did not have specific information as to how much he was administered, whose insulin had been given, but assumed the same units ordered had been given. She indicated the only difference between what the resident was ordered (Novolog FlexPen) and what had been given (Novolin R) is that one was fast acting, and one was intermediate acting. She indicated at that time that Novolog and Novolin were the same thing. On 9/12/24 at 2:20 P.M., the Administrator provided a current Administering Medications policy, dated 12/2012, that indicated Medications must be administered in accordance with the orders, including any required time frame . The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure the physician and resident representative were notified of a change in condition for 1 of 4 residents reviewed for falls. The physician and resident representative were not notified of a resident's fall or x-ray results, and the resident representative was not notified of an injury. (Resident 8) Findings include: On 9/9/24 at 10:29 A.M., Resident 8's representative indicated she had not been contacted in several months about any falls, injuries, or x-rays. To her knowledge, Resident 8 had not fallen or had any injuries recently. At that time, the representative indicated she would be the one to notify of any changes in Resident 8's condition. On 9/10/24 at 10:26 A.M., Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, other abnormalities of gait and mobility, diabetes, and Down's Syndrome. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 6/11/24, indicated a severe cognitive impairment, and a requirement of setup with supervision for bed mobility and transfers. Physician orders included, but were not limited to: x-ray right middle finger for finger pain, dated 8/19/24. Progress notes indicated Resident 8 experienced a fall on 8/25/24 with no apparent injury. The clinical record lacked a notification to the physician or representative at the time of the fall. A nurse's note, dated 8/18/24, indicated Resident 8's right middle finger was swollen and crooked. The resident indicated to the nurse the finger had been injured on the bed enabler while getting up. The resident's representative and Nurse Practitioner (NP) were notified of the resident's condition and the note indicated the NP would visit the resident the following day. X-Ray report in the record for Resident 8 had an x-ray of the right middle finger on 8/19/24 related to the finger being swollen and crooked. The clinical record lacked notification to the resident's representative that the x-ray had been ordered. The x-ray result, dated 8/19/24, indicated no fractures. The result and clinical record lacked notification to the provider or resident representative of the results. On 9/12/24 at 1:15 P.M., the Director of Nursing (DON) indicated the nurse on duty when a resident falls should notify the DON, physician, and the family. She indicated on 8/25/24, no one had been notified of Resident 8's fall. She indicated a risk management note may have been entered (not part of the clinical record) and would include notification to the physician and family, but a progress note of the notification should have been put in as well. At that time, she indicated staff was expected to notify the physician and family of injuries and x-rays, and should have been done for Resident 8 for the finger pain and x-ray. On 9/13/24 at 11:00 A.M., the Administrator indicated although it was not in the facility policy to notify the physician after every fall (only those resulting in injury), it was best practice for staff to notify family and the physician following every fall. At that time, she indicated staff should be notifying family and the physician of any test results, including x-rays. On 9/13/24 at 12:00 P.M., a current Notification policy, dated 11/28/16, was provided and indicated Our facility shall promptly notify the Resident, his or her Physician/Physician Assistant/Nurse Practitioner, and Resident Representative/interested family member of changes in the Resident's medical/mental condition and/or status . The Nurse will notify the Resident's Physician Assistant/Nurse Practitioner when there has been (including, but not limited to) . An accident or incident involving the resident . A discovery of injuries of an unknown source 3.1-5(a)

Based on observation, interview, and record review, the facility failed to uphold professional standards of colostomy care for 1 of 1 residents reviewed for ostomy care. A resident's colostomy bag was adhered to the resident with duct tape in preparation for resident transport to a local hospital. (Resident D) Finding includes: During record review on 8/23/24 at 10:30 A.M., Resident D's diagnoses included, but were not limited to, acquired absence of other specified parts of digestive tract and schizoaffective disorder. Resident D's most recent Quarterly Minimum Data Set (MDS) assessment, dated 6/19/24, indicated Resident D had an ostomy, required supervision with activities of daily living (ADL's) including toileting, bathing, and personal hygiene, and had delusions one to three days during a seven day review period, and had severe cognitive impairment. Resident D's physician orders included, but were not limited to, provide right upper quadrant (RUQ) colostomy care and change every Monday and Thursday on night shift and as needed if soiled or due to dislodgment. Use Skin-Prep (protective wipes that form a barrier between the skin and adhesives to protect and maximize skin health) for every change (started 6/22/23), asses skin integrity in around stoma site during care (started 1/10/24), monitor unusual physical behavior such as sticking items in stoma (started 8/22/24), disrobing (started 2/17/24), and removing ostomy bag (started 7/29/24). Resident D's care plan included, but was not limited to, resident has colostomy and may need assist with ostomy care per staff. Interventions included, change bag after each bowel episode or when full, change wafer as ordered, place proper-fitting wafer around ostomy site, and provide proper fitting bags (initiated 6/21/23). Resident at risk for exhibiting behaviors such as pulling off colostomy bag and painting floors, walls, and furniture with content of bag (revised 8/6/24). Resident D's nurse's progress notes included a behavior note, dated 7/26/24 at 3:47 P.M. The note indicated that the Director of Nursing (DON) and Facility Administrator were called to the second floor. Resident D was rolling around on the floor with fecal matter, she had pulled her colostomy bag off and was smearing it on the floor with her body. Resident has poor safety awareness for self and others. Staff cleaned resident with soapy washcloths and water basins and colostomy bag reapplied and taped for reinforcement. Resident trying to pull colostomy bag off. Order received to send resident to hospital for evaluation. Resident transported without difficulty and report was called into Emergency Department (ED) nurse. A hospital ED provider note dated 7/26/24 at 3:45 P.M., indicated resident was disoriented upon arrival from nursing facility. Facility reported that resident had been removing her ostomy. On arrival, ostomy site was duct taped to patient's abdomen. During an observation on 8/23/24 at 11:00 A.M., Resident D was observed in her room laying face down on a blanket on the floor without clothing. Resident D's room contained an odor of bowel movement (BM) and the blanket Resident D was lying on had areas with a visible brown substance. As staff assisted Resident D to her feet, an uncovered stoma was observed on the resident's abdomen. LPN 4 retrieved a colostomy bag as LPN 2 assisted Resident D in cleaning up and dressing. Staff applied the colostomy bag and dressed Resident D. At 11:30 A.M., LPN 4 indicated that Resident D had disrobed and removed her colostomy bag. During an interview on 8/23/24 at 11:40 A.M., LPN 2 indicated that Resident D often removed her colostomy bag herself. One way to help the bag adhere to the resident is to use Skin-Prep barrier wipes when applying the colostomy bag. LPN 2 indicated that duct tape should not be used to adhere a colostomy bag to a resident and would be inappropriate. During an interview on 8/23/24 at 1:10 P.M., the Facility Administrator indicated that staff had used duct tape on Resident D's colostomy bag to hold it in place during transportation from the facility to the hospital following a request from the ambulance service to secure Resident D's colostomy bag. The facility Administrator indicated that staff had tried medical grade adhesives without success and that the facility did not have an abdominal binder or other means to secure Resident D's colostomy bag. According to the U.S. Department of Health and Human Services, The Food and Drug Administration identifies medical adhesive tape and adhesive bandages as, a device intended for medical purposes that consists of a strip of fabric material or plastic, coated on one side with an adhesive, and may include a pad of surgical dressing without a disinfectant. The device is used to cover and protect wounds, to hold together the skin edges of a wound, to support an injured part of the body, or to secure objects to the skin (3/22/24). The EchoTape product catalog specification sheet, reviewed 8/26/24, indicated Industrial Strength Utility Grade Duct Tape applications for use include the following: General purpose construction use and repair Patching and seaming a wide variety of materials Temporary holding and bonding Hanging and patching polyethylene sheeting Sealing polyethylene waste disposal bags Duct work and contractor uses Multiple applications in manufacturing & Industrial environments Bundling and color coding On 8/23/24 at 1:40 P.M., the Facility Administrator supplied a facility policy titled Colostomy/Ileostomy Care, dated 09/2005. The policy included, The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter . 1. Review the resident's care plan to assess for any special needs of the resident . The following equipment and supplies will be necessary when performing this procedure: .4. Adhesives (if indicated) . This citation relates to complaint IN00440005. 3.1-47(a)(3)

Based on interview and record review, the facility failed to ensure timely reporting of an allegation of abuse for 1 of 1 allegations of abuse reviewed. Following an allegation of perceived abuse, the facility failed to report the incident and findings to the State Survey Agency within the required time frame. (Resident D) Finding includes: During record review on 1/9/24 at 11:30 A.M., Resident D's diagnoses included but were not limited to, generalized anxiety, chronic pain, and major depressive disorder. Resident D's most recent quarterly MDS (Minimum Data Set) assessment, dated 10/14/23, included that the resident was cognitively intact. Resident D's nurses notes included, but were not limited, to a behavior note, dated 12/18/23, at 12:07 P.M. The note included, Resident is continuous [sic] about telling staff about the bruise she received on her arm. (Director of Nursing, Facility Administrator, Social Service), MDS have already investigated bruise and spoke with resident about the incident and resident agrees there was no harm intended but continues to tell staff and anyone who will listen that CNAs were rough with her . During an interview on 1/9/24 at 10:00 A.M., Resident D indicated that she felt she had been physically abused approximately two months prior when CNA 4 was assisting her in bed following a transfer. Resident D indicated that CNA 4 had pulled her arm too hard causing her to become dizzy and vomit. The resident stated there was bruising from her fingers to her elbow and that she reported CNA 4 to multiple staff members. During an interview on 1/9/24 at 10:20 A.M., the Facility Administrator indicated being aware of the allegation from Resident D and that the resident had also called the local hospital and told them that someone had broken her arm. The Facility Administrator included that, at the time of the allegation, the resident did not indicate to staff that the incident with CNA 4 was abuse. During an interview on 1/9/24 at 10:35 A.M., the Director of Nursing (DON) indicated that staff were made aware of an incident reported by Resident D and that interviews and inservices were completed. The DON included that Resident D was inconsistent with her accusation and that they were unable to substantiate the allegation. During a review of the facility's investigation of the reported incident from Resident D on 1/9/24 at 11:30 A.M., an undated written statement from CNA 6, included, . On December 17, (CNA 8) and I went in to get (Resident D) up in the morning, when we were in there we noticed a large puple [sic] bruised area on her right wrist, she said that (CNA 4) had grabbed her and pulled her over by her wrist. We went to tell the nurse to report it. A typed statement, dated 12/18/23 and signed by the MDS nurse, included, This writer was called into (Resident D's) room around (9:45 A.M.) . the resident began to question this writer if I knew what happened to her as she began to slide her long sleeve shirt up on her right side, exposing bruising to her wrist and forearm. I told her that the DON had informed me this morning and that the DON is investigating the root cause. The resident stated it was caused by a CNA during care on Friday evening. She then said it was abuse by the way the CNA grabbed her arm and was rolling her over from the bed pan . On 1/9/23 at 11:05 A.M., the facility administrator supplied a facility policy titled, Abuse Policy, dated 1/2020. The policy included, .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies . This citation relates to complaint IN00425501. 3.1-28(c)

Based on interview, observation, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards for food service for 2 of 2 kitchen observations. The staff lacked knowledge of the test strips used to test the sanitation chemicals in 1 of 2 observations of dishwasher use. Foods were not labeled correctly and a used cooking utensil was dropped into the food to be served. Findings include: 1. On [DATE] at 9:53 A.M., the following was observed in the kitchen: 5- loaves of bread were on a shelf not labeled Refrigerator: Mechanical sausage dated ,d+[DATE] (no year) Beef stew dated ,d+[DATE] (no year) Gravy dated ,d+[DATE] (no year) Gallon of dill pickles opened ,d+[DATE] (no year) Pear sauce dated ,d+[DATE] (no year) 4 packs of sliced cheese in plastic wrap each dated ,d+[DATE] (no year) Dishwasher: During an interview on [DATE] at 10:15 A.M., Kitchen Staff 1 indicated the dishwasher needed to run 3 times before it got to the correct temperature if it had not been used recently. She indicated she was not sure what sanitized the dishes, the temperature or the chemicals. There was an undated bottle of test strips on top of the machine that started testing at 200 ppm. She indicated this was the bottle they used for testing the sanitation chemical ppm (parts per million). During an interview on [DATE] at 10:25 A.M., Kitchen Staff 1 indicated the test strips were used once a day and if it was not checked in the morning, then they would check at night to make sure the ppm was high enough. She took the bottle of test strips down from the top of the dishwasher and tested the water 6 times indicating that the ppm should be ,d+[DATE] ppm but this test strip color was not changing. At that time, the Dietary Manager indicated that the strips almost always measured 400 ppm and she was not sure why it was not working now because the maintenance man had just been there a couple weeks ago to work on the dishwasher tubing. The dietary manager went to get another bottle of strips that was identical to the first bottle from her office and Kitchen Staff 1 re-tested the machine 2 more times but the strip color did not change. The dietary manager indicated she would call the dishwasher maintenance man to come look at the machine at that time. On [DATE] at 10:45 A.M., the testing logs were reviewed for the dishwasher and indicated from [DATE] to [DATE] the AM, Noon, and PM wash temperature was 120 degrees and the rinse was 50 ppm. At that time, Kitchen Staff 1 indicated that the temperature and ppm that were in the book were the actual tested values. On [DATE] at 10:49 A.M., the Dietary Manager brought a different litmus paper roll to Kitchen Staff 1. There was not a key to compare the test strip to, only the picture on the box. The Administrator observed the test strip color indicating 200 ppm. On [DATE] at 10:53 P.M., the Dietary Manager found another litmus paper roll. During an interview on [DATE] at 11:15 A.M., the Kitchen Manager indicated she found the other test strips in her desk drawer. At that time, she indicated the bottle of test strips we saw was what they were using and the test strips were indicating 400 ppm before the maintenance man worked on the machine. She indicated staff should have been using both the bottle of test strips and the other litmus paper. During an interview on [DATE] at 11:35 A.M., the Administrator indicated the flustered kitchen staff had accidentally used the test strips for testing the sanitation of the 3 compartment sink. During an interview on [DATE] at 2:36 P.M., the Kitchen Manager indicated they would have a meeting with kitchen all kitchen staff to go over everything so all staff know which strips to use and where they are kept. At that time, she indicated they test the machine daily but should actually be checking it after each meal. On [DATE] at 10:38 A.M., the following was observed in the kitchen Refrigerator: Mechanical sausage dated ,d+[DATE] (no year) Gravy dated ,d+[DATE] (no year) Gallon of dill pickles opened ,d+[DATE] (no year) Pear sauce dated ,d+[DATE] (no year) 4 packs of sliced cheese in plastic wrap each dated ,d+[DATE] (no year) During an interview on [DATE] at 10:50 A.M., the Dietary Manager indicated when food is taken out of original package, a label with the date (month/day/year) should be written on it to indicate when opened, the other date is when it expired. They put that days date on it and count that day for day 1 and keep for 3 days. At that time, she indicated she tried to look at the food in the refrigerator for outdated items when she got there in the mornings. During an interview on [DATE] at 11:30 A.M., the Dishwasher Maintenance Man indicated he didn't really look at the logs but would check the chlorine ppm each time he came which was usually once a month or sooner if needed. At that time, he indicated the bottle of test strips that tested 200 ppm and above would not be appropriate to test the dishwasher because if the chlorine ppm was testing that high, they could have big problems, possibly toxic levels, because it's only expected to be ,d+[DATE] ppm for proper sanitation. During an interview on [DATE] at 11:35 A.M., the Administrator indicated their dishwasher policy didn't specify which test strip staff should use and they would follow the dishwasher manufacturer's guidelines. 38770 2. On [DATE] at 10:08 A.M., the Kitchen Manager was observed to prepare puree meals for lunch. She was observed to wash her hands, did not put on gloves, and walked to the opposite side of the kitchen to look at a recipe binder, touching the papers. She then obtained a container of green beans from the counter, and scooped them into the blender, handing the outside of the blender to operate the machine. After blending, she picked up a spatula from a tray on the counter and used it to scrape the sides of the blender. She then placed the spatula into the original green bean container that still contained whole green beans with the handle sticking out. The spatula then slipped into the container with the green beans. The Kitchen Manager then used the scoop that was in the green bean container to retrieve the spatula, grabbing onto the handle when it came up. She then used that spatula to scrape the pureed green beans from the blender into another container. The spatula was then placed on a tray with other dirty dishes. The container with the whole green beans was then covered and placed into the warmer. On [DATE] at 11:31 A.M., the container that contained the whole green beans was observed on the steamtable. At that time, the Kitchen Manager indicated they were being used as an alternative for the lunch meal, and that a few residents were going to be served the green beans. At 11:49 A.M., the first two trays that were plated were given a scoop of the whole green beans. On [DATE] at 12:04 P.M., the Administrator indicated the container of whole green beans should have been thrown out after the spatula had fallen into it. On [DATE] at 1:37 P.M., a current Bare Hand Contact with Food and the Use of Plastic Gloves policy, dated ,d+[DATE], was provided and indicated Staff appropriately use utensils such as gloves, tongs, deli paper and spatulas to prevent food borne illness A current Food Storage Policy, revised [DATE], was provided on [DATE] at 9:15 A.M., by the Administrator and indicated . foods shall be received and stored in a manner that complies with safe food handling practices . all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to deliver mail to the residents on Saturdays. Two of ten anonymous residents interviewed indicated they failed to get mail every Saturday. Findings include: During an interview with ten resident council members on 9/7/23 at 10:05 A.M., two anonymous residents indicated they did not receive mail on Saturdays. During the meeting, those two anonymous residents were the only ones that were answering questions. During an interview on 9/7/23 at 1:01 P.M., the Activities Director indicated she delivered mail Monday through Friday and was unsure if it should be delivered on Saturdays. During an interview on 9/7/23 at 1:23 P.M., the Activities Director indicated Activities Assistant 27 delivered the mail on Saturdays. During an interview on 9/7/23 at 1:34 P.M., Activities Assistant 27 indicated she had not delivered mail on Saturdays and was unsure if it should be delivered on Saturdays. During an interview on 9/8/23 at 10:31 A.M., the Administrator indicated the facility's policy was to deliver mail every day it was received, including Saturdays. 3.1-3(s)(1)

Based on observation, interview, and record review, the facility failed to ensure MDS (Minimum Data Set) Assessments were accurate for 1 of 5 residents reviewed for unnecessary medications, and 1 of 1 resident reviewed for dialysis. (Resident 48, Resident 7) Findings include: 1. On 9/6/23 at 1:13 P.M., Resident 48's clinical record was reviewed. Diagnosis included, but were not limited to, psychotic disorder with delusions, dementia, and autistic disorder. The most recent quarterly MDS, dated [DATE], indicated a moderate cognitive impairment, and a requirement of supervision with setup for ADLs (activities of daily living). The MDS indicated Resident 48 had received at least one antipsychotic medication 7 of 7 days during the look back assessment period. The MDS also indicated a GDR (gradual dose reduction) was not done because an antipsychotic medication had not been administered. Current physician orders included, but were not limited to: Risperdal (an antipsychotic medication) give 2 mg (milligrams) twice a day related to psychotic disorder with delusions, dated 6/7/23. Resident 48's MAR (Medication Administration Record) for the months of July 2023 and August 2023 indicated an antipsychotic medication had been administered from 7/28/23 through 8/3/23. On 9/8/23 at 9:42 A.M., the MDS Coordinator indicated Resident 48's MDS should not have been marked that an antipsychotic medication had not been received, and was entered in error. 45933 2. On 9/7/23 at 10:43 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease, renal insufficiency, and renal failure. The most recent admission MDS, dated [DATE], indicated Resident 7 was not on dialysis. Current Physician's Orders included, but was not limited to, dialysis on Monday, Wednesday, and Friday, dated 6/26/23. During an interview on 9/8/23 at 9:43 A.M., the MDS Coordinator indicated Resident 7's admission MDS assessment should have indicated she received dialysis. On 9/8/23 at 9:42 A.M., the MDS Coordinator indicated there was not a policy for entering MDS information, but that the RAI (resident assessment indicator) manual was used in place of a policy for entering resident information. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure that appropriate treatment and services were provided for a resident that resulted in multiple urinary tract infections (UTI) and two UTI related hospitalization s for 1 of 1 residents reviewed for hospitalization s. Physician's orders were not followed and follow up with the urologist was not scheduled. (Resident 4) Finding includes: On 9/7/23 at 10:27 A.M., Certified Nurse Aide (CNA) 7 and Licensed Practical Nurse (LPN) 3 performed suprapubic catheter care on Resident. Resident 4 was observed lying in bed with a suprapubic catheter and the urinary catheter bag, dated 9/6/23, with 200 cubic centimeters (cc) of clear, yellow urine hanging on the right side of the bed. On 9/7/23 at 9:58 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, schizophrenia, Benign Prostatic hyperplasia with lower urinary tract symptoms, End Stage Renal Disease (ESRD), dementia, personal history of UTIs, and obstructive and reflux uropathy. The most recent Annual Minimum Data Set (MDS) Assessment, dated 7/28/23, indicated Resident 4 was cognitively intact, had a catheter, on an anticoagulant (blood thinner), was an extensive assist of 2 staff for bed mobility, transfer, and toileting, totally dependent on staff for bathing, and frequently incontinent of bowel movements. Current Physician's Orders included, but were not limited to the following: Empty and chart Foley bag every 2 hours and as needed, dated 3/13/23 cleanse suprapubic catheter site with Normal Saline Solution (NSS) and apply dry dressing every night shift for infection control and hygiene, dated 2/6/23 check catheter function every shift, dated 2/4/23 check catheter site for any redness, pain, swelling, or any discharge. Wash site daily with mild soap and water, gently pat and dry. Apply gauze around the site as needed. Keep catheter bag below the waist and tubing un-kinked every shift, dated 2/3/23 may utilize in-house urine testing strips for any signs or symptoms of a UTI, dated, 8/26/23 Ertapenem Sodium (antibiotic) Solution reconstituted with 100 milliliters (mL) of normal saline, 1 gram intravenously over 1 hour every 24 hours for infection for 13 days, dated 9/7/23 Supra-pubic catheter care after each bowel movement, dated 9/8/23 A current Suprapubic Catheter Care Plan, dated 3/24/23, included, but was not limited to, the following interventions: monitor and document intake and output as per facility policy, initiated 3/24/23 check tubing for kinks each shift, initiated 3/24/22 catheter care every shift, initiated 1/9/23 observe for, document, and report to Medical Doctor (MD): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and/or change in eating patterns, initiated 3/24/22 A current increased risk for bleeding Care Plan, dated 1/10/19 included, but was not limited to the following intervention: labs as ordered, initiated 4/26/22 A urology visit note, dated 3/1/23, indicated Resident 4 had a suprapubic catheter placed on 2/3/23 after he had developed traumatic hypospadias from repeatedly removing his catheter. [Doctor's name] consulted as tube was difficult to remove. He was able to remove it without incident. We'll change next months. Follow up in about 4 weeks. Resident 4 had the following documented infections since 3/1/23: 1. On 5/2/23 a urine culture result revealed > 100,000 CFU (colony forming units) E. Coli (the bacteria Escherichia coli usually found in stool) and > 100,000 CFU Morganella morganii. Resident 4 was hospitalized from 5/5/23 to 5/8/23. 2. On 6/15/23 a urine culture result revealed > 100,000 CFU Pseudomonas putida and > 100,000 CFU Enterococcus species. 3. On 6/19/23 a urine culture result revealed > 100,000 Citrobacter freundii. 4. On 6/27/23 a C. Diff (clotridoides difficile, a bacteria that causes diarrhea and could be linked to antibiotic use) result was positive. 5. On 9/2/23 a urine culture result revealed > 100,000 CFU E. coli and > 100,000 CFU Klebsiella oxytoca. 6. On 9/4/23 a urine culture result revealed > 35,000 CFU E. coli. Resident 4 was hospitalized from 9/4/23 to 9/7/23. hospitalization #1: A progress note on 3/18/23 at 9:55 A.M., indicated Resident 4 had red tinged urine in catheter bag, assessed, bloody discharge from stoma noted; cleaned, split dressing applied; catheter bag changed, urine clear yellow; no c/o [complaints of] discomfort or pain. A progress note, dated 3/30/23 at 3:58 P.M., indicated N.O. [new order] received from [nurse practitioner's name] CBC [complete blood count] d/t [due to] pink color in urine, and push fluids. A nurse practitioner note, dated 4/27/23, indicated nursing states the resident has increased anxiety and confusion. I ordered labs and a UA [urinalysis] with culture if indicated. A progress note, dated 5/2/23 at 9:19 A.M., indicated I reviewed the following labs: Lactic acid (2.3-high), CBC w/diff [with differential] (WBC [white blood cells]- only 8.0- WNL [within normal limits]), CMP [comprehensive metabolic profile], uric acid (WNL). Awaiting UA and UA culture. I will continue to monitor. A progress note on 5/4/23 at 1:24 P.M., indicated I reviewed the following lab: UA (Large leukocytes, + nitrates). Resident is symptomatic and lethargic from UTI. I ordered and gave an IM [intramuscular] injection into right buttocks. I stayed at bedside for an additional 45 minutes monitoring for any reactions. I placed a subcutaneous needle into the RLQ [right lower quadrant] to transfuse one liter of normal saline x [for] 1 liter, so I can hydrate and flush out the resident's kidneys. I replaced the suprapubic catheter. 1,100 ml of dark yellowish urine came out of the new catheter. Catheter was clamped for 15 minutes. Catheter was unclamped after the 15 minutes and additional 250 ml of dark yellowish urine with sediment came out of new catheter. I ordered Rocephin [an antibiotic] 1 gram IM x 3 days, Keflex 500 mg [milligram] PO [by mouth] TID [three times a day] x 7 days after Rocephin is completed and to monitor the suprapubic catheter close for obstruction. Resident states he feels so much better. Vitals signs are stable. Resident is stable at this time. I will continue to monitor close. A progress note on 5/5/2023 at 1:07 P.M., indicated Res [resident] completed IV [intravenous] fluids, res states, 'I don't feel good' NP [nurse practitioner] notified of res statement, no new orders given at this time. Res remains on ATB [antibiotic], will continue to monitor. A progress note on 5/5/23 at 4:05 P.M., indicated Upon getting resident up for supper CNA asked this nurse to come to room and assess resident for a fever. This nurse notes resident's temp is 102.0 and resident noted to be shivering. B/P [blood pressure] noted at 193/117, Pulse 107, Respirations 19, O2 Sat [oxygen saturation] noted to be 91% on room air. Urine output is noted to be dark, with lots of sediment present in tubing and bag. NP notified and verbal order obtained to send resident to [hospital name] ER [emergency room ] for further eval [evaluation] and tx [treatment]. EMS [emergency medical services] telephoned. Resident notified of order rec'd [received]. Resident's Guardian notified and verbalizes understanding. Report called to ER [nurse name] at [hospital name]. The Treatment Administration Record (TAR) for 4/22/23 through 5/5/23 were reviewed for urinary output every two hours and indicated the following were recorded as cc's: 4/22/23 4:00 A.M. NA (non-applicable) 4/22/23 10:00 A.M. NA 4/22/23 2:00 P.M. NA 4/22/23 6:00 P.M. NA 4/22/23 10:00 P.M. NA 4/23/23 12:00 A.M. NA 4/23/23 2:00 A.M. NA 4/23/23 4:00 A.M. NA 4/23/23 10:00 A.M. NA 4/23/23 12:00 P.M. NA 4/23/23 4:00 P.M. NA 4/24/23 4:00 P.M. was blank 4/26/23 2:00 P.M. was blank 4/26/23 4:00 P.M. was blank 4/27/23 8:00 A.M. 0 4/27/23 10:00 A.M. 0 4/27/23 12:00 P.M. 0 4/27/23 4:00 P.M. 0 4/27/23 6:00 P.M. 0 4/27/23 10:00 P.M. 0 4/28/23 10:00 A.M. 0 4/28/23 12:00 P.M. 0 4/29/23 12:00 A.M. NA 4/29/23 2:00 A.M. NA 4/29/23 4:00 A.M. NA 4/29/23 8:00 A.M. 0 4/29/23 10:00 A.M. 0 4/29/23 2:00 P.M. 0 4/29/23 10:00 P.M. NA 4/30/23 12:00 A.M. NA 4/30/23 2:00 A.M. NA 4/30/23 4:00 A.M. NA 5/3/23 6:00 P.M. 0 5/3/23 8:00 P.M. 0 5/3/23 10:00 P.M. 0 5/4/23 12:00 A.M. 0 5/4/23 2:00 A.M. 0 5/4/23 4:00 A.M. 0 5/4/23 6:00 A.M. 0 5/4/23 8:00 A.M. 0 5/4/23 12:00 P.M. 0 5/4/23 4:00 P.M. 0 5/5/23 8:00 A.M. was blank 5/5/23 10:00 A.M. was blank 5/5/23 12:00 P.M. was blank 5/5/23 2:00 P.M. was blank Hospital records, dated 5/5/23, provided by the Administrator on 9/11/23 at 10:30 A.M., indicated . in the ED [Emergency Department], patient was febrile and tachycardic . patient met sepsis criteria [a life-threatening complication of an infection] . source likely UTI due to indwelling urethral catheter . lab results from 5/2/23 revealed urine with large leukocytes, positive nitrates, > [greater than] 100 wbc's [white blood cells]. Urine culture revealed > 100,000 CFU [colony forming units] E. Coli [the bacteria Escherichia coli usually found in stool] and > 100,000 CFU Morganella morganii . E. coli was multi-drug resistance reflective of ESBL [Extended Spectrum Beta-Lactamase enzymes produced by some bacteria that may make them resistant to some antibiotics .production is associated with bacteria usually found in the bowel] E. Coli . blood cultures were also positive 2 of 2 for E. coli . the patient was started on IV [intravenous] Zosyn [an antibiotic] . received aggressive IV hydration on admission . prior to discharge he was transitioned to ertapenem once daily to complete a course of 14 doses. He will have repeat labs prior to his follow-up with his accepting physician [doctor's name]. The clinical record lacked a CBC lab result from the 3/30/23 order. During an interview on 9/8/23 at 9:52 A.M., the Administrator indicated no order was put in for that cbc so it was not completed. During an interview on 9/8/23 at 10:00 A.M., the Director of Nursing (DON) indicated that she was not sure why the urine specimen was not collected after being ordered on 4/27/23 because they would just collect it from the catheter. She was not sure why it was not collected until 5/2/23 at 10:00 P.M. She indicated the blanks and N/A documented in the TAR were because staff would sometimes document total urine output on the TAR for their shift instead of marking down every two hours as ordered. hospitalization #2: A progress note on 9/2/23 at 12:42 P.M., indicated Resident noted to be very lethargic and weak during lunch this shift. Resident also noted to have poor PO [by mouth] intake as well. Upon assessment this nurse notes resident to have turbid urine in catheter bag and tubing. NP notified regarding resident's COC [change of condition], awaiting orders at this time. A progress note on 9/2/23 at 12:52 P.M., indicated N.O's [new orders] rec'd [received] to start IV NS [normal saline] at 75 [sic] for entire liter. Obtain UA with C&S [culture and sensitivity] if indicated, CBC/CMP/Lactic Acid STAT [immediately] . Start IV Rocephin [an antibiotic] 2 gm [grams] daily x 7 days . Monitor Resident for further S/S [signs/symptoms] of infection . A progress note on 9/3/23 at 3:32 P.M., indicated THIS NURSE NOTES THAT RESIDENT IS SITTING IN HALLWAY AND IS SLUMPED OVER IN W/C [wheelchair] TO THE RIGHT SIDE AND FORWARD . AWAITING ORDERS AT THIS TIME. A progress note on 9/4/2023 at 2:26 P.M., indicated . 400 mL [milliliter] dark yellow urine emptied from catheter bag within eight hours. [nurse practitioner] notified, received new order to send to [hospital name] ER for eval and tx. EMS here at 1435 [2:35 P.M.] to transfer resident . The Treatment Administration Record (TAR) for 8/20/23 through 9/4/23 were reviewed for urinary output every two hours and indicated the following were recorded as cc's: 8/20/23 12:00 A.M. 0 8/20/23 2:00 A.M. 0 8/20/23 8:00 A.M. was blank 8/20/23 10:00 A.M. was blank 8/20/23 12:00 P.M. was blank 8/20/23 2:00 P.M. was blank 8/20/23 4:00 P.M. was blank 8/21/23 12:00 P.M. 0 8/21/23 8:00 P.M. 0 8/22/23 12:00 A.M. 0 8/22/23 4:00 A.M. 0 8/22/23 12:00 P.M. 0 8/22/23 2:00 P.M. 0 8/23/23 2:00 P.M. 0 8/23/23 8:00 P.M. NA 8/23/23 10:00 P.M. NA 8/24/23 12:00 A.M. NA 8/24/23 2:00 A.M. NA 8/24/23 4:00 A.M. NA 8/24/23 8:00 A.M. was blank 8/24/23 10:00 A.M. was blank 8/24/23 12:00 P.M. was blank 8/24/23 2:00 P.M. was blank 8/24/23 4:00 P.M. was blank 8/24/23 6:00 P.M. NA 8/24/23 8:00 P.M. NA 8/24/23 10:00 P.M. NA 8/25/23 12:00 A.M. NA 8/25/23 2:00 A.M. NA 8/25/23 4:00 A.M. NA 8/25/23 8:00 A.M. was blank 8/25/23 10:00 A.M. was blank 8/25/23 12:00 P.M. was blank 8/25/23 2:00 P.M. was blank 8/25/23 4:00 P.M. was blank 8/25/23 6:00 P.M. 0 8/25/23 8:00 P.M. 0 8/26/23 12:00 A.M. 0 8/26/23 2:00 A.M. 0 8/26/23 6:00 A.M. 0 8/26/23 8:00 P.M. 0 8/26/23 10:00 P.M. 0 8/27/23 12:00 A.M. 0 8/27/23 2:00 A.M. 0 8/27/23 4:00 A.M. 0 8/29/23 8:00 P.M. 0 8/29/23 10:00 P.M. NA 8/30/23 12:00 A.M. NA 8/30/23 2:00 A.M. NA 8/30/23 4:00 A.M. NA 8/31/23 12:00 A.M. NA 8/31/23 2:00 A.M. NA 8/31/23 4:00 A.M. NA 8/31/23 8:00 A.M. was blank 8/31/23 10:00 A.M. was blank 8/31/23 12:00 P.M. was blank 8/31/23 2:00 P.M. was blank 8/31/23 4:00 P.M. was blank 8/31/23 8:00 P.M. NA 8/31/23 10:00 P.M. NA 9/1/23 12:00 A.M. NA 9/1/23 2:00 A.M. NA 9/1/23 4:00 A.M. NA 9/1/23 8:00 A.M. was blank 9/1/23 10:00 A.M. was blank 9/1/23 12:00 P.M. was blank 9/1/23 2:00 P.M. was blank 9/1/23 4:00 P.M. was blank 9/1/23 6:00 P.M. 0 9/1/23 8:00 P.M. 0 9/1/23 10:00 P.M. 0 9/2/23 12:00 A.M. 0 9/2/23 4:00 A.M. 0 9/2/23 8:00 A.M. was blank 9/2/23 10:00 A.M. was blank 9/2/23 12:00 P.M. was blank 9/2/23 2:00 P.M. was blank 9/2/23 4:00 P.M. was blank 9/2/23 6:00 P.M. 0 9/2/23 8:00 P.M. 0 9/2/23 10:00 P.M. 0 9/3/23 12:00 A.M. 0 9/3/23 2:00 A.M. 0 9/3/23 4:00 A.M. 0 9/3/23 8:00 A.M. was blank 9/3/23 10:00 A.M. was blank 9/3/23 12:00 P.M. was blank 9/3/23 2:00 P.M. was blank 9/3/23 4:00 P.M. was blank Hospital records, dated 9/4/23, provided by the Administrator on 9/11/23 at 10:30 A.M., indicated . presented to ER from [name of facility] . due to poor oral intake, possible altered mental status, with history of Gram-negative bacteremia and frequent UTIs with indwelling suprapubic catheter . during admission, 2 of 2 blood cultures resulted positive .urine culture from ER grew E. coli and Klebsiella, E. coli isolated ESBL . urinary tract infection associated with indwelling urethral catheter . Patient's antibiotics were changed to ertapenem (an antibiotic) and patient will complete a 14 day course of antibiotics at the nursing home . suprapubic catheter was replaced . An MD progress note, dated 9/8/23 at 12:06 P.M., indicated . I was asked to evaluate the patient for recurrent urinary tract infections . patient had a suprapubic catheter done by [doctor's name] for hypospadias due to pressure necrosis from chronic indwelling catheter which has been placed because of urinary retention but unfortunately the patient did not have a follow-up with urologist nor the [sic] urologist recommended [sic] any follow-up after the procedure from February . patient has multiple rounds of urinary tract infections . based on my evaluation i feel that the patient would best benefit from a broad-spectrum coverage [sic] like Macrobid 100 mg daily as prophylaxis we could give him prophylaxis for a month to see if it would change his outcome and based on that we can continue that change it or discontinue . I have also recommended the staff to make a follow-up appointment with urologist . Interview on 9/8/23 at 10:05 A.M., the DON indicated they discovered a problem with the lab process in place and made revisions to it in June. Interview on 9/11/23 at 9:38 A.M., Qualified Medication Aide (QMA) 21 indicated the nurses change out the catheter bag and tubing. When she emptied the urine catheter bag, she looked at the urine to observe for clarity. She indicated if Resident 4 doesn't feel good, he would usually stop talking and lean to the side. Interview on 9/11/23 at 9:51 A.M., LPN 3 indicated Resident 4 was more cognitive than others. She monitored his eating, urine output, urine color, and resident's speech. On her shift, she would monitor his catheter site and watch for abdominal pain or distention. Interview on 9/11/23 at 10:15 A.M., the Administrator indicated the hospital should have seen he's been there multiple times for UTIs and had urology consulted there instead of him just having another hospital stay and then send him back without an antibiotic to complete. She indicated urology hadn't been involved since they put in his catheter and hadn't recommended follow-up. At that time, she indicated the doctor had been in to evaluate the resident, put him on a prophylactic antibiotic, and ordered a urology follow up. Interview on 9/11/23 at 10:30 A.M., the Administrator indicated there wasn't a policy for UTIs, but they use McGreer's criteria for antibiotic usage. An undated current undated Antibiotic Stewardship Policy was provided by the Infection Preventionist on 9/11/23 at 10:11 A.M., and indicated Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship . An undated Suprapubic Catheter Care Policy was provided by the DON on 9/11/23 at 10:24 A.M., and indicated, The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract . General Guidelines 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly . 3. Check the urine for unusual appearance (i.e., color, blood, etc) 5. Check the resident frequently to be sure the tubing is free of kinks . 8. Observe the resident for signs and symptoms of urinary tract infection and urinary retention . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure that a class II controlled substance was stored using acceptable professional practices for 1 of 1 residents reviewed for unlocked drugs. A resident's liquid narcotic pain medication was left in his room and not stored in a double lock box. (Resident 40) Finding includes: On 9/5/23 at 12:17 P.M., Resident 40 was observed in his bed asleep with a bottle of oxycodone hcl 100 mg/5 ml in a box with 2 syringes on a bedside table by the window. On 9/6/23 at 11:23 A.M., Resident 40's clinical record was reviewed. Diagnoses included, dementia with behavioral disturbance and low back pain. The most recent Admission MDS (Minimum Data Set) Assessment, dated 8/14/23, indicated Resident 40 was moderately cognitively impaired, required extensive assist of 2 staff with bed mobility and toileting, and totally dependent on 2 staff for transfers. Current Physician's orders included, but were not limited to, Oxycodone oral concentrate (pain medication)100 mg (milligram)/5 mL (milliliter), give 0.5 mL by mouth four times a day for pain and every 15 minutes as needed for pain , dated 8/15/23 A current Pain Care Plan, dated 8/7/23, included, but was not limited to, the following interventions: Provide pain medication as ordered, initiated 8/7/23 During an interview on 9/5/23 at 12:57 P.M., QMA (Qualified Medication Aide) 21 indicated the nurse gave narcotic pain medication. She indicated the aides should not have any access to it. During an interview on 9/5/23 at 12:30 P.M., LPN (Licensed Practical Nurse) 25 indicated she passed medications around 12:00 P.M. to Resident 40. She indicated it was during that medication pass that she left the bottle of oxycodone in the resident's room. She indicated that oxycodone was a narcotic and should be kept in the locked narcotic drawer of the locked medication cart. A current Controlled Medication Storage Policy, dated 5/21/18, was provided by the Administrator on 9/7/23 at 8:57 A.M., and indicated . Only authorized licensed nursing and pharmacy personnel have access to controlled medications . Store all controlled substances and other medication (s) subject to abuse in a locked/secure cabinet or drawer, separate from all other mediation(s) [sic] . Schedule II controlled medication(s) are maintained within a separately locked, permanently affixed compartment . 3.1-45(a)(1)

Based on observation and interview, the facility failed to ensure infection control practices were in place for 3 of 4 residents observed during care. Staff failed to change gloves between dirty to clean tasks. (Resident 4, Resident 8, Resident 19) Findings include: 1. During an observation on 9/7/23 at 10:27 A.M., CNA (Certified Nurse Aide) 7 and LPN (Licensed Practical Nurse) 3 performed catheter care on Resident 4. CNA 7 donned gloves and removed the catheter bag from the right side of the bed and placed the catheter bag in a clean bag. CNA 7 used her gloved left hand to lower the bed, moved the bed away from the wall using both gloved hands, and then used her left gloved hand and raised the bed back up. CNA 7 failed to remove her gloves at that time and continued to remove Resident 4's brief. At that time, she grabbed a wet washcloth from the basin and rubbed soap into the wash cloth with her left gloved hand. CNA 7 used the washcloth and cleaned around the opening of Resident 4's stoma. CNA 7 grabbed another wash cloth and rubbed soap on it with her gloved left hand and then cleaned the catheter tubing while holding it in place at the stoma with her gloved left hand. CNA 7 used another wet wash cloth and rinsed the area and then used a dry wash cloth to pat the area dry. LPN 3 placed gauze over the stoma and CNA 7 grabbed the tape and held it for LPN 3 with the same gloves. CNA 7 pulled Resident 4's brief up and fastened it, pulled his shirt back down, pulled up his pants, and placed his call light in reach. At that time she used the same gloved hand and hung the catheter on the right side of the bed, gathered trash, and removed her gloves. CNA 7 lowered the bed back down and pushed it back against the wall. CNA 7 failed to change gloves and perform hand hygiene between dirty and clean tasks. During an interview on 9/8/23 at 2:20 P.M., the DON (Director of Nursing) indicated dirty gloves should not be worn when catheter care was performed. 46882 2. On 9/07/23 at 8:58 A.M., Resident 19's most recent quarterly MDS (Minimum Data Set) Assessment, dated 6/26/23, indicated cognition status was unable to be assessed, extensive assistance of 2 was needed for bed mobility and transfers, total dependence of two was needed for toilet use and bathing. On 9/8/23 at 8:26 A.M., CNA (Certified Nurse Aide) 7 pushed Resident 19's wheelchair into his room so he could go to bed for a nap. CNA 7 and CNA 9 washed their hands in the sink then put gloves on. CNA 7 removed the blanket from Resident 19's lap, behind his back and under his feet and placed them in a chair. CNA 7 pushed the lift over to Resident 19's wheelchair. CNA 9 attached the lift pad to the lift. CNA 7 raised the resident from the wheelchair and steered the lift toward the bed while CNA 9 guided the resident to the middle of the bed. CNA 7 lowered Resident 19 to the bed. Both CNA 7 and CNA 9 unhooked the lift pad from the lift. CNA 7 moved the lift away from the bed. CNA 9 placed a clean trash bag on the end of the bed. CNA 7 assisted Resident 19 to turn to the right side while CNA 9 pushed the lift pad under the resident. CNA 9 assisted the resident to turn to the left side and CNA 7 removed the lift pad from the bed. The CNAs did not change gloves. Resident 19 was turned to his back, the brief was unfastened and CNA 9 assisted the resident to turn to the left. CNA 7 cleaned Resident 19's backside with multiple wipes and threw them in the trash can beside the bed, removed the soiled brief and put it in the trash can. CNA 7 placed a clean brief under Resident 19 and assisted him to turn to the right side. CNA 9 pulled the brief through and assisted him to turn to his back. CNA 7 cleaned the front of the resident with multiple wipes and threw them in the trash can. She did not change gloves when going from the back side of the resident to the front side of the resident. CNA 7 pulled the brief up between Resident 19's legs and fastened brief. Using the lift sheet under the resident, CNA 7 and CNA 9 pulled him up in bed. CNA 7 removed her gloves ad threw them in the trash bag. CNA 9 covered Resident 19 up with blankets, unlocked the bed and pushed it against the wall and locked the wheels. CNA 9 removed her gloves, put them in the trash bag, removed trash bag from trash can, tied bag, placed a clean trash bag inside the trash can. CNA 7 raised the head of the bed, lowered the bed, and gave the call light to the resident. CNA 9 washed her hands in the sink in the bathroom. CNA 7 washed her hands in the sink. CNA 9 took the tied trash bag and lift out of the room. 45933 3. On 9/8/23 at 8:51 A.M., CNA 7 and CNA 9 were observed to perform incontinence care for Resident 8. After CNA 7 donned (put on) gloves, she touched the television to turn the volume down, removed the blankets, removed Resident 8's brief, helped roll Resident 8 to her right side and then removed the brief and incontinence pad. CNA 7 then placed a clean incontinence pad under the resident, placed both gloved hands on the resident to help her roll to the other side. CNA 7 then pulled the pillow under the resident's head wearing the same gloves. CNA 7 failed to change gloves during care or dirty to clean tasks. During an interview on 9/08/23 at 9:01 A.M., the ADON (Assistant Director of Nursing) indicated gloves should be changed between the care of residents, if they become soiled or torn. Gloves should also be changed if care was done to the back side of a resident before care was done to the front side. During an interview on 9/8/23 at 9:37 A.M., the Infection Preventionist indicated handwashing should be performed for 30 seconds if items are touched with gloved hands before care was performed for residents, and gloves should be changed between dirty and clean tasks during care. He further indicated it was the facility's policy to change gloves when they were soiled as well as if items are touched while performing incontinence or catheter care. 3.1-18(l)

Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for sliding scale insulin. A resident did not receive sliding scale insulin when it was indicated by the acucheck. (Resident 27) Findings include: On 9/7/23 at 11:06 A.M., Resident 27's clinical records were reviewed. She was admitted on [DATE]. Diagnosis included but were not limited to, Type II diabetes mellitus without complications, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The current annual MDS (Minimum Data Set) Assessment, dated 6/27/23, indicated Resident 27 was cognitively intact, needed extensive assistance of two for bed mobility, transfers, toilet use, and total dependence of one for bathing. She had no behaviors or mood issues. She received insulin for 7 of 7 days during the look back period. Physician orders included, but not limited to the following: Insulin lispro solution 100 UNIT/ML Inject 5 unit subcutaneously four times a day related to Type II diabetes mellitus without complications (E11.9), dated 4/21/21 HumaLOG Solution 100 UNIT/ML (Insulin lispro) Inject as per sliding scale: if 71 - 150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously three times a day related to Type II diabetes mellitus without complications (E11.9), dated 4/28/2021 Review of the MAR (Medication Administration Record) during the look back period from 6/21/23 to 6/27/23, indicated on 6/23/23 at 8:00 A.M. Resident 27's blood sugar was 188. The MAR was marked 28-no insulin required. The physician order for sliding scale insulin indicated a blood sugar of 151-200=2 units of Humalog (insulin lispro). The blood sugar on 6/22/23 at 5:00 P.M. was 141. The MAR was marked 28-no insulin required. The blood sugar on 6/23/23 at 12:00 P.M. was 229. 4 units of Humalog was given. No documentation of refusal by the resident during the look back dates from 6/21/23 through 6/27/23. During an interview on 9/8/23 at 2:33 P.M., the Administrator indicated Resident 27 refuses accuchecks and medications at times. Review of the Nurse's Notes on 6/23/23 lacked documentation of the resident refusing her medication at 8:00 A.M. During an interview on 9/11/23 at 9:51 A.M., LPN 3 indicated she told residents their BS (blood sugar) when she did an accucheck. If a resident refused insulin it had to be documented in the record, marked on the MAR and the provider notified. If the resident didn't require sliding scale insulin, she only monitored them for symptoms of hypoglycemia. LPN 3 indicated no other assessment was done at that time. She indicated she talked to the residents about hypo and hyperglycemia signs and symptoms and told them to notify the staff if they felt like their sugar was too low so an accucheck could be done and snacks were always available if a sugar got too low. During an interview on 9/11/23 at 9:40 A.M., Resident 27 indicated she does not know the signs and symptoms of hypo or hyperglycemia (low or high blood sugar). No one had ever told me what they were. She indicated they did tell her and show her what her blood sugar was when they do an accucheck. During an interview on 9/11/23 at 9:59 A.M., LPN 5 indicated, while looking at the June 23rd MAR, with a blood sugar of 188 and the sliding scale orders listed, the resident should have been given 2 units of insulin. On 9/8/23 at 9:42 A.M., an undated Medication Administration policy provided by the Administrator, indicated The nurse and /or QMA (Qualified Medication Aide) shall administer all medications in accordance with the physician's orders . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and sanitary environment was maintained in 2 of 2 resident halls, 1 of 2 dining rooms and 7 of 10 resident rooms. Floors were sticky, handrails were missing or loose, doorframes had missing paint, bathrooms and sinks were dirty, and debris was on resident room floors. (Room 13, Room 9, First Floor Hall, Second Floor Hall, Room 35, Second Floor Shower Room, Room 33, Room 23, Room 25, Room 29, Second Floor Dining Room) Findings include: 1. On 5/19/22 at 9:25 A.M., Room 13's bathroom was observed with the drywall cracked and coming loose around the vent in the ceiling. On 5/19/22 at 2:27 P.M., the same was observed. 2. On 5/19/22 at 9:30 A.M., Room 9 was observed with food debris, wrappers, and trash on the floor. The bathroom floor was sticky with trash on the floor and the floor was observed with a dark substance around the base of the toilet and around the bottom of the baseboards. The sink was observed with brown spots. On 5/19/22 at 2:27 P.M., the same was observed. 3. On 5/19/22 at 9:33 A.M., the following was observed in the halls: The First Floor Hall was sticky with debris. The Second Floor Hall was sticky with debris. The handrails on the first floor and second floor were sticky. The handrail by Room 4, Room 27, and Room 42 were loose. The handrail was missing by Room 28 and Room 33. On 5/19/22 at 2:27 P.M., the same was observed. 4. On 5/19/22 at 9:42 A.M., Room 35 was observed with debris on the floor. On 5/19/22 at 2:27 P.M., the same was observed. 5. On 5/19/22 at 9:44 A.M., the vent above the second floor shower room was observed with a thick layer of dirt and dust in the openings. On 5/19/22 at 2:27 P.M., the same was observed. 6. On 5/19/22 at 9:50 A.M., Room 33's bathroom was observed with an uncovered bedpan sitting on the toilet seat with yellow spots on the toilet seat. No toilet paper holder was observed and a roll of toilet paper was observed sitting on the back of the toilet. The bathroom floor was observed with a dark substance around the base of the toilet and around the bottom of the baseboards. A bedside commode was observed in the room with a brown substance in the bottom of the bucket. A fan was observed on the resident's bedside table with a thick layer of dust and dirt in the openings on the front. On 5/19/22 at 2:27 P.M., the same was observed. 7. On 5/19/22 at 10:13 A.M., Room 23's bathroom was observed with a missing cord coming from the call light and paint was missing from around the doorframe. The resident's room was observed with debris on the floor. On 5/19/22 at 2:27 P.M., the same was observed. 8. On 5/19/22 at 10:15 A.M., Room 25's bathroom was observed with a missing cord coming from the call light and an uncovered cracked bedpan sitting on the toilet seat. On 5/19/22 at 2:27 P.M., the same was observed. 9. On 5/19/22 at 12:01 P.M., Room 29 was observed with debris on the floor and under the bed. On 5/19/22 at 2:27 P.M., the same was observed. 10. On 5/19/22 at 12:03 P.M., the entrance to the second floor dining room and the dining room floor were observed to be sticky. On 5/19/22 at 2:27 P.M., the same was observed. During an interview on 5/19/22 at 9:41 A.M., Housekeeper 7 indicated resident rooms were supposed to be swept and mopped daily during day shift. Housekeeper 7 indicated there were currently two (2) housekeeping staff for the entire building. On 5/19/22 at 2:55 P.M., a walk through of the facility was completed with Housekeeper 7 who indicated at that time the Maintenance Supervisor was currently unavailable. Housekeeper 7 indicated they were aware of the sticky floors, had recently changed chemicals, but after using a different product a few times, the floors always got sticky again. Housekeeper 7 indicated they were not aware of the fan in Room 33 or the vent above the shower room and indicated housekeeping staff would need to clean the bathrooms more thoroughly. Housekeeper 7 indicated work orders were initiated through a computer system and by verbal communication as needed. During an interview on 5/19/22 at 3:57 P.M., the Administrator indicated there was not a policy related to maintenance or housekeeping, but that is was the facility's policy to keep rooms clean and in working order. This Federal tag relates to Complaint IN 630. 3.1-19(f)

Based on interview and record review, the facility failed to ensure a resident with an extensive psychiatric history and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was started on [MEDICATION(S)], a medication which was toxic to the kidneys, which resulted in hospitalization for [MEDICATION(S)] toxicity. This affected 1 of 3 residents reviewed with behaviors and [CONDITION(S)] medications. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 9/20/21 at 10:50 A.M. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had been hospitalized from 12/9/20 through 3/11/21 on a psychiatric ward. Hospital discharge information, dated 3/11/21, included: Special Instructions: Please keep all appointments for follow-up .Physician Follow Up Instructions: Outpatient psychiatric follow-up will take place with [name] through [name of hospital counseling center]. Frequent updates will need to be provided to [name of counseling center] as patient will remain on the state hospital waiting list. Will see [name of hospital Nurse Practitioner] on 3/23 @ [name of facility] .Consultant Follow Up Instructions: Follow-up with receiving within one week .Reason for Transfer: Continuing of Care, Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Outpatient Orders: BMP [basic metabolic profile], Date: 03/15/21 Included with the hospital discharge information was a typed document, labeled with Resident B's name, and undated. The document included: [CONDITION(S)], stage IV (severe) .Increase oral fluids, she may require frequent reminders, Monitor for confusion .Medications not effective or have caused side effects: .[MEDICATION(S)] - kidney failure, toxicity . A Care Plan, dated 3/12/21, indicated, The resident has [CONDITION(S)] r/t [related to] Kidney disease stage 4. The Interventions included: Labs per MD order. Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; seizures. An additional Care Plan, dated 3/16/21, indicated, Ineffective coping r/t anxiety, [CONDITION(S)], history of traumatic event. The Interventions included: Collaborate care with medical providers and psych services as needed. Lab results from 3/15/21 was not found in the clinical record. A psychiatric consult note, dated 3/23/21, was not found in the clinical record. A Nursing Progress Note, dated 4/2/21 at 5:42 P.M., indicated, [Name of consultant psychiatric Nurse Practitioner] here to see resident. New orders received. POA [power of attorney] aware of new orders. Labs included. Will continue to monitor. A Psychiatric Initial Assessment, dated 4/4/21 [sic], included: Primary DX: [CONDITION(S)], current episode mixed, moderate. Secondary Dx: Anxiety disorder .Reason for Referral: [CONDITION(S)], [CONDITION(S)] .Resident was referred to service for psychiatric evaluation and medication management. She has a long history of mental illness .She has had multiple psychiatric hospitalization s .Assessment/Plan: 1. [CONDITION(S)] .Currently has some mixed symptoms .however overall more stable from prior to admission. Medications reviewed .Mainstay of [CONDITION(S)] is a mood stabilizer, unclear why not on at this time .Recommend adding [MEDICATION(S)] 300 mg three times daily and observe response, check level in 1 week .Also need a baseline CBC, BMP, and TSH [lab work]. Revisit resident in 1 week and can hopefully touch base with significant other as well . The psychiatric Nurse Practitioner orders, dated 4/2/21, included, Start [MEDICATION(S)] 300 mg tablet [a mood stabilizer]. Take one tab by mouth three times daily ([CONDITION(S)]). The order was written on a prescription pad. Documentation that the primary physician was notified of the new medication orders at that time was not found in the clinical record. Nursing Progress Notes included: 4/2/21 at 5:51 P.M.: physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Has triggered the following drug protocol alerts/warning(s) .The systems has identified a possible drug interaction with the following orders .[MEDICATION(S)] 1 mg [an anti-psychotic medication] .Interaction: The combination of [MEDICATION(S)] [MEDICATION(S)] Capsule 300 mg and [MEDICATION(S)] tablet 1 mg may produce adverse effects including confusion, elevated white blood cell count, and elevated creatinine phosphokinase. Documentation that the primary physician was notified at that time of the potential interaction of the medications was not found in the clinical record. The resident's first dose of [MEDICATION(S)] was given on 4/3/21. The resident had lab work, including a BMP, on 4/5/21. The results included the following indicators of kidney function: BUN 42 (high, normal 7-17), Creatinine 2.66 (high, normal .52-1.04), and GFR - 18 (Stage 4 - 15-29). Nursing Progress Notes continued: 4/5/21 at 12:46 P.M.: Resident received lab work this am by [name] lab. Results received and sent to MD. Documentation that the prescribing psychiatric Nurse Practitioner was notified of the lab results was not found in the clinical record. 4/6/21 at 4:13 P.M.: Social Services Note .Resident continues to be seen by [consulting psychiatric service] and recent medication changes and counseling have been implemented and resident will continue with counseling weekly A Physician's note, dated 4/8/21, included: Impression/Plan: 1. [CONDITION(S)] with mixed features, 2. [CONDITION(S)], stage IV and listed medication the resident was on. The physician did not list the [MEDICATION(S)]. A typed list of the resident's medications did not include the [MEDICATION(S)]. A psychiatric Nurse Practitioner's note, dated 4/9/21, did not document the lab work from 4/5/21, including the elevated BUN and creatinine. The note did not document the history of [CONDITION(S)]. Nursing Progress Notes continued: 4/12/21 at 10:44 A.M.: [MEDICATION(S)] level drawn this AM, Lab reports critical value of 3.2. MD notified. [Psychiatric service] notified. Will continue to monitor. 4/12/21 at 12:35 P.M.: N/O [new order] received per [Psychiatric service], Hold [MEDICATION(S)] et [and] recheck level in 2 days A Physician's office note, dated 4/12/21 and untimed, indicated, Received a call from [staff name] at [name of facility] stating that res [resident] has a critical [MEDICATION(S)] level of 3.2. I asked who gave the [MEDICATION(S)] [sic] as we don't even have recorded that she is taking this. Nurse states 'I guess [psychiatric service] if it isn't you' .I asked how much [MEDICATION(S)] she was on .I asked for MAR [medication administration record] to be sent over so I can reconcile med list An additional Physician's office noted, dated 4/12/21 and untimed, indicated the physician's office received a call from the facility stating the resident's [MEDICATION(S)] was on hold and a level would be checked in 2 days. The note included: I also called [facility staff] back and advised her to please call [psychiatric service] MD and make sure he is aware that res [resident] kidney function is so poor due to her being on the [MEDICATION(S)] and [MEDICATION(S)] is caustic to the kidneys .I checked her MAR's [medication administrator record] against what you had and I found 3 discrepancies, one being the [MEDICATION(S)] that we didn't know about Nursing Progress Notes continued: 4/13/21 at 2:57 P.M.: Resident continues to be lethargic. Resident is difficult to wake, not eating or drinking. Resident is unable to transfers [sic] without assist. Resident being closely monitored by nursing staff. Will continue to monitor. 4/13/21 at 7:16 P.M.: Resident continues to be lethargic .This nurse informed MD of concern. MD gave new order to send to ER An ambulance report, dated 4/13/21 at 7:32 P.M., included: The nurse on scene told us that .patient was in renal failure and the behavioural [sic] doctor prescribed [MEDICATION(S)] and had been on it for the last week An emergency room physician's note, dated 4/13/21 at 7:52 P.M., indicated, This started several days ago and is still present. The patient is described as having decreased responsiveness .The patient was started on [MEDICATION(S)] recently and patient's significant other is concerned that all of her symptoms are related to this medication .BUN 61, Creatinine 4.79, Progress and Procedures .The patient is found to have chronic [MEDICATION(S)] toxicity .The patient's blood work also shows evidence of acute kidney injury .[Family members] have decided that the patient would want further aggressive treatment including [CONDITION(S)]. Therefore, the patient will be transferred for possible [CONDITION(S)] .Condition: Guarded .Clinical Impression: Acute mental status change, Chronic [MEDICATION(S)] toxicity, Acute kidney injury On 9/20/21 at 2:45 P.M., during an interview with the Director of Nursing (DON), she indicated the resident had been at the local hospital for over 3 months prior to admission, and was awaiting state hospital placement. The facility contracts with an outside psychiatric service to provide counseling and medication management for residents. The local hospital did not come to the facility and provide counseling. She would expect either staff to fax over a new prescription to the primary physician, or to somehow let him know of the new medication being started. The DON indicated the primary physician was in the facility often, and she felt that he probably did know of the [MEDICATION(S)] order, but it was not documented. On 9/21/21 at 9:15 A.M., during an interview with the Administrator, she indicated she thought it would be a professional courtesy to notify the primary physician of the consulting Nurse Practitioner's orders, but that she did not think it was a regulation. On 9/21/21 at 10:00 A.M., Nurse 1 at the primary physician's office was interviewed. Nurse 1 indicated she was one of the primary physician's nurses. She indicated the physician was unaware that Resident B had been started on [MEDICATION(S)] until 4/12/21, when the resident's [MEDICATION(S)] level was critical. Nurse 1 indicated the physician should have been made aware when the order for the [MEDICATION(S)] was given by the consulting psychiatric service. The primary physician required the facility to give him all of the resident's information, and he did not get all of the information. The facility did not fax a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/21/21 at 12:30 P.M., the Administrator indicated she could not find evidence of the lab drawn on 3/15/21, nor documentation that the follow up psychiatric consultation occurred on 3/23/21. The Administrator indicated the psychiatric staff probably just did not come to the facility. This Federal tag relates to Complaint IN 860. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's primary physician was notified of the initiation of a new medication, for 1 of 3 residents reviewed for notification. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 9/20/21 at 10:50 A.M. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses progress note, dated 4/2/21 at 5:42 P.M., indicated, [Name of psychiatric Nurse Practitioner] here to see resident. New orders received. POA [power of attorney] aware of new orders. Labs included. Will continue to monitor. The psychiatric Nurse Practitioner orders, dated 4/2/21, included, Start [MEDICATION(S)] 300 mg tablet [a mood stabilizer]. Take one tab by mouth three times daily ([CONDITION(S)]). Documentation that the primary physician was notified of the new medication orders at that time was not found in the clinical record. A Physician's office note, dated 4/12/21 and untimed, indicated, Received a call from [staff name] at [name of facility] stating that res [resident] has a critical [MEDICATION(S)] level of 3.2. I asked who gave the litium [sic] as we don't even have recorded that she is taking this. Nurse states 'I guess [psychiatric service] if it isn't you' .I asked how much [MEDICATION(S)] she was on .I asked for MAR [medication administration record] to be sent over so I can reconcile med list On 9/20/21 at 2:45 P.M., during an interview with the Director of Nursing (DON), she indicated she would expect either staff to fax over the new prescription to the primary physician, or to somehow let him know of the new medication being started. The DON indicated the primary physician was in the facility often, and she felt that he probably did know of the [MEDICATION(S)] order, but it was not documented. On 9/21/21 at 9:15 A.M., during an interview with the Administrator, she indicated she thought it would be a professional courtesy to notify the primary physician of the consulting Nurse Practitioner's orders, but that she did not think it was a regulation. On 9/21/21 at 10:00 A.M., Nurse 1 at the primary physician's office was interviewed. Nurse 1 indicated she was one of the primary physician's nurses. She indicated the physician was unaware that Resident B had been started on [MEDICATION(S)] until 4/12/21, when the resident's [MEDICATION(S)] level was critical. Nurse 1 indicated the physician should have been made aware when the order for the [MEDICATION(S)] was given by the consulting psychiatric service. The primary physician required the facility to give him all of the resident's information, and he did not get all of the information. The facility did not fax a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/21/21 at 9:50 A.M., the Administrator provided the current facility policy Notification of Change in Resident's Condition or Status, dated 11/28/16. The policy included: The Nurse will notify the Resident's Physician/Physician Assistant/Nurse Practitioner when there has been (including, but not limited to) .A need to alter the Resident's medical treatment significantly . Notification of appropriate individuals will occur in a timely manner. The Nurse will record in the Resident's medical record information .as well as notification of appropriate individuals. This Federal tag relates to Complaint IN 860. 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure that appropriate treatment and services were provided for an incontinent resident with a UTI (urinary tract infection) that resulted in a sharp decline in mental status with increased behaviors for 1 of 1 resident reviewed for UTI. A resident's UTI was not treated in a timely manner, the physician was not notified of a positive urine result, and the resident was incorrectly medicated. (Resident 12) Finding includes: On 7/13/21 at 2:14 P.M., Resident 12 was observed lying in bed with a full food tray on her bedside table. She indicated I can't hear what I'm saying, as well as other nonsensical speech. On 7/14/21 at 9:28 A.M., CNA 5, CNA 2, and RN 6 were observed to provide incontinence care for Resident 12. Before entering the room, RN 6 indicated to CNA 2 that the resident was refusing her food and care. All staff entered the room and put on gloves. RN 6 pulled the front of Resident 12's brief down and wiped her vaginal area front to back. Using the same wipe, she wiped her vaginal area again front to back. Using the same wipe, visibly soiled with a brown substance, she wiped her vaginal area a third time. RN 6 then removed several wipes from the package and laid them down on the bed and the corner of the soiled brief still secured under the resident. Resident 12 was rolled to her right side and the brief she was wearing was visibly saturated with urine to the back absorbency line on the brief. She had also had a bowel movement. At that time, RN 6 indicated Resident 12's shirt was wet, and needed to be changed. After the resident was assisted to the left side and the saturated brief removed, CNA 2 held the soiled brief in her right gloved hand, and the soiled pad that was under the resident in her left gloved hand. The pad had several areas with a brown substance that were being touched by CNA 2's left gloved hand. CNA 2 utilized her right hand, with a soiled brief still in her hand and attempted to obtain a clean wipe from the package. CNA 2 utilized her left hand, with a soiled incontinence pad still in her hand it to anchor the wipe package down to get a wipe out. After obtaining a wipe, CNA 2 disposed of the soiled brief and utilized an incontinence wipe to clean her right glove, which was visibly soiled. CNA 2 disposed of the incontinence wipe. CNA 2 then put the soiled pad in a garbage bag, took off her gloves, and left the room. No hand hygiene was observed. CNA 5 then took the incontinence wipes package, closed the lid, and placed it in the resident's bedside table. CNA 5 and RN 6 were observed to wash their hands before exiting the room. During care, Resident 12 was observed with nonsensical speech and indicated several times she was burning. At that time, RN 6 indicated Resident 12 had a UTI, and she believed she was complaining about burning related to her UTI symptoms. On 7/13/21 at 12:04 P.M., Resident 12's clinical record was reviewed. Resident 12's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimal Data Set) assessment, dated 5/3/21, indicated the resident was cognitively intact, was frequently incontinent of bladder and bowel, and had delusions. The MDS indicated Resident 12 had no behaviors. Resident 12's listed allergies included, but were not limited to, sulfamethaxazole/[MEDICATION(S)], and other sulfa antibiotics. Current care plans included, but were not limited to: ADL (activities of daily living) self-care performance deficit that included the intervention, but was not limited to, staff to assist with toileting as needed, initiated 4/26/21. Incontinent bladder that included the intervention, but was not limited to, observe/report/document to MD (medical doctor) signs and symptoms of UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns, initiated 4/26/21. At risk for bowel incontinence the interventions included, but were not limited to, check resident every two hours ad assist with toileting as needed, and provide peri-care after each incontinent episode, initiated 4/26/21. Allergy to [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]/[MEDICATION(S)], NSAIDs, Sulfa Antibiotics, Gluten, Strawberries, initiated 4/26/21. Resident 12 had the following UTIs: 1. Progress notes on 5/18/21 indicated Resident has history of UTI with increased confusion. UA (urinalysis) C&S (culture and sensitivity) if indicated. Progress notes on 5/19/21 indicated spoke to (MD office), may straight catheter if needed for UA. The TAR (treatment administration record) from 5/2021 indicated the following: UA, C&S if needed one time only for confusion completed on 5/20/21. The TAR lacked any other labs that had been completed at that time. A urinalysis and C&S from 5/21/21 indicated >100 WBC (white blood cells), cloudy appearance, trace blood, and large leukocyte est. The UA indicated a C&S, which was completed on 5/23/21 and indicated organism Proteus mirabilis with a colony count of >100,000 CFU/ML (colony forming units per milliliter) The clinical record lacked notification to the doctor of the urine test results, or any treatment given. 2. On 6/17/21 a urinalysis collected and completed that indicated 10-20 WBC, and large leukocyte est. The UA indicated a C&S, which was completed on 6/19/21 and indicated organism Proteus mirabilis with a colony count of >100,000 CFU/ML (the same organism from the 5/23/21 urine culture and sensitivity). an order for [MEDICAL RECORD OR PHYSICIAN ORDER] &S returned) and ended 6/26/21. Resident 12's allergy list indicated she was allergic to that medication. That medication was administered once on 6/25/21 and once on 6/26/21. On 6/25/21, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/26/21, Resident 12 was given a PRN (as needed) dose of [MEDICATION(S)] (an allergy medication). The clinical record did not indicate why the medication had been given. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] &S returned). On 6/28/21 an MD note from date of service 6/25/21 indicated The patient was recently noted to have some UTI symptoms. A urinalysis was obtained which came back positive. The patient was started on [MEDICATION(S)] .Plan: UTI: continue [MEDICATION(S)] to complete course of treatment . 3. On 7/7/21, a progress note indicated Resident is still crying out in room . Social worker informed the nurse resident was complaining of chest pain and discomfort. Notified MD with new order to send resident to ER for evaluation and treatment . On 7/7/21, a progress note indicated Resident returned from ER. Resident still with noted behaviors. Resident is noted to have UTI with antibiotic ordered . On 7/14/21 at 11:33 A.M., Resident 12's ER visit summary from 7/7/21 was reviewed and indicated UTI with a new order for [MEDICATION(S)] 500 mg for 10 days. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (an antibiotic) 500 mg four times a day for UTI for 10 days, started 7/8/21 and ended 7/8/21. [MEDICATION(S)] solution (an antibiotic) 1gm (gram) to inject IM (intramuscular) one time a day for UTI for 3 days, started 7/8/21. The MAR (medication administration record) for July 2021 indicated the following: [MEDICATION(S)] 500mg was given at 8am and 12pm on 7/8/21. [MEDICATION(S)] solution 1gm IM was given on 7/8/21 and 7/9/21. The resident refused on 7/10/21. The clinical record lacked any additional attempts to administer the antibiotic. MD notified of resident's refusal, but the record lacked any further treatment options for the resident to finish the antibiotic. Resident 12's behaviors increased from May 2021 to July 2021, during the time of the urinary tract infections. Behavior monitoring (false beliefs/false allegations) for May 2021 indicated Resident 12 had behaviors on the following dates: 5/31/21 (twice) Behavior monitoring (hallucinations/delusions) for May 2021 indicated Resident 12 had behaviors on the following dates: 5/31/21 (twice) Behavior monitoring (false beliefs/false allegations) for June 2021 indicated Resident 12 did not have these behaviors. Behavior monitoring (hallucinations/delusions) for June 2021 indicated Resident 12 had behaviors on the following dates: 6/12/21 (once) Behavior monitoring (false beliefs/false allegations) for May 2021 indicated Resident 12 had behaviors on the following dates: 7/4/21 (twice) 7/6/21 (4 times) 7/7/21 (7 times) 7/8/21 (3 times) 7/12/21 (4 times 7/13/21 (5 times) Behavior monitoring (hallucinations/delusions) for July 2021 indicated Resident 12 had behaviors on the following dates: 7/6/21 (6 times) 7/7/21 (10 times) 7/8/21 (5 times) 7/9/21 (once) 7/10/21 (6 times) 7/11/21 (5 times) 7/12/21 (7 times) 7/13/21 (5 times) All other days, no behaviors documented on the TAR. Progress notes included, but were not limited to, the following with behaviors increasing since admission: 4/27/21 . resident is compliant with her med care and displays no signs/symptoms of illness at that time. 4/27/21 Resident is pleasant with staff during care . 5/3/21 .She is understood with clear speech and understands as she answers interview questions appropriately . 5/11/21 .Resident became tearful and was not making sense . 5/17/21 MD notified of increased confusion and tearfulness, awaiting new orders . 6/8/21 Noted to have scratches to bilateral (both) arms . resident stated areas were blisters caused by explosions. 6/16/21 MD note: Date of service 6/11/21 .staff reports false accusations made toward staff and delusional behavior such as hearing babies crying in the hallway . 6/16/21 Social Services behavior note: Resident continues to be very paranoid and having audio hallucinations. 7/6/21 Resident has been crying this afternoon and having delusions/hallucinations . 7/8/21 Social Services note: Resident continues to have [CONDITION(S)] and delusions. She is tearful and distraught 7/8/21 Resident was crying hysterically at beginning of this shift. Was not re-directable from the hallucinations she was having . 7/8/21 . Resident alert and able to swallow, OJ provided but resident only able to consume a few sips . 7/8/21 Received new order from nurse practitioner to increase [MEDICATION(S)] and [MEDICATION(S)] . 7/8/21 Resident continues to yell/cry out. Nonsensical speaking, resident refusing food . 7/9/21 Resident is noted to be non sensical with [CONDITION(S)]. Resident is prolonging words . 7/9/21 IDT note: resident has had a decline in overall condition, is currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD is updated and changed antibiotic. (Psych services) have seen resident and medication adjustments have been made. Discussed with family hospice care and current condition. Resident appetite is poor . She has been refusing her medications at time due to [CONDITION(S)] . 7/9/21 .Resident continues to have delusions that her son and mother are being hurt however resident is not as hysterical as she has been the past few days. 7/12/21 Resident resistive to care throughout shift . 7/12/21 MD note: Date of service 7/9/21 .The patient continues to refuse medications, care, and oxygen use. She continues with delusional behaviors, as well as aggressive behaviors toward the staff when attempting to provide care for the patient . 7/13/21 Nurse notified by housekeeping and laundry staff resident is yelling at them to get out of room . 7/13/21 Resident is noted to continue to refuse all care and medication. Resident is refusing for any staff to enter room . 7/13/21 (MD) in facility to evaluate resident. Resident refused x 3 . 7/13/21 Resident refused all med care during this shift . 7/14/21 Resident continues to refuse all care including medications, toileting, changing, repositioning . 7/14/21 Resident continues to refuse all care and medications. Resident has refused all meals this shift. Resident noted to say nonsensical speech during shift . 7/14/21 . Resident continues to speak noncoherently stating that she was on fire . 7/15/21 Resident has been loudly yelling out most of this night . 7/15/21 It was reported to nurse of residents' complaints. Notified MD and noted to do a UA with C&S if indicated, and resident refused. Hospice notified family, and indicated family stated she does not want a UA on this resident and no antibiotic treatment. During an interview on 7/15/21 at 10:24 A.M., RN 6 indicated Resident 12 was admitted to the facility with a history of UTIs. She indicated on 7/7/21, the resident was saying some off the wall thing and screaming, so she called the MD to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 6 indicated the resident came back from the ER with a UTI and had received IV [intravenous] antibiotics before being sent back to the facility. She indicated at that point, the resident really started to decline, and a new antianxiety medication was started by psych, but she had continued to decline after that as well. During an interview on 7/15/21 at 11:27 A.M., the DON (Director of Nursing) indicated on 5/20/21, the MD had ordered several labs, and a UA with C&S if indicated as one of them. She indicated Resident 12 did not have any symptoms at that time. When the UA and C&S were resulted, the MD would have been called or she would have talked with him about the results during rounds, but that notification was not documented. The DON indicated the MD would not treat a resident with an antibiotic based on a culture alone, unless the resident had symptoms as well. She also indicated the MD stated he had treated Resident 12 with [MEDICATION(S)] in the past with no issues, and was fine with prescribing it again, which was why it was ordered on 6/25/21, and that [MEDICATION(S)] was given prophylactically. At that time, the DON indicated she was unaware of Resident 12 complaining of current burning during incontinence care. During an interview on 7/15/21 at 2:03 P.M., the Administrator indicated [MEDICATION(S)] was given to Resident 12 on 6/26/21 because that was when it was identified that the resident had been given a medication, she was allergic to. She indicated it was not given for an actual reaction. During an interview on 7/15/21 at 2:36 P.M., CNA 15 indicated when providing incontinence care for a female resident, staff should wipe from front to back, using a different wipe each time. On 7/14/21 at 1:40 P.M., a current Urinary Tract Infection/Bacteriuria Policy, dated 4/2018, was provided, and indicated .Nurses should observe, document, and report signs and symptoms . in detail . The physician and nursing staff will review the status of individuals who are being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/21 at 1:40 P.M., an undated Activities of Daily Living-Perineal Care Policy was provided and indicated .Do not reuse the same washcloth or water to clean the urethra or labia [as the perineum] . [after care] Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly . clean wash basin and return to designated storage area . 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a staff member who was lying in bed with a resident was immediately removed from the bed, and failed to notify the Administrator immediately of the incident, resulting in the resident's psychosocial distress and allegation of sexual abuse, for 1 of 7 residents reviewed for abuse/neglect, in a sample of 7. (Resident A) The Immediate Jeopardy began on 5/25/14 when a staff member was observed in bed with a resident, the staff member was not removed and/or the Administrator was not notified immediately. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 4:40 P.M. on 6/18/14. The immediate jeopardy was removed on 6/20/14, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On 6/17/14 at 10:00 A.M., the Administrator provided an "Indiana State Department of Health" Incident Report Form regarding Resident A. The report included: "Initial Report, Date: 5/26/14, Incident Date: 5/25/14, Incident Time: 9:45 PM, Resident Name: (Resident A)...Brief Description of Incident: CNA (CNA # 1) was found on the floor in (room number) beside (Resident A's) bed. She had BM on both hands. She was not responsive to name being called. EMT's called and (CNA # 1) taken to hospital. When asked what happened (Resident A) stated that (CNA # 1) had been in bed with him...." A Follow-Up report, dated 5/30/14, indicated, "...At approximately 4:00 am (Resident A) told (LPN # 1) that (CNA # 1) touched him in an inappropriate sexual manner...Immediate Action Taken: Administrator notified immediately. Staff instructed to begin investigation. (CNA # 1) suspended and removed from schedule...Preventive measures taken: All staff inservice scheduled on abuse and the elder care act...." A written statement by LPN # 1, dated 5/26/14, indicated, "9:45 PM. On 5/25/14, I found (CNA # 1) on the floor face down beside (Resident A's) bed...Before I found her on the floor, she was laying in bed (with) her arm draped over the resident. He was not upset, but had been earlier in the shift. I thought she was consoling him from earlier. It did not seem inappropriate bx (behavior), I thought she was helping. 5/26/14 0400 (4:00 A.M.) I believe I called (Administrator) to tell him the following that (Resident A) told me @ first. He stated the CNA was on top of him, holding him down, kissing his face & calling him 'baby, sexy bunny, sexy...'...I was told to get his statement...." An additional written statement by LPN # 1, written on 5/27/14, indicated, "When I re-entered the room to tell (CNA # 1) to go ahead & get started on bed check she was face down on the floor...I asked (Resident A) 'what happened' he said 'she fell off the bed.'...." A written statement by CNA # 2, dated 5/26/14, indicated, "I walked in the door and saw (CNA # 1) laying on the floor...Later on I found (CNA # 1's) shoes in (room number of Resident A). I asked and (Resident A) replied (CNA # 1) removed them before climbing in bed." On 6/17/14 at 11:30 A.M., during an interview with LPN # 1, she indicated she was working on 5/25/14. She indicated at approximately 9:30 P.M., she was passing medications, and entered Resident A's room to give his roommate medication. She indicated she saw CNA # 1 laying in bed with Resident A with her arm over him. She indicated Resident A had been upset earlier in the shift, and "some of the new aides had been lying with residents to console them." She indicated it did not look inappropriate, so she didn't say anything. She indicated the resident did not appear upset. She indicated CNA # 1 did not speak. She indicated she did not know if CNA # 1's eyes were open or not, because her hair was in her face. LPN # 1 indicated that CNA # 1 soon came out to the desk, a call light went off, and CNA # 1 answered Resident A's light. She indicated she did not see CNA # 1 doing bed check, so she went to check on her, and found her on the floor beside Resident A's bed, BM (bowel movement) was observed on the CNA's hands and forearms. She indicated she asked Resident A what happened, and he told her, "She rolled out of bed." LPN # 1 indicated she then took care of sending CNA # 1 to the hospital, and when she checked on Resident A, approximately 45 minutes later, he was sleeping. She indicated that when the resident awoke at 4:00 A.M., she went in to talk with him and ask him what had happened. The resident was assessed at that time. She indicated that is when the resident told her the CNA sexually abused him, and she called the Administrator at that time. On 6/17/14 at 1:45 P.M., during an interview with the Social Services Director (SSD), she indicated she was aware of a CNA who had laid with a resident. She indicated she would not be comfortable with that, but that she was not familiar with what the evening and night shift staff do. The SSD indicated the resident tends to be "an attention-seeker," and that both the psychologist and primary physician had visited with him. On 6/17/14 at 3:00 P.M., during an interview with the Director of Nursing (DON), she indicated that lying in bed with a resident was not appropriate behavior. She indicated she had first heard of CNA # 3 lying down with Resident B, because Resident B had back pain. She indicated that CNA # 3 was new, and was just trying to help. She indicated she told the CNA and nurse that lying down with residents was not a good practice. She indicated she had stand-up meetings every day with her staff, and informed them then that lying down with residents would be inappropriate. The DON indicated she had no documentation of that inservice. On 6/17/14 at 3:45 P.M., during an interview with the Administrator and DON, the Administrator indicated it was not common practice for a staff member to lie down with a resident, and that there was only 1 previous incident with CNA # 3 and Resident B prior to the incident with CNA # 1 and Resident A. CNA # 3 was lying crossways in that resident's bed. The clinical record of Resident A was reviewed on 6/17/14 at 1:30 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 5/21/14, indicated the resident scored a 15 out of 15 for cognition, indicating no memory impairment. The MDS assessment indicated the resident required limited assistance of one person for bed mobility and transfer, and extensive assistance of two+ staff for toilet use. The resident was assessed as frequently incontinent of bladder, and always continent of bowel. Documentation regarding the resident's allegation of 5/25/14 was not found in the clinical record. 2. On 6/19/14 at 12:05 P.M., the Director of Nursing provided the current facility policy on "Resident Mistreatment, Neglect, Abuse & Misappropriation of Property," dated February 2014. The policy included: "Residents will be free from mistreatment, neglect, abuse, misappropriation of resident funds and property, verbal, mental, sexual, and physical abuse...Neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by the residents...Prevention:...Staff...will be monitored and supervised by their respective supervisors to ensure that the residents receive appropriate care and services to meet their needs and to prevent the potential of neglect and/or abuse...Investigation: All reported incidents of alleged violations involving mistreatment, neglect or abuse...are reported to the Administrator immediately...." The immediate jeopardy that began on 5/25/14 was removed on 6/20/14 when the facility began inservicing staff on the inappropriateness of lying with residents, and to immediately report such incidents to the Administrator immediately, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. This Federal tag relates to Complaint IN 893. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a staff member who was lying in bed with a resident was immediately removed from the bed, and failed to notify the Administrator immediately of the incident, resulting in the resident's psychosocial distress and allegation of sexual abuse, for 1 of 7 residents reviewed for abuse/neglect, in a sample of 7. (Resident A) The Immediate Jeopardy began on 5/25/14 when a staff member was observed in bed with a resident, the staff member was not removed and/or the Administrator was not notified immediately. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 4:40 P.M. on 6/18/14. The immediate jeopardy was removed on 6/20/14, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On 6/17/14 at 10:00 A.M., the Administrator provided an "Indiana State Department of Health" Incident Report Form regarding Resident A. The report included: "Initial Report, Date: 5/26/14, Incident Date: 5/25/14, Incident Time: 9:45 PM, Resident Name: (Resident A)...Brief Description of Incident: CNA (CNA # 1) was found on the floor in (room number) beside (Resident A's) bed. She had BM on both hands. She was not responsive to name being called. EMT's called and (CNA # 1) taken to hospital. When asked what happened (Resident A) stated that (CNA # 1) had been in bed with him...." A Follow-Up report, dated 5/30/14, indicated, "...At approximately 4:00 am (Resident A) told (LPN # 1) that (CNA # 1) touched him in an inappropriate sexual manner...Immediate Action Taken: Administrator notified immediately. Staff instructed to begin investigation. (CNA # 1) suspended and removed from schedule...Preventive measures taken: All staff inservice scheduled on abuse and the elder care act...." A written statement by LPN # 1, dated 5/26/14, indicated, "9:45 PM. On 5/25/14, I found (CNA # 1) on the floor face down beside (Resident A's) bed...Before I found her on the floor, she was laying in bed (with) her arm draped over the resident. He was not upset, but had been earlier in the shift. I thought she was consoling him from earlier. It did not seem inappropriate bx (behavior), I thought she was helping. 5/26/14 0400 (4:00 A.M.) I believe I called (Administrator) to tell him the following that (Resident A) told me @ first. He stated the CNA was on top of him, holding him down, kissing his face & calling him 'baby, sexy bunny, sexy...'...I was told to get his statement...." An additional written statement by LPN # 1, written on 5/27/14, indicated, "When I re-entered the room to tell (CNA # 1) to go ahead & get started on bed check she was face down on the floor...I asked (Resident A) 'what happened' he said 'she fell off the bed.'...." On 6/17/14 at 11:30 A.M., during an interview with LPN # 1, she indicated she was working on 5/25/14. She indicated at approximately 9:30 P.M., she was passing medications, and entered Resident A's room to give his roommate medication. She indicated she saw CNA # 1 laying in bed with Resident A with her arm over him. She indicated Resident A had been upset earlier in the shift, and "some of the new aides had been lying with residents to console them." She indicated it did not look inappropriate, so she didn't say anything. She indicated the resident did not appear upset. She indicated she did not know if CNA # 1's eyes were open or not, because her hair was in her face. LPN # 1 indicated that CNA # 1 soon came out to the desk, a call light went off, and CNA # 1 answered Resident A's light. She indicated she did not see CNA # 1 doing bed check, so she went to check her, and found her on the floor beside Resident A's bed, BM was observed on hands and forearms of the CNA. She indicated she asked Resident A what happened, and he told her, "She rolled out of bed." LPN # 1 indicated she then took care of sending CNA # 1 to the hospital, and when she checked on Resident A, approximately 45 minutes later, he was sleeping. She indicated that when the resident awoke at 4:00 A.M., she went in to talk with him and ask him what had happened. She indicated that is when the resident told her the CNA sexually abused him, and she called the Administrator then. On 6/17/14 at 3:45 P.M., during an interview with the Administrator and DON, the Administrator indicated it was not common practice for a staff member to lie down with a resident, and he did not know why LPN # 1 did not ask CNA # 1 to get out of the resident's bed or notify him. 2. On 6/19/14 at 12:05 P.M., the Director of Nursing provided the current facility policy on "Resident Mistreatment, Neglect, Abuse & Misappropriation of Property," dated February 2014. The policy included: "Residents will be free from mistreatment, neglect, abuse, misappropriation of resident funds and property, verbal, mental, sexual, and physical abuse...Neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by the residents...Prevention:...Staff...will be monitored and supervised by their respective supervisors to ensure that the residents receive appropriate care and services to meet their needs and to prevent the potential of neglect and/or abuse...Investigation: All reported incidents of alleged violations involving mistreatment, neglect or abuse...are reported to the Administrator immediately...." The immediate jeopardy that began on 5/25/14 was removed on 6/20/14 when the facility began inservicing staff on the inappropriateness of lying with residents, and to immediately report such incidents to the Administrator immediately, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. This Federal tag relates to Complaint IN 893. 3.1-28(c)

Based on interview and record review, the facility failed to implement their policy in that a staff member who was lying in bed with a resident was not immediately removed from the bed, and failed to notify the Administrator immediately of the incident, resulting in the resident's psychosocial distress and allegation of sexual abuse, for 1 of 7 residents reviewed for abuse/neglect, in a sample of 7. (Resident A) The Immediate Jeopardy began on 5/25/14 when a staff member was observed in bed with a resident, the staff member was not removed and/or the Administrator was not notified immediately. The Administrator and Director of Nursing were notified of the Immediate Jeopardy at 4:40 P.M. on 6/18/14. The immediate jeopardy was removed on 6/20/14, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On 6/17/14 at 10:00 A.M., the Administrator provided an "Indiana State Department of Health" Incident Report Form regarding Resident A. The report included: "Initial Report, Date: 5/26/14, Incident Date: 5/25/14, Incident Time: 9:45 PM, Resident Name: (Resident A)...Brief Description of Incident: CNA (CNA # 1) was found on the floor in (room number) beside (Resident A's) bed. She had BM on both hands. She was not responsive to name being called. EMT's called and (CNA # 1) taken to hospital. When asked what happened (Resident A) stated that (CNA # 1) had been in bed with him...." A Follow-Up report, dated 5/30/14, indicated, "...At approximately 4:00 am (Resident A) told (LPN # 1) that (CNA # 1) touched him in an inappropriate sexual manner...Immediate Action Taken: Administrator notified immediately. Staff instructed to begin investigation. (CNA # 1) suspended and removed from schedule...Preventive measures taken: All staff inservice scheduled on abuse and the elder care act...." A written statement by LPN # 1, dated 5/26/14, indicated, "9:45 PM. On 5/25/14, I found (CNA # 1) on the floor face down beside (Resident A's) bed...Before I found her on the floor, she was laying in bed (with) her arm draped over the resident. He was not upset, but had been earlier in the shift. I thought she was consoling him from earlier. It did not seem inappropriate bx (behavior), I thought she was helping. 5/26/14 0400 (4:00 A.M.) I believe I called (Administrator) to tell him the following that (Resident A) told me @ first. He stated the CNA was on top of him, holding him down, kissing his face & calling him 'baby, sexy bunny, sexy...'...I was told to get his statement...." An additional written statement by LPN # 1, written on 5/27/14, indicated, "When I re-entered the room to tell (CNA # 1) to go ahead & get started on bed check she was face down on the floor...I asked (Resident A) 'what happened' he said 'she fell off the bed.'...." A written statement by CNA # 2, dated 5/26/14, indicated, "I walked in the door and saw (CNA # 1) laying on the floor...Later on I found (CNA # 1's) shoes in (room number of Resident A). I asked and (Resident A) replied (CNA # 1) removed them before climbing in bed." On 6/17/14 at 11:30 A.M., during an interview with LPN # 1, she indicated she was working on 5/25/14. She indicated at approximately 9:30 P.M., she was passing medications, and entered Resident A's room to give his roommate medication. She indicated she saw CNA # 1 laying in bed with Resident A with her arm over him. She indicated Resident A had been upset earlier in the shift, and "some of the new aides had been lying with residents to console them." She indicated it did not look inappropriate, so she didn't say anything. She indicated the resident did not appear upset. She indicated she did not know if CNA # 1's eyes were open or not, because her hair was in her face. LPN # 1 indicated that CNA # 1 soon came out to the desk, a call light went off, and CNA # 1 answered Resident A's light. She indicated she did not see CNA # 1 doing bed check, so she went to check her, and found her on the floor beside Resident A's bed. She indicated she asked Resident A what happened, and he told her, "She rolled out of bed." LPN # 1 indicated she then took care of sending CNA # 1 to the hospital, and when she checked on Resident A, approximately 45 minutes later, he was sleeping. She indicated that when the resident awoke at 4:00 A.M., she went in to talk with him and ask him what had happened. She indicated that is when the resident told her the CNA sexually abused him, and she called the Administrator then. On 6/17/14 at 3:45 P.M., during an interview with the Administrator and DON, the Administrator indicated it was not common practice for a staff member to lie down with a resident, and he did not know why LPN # 1 did not make CNA # 1 get out of the bed. 2. On 6/19/14 at 12:05 P.M., the Director of Nursing provided the current facility policy on "Resident Mistreatment, Neglect, Abuse & Misappropriation of Property," dated February 2014. The policy included: "Residents will be free from mistreatment, neglect, abuse, misappropriation of resident funds and property, verbal, mental, sexual, and physical abuse...Neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by the residents...Prevention:...Staff...will be monitored and supervised by their respective supervisors to ensure that the residents receive appropriate care and services to meet their needs and to prevent the potential of neglect and/or abuse...Investigation: All reported incidents of alleged violations involving mistreatment, neglect or abuse...are reported to the Administrator immediately...." The immediate jeopardy that began on 5/25/14 was removed on 6/20/14 when the facility began inservicing staff on the inappropriateness of lying with residents, and to immediately report such incidents to the Administrator immediately, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. This Federal tag relates to Complaint IN 893. 3.1-28(a)

Based on observation, interview, and record review the facility failed to ensure insulin was administered correctly for 3 of 5 residents reviewed for diabetes management, in that fast-acting insulin was administered to 1 of 3 residents (Resident C) too far in advance of a meal, without a snack, and resulted in an episode of [DIAGNOSES REDACTED] that required emergent intervention, and the insulin was administered too far in advance of a meal, without snack, for 2 of 3 residents (Resident A and Resident B) who received sliding scale insulin in the morning in the sample of 23. (Resident C, Resident A, and Resident B) Findings include: 1. Resident C was observed on 08/19/13 at 5:50 a.m. to be lying in bed. During an interview, at that time, LPN #1 indicated she would have to wait to administer the fast-acting insulin to Resident C, because when it had been administered early on 08/10/13 Resident C had experienced a bad reaction. LPN #1 then indicated, she usually gives Resident C insulin around 6:25 a.m. because Resident C eats breakfast in her room and medications can be given one hour before or after the scheduled time. The clinical record of Resident C was reviewed on 08/20/13 at 10:00 a.m. The record indicated the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set Assessment) dated 06/12/13 indicated Resident C experienced minimal cognitive impairment. The most recent Physician order [REDACTED]. times a day) 0600 (6:00 a.m.)[MEDICATION NAME] s/s (sliding scale) inject SQ as follows: 0-120 = 0 units...". The August 2013 MAR (Medication Administration Record) indicated an Accucheck was performed on 08/10/13 at 0600 (6:00 a.m.) with a result of 106. The time of 0600 was observed to be overwritten with undated bold numbers of 0730 (7:30 a.m.). The MAR further indicated Resident C received 1 unit of [MEDICATION NAME] per sliding scale on 08/10/13 at 6:30 a.m. for a total of 7 units of fast-acting insulin. The MAR indicated [REDACTED]. A Physician Telephone Order dated 08/10/13 at 0910 (9:10 a.m.) indicated, "Send to ER (emergency room ) for eval (evaluation) and tx (treatment)" A Physician Telephone Order dated 08/10/13 at 1015 (10:15 a.m.) indicated, "Give RTN (routine) insulin only with meals in A.M. (morning)...". A untimed Nursing note dated 08/10/13 indicated, "This nurse went in res (resident) room to take meds (medicines) @ (at) 0830 (8:30 a.m.) et (and) noticed res breakfast had not been touched. Noted res slow to respond et diaphoretic BS (blood sugar) taken @ this time 33. Gave glucose gel @ 0840 (8:40 a.m.). BS taken at 0850 (8:50 a.m.) to be 32. Paged MD (physician) @ 0852 (8:52 a.m.). BS taken at 0900 (9:00 a.m.) BS was 30. [MEDICATION NAME] (a medication for low blood sugar) given @ 0901 (9:01 a.m.). MD returned page @ 0911 (9:11 a.m.). Res was unresponsive @ this time, diaphoretic...MD gave order to send to ER ..." A Care Plan dated 06/18/13 for Diabetes included, but was limited to, an intervention of "...provide insulin as ordered...". During an interview on 08/20/13 at 10:00 a.m. Resident C stated, "They take my Accucheck around 6:00 every morning and then give me my insulin right after that...I eat around 7:30 a.m." During an interview on 08/21/13 at 12:15 p.m., the DoN indicated she had not been told the hypoglycemic episode was the result of fast-acting insulin being administered 1-2 hours before eating. The DoN further indicated, at that time, fast-acting insulin should not be administered more than 10 (ten) minutes before a meal. The DoN then indicated the nursing staff had been instructed not to administer fast-acting insulin more than 10 minutes before a meal, but if it was necessary situation, the nurses should provide a substantial snack with the administration. During an interview on 08/21/13 at 2:00 p.m. the DoN indicated a formal policy could not be located for reporting medication errors. The DoN further indicated, at that time, the nursing staff should have reported the error to her immediately. 2. Resident A was observed on 08/19/13 at 6:00 a.m. sitting in an upright chair in her room. During an interview on 08/19/13 at 12:05 p.m., Resident A stated, "...get my Accucheck around 5:00 a.m. every morning, then I get my insulin right away after that if I need it. They don't give me a snack...". The clinical record of Resident A was reviewed on 08/20/13 at 9:20 a.m. The record indicated the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident A experienced no cognitive impairment. The most recent Physician order [REDACTED].@ 0600...with [MEDICATION NAME] 100 u/ml use sliding scale ..." The August 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Care Plan for Diabetes dated 04/28/13 included, but was not limited to, an intervention of "...administer meds per order..." 3. Resident B was observed on 08/19/13 at 5:55 a.m. lying in bed. LPN #1 was observed, at that time, to perform a blood sugar check without wearing gloves. The clinical record of Resident B was reviewed on 08/20/13 at 9:00 a.m. The record indicated the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident B experienced severe cognitive impairment. The most recent Physician order [REDACTED].@ 0600...with [MEDICATION NAME] sliding scale ..." The August 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Care Plan dated 06/04/13 for Diabetes included, but was not limited to, an intervention of "...administer meds per order..." During an interview with on 08/19/13 at 9:00 a.m., the ADON (Assistant Director of Nursing) indicated the blood sugar checks were typically scheduled for 6:00 a.m. and the insulins were typically scheduled for 6:30 and stated, "...they have one hour before and one after to do Accucheck and administer insulin." A Listing of Mealtimes provided by the DoN on 08/19/13 at 11:15 a.m. indicated Breakfast was served at 7:30 a.m. During an interview on 08/21/13 at 10:45, RPH (Pharmacist) #1 indicated a blood sugar will start to drop within 15 minutes of fast-acting insulin administration and the peak action of fast-acting insulin would occur within 1 (one) to 3 (three) hours. RPH #1 further indicated, at that time, fast-acting insulin should be given with a snack if greater than 15 minutes before a meal. A Drug Facts and Comparison Information Sheet for Antidiabetic Agents provided by RPH #1 on 08/21/13 at 10:45 a.m. indicated, "[MEDICATION NAME] (fast-acting insulin)...Administration and Dosage...Administration...Because insulin [MEDICATION NAME] (fast-acting insulin) has a more rapid onset and a shorter duration of activity...it should be injected immediately (within 5-10 minutes) before a meal." An undated Insulin Administration Policy provided by the DoN (Director of Nursing) on 08/20/13 at 3:00 p.m., indicated, "...Insulin Administration Procedure...If insulin must be given with a meal and time does not allow, then patient may be given snack with insulin administration to prevent low blood sugars/[DIAGNOSES REDACTED]...". During an interview on 08/20/13 at 10:45 a.m. MD #1 indicated he was the attending physician of Resident C, Resident A, and Resident B. MD #1 further indicated, at that time, he had been told by a facility nurse that Resident C experienced a hypoglycemic episode because she had received fast-acting insulin 1 (one) -2 (two) hours before eating and had not been offered a snack. MD #1 then indicated he would not recommend giving insulin more than 10 minutes before a meal. This federal tag relates to complaint number IN 379. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to develop and implement policies to prohibit abuse in that staff accused of abuse were not suspended during the abuse investigation, staff failed to report allegations of abuse, and Administration failed to immediately begin an investigation into an abuse allegation resulting in the ongoing physical and verbal abuse of 1 of 3 residents reviewed for abuse (Resident A) in the sample of 3. This deficient practice had the potential to affect 53 of 53 residents residing in the facility who were at risk being abused by the three accused staff members (CNAs # 1, # 3, # 4). This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 1/31/13 and began on 9/17/12. The Director of Nursing and Assistant Director of Nursing were notified of the Immediate Jeopardy at 11:35 A.M. on 1/31/13. The Immediate Jeopardy was removed on 2/4/13, but the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been inserviced on the new policy of abuse reporting. Findings include: 1. On 1/30/13 at 10:55 A.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/16/12, indicated the resident was unable to complete an interview regarding mental status, had a short-term and long-term memory problem, and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident was totally dependent on two + staff for bed mobility, transfer, dressing, and personal hygiene. On 1/30/13 at 11:30 A.M., during interview with investigators from the Medicaid Fraud Control Unit of the Office of the Indiana Attorney General (AG), AG # 1 and AG # 2, AG # 2 indicated they had placed a surveillance camera in Resident A's room, with the permission of Resident A's family, since September 2012. AG # 2 indicated they entered the facility on 1/25/13 and informed the Administrator they had video evidence CNA # 1 was abusing Resident A. AG # 2 indicated the video was dated 1/19/13 from 11:55 A.M. to approximately 12:05 P.M. and provided the video at that time. The video included CNA # 1 rolling Resident A from side to side roughly, throwing a chux at his face, raising her arm at him in a threatening manner, and slapping at him. The video also included CNA # 1 appearing to place a chux or sheet on the resident's face and pushing down on the chux with her hands briefly. On 1/30/13 at 12:55 P.M., during interview with CNA # 2, she indicated she had witnessed abuse in the facility by CNA # 3 and CNA # 4. CNA # 2 indicated that in September 2012, she had witnessed CNA # 3 and CNA # 4 be abusive to Resident A, by rolling him over "as hard as they could," and holding his arms up over his head as he yelled. CNA # 2 indicated she had reported the abuse in the past and reported it to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) but "nothing had been done." CNA # 2 indicated she "had even texted a board member, and he told me to follow the chain of command." CNA # 2 indicated she was no longer scheduled on the 2nd floor, where she had witnessed the abuse, after she complained in September. CNA # 2 indicated CNA # 4 was fired in December, but CNA # 3 still worked at the facility. On 1/30/13 at 2:45 P.M., during interview with CNA # 5, she indicated she had witnessed abuse in the facility. CNA # 5 indicated the abuse "was not that long ago; maybe November or December." CNA # 5 indicated she witnessed CNA # 3 clapping in Resident A's face, taunting him. CNA # 5 indicated CNA # 3 laid Resident A down in bed, and was "hateful," telling him "roll your big butt over." CNA # 5 indicated she informed CNA # 6 about the abuse, and CNA # 6 informed her, "It doesn't matter if you tell (the DON); she won't do anything about it." CNA # 5 indicated she did not report the abuse to a nurse. CNA # 5 indicated she had previously put notes under the Administrator's door regarding concerns, and "nothing happened." CNA # 5 indicated staff was intimidated by CNA # 3 and CNA # 4, and would not report anything because "they are good friends with (the DON)." On 1/30/13 at 3:50 P.M., during interview with the ADON, she indicated in September 2012 she had been told by CNA # 2 that Resident A "had been abused awhile." The ADON indicated CNA # 2 mentioned CNA # 3 and CNA # 4 as the abusers. The ADON indicated she called the DON, who was out of the building, to report the allegation, and started her investigation. The ADON indicated she thought CNA # 3 and CNA # 4 were off that weekend, so they were not suspended. On 1/30/13 at 5:00 P.M., during interview with the Administrator, he indicated he was informed of the abuse by CNA # 1 against Resident A on 1/25/13 by AG # 1 and AG # 2. He indicated he had the DON immediately terminate CNA # 1. He indicated he did not begin an investigation, or re-inservice staff of the abuse policy. He indicated he was told he could not discuss the abuse investigation by the AG staff. The Administrator indicated after a September 2012 complaint survey, regarding a different allegation of abuse, the abuse policy was changed to notifying the charge nurse and the DON. The Administrator indicated he would probably change that policy to "notifying the Administrator immediately." On 1/31/13 at 9:40 A.M., during interview with the DON, she indicated she did receive an allegation of abuse on September 14, 2012. She indicated she was out of town, and the ADON called her, and told her CNA # 2 had said CNA # 3 and CNA # 4 had abused Resident A months and months previously. The DON indicated she spoke to the Administrator by phone, and asked if CNA # 3 and CNA # 4 should be suspended during the investigation. The DON indicated the Administrator informed her there would be no reason to "lay off" the employees, since the time frame was unclear. The DON indicated CNA #3 continued to work, including 9/15, 9/16, 9/17, and 9/18, and CNA # 4 continued to work, including 9/14, 9/15, and 9/16. The DON indicated they did an investigation, and could not substantiate the abuse. The DON indicated, "In hindsight, I should have suspended them." The DON indicated CNA # 4 was terminated in December 2012 for "failure to observe resident rights." The DON indicated CNA # 3 still worked at the facility. At that time, the DON provided an investigation into the allegation of abuse, undated. The report included: "... Alleged abuse of verbal and physical abuse of Resident (A) was reported at 3 pm on Friday 9/14/12. Statement received by CNA (# 2) was unable to mention the nurse she reported alleged abuse to nor dates and times, statement also didn't give names, all other staff deny per their written statements...." The investigation did not document the names of CNA # 3 or CNA # 4 as the alleged abusers. The investigation was signed by the DON, Administrator, and Social Services Director. The investigation documents included a hand-written statement by CNA # 9. The statement, undated, included: "I (CNA # 9) noticed that some of the 2nd shifts that I work that some are rude to (Resident A). Roll him hard...She rolled him in anger, so I put my hand on the metal rail so his head would not bounce off of it. They make fun of him...I do not think its right to be rough with him...some CNAs lay on his bed to hold him down...he is treated like he is 2, he gets very rough treatment and a lot of times verbal abuse too...there is no reason to sit on him or cuse (sic) at him or be rough with him cause your (sic) mad or he is not happy...." On 1/31/13 at 2:15 P.M., during interview with CNA # 9, she indicated she worked at the facility for approximately one month around September 2012. She indicated, "They terminated me because I wouldn't work with those abusers." CNA # 9 mentioned CNA # 3 and CNA # 4 by name, and indicated, CNA # 3 "was the main one." She indicated CNA # 3 would "roll him so hard his face would hit the metal bar." She indicated CNA # 1 "was unstable," and preferred to work by herself. She indicated she witnessed CNA # 1 "throwing a resident in like a sack of potatoes," but she could not remember the resident's name. She indicated she did inform the DON, but that "I got written up instead of them." CNA # 9 indicated she did talk to the Administrator after she was terminated about the abuse, but he just told her the DON "was just doing her job." On 2/1/13 at 10:10 A.M., during interview with the Administrator, he indicated he would usually review investigations into abuse allegations. He indicated he never told the DON not to suspend CNA # 3 and CNA # 4 on September 14, 2012; that they should have been suspended during the investigation. The Administrator indicated he didn't recall speaking to any CNA regarding allegations of abuse, and he never received letters under his door regarding abuse. 2. On 1/30/13 at 10:15 A.M., the Social Services Director provided the current policy and procedure on Abuse Reporting, dated 9/17/12. The policy included: "...If you have suspect (sic) or witnessed abuse, neglect or misuse of resident's property, follow the steps outlined below:...2. After the resident is safe notify the person in charge of the facility at the time of the occurrence and Director of Nursing. The person in charge or the Director of Nursing must immediately notify the Administrator and the Social Service Director...Measures to prevent further (potential) abuse will be immediately initiated and remain in effect to protect the residents. 7. If the alleged abuser is an employee, the staff member in charge of the facility at the time the incident occurred will immediately suspend the employee. The employee will be suspended until the investigation is completed...8. The charge nurse responsible for the resident alleged to have been abused will document in the resident's chart the events that occurred and will notify the resident's physician and family...." An Immediate Jeopardy was identified on 1/31/13. The Immediate Jeopardy began on 9/17/12 when staff accused of abuse were allowed to work during an abuse investigation. The Director of Nursing and Assistant Director of Nursing were notified at 11:35 A.M. on 1/31/13 of the Immediate Jeopardy related to failure to protect residents from abuse. The Immediate Jeopardy was removed on 2/4/13 when through observations, interviews and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility suspended, then terminated CNA # 3, developed a new policy of abuse prohibition that specified notifying the Administrator immediately of allegations of abuse, and inserviced staff of the new policy. Nursing staff, CNAs and activity staff were interviewed on 2/04/13 and demonstrated knowledge of the new abuse prohibition policy, including immediately notifying the Administrator of allegations of abuse. Even though the facility's corrective actions removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to Complaint IN 384. 3.1-27(a)(1) 3.1-27(b) 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from ongoing physical and verbal abuse, after the failure of the facility to ensure abuse was immediately reported, investigated, and involved staff suspended during the investigation, for 1 of 3 residents reviewed for abuse in the sample of 3. (Resident A). This deficient practice had the potential to affect 53 of 53 residents residing in the facility who were at risk of being abused by the three accused staff members (CNAs # 1, # 3, # 4). This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 1/31/13 and began on 9/17/12. The Director of Nursing and Assistant Director of Nursing were notified of the Immediate Jeopardy at 11:35 A.M. on 1/31/13. The Immediate Jeopardy was removed on 2/4/13, but the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been inserviced on the new policy of abuse reporting. Findings include: 1. On 1/30/13 at 10:55 A.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/16/12, indicated the resident was unable to complete an interview regarding mental status, had a short-term and long-term memory problem, and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident was totally dependent on two + staff for bed mobility, transfer, dressing, and personal hygiene. On 1/30/13 at 11:30 A.M., during interview with investigators from the Medicaid Fraud Control Unit of the Office of the Indiana Attorney General (AG), AG # 1 and AG # 2, AG # 2 indicated they had placed a surveillance camera in Resident A's room, with the permission of Resident A's family, since September 2012. AG # 2 indicated they entered the facility on 1/25/13 and informed the Administrator they had video evidence CNA # 1 was abusing Resident A. AG # 2 indicated the video was dated 1/19/13 from 11:55 A.M. to approximately 12:05 P.M. and provided the video at that time. The video included CNA # 1 rolling Resident A from side to side roughly, throwing a chux at his face, raising her arm at him in a threatening manner, and slapping at him. The video also included CNA # 1 appearing to place a chux or sheet on the resident's face and pushing down on the chux with her hands briefly. On 1/30/13 at 12:55 P.M., during interview with CNA # 2, she indicated she had witnessed abuse in the facility by CNA # 3 and CNA # 4. CNA # 2 indicated that in September 2012, she had witnessed CNA # 3 and CNA # 4 be abusive to Resident A, by rolling him over "as hard as they could," and holding his arms up over his head as he yelled. CNA # 2 indicated she had reported the abuse in the past and reported it to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) but "nothing had been done." CNA # 2 indicated she "had even texted a board member, and he told me to follow the chain of command." CNA # 2 indicated she was no longer scheduled on the 2nd floor, where she had witnessed the abuse, after she complained in September. CNA # 2 indicated CNA # 4 was fired in December, but CNA # 3 still worked at the facility. On 1/30/13 at 2:45 P.M., during interview with CNA # 5, she indicated she had witnessed abuse in the facility. CNA # 5 indicated the abuse "was not that long ago; maybe November or December." CNA # 5 indicated she witnessed CNA # 3 clapping in Resident A's face, taunting him. CNA # 5 indicated CNA # 3 laid Resident A down in bed, and was "hateful," telling him "roll your big butt over." CNA # 5 indicated she informed CNA # 6 about the abuse, and CNA # 6 informed her, "It doesn't matter if you tell (the DON); she won't do anything about it." CNA # 5 indicated she did not report the abuse to a nurse. CNA # 5 indicated she had previously put notes under the Administrator's door regarding concerns, and "nothing happened." CNA # 5 indicated staff was intimidated by CNA # 3 and CNA # 4, and would not report anything because "they are good friends with (the DON)." On 1/30/13 at 3:50 P.M., during interview with the ADON, she indicated in September 2012 she had been told by CNA # 2 that Resident A "had been abused awhile." The ADON indicated CNA # 2 mentioned CNA # 3 and CNA # 4 as the abusers. The ADON indicated she called the DON, who was out of the building, to report the allegation, and started her investigation. The ADON indicated she thought CNA # 3 and CNA # 4 were off that weekend, so they were not suspended. On 1/30/13 at 5:00 P.M., during interview with the Administrator, he indicated he was informed of the abuse by CNA # 1 against Resident A on 1/25/13 by AG # 1 and AG # 2. He indicated he had the DON immediately terminate CNA # 1. He indicated he did not begin an investigation, or re-inservice staff of the abuse policy. He indicated he was told he could not discuss the abuse investigation by the AG staff. The Administrator indicated after a September 2012 complaint survey, regarding a different allegation of abuse, the abuse policy was changed to notifying the charge nurse and the DON. The Administrator indicated he would probably change that policy to "notifying the Administrator immediately." On 1/31/13 at 9:40 A.M., during interview with the DON, she indicated she did receive an allegation of abuse on September 14, 2012. She indicated she was out of town, and the ADON called her, and told her CNA # 2 had said CNA # 3 and CNA # 4 had abused Resident A months and months previously. The DON indicated she spoke to the Administrator by phone, and asked if CNA # 3 and CNA # 4 should be suspended during the investigation. The DON indicated the Administrator informed her there would be no reason to "lay off" the employees, since the time frame was unclear. The DON indicated CNA #3 continued to work, including 9/15, 9/16, 9/17, and 9/18, and CNA # 4 continued to work, including 9/14, 9/15, and 9/16. The DON indicated they did an investigation, and could not substantiate the abuse. The DON indicated, "In hindsight, I should have suspended them." The DON indicated CNA # 4 was terminated in December 2012 for "failure to observe resident rights." The DON indicated CNA # 3 still worked at the facility. At that time, the DON provided an investigation into the allegation of abuse, undated. The report included: "... Alleged abuse of verbal and physical abuse of Resident (A) was reported at 3 pm on Friday 9/14/12. Statement received by CNA (# 2) was unable to mention the nurse she reported alleged abuse to nor dates and times, statement also didn't give names, all other staff deny per their written statements...." The investigation did not document the names of CNA # 3 or CNA # 4 as the alleged abusers. The investigation was signed by the DON, Administrator, and Social Services Director. The investigation documents included a hand-written statement by CNA # 9. The statement, undated, included: "I (CNA # 9) noticed that some of the 2nd shifts that I work that some are rude to (Resident A). Roll him hard...She rolled him in anger, so I put my hand on the metal rail so his head would not bounce off of it. They make fun of him...I do not think its right to be rough with him...some CNAs lay on his bed to hold him down...he is treated like he is 2, he gets very rough treatment and a lot of times verbal abuse too...there is no reason to sit on him or cuse (sic) at him or be rough with him cause your (sic) mad or he is not happy...." On 1/31/13 at 2:15 P.M., during interview with CNA # 9, she indicated she worked at the facility for approximately one month around September 2012. She indicated, "They terminated me because I wouldn't work with those abusers." CNA # 9 mentioned CNA # 3 and CNA # 4 by name, and indicated, CNA # 3 "was the main one." She indicated CNA # 3 would "roll him so hard his face would hit the metal bar." She indicated CNA # 1 "was unstable," and preferred to work by herself. She indicated she witnessed CNA # 1 "throwing a resident in like a sack of potatoes," but she could not remember the resident's name. She indicated she did inform the DON, but that "I got written up instead of them." CNA # 9 indicated she did talk to the Administrator after she was terminated about the abuse, but he just told her the DON "was just doing her job." On 2/1/13 at 10:10 A.M., during interview with the Administrator, he indicated he would usually review investigations into abuse allegations. He indicated he never told the DON not to suspend CNA # 3 and CNA # 4 on September 14, 2012; that they should have been suspended during the investigation. The Administrator indicated he didn't recall speaking to any CNA regarding allegations of abuse, and he never received letters under his door regarding abuse. 2. On 1/30/13 at 10:15 A.M., the Social Services Director provided the current policy and procedure on Abuse Reporting, dated 9/17/12. The policy included: "...If you have suspect (sic) or witnessed abuse, neglect or misuse of resident's property, follow the steps outlined below:...2. After the resident is safe notify the person in charge of the facility at the time of the occurrence and Director of Nursing. The person in charge or the Director of Nursing must immediately notify the Administrator and the Social Service Director...Measures to prevent further (potential) abuse will be immediately initiated and remain in effect to protect the residents. 7. If the alleged abuser is an employee, the staff member in charge of the facility at the time the incident occurred will immediately suspend the employee. The employee will be suspended until the investigation is completed...8. The charge nurse responsible for the resident alleged to have been abused will document in the resident's chart the events that occurred and will notify the resident's physician and family...." An Immediate Jeopardy was identified on 1/31/13. The Immediate Jeopardy began on 9/17/12 when staff accused of abuse were allowed to work during an abuse investigation. The Director of Nursing and Assistant Director of Nursing were notified at 11:35 A.M. on 1/31/13 of the Immediate Jeopardy related to failure to protect residents from abuse. The Immediate Jeopardy was removed on 2/4/13 when through observations, interviews and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility suspended, then terminated CNA # 3, developed a new policy of abuse prohibition that specified notifying the Administrator immediately of allegations of abuse, and inserviced staff of the new policy. Nursing staff, CNAs and activity staff were interviewed on 2/04/13 and demonstrated knowledge of the new abuse prohibition policy, including immediately notifying the Administrator of allegations of abuse. Nursing staff, CNAs and activity staff were interviewed on 2/04/13 and demonstrated knowledge of the new abuse prohibition policy, including immediately notifying the Administrator of allegations of abuse. Even though the facility's corrective actions removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to Complaint IN 384. 3.1-27(a)(1) 3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure Administration was actively aware of abuse allegations and investigations, in that staff accused of abuse were not suspended during an abuse investigation, staff failed to report allegations of abuse, and Administration failed to immediately begin an investigation into an abuse allegation resulting in the ongoing physical and verbal abuse of 1 of 3 residents reviewed for abuse (Resident A) in the sample of 3. This deficient practice had the potential to affect 53 of 53 residents residing in the facility who were at risk being abused by the three accused staff members (CNAs # 1, # 3, # 4). This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 1/31/13 and began on 9/17/12. The Director of Nursing and Assistant Director of Nursing were notified of the Immediate Jeopardy at 11:35 A.M. on 1/31/13. The Immediate Jeopardy was removed on 2/4/13, but the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been inserviced on the new policy of abuse reporting. Findings include: 1. On 1/30/13 at 10:55 A.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/16/12, indicated the resident was unable to complete an interview regarding mental status, had a short-term and long-term memory problem, and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident was totally dependent on two + staff for bed mobility, transfer, dressing, and personal hygiene. On 1/30/13 at 11:30 A.M., during interview with investigators from the Medicaid Fraud Control Unit of the Office of the Indiana Attorney General (AG), AG # 1 and AG # 2, AG # 2 indicated they had placed a surveillance camera in Resident A's room, with the permission of Resident A's family, since September 2012. AG # 2 indicated they entered the facility on 1/25/13 and informed the Administrator they had video evidence CNA # 1 was abusing Resident A. AG # 2 indicated the video was dated 1/19/13 from 11:55 A.M. to approximately 12:05 P.M. and provided the video at that time. The video included CNA # 1 rolling Resident A from side to side roughly, throwing a chux at his face, raising her arm at him in a threatening manner, and slapping at him. The video also included CNA # 1 appearing to place a chux or sheet on the resident's face and pushing down on the chux with her hands briefly. On 1/30/13 at 12:55 P.M., during interview with CNA # 2, she indicated she had witnessed abuse in the facility by CNA # 3 and CNA # 4. CNA # 2 indicated that in September 2012, she had witnessed CNA # 3 and CNA # 4 be abusive to Resident A, by rolling him over "as hard as they could," and holding his arms up over his head as he yelled. CNA # 2 indicated she had reported the abuse in the past and reported it to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) but "nothing had been done." CNA # 2 indicated she "had even texted a board member, and he told me to follow the chain of command." CNA # 2 indicated she was no longer scheduled on the 2nd floor, where she had witnessed the abuse, after she complained in September. CNA # 2 indicated CNA # 4 was fired in December, but CNA # 3 still worked at the facility. On 1/30/13 at 2:45 P.M., during interview with CNA # 5, she indicated she had witnessed abuse in the facility. CNA # 5 indicated the abuse "was not that long ago; maybe November or December." CNA # 5 indicated she witnessed CNA # 3 clapping in Resident A's face, taunting him. CNA # 5 indicated CNA # 3 laid Resident A down in bed, and was "hateful," telling him "roll your big butt over." CNA # 5 indicated she informed CNA # 6 about the abuse, and CNA # 6 informed her, "It doesn't matter if you tell (the DON); she won't do anything about it." CNA # 5 indicated she did not report the abuse to a nurse. CNA # 5 indicated she had previously put notes under the Administrator's door regarding concerns, and "nothing happened." CNA # 5 indicated staff was intimidated by CNA # 3 and CNA # 4, and would not report anything because "they are good friends with (the DON)." On 1/30/13 at 3:50 P.M., during interview with the ADON, she indicated in September 2012 she had been told by CNA # 2 that Resident A "had been abused awhile." The ADON indicated CNA # 2 mentioned CNA # 3 and CNA # 4 as the abusers. The ADON indicated she called the DON, who was out of the building, to report the allegation, and started her investigation. The ADON indicated she thought CNA # 3 and CNA # 4 were off that weekend, so they were not suspended. On 1/30/13 at 5:00 P.M., during interview with the Administrator, he indicated he was informed of the abuse by CNA # 1 against Resident A on 1/25/13 by AG # 1 and AG # 2. He indicated he had the DON immediately terminate CNA # 1. He indicated he did not begin an investigation, or re-inservice staff of the abuse policy. He indicated he was told he could not discuss the abuse investigation by the AG staff. The Administrator indicated after a September 2012 complaint survey, regarding a different allegation of abuse, the abuse policy was changed to notifying the charge nurse and the DON. The Administrator indicated he would probably change that policy to "notifying the Administrator immediately." On 1/31/13 at 9:40 A.M., during interview with the DON, she indicated she did receive an allegation of abuse on September 14, 2012. She indicated she was out of town, and the ADON called her, and told her CNA # 2 had said CNA # 3 and CNA # 4 had abused Resident A months and months previously. The DON indicated she spoke to the Administrator by phone, and asked if CNA # 3 and CNA # 4 should be suspended during the investigation. The DON indicated the Administrator informed her there would be no reason to "lay off" the employees, since the time frame was unclear. The DON indicated CNA #3 continued to work, including 9/15, 9/16, 9/17, and 9/18, and CNA # 4 continued to work, including 9/14, 9/15, and 9/16. The DON indicated they did an investigation, and could not substantiate the abuse. The DON indicated, "In hindsight, I should have suspended them." The DON indicated CNA # 4 was terminated in December 2012 for "failure to observe resident rights." The DON indicated CNA # 3 still worked at the facility. At that time, the DON provided an investigation into the allegation of abuse, undated. The report included: "... Alleged abuse of verbal and physical abuse of Resident (A) was reported at 3 pm on Friday 9/14/12. Statement received by CNA (# 2) was unable to mention the nurse she reported alleged abuse to nor dates and times, statement also didn't give names, all other staff deny per their written statements...." The investigation did not document the names of CNA # 3 or CNA # 4 as the alleged abusers. The investigation was signed by the DON, Administrator, and Social Services Director. The investigation documents included a hand-written statement by CNA # 9. The statement, undated, included: "I (CNA # 9) noticed that some of the 2nd shifts that I work that some are rude to (Resident A). Roll him hard...She rolled him in anger, so I put my hand on the metal rail so his head would not bounce off of it. They make fun of him...I do not think its right to be rough with him...some CNAs lay on his bed to hold him down...he is treated like he is 2, he gets very rough treatment and a lot of times verbal abuse too...there is no reason to sit on him or cuse (sic) at him or be rough with him cause your (sic) mad or he is not happy...." On 1/31/13 at 2:15 P.M., during interview with CNA # 9, she indicated she worked at the facility for approximately one month around September 2012. She indicated, "They terminated me because I wouldn't work with those abusers." CNA # 9 mentioned CNA # 3 and CNA # 4 by name, and indicated, CNA # 3 "was the main one." She indicated CNA # 3 would "roll him so hard his face would hit the metal bar." She indicated CNA # 1 "was unstable," and preferred to work by herself. She indicated she witnessed CNA # 1 "throwing a resident in like a sack of potatoes," but she could not remember the resident's name. She indicated she did inform the DON, but that "I got written up instead of them." CNA # 9 indicated she did talk to the Administrator after she was terminated about the abuse, but he just told her the DON "was just doing her job." On 2/1/13 at 10:10 A.M., during interview with the Administrator, he indicated he would usually review investigations into abuse allegations. He indicated he never told the DON not to suspend CNA # 3 and CNA # 4 on September 14, 2012; that they should have been suspended during the investigation. The Administrator indicated he didn't recall speaking to any CNA regarding allegations of abuse, and he never received letters under his door regarding abuse. 2. On 1/30/13 at 10:15 A.M., the Social Services Director provided the current policy and procedure on Abuse Reporting, dated 9/17/12. The policy included: "...If you have suspect (sic) or witnessed abuse, neglect or misuse of resident's property, follow the steps outlined below:...2. After the resident is safe notify the person in charge of the facility at the time of the occurrence and Director of Nursing. The person in charge or the Director of Nursing must immediately notify the Administrator and the Social Service Director...Measures to prevent further (potential) abuse will be immediately initiated and remain in effect to protect the residents. 7. If the alleged abuser is an employee, the staff member in charge of the facility at the time the incident occurred will immediately suspend the employee. The employee will be suspended until the investigation is completed...8. The charge nurse responsible for the resident alleged to have been abused will document in the resident's chart the events that occurred and will notify the resident's physician and family...." An Immediate Jeopardy was identified on 1/31/13. The Immediate Jeopardy began on 9/17/12 when staff accused of abuse were allowed to work during an abuse investigation. The Director of Nursing and Assistant Director of Nursing were notified at 11:35 A.M. on 1/31/13 of the Immediate Jeopardy related to failure to protect residents from abuse. The Immediate Jeopardy was removed on 2/4/13 when through observations, interviews and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility suspended, then terminated CNA # 3, developed a new policy of abuse prohibition that specified notifying the Administrator immediately of allegations of abuse, and inserviced staff of the new policy. Nursing staff, CNAs and activity staff were interviewed on 2/04/13 and demonstrated knowledge of the new abuse prohibition policy, including immediately notifying the Administrator of allegations of abuse. Even though the facility's corrective actions removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to Complaint IN 384. 3.1-13(a) 3.1-13(g) 3.1-13(q) 3.1-13(r) 3.1-27(a)(1) 3.1-27(b) 3.1-28(a) 3.1-28(c) 3.1-28(d) 3.1-28(e)

Based on observation, interview, and record review, the facility failed to ensure the Administrator was immediately notified of alleged abuse, all alleged violations were thoroughly investigated, and that staff accused of abuse were suspended during the abuse investigation, resulting in the ongoing physical and verbal abuse of 1 of 3 residents reviewed for abuse (Resident A) in the sample of 3. This deficient practice had the potential to affect 53 of 53 residents residing in the facility who were at risk being abused by the three accused staff members (CNAs # 1, # 3, # 4). This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 1/31/13 and began on 9/17/12. The Director of Nursing and Assistant Director of Nursing were notified of the Immediate Jeopardy at 11:35 A.M. on 1/31/13. The Immediate Jeopardy was removed on 2/4/13, but the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been inserviced on the new policy of abuse reporting. Findings include: 1. On 1/30/13 at 10:55 A.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/16/12, indicated the resident was unable to complete an interview regarding mental status, had a short-term and long-term memory problem, and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident was totally dependent on two + staff for bed mobility, transfer, dressing, and personal hygiene. On 1/30/13 at 11:30 A.M., during interview with investigators from the Medicaid Fraud Control Unit of the Office of the Indiana Attorney General (AG), AG # 1 and AG # 2, AG # 2 indicated they had placed a surveillance camera in Resident A's room, with the permission of Resident A's family, since September 2012. AG # 2 indicated they entered the facility on 1/25/13 and informed the Administrator they had video evidence CNA # 1 was abusing Resident A. AG # 2 indicated the video was dated 1/19/13 from 11:55 A.M. to approximately 12:05 P.M. and provided the video at that time. The video included CNA # 1 rolling Resident A from side to side roughly, throwing a chux at his face, raising her arm at him in a threatening manner, and slapping at him. The video also included CNA # 1 appearing to place a chux or sheet on the resident's face and pushing down on the chux with her hands briefly. On 1/30/13 at 12:55 P.M., during interview with CNA # 2, she indicated she had witnessed abuse in the facility by CNA # 3 and CNA # 4. CNA # 2 indicated that in September 2012, she had witnessed CNA # 3 and CNA # 4 be abusive to Resident A, by rolling him over "as hard as they could," and holding his arms up over his head as he yelled. CNA # 2 indicated she had reported the abuse in the past and reported it to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) but "nothing had been done." CNA # 2 indicated she "had even texted a board member, and he told me to follow the chain of command." CNA # 2 indicated she was no longer scheduled on the 2nd floor, where she had witnessed the abuse, after she complained in September. CNA # 2 indicated CNA # 4 was fired in December, but CNA # 3 still worked at the facility. On 1/30/13 at 2:45 P.M., during interview with CNA # 5, she indicated she had witnessed abuse in the facility. CNA # 5 indicated the abuse "was not that long ago; maybe November or December." CNA # 5 indicated she witnessed CNA # 3 clapping in Resident A's face, taunting him. CNA # 5 indicated CNA # 3 laid Resident A down in bed, and was "hateful," telling him "roll your big butt over." CNA # 5 indicated she informed CNA # 6 about the abuse, and CNA # 6 informed her, "It doesn't matter if you tell (the DON); she won't do anything about it." CNA # 5 indicated she did not report the abuse to a nurse. CNA # 5 indicated she had previously put notes under the Administrator's door regarding concerns, and "nothing happened." CNA # 5 indicated staff was intimidated by CNA # 3 and CNA # 4, and would not report anything because "they are good friends with (the DON)." On 1/30/13 at 3:50 P.M., during interview with the ADON, she indicated in September 2012 she had been told by CNA # 2 that Resident A "had been abused awhile." The ADON indicated CNA # 2 mentioned CNA # 3 and CNA # 4 as the abusers. The ADON indicated she called the DON, who was out of the building, to report the allegation, and started her investigation. The ADON indicated she thought CNA # 3 and CNA # 4 were off that weekend, so they were not suspended. On 1/30/13 at 5:00 P.M., during interview with the Administrator, he indicated he was informed of the abuse by CNA # 1 against Resident A on 1/25/13 by AG # 1 and AG # 2. He indicated he had the DON immediately terminate CNA # 1. He indicated he did not begin an investigation, or re-inservice staff of the abuse policy. He indicated he was told he could not discuss the abuse investigation by the AG staff. The Administrator indicated after a September 2012 complaint survey, regarding a different allegation of abuse, the abuse policy was changed to notifying the charge nurse and the DON. The Administrator indicated he would probably change that policy to "notifying the Administrator immediately." On 1/31/13 at 9:40 A.M., during interview with the DON, she indicated she did receive an allegation of abuse on September 14, 2012. She indicated she was out of town, and the ADON called her, and told her CNA # 2 had said CNA # 3 and CNA # 4 had abused Resident A months and months previously. The DON indicated she spoke to the Administrator by phone, and asked if CNA # 3 and CNA # 4 should be suspended during the investigation. The DON indicated the Administrator informed her there would be no reason to "lay off" the employees, since the time frame was unclear. The DON indicated CNA #3 continued to work, including 9/15, 9/16, 9/17, and 9/18, and CNA # 4 continued to work, including 9/14, 9/15, and 9/16. The DON indicated they did an investigation, and could not substantiate the abuse. The DON indicated, "In hindsight, I should have suspended them." The DON indicated CNA # 4 was terminated in December 2012 for "failure to observe resident rights." The DON indicated CNA # 3 still worked at the facility. At that time, the DON provided an investigation into the allegation of abuse, undated. The report included: "... Alleged abuse of verbal and physical abuse of Resident (A) was reported at 3 pm on Friday 9/14/12. Statement received by CNA (# 2) was unable to mention the nurse she reported alleged abuse to nor dates and times, statement also didn't give names, all other staff deny per their written statements...." The investigation did not document the names of CNA # 3 or CNA # 4 as the alleged abusers. The investigation was signed by the DON, Administrator, and Social Services Director. The investigation documents included a hand-written statement by CNA # 9. The statement, undated, included: "I (CNA # 9) noticed that some of the 2nd shifts that I work that some are rude to (Resident A). Roll him hard...She rolled him in anger, so I put my hand on the metal rail so his head would not bounce off of it. They make fun of him...I do not think its right to be rough with him...some CNAs lay on his bed to hold him down...he is treated like he is 2, he gets very rough treatment and a lot of times verbal abuse too...there is no reason to sit on him or cuse (sic) at him or be rough with him cause your (sic) mad or he is not happy...." On 1/31/13 at 2:15 P.M., during interview with CNA # 9, she indicated she worked at the facility for approximately one month around September 2012. She indicated, "They terminated me because I wouldn't work with those abusers." CNA # 9 mentioned CNA # 3 and CNA # 4 by name, and indicated, CNA # 3 "was the main one." She indicated CNA # 3 would "roll him so hard his face would hit the metal bar." She indicated CNA # 1 "was unstable," and preferred to work by herself. She indicated she witnessed CNA # 1 "throwing a resident in like a sack of potatoes," but she could not remember the resident's name. She indicated she did inform the DON, but that "I got written up instead of them." CNA # 9 indicated she did talk to the Administrator after she was terminated about the abuse, but he just told her the DON "was just doing her job." On 2/1/13 at 10:10 A.M., during interview with the Administrator, he indicated he would usually review investigations into abuse allegations. He indicated he never told the DON not to suspend CNA # 3 and CNA # 4 on September 14, 2012; that they should have been suspended during the investigation. The Administrator indicated he didn't recall speaking to any CNA regarding allegations of abuse, and he never received letters under his door regarding abuse. 2. On 1/30/13 at 10:15 A.M., the Social Services Director provided the current policy and procedure on Abuse Reporting, dated 9/17/12. The policy included: "...If you have suspect (sic) or witnessed abuse, neglect or misuse of resident's property, follow the steps outlined below:...2. After the resident is safe notify the person in charge of the facility at the time of the occurrence and Director of Nursing. The person in charge or the Director of Nursing must immediately notify the Administrator and the Social Service Director...Measures to prevent further (potential) abuse will be immediately initiated and remain in effect to protect the residents. 7. If the alleged abuser is an employee, the staff member in charge of the facility at the time the incident occurred will immediately suspend the employee. The employee will be suspended until the investigation is completed...8. The charge nurse responsible for the resident alleged to have been abused will document in the resident's chart the events that occurred and will notify the resident's physician and family...." An Immediate Jeopardy was identified on 1/31/13. The Immediate Jeopardy began on 9/17/12 when staff accused of abuse were allowed to work during an abuse investigation. The Director of Nursing and Assistant Director of Nursing were notified at 11:35 A.M. on 1/31/13 of the Immediate Jeopardy related to failure to protect residents from abuse. The Immediate Jeopardy was removed on 2/4/13 when through observations, interviews and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility suspended, then terminated CNA # 3, developed a new policy of abuse prohibition that specified notifying the Administrator immediately of allegations of abuse, and inserviced staff of the new policy. Nursing staff, CNAs and activity staff were interviewed on 2/04/13 and demonstrated knowledge of the new abuse prohibition policy, including immediately notifying the Administrator of allegations of abuse. Even though the facility's corrective actions removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to Complaint IN 384. 3.1-27(a)(1) 3.1-27(b) 3.1-28(c) 3.1-28(d) 3.1-28(e)

Based on interview and record review, the facility failed to supervise a cognitively impaired resident at risk for falls resulting in his leaving the dining room unattended, going to his room, falling and suffering a shoulder fracture, for 1 of 1 resident reviewed for falls, in the sample of 15. Resident #9 Findings include: The clinical record for Resident # 9 was reviewed on 11/14/11 at 11:00 A.M. The record indicated Resident # 9 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 9/11/11, indicated Resident # 9 had moderately impaired cognition. Resident # 9 required limited assistance of one with transfers and ambulation. The assessment indicated Resident # 9 had no fall since the previous assessment. A Fall Risk Assessment, dated 7/1/11, indicated a score of 18. The form indicated, "Total score of 10 or above represents HIGH RISK." A Care Plan, dated 7/15/11, indicated a problem of "Potential for falls R/T (related to) hx (history) of falls and has [DIAGNOSES REDACTED]." The interventions included, but were not limited to, "Resident reminded to ask staff to assist with picking up anything from floor, up with one assist, bed alarm when in bed, and personal alarm to chair." A Physician/Family Notification, dated 9/3/11, no time, indicated, "...Resident stood up from w/c took 2 steps and fell down. Gait very unsteady. Nurse called to resident to sit down when he stood up but res (resident) kept trying to walk. No c/o (complaint of) pain at the time assess...Nursing intervention attempted: Resident to be transferred to recliner or bed by staff member between meals et after dinner..." A Fall Risk Assessment, dated 9/3/11, indicated a score of 20. The form indicated, "Total score of 10 or above represents HIGH RISK." The 7/15/11 fall care plan was updated on 9/3/11 to include the intervention of "rsd (resident) to be assisted to recliner or bed between meals." The Nurses Notes, dated 9/26/11 at 8:50 A.M., indicated, "ii (two) CNAs heard w/c alarm sounding and upon entering room found resident to be on floor. Nurse assessed and v/s (vital signs) taken. Dr (name) made aware of incident. Neuro checks iniciated (sic). Order received to send to ER (emergency room ) for eval and tx (evaluation and treatment)." A Hospital Xray report, dated 9/26/11, indicated, "...Indications: fall and pain. Findings:...An avulsion fracture is suspected, however, calcific (sic) tendinitis is in the differential...." A Hospital Visit Information, dated 9/26/11, indicated, "...Patient Instructions Reviewed...Sprains. Suture Care- Skin Glue...." A Physician/Family Notification form, dated 9/26/11, no time, indicated, "...Assessed skin glue to laceration R temple area has a bruise to R elbow sling intact to R arm for shoulder discomfort...." A Restorative Fall Memo, dated 9/28/11, no time, indicated, "rsd (resident) had fall on 9/26/11 at 0850 (8:50 A.M.). rsd finished am meal propelled self into room et attempted to take self to bathroom. rsd alarm sounded staff x (times) 2 entered room et found rsd on floor. rsd noted to have laceration to R (right) temple, abrasion to R lower ex (extremities) et c/o R shoulder pain was sent to ER (emergency room ) for eval et tx (evaluation and treatment) MD, family, DON (Director of Nursing), ADON notified of fall. Returned to facility rsd ref (refused) to transfer to recliner or bed at x's. Will offer to transfer to stationary chair with bedside table with activities such as but not limited to puzzles coloring etc. encouraged rsd to ask for assist prior to transfers offer toilet rsd after meals. fall et pain assess completed care plans updated...." A physician progress notes [REDACTED]." The Nurses Notes, dated 11/3/11 at 0230 (2:30 A.M.), indicated, "...Resident trying to get out of bed alarms in place went off. CNA et nurse went to room found resident sitting on floor, No s/s (signs and symptoms) of injury...." 3.1-45(a)(2)

Based on interview and record review the facility failed to ensure physician's orders for medication were followed upon return of a resident to the facility from a hospital. This resulted in a resident not receiving her medication as ordered, worsening of the resident's condition, and a return of the resident to the hospital. This affected 1 of 3 residents reviewed for being transferred back to the facility from a hospital. (Resident #B) Findings Include: Interview of the ADON (Assistant Director of Nursing) on 04/14/11 at 12:00 p.m. indicated Resident #B was sent out to the hospital on [DATE] for increased shortness of breath. The ADON indicated the resident returned to the facility on [DATE] with new orders for [MEDICATION NAME] (medication used to treat inflammation). The ADON indicated the new order did not get transcribed on the MAR (Medical Administration Record) and therefore the resident did not receive the medication. The ADON indicated the resident's condition worsened and she (Resident #B) returned back to the hospital on [DATE]. The ADON indicated the resident had received [MEDICATION NAME] in the hospital but the medication was not continued upon the resident's return to the facility. The ADON indicated the hospital reported the resident was in [MEDICATION NAME] withdrawal. Review of Resident #B's clinical record on 04/14/11 at 12:30 p.m. indicated the following: Resident #B had [DIAGNOSES REDACTED]. A Physician/Family Notification form, dated 03/31/11, indicated Resident #B was short of breath with oxygen saturation of 90 % on room air when sitting and 85-88% when (up) walking. The notification form indicated Resident #B was on oxygen at 2 liters for comfort and had routine breathing treatments. The notification form indicated the resident had inspiratory and expiratory wheezing and elevated blood pressure. This notification form indicated an ambulance arrived at the facility on 03/31/11 at 4:25 p.m. and the resident was transferred to a local hospital where she was admitted . A nurse's note, dated 04/04/11 at 4:00 p.m. indicated, "(Resident #B) returned to facility from (a local hospital)....L/S (Lung sounds) clear (with) expiratory wheezes noted. No open areas noted....Skin W&D (warm and dry). (No) distress noted. Orders received from hospital and (pharmacy) notified." A "Transfer Sheet" from a local hospital, dated 04/04/11, indicated discharge orders which included, "[MEDICATION NAME] 20 mg (milligrams) po (by mouth) BID (twice daily) x (times) 3 days, then 10 mg po BID x 3 days, then 10 mg po (daily) x 3 days...." A "Medication Record," for April, 2011, indicated Resident #B did not receive [MEDICATION NAME] as ordered upon return to facility. The record indicated no [MEDICATION NAME] doses were given on 04/04/11, 05/05/11, and the a.m. dose was missed on 04/06/11. A "Nursing Assessment and Data Collection" form, indicated: On 04/05/11 at 5:30 a.m., (Resident #1) had (increased) wheezes. On 04/05/11 at 8:00 a.m. the resident's vital signs were documented as being stable and her oxygen saturation was 94% on room air. On 04/06/11 (no time documented) the resident's vital signs were stable, oxygen saturation was 87-90% and the resident complained of not feeling well. The assessment indicated, "O2 (Oxygen) applied per nursing measure." On 04/06/11 (no time documented), indicated, "(Resident #1) continues to not feel well. MD paged - Order to send to E/R for (evaluation and treatment)...." On 04/06/11 at 4:45 a.m. indicated an ambulance had arrived at the facility to transfer the resident to the hospital. On 04/06/11 at 5:00 p.m. the Resident returned to the facility from the hospital. The resident was in no distress, arrived with new orders which were sent to the pharmacy and entered on the Medical Record. On 04/06/11 at 8:00 p.m. the Resident was alert and oriented and "feeling better." 3.1-25(b)(9)

Based on interview and record review the facility failed to ensure physician's orders were followed upon return of a resident to the facility from a hospital. This resulted in worsening of the resident's condition and a return of the resident to the hospital. This affected 1 of 3 residents reviewed for being transferred back to the facility from a hospital. (Resident #B) Findings Include: Interview of the ADON (Assistant Director of Nursing) on 04/14/11 at 12:00 p.m. indicated Resident #B was sent out to the hospital on [DATE] for increased shortness of breath. The ADON indicated the resident returned to the facility on [DATE] with new orders for [MEDICATION NAME] (medication used to treat inflammation). The ADON indicated the new order did not get transcribed on the MAR (Medical Administration Record) and therefore the resident did not receive the medication. The ADON indicated the resident's condition worsened and she (Resident #B) returned back to the hospital on [DATE]. The ADON indicated the resident had received [MEDICATION NAME] in the hospital but the medication was not continued upon the resident's return to the facility. The ADON indicated the hospital reported the resident was in [MEDICATION NAME] withdrawal. Review of Resident #B's clinical record on 04/14/11 at 12:30 p.m. indicated the following: Resident #B had [DIAGNOSES REDACTED]. A Physician/Family Notification form, dated 03/31/11, indicated Resident #B was short of breath with oxygen saturation of 90 % on room air when sitting and 85-88% when (up) walking. The notification form indicated Resident #B was on oxygen at 2 liters for comfort and had routine breathing treatments. The notification form indicated the resident had inspiratory and expiratory wheezing and elevated blood pressure. This notification form indicated an ambulance arrived at the facility on 03/31/11 at 4:25 p.m. and the resident was transferred to a local hospital where she was admitted . A nurse's note, dated 04/04/11 at 4:00 p.m. indicated, "(Resident #B) returned to facility from (a local hospital)....L/S (Lung sounds) clear (with) expiratory wheezes noted. No open areas noted....Skin W&D (warm and dry). (No) distress noted. Orders received from hospital and (pharmacy) notified." A "Transfer Sheet" from a local hospital, dated 04/04/11, indicated discharge orders which included, "[MEDICATION NAME] 20 mg (milligrams) po (by mouth) BID (twice daily) x (times) 3 days, then 10 mg po BID x 3 days, then 10 mg po (daily) x 3 days...." A "Medication Record," for April, 2011, indicated Resident #B did not receive [MEDICATION NAME] as ordered upon return to facility. The record indicated no [MEDICATION NAME] doses were given on 04/04/11, 05/05/11, and the a.m. dose was missed on 04/06/11. A "Nursing Assessment and Data Collection" form, indicated: On 04/05/11 at 5:30 a.m., (Resident #B) had (increased) wheezes. On 04/05/11 at 8:00 a.m. the resident's vital signs were documented as being stable and her oxygen saturation was 94% on room air. On 04/06/11 (no time documented) the resident's vital signs were stable, oxygen saturation was 87-90% and the resident complained of not feeling well. The assessment indicated, "O2 (Oxygen) applied per nursing measure." On 04/06/11 (no time documented), indicated, "(Resident #B) continues to not feel well. MD paged - Order to send to E/R for (evaluation and treatment)...." On 04/06/11 at 4:45 a.m. indicated an ambulance had arrived at the facility to transfer the resident to the hospital. On 04/06/11 at 5:00 p.m. the Resident returned to the facility from the hospital. The resident was in no distress, arrived with new orders which were sent to the pharmacy and entered on the Medical Record. On 04/06/11 at 8:00 p.m. the Resident was alert and oriented and "feeling better." 3.1-35(g)(2)

A. Based on observation, interview and record review, the facility failed to ensure a resident with repeated falls within the facility was supervised while she was in the lobby area, resulting in the resident falling for the eighth time in a 6 week period and fracturing her hip, for 1 of 5 residents reviewed with falls in the sample of 14. B. Based on observation, interview and record review, the facility failed to ensure Resident A was closely supervised and the smoke apron in place to prevent burns while smoking, in that resident A was documented to have burns on his hands and ankle and staff were observed to not ensure the smoke apron was in place over his legs and to have left him unattended, for 1 of 2 smokers reviewed in the sample of 14. This had the potential to affect all 5 smokers who reside in the facility and require supervision while smoking. Findings include: A.1. Resident B was identified on the initial tour of the facility on 8/29/10 at 1:15 P.M. by the charge nurse, RN#2, as having had a recent fall, a hip fracture, and cognitively impaired. Resident B was observed to have been in bed at the time of the tour. Resident B's bed was observed to have sensor mats on each side of the bed on the floor, and a motion sensor on the wall on each side of the bed. The resident's bed was observed on the opposite side of the room from the sink area in the room and bathroom. Resident B had to go around her roommate's bed to get to the bathroom and sink area. Resident B's clinical record was reviewed on 8/29/10 at 2:30 P.M. The resident was admitted to the facility on [DATE] from home. [DIAGNOSES REDACTED]." The admission MDS (minimum data set) assessment, dated 7/2/10, indicated the resident required cues and supervision, had a short term (does not recall after 5 minutes) and a long term memory loss and had fallen in the past 30 days. Resident B required extensive assist of two staff with transfers, and ambulation, and assist of one staff with bed mobility. A fall risk assessment, dated 6/28/10, indicated the resident was at a high risk of falls. Admission physician orders, dated 6/25/10, included orders for "wheelchair prn (as needed) when unsteady," "up with walker and 1 assist," "bed alarm while in bed" and"may use personal alarm in chair." During an interview with Resident B's family member on 8/30/10 at 8:30 a.m., she indicated Resident B had a history of [REDACTED]. A care plan problem, dated 6/25/10, indicated "Resident is at risk for falls related to alzheimer dementia and weakness." The goal was resident will be free of falls. Approaches were "assist as needed with ambulation," "monitor increased weakness," "personal alarm," "bed alarm," "discourage from getting up by herself," "Utilize wheelchair as needed." The restorative fall safety notes, written by the restorative nurse, indicated a history of falls as follows: Resident B fell on [DATE] at 3:40 p.m. was found sitting on floor near sink in room, an added intervention of anti-roll backs to the wheelchair were added. Resident B had a fall on 6/30/10 at 4:30 p.m., was found lying in floor in front of wheelchair near smoke room door, personal alarm had slipped off, a locking clip was added to the alarm. Resident B fell on [DATE] at 11:00 a.m., alarm sounded, resident was found on her hands and knees next to bed. Bilateral sensor alarms were added to the wall by the bed. Resident B fell on [DATE] at 8:30 p.m., alarms rang and resident was found sitting on floor next to bed, the incontinence pad had slipped off the bed with the resident. Alarming floor mats were added, along with hipsters for the resident. Resident B fell on [DATE] at 4:08 p.m. the alarm rang, resident stood from recliner in front lobby, lost balance and fell to ground. Interventions added were staff to walk resident when restless and keep close to nurses staff when restless in lobby. Resident B fell on [DATE] at 9:45 A.M., the alarm sounded, resident slid from wheelchair to floor, cushion to wheelchair slid, Dycem was added to wheelchair. Resident B fell on [DATE], her alarm sounded as she stood from the wheelchair and slid to the floor. Interventions was to place at desk next to nurses station when in lobby. Staff to keep close by when not in lobby area to supervise. The interventions listed in the restorative note were also added to the care plan for falls, with the onset date. The care plan problem for falls, dated 6/25/10, was updated 8/2/10, with "nursing place at desk next to nurses station close to staff, staff to keep close when no staff in lobby area." The nurses' station and lobby area were observed on 8/29/10 at 1:00 p.m. to be one large area with the nurses' desk at the back of the lobby area, with the hallway where resident rooms were located off one side of the area. A physician's notification dated 8/7/20 at 4:40 p.m. indicated "Pt (patient) fell in day room alarms and hipsters in place. c/o (complains) of all over pain, pain in right hip leg pelvis, complains of all over pain with increased intensity with range of motion, transferred to bed...guarding right leg and hip and pelvis." The resident was sent to a local emergency room . Nurse notes dated 8/7/10 at 6:15 p.m. indicated the resident was admitted to the hospital with [REDACTED]. The restorative fall notes, indicated "8/10/10 resident noted to have fall on 8/7/10 at 4:40 p.m. resident alarm sounded. CNA witnessed resident walking across floor, as CNA went to resident turned falling onto floor, alarm was on and hipsters were on." During interview with RN #4, the restorative nurse who investigates falls and writes the notes, on 8/30/10 at 10:00 A.M., she indicated she did not know where all the staff were at the time of the fall. She indicated CNA #5 was down the hall passing ice water in a resident's room. She indicated she had not asked where the other staff were but would make calls and try to find out. The daily assignment sheets provided by the DON on 8/30/10 at 10:00 A.M. indicated staff present in the facility at the time of the falls were RN #2, CNA #5, #11 and #12. She provided a written statement from the CNA who had responded to the alarm. The notes written by CNA #5, indicated "alarm went off came out of room to get her she was walking across floor she turned around before I could get her and she went down on floor...she had been sleeping in chair." The DON and ADON during interview on 8/31/10 at 11:00 A.M. indicated they had phoned the other staff members on duty on 8/7/10 and found out, CNA # 12 had been passing ice water down the hallway from the lobby area in resident rooms with CNA #5, CNA #11 had been out of the area smoking with residents who required supervision, and RN #2 had left the area to go to the bathroom. The DON indicated RN #2 had stated the resident had been sleeping prior to the fall. The facility lacked evidence of having insuring the care plan intervention from 8/2/10 of placing the resident at nurses desk and keeping resident with staff when not in lobby/nurses station area was followed, resulting in the resident having been left alone without supervision and falling for the eighth time in a six week time period, with a resulting hip fracture. The policy and procedure for "surveillance of falls," no date, provided by the DON on 8/30/10 at 9:00 A.M., included "data will be collected for each fall" and "Investigation of the fall will immediately be conducted by the charge nurses to identify elements of the fall." B.1. On the initial tour, on 8/29/10 at 1:20 P.M., the Assistant Director of Nursing indicated Resident A was up with assistance, had Huntington's diagnosis, and was hard to understand. On 8/30/10 at 11:10 A.M., Resident A was observed to be ambulated with one assist from the second floor to the first floor smoking area. At 11:15 A.M., Resident A was observed to be smoking. CNA # 1 and CNA # 9 were observed to be across the room assisting two wheelchair bound residents out the door. Both CNA # 1 and CNA # 9 had their backs to Resident A as he had a lit cigarette in hand. On 8/31/10 at 9:20 A.M., Resident A was observed to be in the smoking room with CNA # 7. Resident A was sitting across the table from CNA # 7. Resident A had one smoking apron on his upper body and another smoking apron was observed to be on the floor at Resident A's feet. CNA # 7 was observed to be smoking and talking on her cell phone. The clinical record for Resident A was reviewed on 8/29/10 at 2:30 P.M. The record indicated Resident A had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 6/16/10, indicated Resident A had short term memory problems and impaired decision making. Resident A required limited assistance of one with transfers and ambulation. A Smoking Assessment, dated 6/11/10, indicated "...Mobility Status- dependent...Resident is able to: Demonstrates physical ability to smoke safely- No. Based on findings of this assessment, (Resident A name) will be placed on supervised smoking and smoke with supervision at all times per facility smoking schedule." A care plan, dated 6/17/10, indicated a problem of "Resident smokes requires supervised (sic) to prevent injury." The interventions were "1. Assess quarterly. 2. Take to smoke room. 3. Supervise while smoking. 4. Wear smoke apron. 5. Staff to report any changes or incidents. 6. Smoke at desinated (sic) smoke times. 7. Staff to sit close to resident while he is smoking." The Nurse's Notes, dated 8/2/10 at 0915 (9:15 A.M.), indicated "Res (resident) noted to have fluid filled vesicle on R (right) hand 4th digit between knuckle and fingernail 2 x (by) 1.4 cm. R hand 5th digit has fluid filled vesicle on middle finger joint 0.4 x 0.8 cm. Periwound skin dark pink. Etiology unknown. Res does smoke with R hand and is unsteady with involuntary movements d/t (due to) huntington's chorea. Res to see Dr (name) in office this AM. Will notify Dr (name) of above." The Nurse's Notes, dated 8/7/10 at 2200 (10:00 P.M.), indicated "Note blister intact to pinky finger at joint scabbed areas to ring finger. No redness or warmth noted. No drng (dressing)." The Nurse's Notes, dated 8/8/10 at 2200 (10:00 P.M.), indicated "...Also note res (resident) has no tx (treatment) orders for fingers to Rt (right) hand. Blister intact to pinky finger. Note left for skin nurse." The Nurse's Notes, dated 8/9/10 at 0830 (8:30 A.M.), indicated "On assessment fluid filled vesicle cont (continues) to R (right) hand 5th digit. No s/s (signs and symptoms) infection noted. R hand 4th digit vesicle has expelled 1.5 x (by) 0.7 cm dk (dark) pink crusted area remains. No c/o (complaints of) pain or discomfort. Dr (name) aware. No N.O. (new orders)." The Nurse's Notes, dated 8/14/10 at 1905 (7:05 P.M.), indicated "CNA brought res (resident) out of smoke rm (room) to show nurse a burned hole in res Rt (right) sock et (and) noted sm (small) superficial area to Rt outer ankle. No blister. States res had not had 1900 (7:00 P.M.) cigarette yet. Unsure of when hole was made or how res taken back to smoke rm. CNAs to now utilize both smoke aprons when smoking. One normal placement the other to cover lap to feet to make sure BLE's (bilateral lower extremities) are covered. Staff aware. Also instructed CNA to sit next to res when cigarette is lit. Instructions left for all staff for these interventions." The Nurse's Notes, dated 8/14/10 at 2000 (10:00 P.M.), indicated "Dr (name) notified of area to Rt (right) outer ankle et (and) interventions. N.O.'s (new orders) received et noted." The Weekly/Monthly Skin Assessment Tool Non-pressure Areas, indicated "...8/17/10 R lat (lateral) ankle burn 1.8 x 1.5 center pale pink outer pink. Treatment Silvadene. Progress N." The form indicated "N-New." The Nurse's Notes, dated 8/18/10 at 2200 (10:00 P.M.), indicated "Open wound to R (right) lat (lateral) ankle area moist with small amt (amount) of serous drainage on old drsg (dressing). Center of wound pale pink, surrounding skin pink. Silvadene et drsg applied. No c/o (complaints of) pain or tenderness. No edema..." The Nurse's Notes, dated 8/20/10 at 1120 (11:20 A.M.), indicated "On assessment R (right) hand fourth digit anterior part of finger where blister expelled 1 x (by) 0.7 x 0.1 cm. Wound bed pink no s/s (signs and symptoms) infection noted. Will notify Dr. (name) of above. No c/o (complaints of) pain or discomfort voiced." The Nurse's Notes, dated 8/26/10 at 2245 (10:45 P.M.), indicated "Tx (treatment) to open area R (right) 4th finger, wound bed pink et (and) moist, no edema, no tenderness voiced. Dry, crusted brown area 0.5 cm diameter noted R 5th finger knuckle, surrounding skin pink, no edema." The Nurse's Notes, dated 8/29/10 at 0500 (5:00 A.M.), indicated "Tx (treatment) completed to Rt (right) 4th digit (hand) slow healing..." The facility smoking policy, dated 7/29/09, was provided by the Assistant Director of Nursing on 8/30/10 at 11:20 A.M. The policy indicated "...Residents assessed to be unable to safely smoke alone will be supervised by staff at all times when smoking..." On 8/31/10 at 9:15 A.M., in an interview with the Director of Nursing and the Assistant Director of Nursing, they indicated the facility had attempted adaptive equipment of a cigarette holder with Resident A a couple months ago but it didn't work. They indicated there was no documentation as to what the problem with the cigarette holder was and they indicated there had been no other adaptive equipment attempted. This federal tag relates to complaint number IN 552. 3.1-45(a)(2)