Every finding on record at Chesterton Manor

Based on observation, record review, and interview, the facility failed to ensure medications were held per blood sugar parameters for 1 of 1 resident reviewed for insulin. The facility also failed to ensure areas of discoloration and dry flaky skin were assessed and monitored for 4 of 4 residents reviewed for skin conditions non-pressure related and signs and symptoms of constipation were monitored and treated for 2 of 2 residents reviewed for constipation. (Residents 53, 3, 69, 58, 176, 13, and 226) Findings include: 1. The record for Resident 53 was reviewed on 3/3/25 at 2:17 p.m. Diagnoses included, but were not limited to, type 2 diabetes and chronic kidney disease stage 3. The Quarterly Minimum Data Set (MDS) assessment, dated 1/27/25, indicated the resident was cognitively intact and he had received insulin injections within the past seven days. A Care Plan, dated 10/29/24 and reviewed on 1/8/25, indicated the resident had a diagnosis of diabetes mellitus which placed him at a risk for medical complications. Interventions included, but were not limited to, administer medications as ordered by the physician. A Physician's Order, dated 1/23/25, indicated the resident was to receive 6 units of Lispro insulin subcutaneously (a method of administering medication by injecting it into the fatty layer of tissue just beneath the skin) three times a day. The insulin was to be held if the resident's blood sugar was 150 or less. The January 2025 Medication Administration Record (MAR) indicated the resident's insulin was administered when his blood sugar was 150 or less for the following dates and times: - 7:00 a.m.: 1/24/25 and 1/27/25 - 5:00 p.m.: 1/24/25 and 1/25/25 The February 2025 MAR indicated the resident's insulin was administered when his blood sugar was 150 or less for the following dates and times: - 7:00 a.m.: 2/6/25, 2/13/25, 2/14/25, 2/18/25, 2/19/25, 2/21/25, 2/22/25, 2/23/25, 2/24/25, and 2/27/25 - 12:00 p.m.: 2/9/25 - 5:00 p.m.: 2/17/25 and 2/28/25 The March 2025 MAR, indicated the resident's insulin was administered when his blood sugar was 150 or less for the following date and time: - 7:00 a.m.: 3/3/25 During an interview on 3/6/25 at 1:15 p.m., the Unit Manager indicated the insulin should have been held as ordered. 2. On 3/2/25 at 2:41 p.m., a fading reddish/purple bruise was observed on the top of Resident 3's right hand. The record for Resident 3 was reviewed on 3/5/25 at 11:21 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, atrial fibrillation (an irregular heart rhythm), and anemia. The 12/2/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and required substantial to maximum assistance with rolling left and right and with chair to bed transfers. A Care Plan, dated 7/27/23 and reviewed on 12/2/24, indicated the resident was at risk for bleeding due to Aspirin therapy. Interventions included, but were not limited to, observe for increased bruising on skin assessments and with care. A Physician's Order, dated 4/23/24 and listed as current on the March 2025 Physician's Order Summary (POS), indicated the resident received Aspirin Enteric Coated 81 milligrams (mg) daily related to atrial fibrillation. There was no order to assess and monitor the discoloration on the right hand. The last Weekly Non-Pressure Bruise Evaluation was dated 1/21/25, which indicated bruising to the left and right forearms was resolved. During an interview on 3/5/25 at 2:25 p.m., the Unit Manager was informed of the discoloration to the resident's right hand. A Nurse's Note, dated 3/6/25 at 7:14 a.m., indicated the resident was observed with a bruise to the right posterior hand, which was pink in color. The area measured 0.5 centimeters (cm) in length and 0.5 cm in width. The area was to be monitored until the bruise was healed. 3. On 3/3/25 at 8:50 a.m., Resident 69 was observed with two small areas of reddish/purple discoloration to the top of her left hand. The record for Resident 69 was reviewed on 3/4/25 at 9:52 a.m. Diagnoses included, but were not limited to, hypertension and fracture of the right femur. The 1/20/25 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making and she required substantial to maximum assistance with rolling left and right and with chair to bed transfers. A Care Plan, dated 1/17/25, indicated the resident was at increased risk for bleeding related to anticoagulant (blood thinner) use of Aspirin. Interventions included, but were not limited to, observe skin with care and report abnormalities to the nurse. There was no order to assess and monitor the discoloration to the left hand. A Weekly Skin Assessment, dated 2/25/25, indicated the resident's skin was intact and a bruise to the right side of her face near her brow was lightening. There was no documentation related to the resident's left hand. During an interview on 3/5/25 at 2:25 p.m., the Unit Manager was informed of the discoloration to the resident's left hand. 10770 4. During an interview on 3/3/25 at 9:34 a.m., Resident 58 indicated she was very constipated and sometimes did not have a bowel movement within 3 days. The record for Resident 58 was reviewed on 3/4/25 at 9:30 a.m. Diagnoses included, but were not limited to, chronic kidney disease, chronic migraines, atrial fibrillation, high blood pressure, major depressive disorder, anxiety, joint disorder, and obsessive compulsive disorder. The 1/29/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, was always incontinent of bowel, and was not on a bowel toileting program. The resident needed substantial to maximum assistance with toileting. The Care Plan, dated 12/2/24, indicated the resident was constipated related to decreased mobility. The nursing approaches were to follow the facility's bowel protocol for bowel management. The bowel movement documentation, in the CNA task section, indicated the resident had no bowel movement on 11/1/24, 11/3/24, 11/4/24, 11/5/24, 11/6/24, 11/8/24, 11/9/24, 11/19/24-11/22/24, and 11/27/24-11/30/24. There was no documentation and was blank on 11/2/24, 11/7/24 and 11/24/24. The resident had no bowel movements on 12/1/24, 12/3/24, 12/4/24, 12/6-12/10, 12/15/24, 12/18/24, 12/22/24, 12/24/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, and 12/31/24. There was no documentation and was blank on 12/2/24, 12/16/24, 12/19/24-12/21/24, 12/23/24, 12/25/24, and 12/30/24. The resident had no bowel movement on 1/4/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/17/25, 1/18/25, 1/19/25, and 1/20/25. There was no documentation and was blank on 1/3/25 and 1/5/25. The resident had no bowel movement on 2/12/25, 2/14/25, 2/15/25, 2/16/25, 2/28/25, 3/2/25, 3/3/25, and 3/4/25. There was no documentation and was blank on 2/13/25, 3/1/25, and 3/5/25. A Physician's Order, dated 11/21/24, indicated Milk of Magnesia oral, give 30 milliliters (ml) by mouth every 24 hours PRN (as needed) for constipation. A Physician's Order, dated 12/1/24, indicated Milk of Magnesia oral, give 30 milliliters (ml) by mouth at bedtime for constipation. The Medication Administration Record (MAR) for the months of 11/2024, 12/2024, 1/2025, and 2/2025 indicated the PRN Milk of Magnesia was only administered two times in four months on 11/29/24 and 2/5/25. During an interview on 3/5/25 at 2:00 p.m., the Unit Manager indicated if a resident had no bowel movement after three days then nursing staff should be administering the PRN medications. 5. During an interview on 3/2/25 at 9:35 a.m., Resident 176 indicated she had constipation and it might be longer than 3 days before she had a bowel movement. The record for Resident 176 was reviewed on 3/3/25 at 2:40 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, wedge compression fracture of T11 and T12 vertebra, anxiety disorder, chronic pain, adult failure to thrive, severe protein calorie malnutrition, and atrial fibrillation. The 2/14/25 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed minimal assistance with toileting. The resident was always continent of bowel and constipation was not present. A Care Plan, dated 2/11/25, indicated the resident had constipation related to decreased mobility. The approaches were to follow the facility protocol for bowel management and record bowel movements each day. The bowel movement documentation, in the CNA task section, indicated the resident had no bowel movement on 2/14/25-2/16/25 and there was no documentation and it was blank on 2/17/25. A Physician's Order, dated 2/10/25, indicated Glycolax Powder, give 17 gram by mouth one time a day for constipation. The 2/2025 and 3/2025 Medication Administration Record (MAR) indicated the Glycolax powder was refused by the resident on 2/22/25, 2/27/25 and 3/4/25. During an interview on 3/5/25 at 2:00 p.m., the Unit Manager indicated if a resident had no bowel movement after three days, then nursing staff should have followed the bowel protocol if the resident had no as needed medications for constipation. The current and revised 9/8/2014 Bowel Protocol policy, provided by the Unit Manager on 3/6/25 at 10:30 a.m., indicated if a resident had no bowel movement after two days, then give prune juice or bran. If no bowel movement after three days, then administer Milk of Magnesia 30 ml and if no results with 24 hours, administer a Dulcolax suppository. If no results after the suppository within 12 hours, administer a Fleets enema. 43293 6. During an observation of wound care on 3/4/25 at 10:27 a.m., a tennis ball-sized purple bruise was observed below Resident 13's right buttock. The record for Resident 13 was reviewed on 3/3/25 at 1:57 p.m. Diagnoses included, but were not limited to, disruption of surgical wound, dementia, and rheumatoid arthritis. The 2/9/25 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required moderate assistance with ADLs (activities of daily living) and transfers. A Care Plan, revised on 2/4/25, indicated the resident was taking a blood thinner. Interventions included watching for bruising and reporting abnormalities. The record lacked an assessment of the bruise below the resident's right buttock. During an interview on 3/5/25 at 11:31 a.m., the Unit Manager indicated the bruise was probably from one of the resident's falls, there was no assessment of that bruise documented, and staff would have to do a new skin assessment. A policy titled, Incidents - Bruising, received as current from the Unit Manager on 3/6/25 at 10:30 a.m. indicated, . The nurse will complete an incident report when a bruise is identified . An identified bruise will be measured. This measurement will be noted on the incident report and in the clinical record . 7. On 3/3/25 at 9:05 a.m., Resident 226's left lower leg was observed to have reddened, scaly, flaking skin below an area with a traumatic wound. The resident indicated her skin had been that way due to cellulitis. On 3/3/25 at 1:12 p.m., the resident was observed seated in her wheelchair with her left leg elevated on the footrest. The skin to her lower leg remained dry and scaly. At that time, the resident indicated there was no treatment being provided for that area. During an observation of wound care on 3/4/25 at 10:48 a.m., the skin to the right lower leg remained unchanged. At that time, LPN 3 indicated she thought there was a treatment for the scaly skin that was flaking off of the resident's leg, but she was not sure what it was. The record for Resident 226 was reviewed on 3/4/25 at 11:31 a.m. Diagnoses included, but were not limited to, cerebral infarction and hypertension. The 2/19/25 Nursing Admission Evaluation assessment indicated the resident was cognitively intact for daily decision making and required limited assistance from staff with ADLs and transfers. There were no orders or care plans for treatment of the resident's dry, scaly skin. During an interview on 3/5/25 at 2:27 p.m., the Unit Manager was informed of the findings and offered no further information. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for residents with a history of falls related to floor mats, bed position, and call lights in reach for 2 of 2 residents reviewed for falls. (Residents 46 and 13) The facility also failed to ensure hot water temperatures were below 120 degrees Fahrenheit on 3 of 4 halls throughout the facility. (100, 300 and 400 halls) This had the potential to affect 53 of the 75 residents who resided in the facility. Findings include: 1. During random observations on 3/2/25 at 9:17 a.m., 9:44 a.m. and 3:05 p.m., Resident 46 was observed in bed. At those times, a green wedge cushion was on the floor and a floor mat for between the beds was folded up against the wall. The floor mat closest to the room door was under the bed. On 3/3/25 at 9:03 a.m., the resident was observed in bed. The green wedge cushion was on the floor and floor mat between the beds was folded up against the wall. The floor mat closest to the room door was half under the bed. On 3/3/25 at 1:07 p.m. and 2:38 p.m., the resident was observed in bed and the floor mat closest to the door was folded up and against the wall. During random observations on 3/4/25 at 9:40 a.m. and 11:00 a.m., the resident was observed in bed. At those times, the floor mat closest to the room door was folded up against the wall. On 3/5/25 at 1:54 p.m., the resident was observed in bed. At that time, the floor mat between the beds was folded up against the wall. LPN 1 was in the room and indicated the resident was to have both floor mats on the floor beside her bed. The record for Resident 46 was reviewed on 3/3/25 at 1:30 p.m. Diagnoses included, but were not limited to, stroke, left side hemiplegia, high blood pressure, anxiety disorder, and major depressive disorder. The 1/9/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had no falls since the last assessment. The Care Plan, revised on 8/4/24, indicated the resident was at risk for falls and preferred to stay in bed. The approaches were to provide a thicker mat on the floor, exit side of bed. A Nurse's Note, dated 11/9/24 at 3:30 p.m., indicated the resident was observed on the floor mat beside the bed. A Nurse's Note, dated 11/25/24 at 12:33 p.m., indicated the resident was found on the floor next to the wheelchair. A Nurse's Note, dated 11/29/24 at 10:17 a.m., indicated the resident was observed on the floor in the lounge. A Nurse's Note, dated 1/28/25 at 8:15 p.m., indicated the resident was observed on the floor at 5:30 p.m., in the dining room. A Nurse's Note, dated 2/5/25 at 5:47 a.m., indicated the resident was observed on the floor next to her roommate's bed. An Interdisciplinary Note, dated 2/7/25 at 9:22 a.m., indicated the resident was in bed and decided she wanted to get up and fell . The intervention was to ask hospice to bring in a thicker floor mat for that side of the bed. A Nurse's Note, dated 2/17/25 at 1:06 p.m., indicated the resident fell out of the broda chair. During an interview on 3/5/25 at 2:00 p.m., the Unit Manager indicated the floor mats were to be on both sides of the bed when the resident was in the bed. 43293 2. During random observations on 3/2/25 at 9:05 a.m. and 11:08 a.m., 3/3/25 at 8:50 a.m. and 1:15 p.m., and 3/4/25 at 10:20 a.m. and 2:28 p.m., Resident 13 was observed resting in bed. She had a WanderGuard band (a safety alarm device for residents who may wander) on her right ankle. The bed was in a high position. During random observations on 3/2/25 at 9:05 a.m., 3/4/25 at 2:28 p.m. and 3:18 p.m., and 3/5/25 at 10:07 a.m., Resident 13 was observed resting in bed. At those times, her call light was out of reach on the floor. The record was reviewed for Resident 13 on 3/3/25 at 1:57 p.m. Diagnoses included, but were not limited to, disruption of surgical wound, dementia, and rheumatoid arthritis. The 2/9/25 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required moderate assistance with ADLs (activities of daily living) and transfers. A Care Plan, revised on 2/11/25, indicated the resident was at risk for falls. Interventions included ensuring the resident's call light was within reach. A Nurse's Note, dated 2/7/25, indicated the CNA found the resident on the floor in her room. A Nurse's Note, dated 2/11/25, indicated the resident fell while at a doctor's appointment with family. A Nurse's Note, dated 2/24/25, indicated the nurse found the resident lying on the floor in her room. On 3/4/25 at 10:27 a.m., when asked about fall prevention and the high position of the bed, LPN 3 indicated the bed could be positioned lower, but she did not think the resident ever fell in the facility. During an interview on 3/5/25 at 10:07 a.m., the resident indicated she would like to have the call light clipped to her blanket. During an interview on 3/5/25 11:31 a.m., the Unit Manager was informed of the findings and offered nothing further. A policy titled, Falls Management System, received as current from the Unit Manager on 3/6/25 at 10:30 a.m. indicated, . It is the policy of this center to provide each resident with appropriate evaluation and interventions to prevent falls and to minimize complications if a fall occurs . 48055 3. During environmental observations on 3/2/25 and 3/3/25, with the Maintenance Director, the hot water temperatures were found to be higher than 120 degrees in multiple rooms throughout the facility. 100 Hallway a. In room [ROOM NUMBER], the hot water in the bathroom was very hot to touch. Two residents shared this bathroom. b. In room [ROOM NUMBER], the hot water in the bathroom was very hot to touch and one's hand could not be held in the stream of hot water flowing from the faucet. One resident resided in this room. 300 Hallway a. In room [ROOM NUMBER], the hot water temperature was checked in the bathroom. The Maintenance Director placed the thermometer under the running water in the bathroom and the temperature gauge displayed 142 degrees. Two residents resided in this room. b. In room [ROOM NUMBER], the hot water in the bathroom was very hot to touch. Two residents resided in this room. 400 Hallway a. In room [ROOM NUMBER], the hot water in the bathroom was very hot to touch. There were two residents who used this bathroom. b. In room [ROOM NUMBER], the hot water in the bathroom was very hot to touch. One resident resided in this room. c. In room [ROOM NUMBER], the hot water in the bathroom was very hot to touch. One resident used the bathroom. d. In room [ROOM NUMBER], the hot water in the bathroom was very hot to touch. One resident resided in this room. During an interview on 3/3/25 at 9:05 a.m., the Maintenance Director indicated the water heater was set at 120 degrees, and that the water heater might have increased on him again. The mixing valve was set at 130 and he would set the hot water tank to 118 degrees. 3.1-19(r)(1) 3.1-19(r)(2) 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to protect a resident's right to be free from misappropriation of property related to bank fraud by Agency CNA 1, for 1 of 1 resident reviewed for misappropriation of property. (Resident 25) The deficient practice was corrected by [DATE], prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the incident related to the bank fraud once being notified by the police. A report was initiated by the police department and a detective was assigned to the case. The Staffing Agency was notified as soon as the Administrator was made aware and the Agency CNA had not worked at the facility since [DATE]. Finding includes: On [DATE] at 2:30 p.m., Resident 25 was observed in her room. She indicated it was not a good time to talk due to her floor being wet and she was busy. On [DATE] at 2:00 p.m., the resident indicated it was not a good time to talk. The record for Resident 25 was reviewed on [DATE] at 3:32 p.m. Diagnoses included, but were not limited to, rheumatoid arthritis, scoliosis, spinal stenosis, and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact. A Social Service Note, dated [DATE] at 3:00 p.m., indicated the Social Service Director met with the resident to inquire about personal items. The resident indicated something was missing, however, they already know. The resident was offered a lock box to secure her valuables but she declined. The resident was observed with a keychain around her wrist with keys. She indicated she was able to keep personal items in her dresser that locked with a key. She presented at her baseline without signs or symptoms of emotional distress. A facility reportable to the State Agency was dated [DATE] and indicated the following: The facility was notified by (name of town) detective of fraudulent funds from the resident's checking account. The police were notified by the resident's daughter of the fraudulent activity occurring since November. The detective notified the facility of the alleged involvement by an agency employee. The staffing agency was notified and the suspected staff member was removed from the schedule. The facility was working with the family and detective. The physician was notified and the resident was offered to keep her possessions in the safe in the business office. A statement completed by the Administrator indicated, on [DATE], a detective arrived at the facility and met with the Administrator. The detective informed the writer (Administrator) there were fraudulent charges on Resident 25's checking account going back to [DATE]. The detective informed the Administrator of the Agency CNA's name. The CNA's file was pulled and the last time she had worked was [DATE], her certificate expired [DATE], and she had not worked in the facility since [DATE]. The Administrator called the staffing agency and alerted them of the investigation and indicated there might be two more aides involved but the detective had no evidence yet. The Administrator spoke with the resident to ask if she had anything of value in her room and if she would like to have it locked up. The bank had refunded the lost funds to the resident. Resident interviews were completed related to misappropriation of property on [DATE] and [DATE] and no concerns were voiced. On [DATE], the Administrator went in with the Human Resource (HR) Director and met with the resident, and asked her again if she had anything she would like put in the safe. The resident indicated she had $150 in her night stand and the Administrator encouraged her to please put the money in the safe. The resident handed over an envelope that had $120 in it. The resident's daughter was called and informed of amount of money her mother had as well as another envelope with $30 that she wanted to keep. A follow up investigation on [DATE], indicated the detective alerted the facility of an agency aide in possible connection with fraudulent activity in the resident's checking account. The aide last worked in the facility on [DATE] and has since been put on the do not return list. The resident agreed to have the facility place any cash or checks in the facility safe. The facility was cooperating with the police department and the resident's bank had replaced the cash back into the resident's account. On [DATE], the Administrator called the detective for an update, who indicated he was pressing charges against the aide and had just started an investigation on the other two agency aides and would keep the facility updated. During an interview on [DATE] at 8:51 a.m., the Administrator indicated she had no previous knowledge of the incident prior to the detective coming to the facility on [DATE]. The resident's daughter had not brought the issue to her attention or any other staff member. As soon as the Administrator was aware of the alleged incident, she called the staffing agency to make them aware. The staffing agency indicated the CNA no longer worked there. The Nurse Consultant was also notified due to the facility having a sister facility in the same city where the staffing agency was located. The Administrator indicated staff and residents who worked and resided on the 100 Unit were interviewed with no concerns voiced. 3XXX,d+[DATE](a)

Based on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 2 of 2 residents reviewed for nutrition. (Residents 6 and 176) Findings include: 1. The record for Resident 6 was reviewed on 3/4/25 at 12:22 p.m. Diagnoses included, but were not limited to, protein calorie malnutrition, feeding difficulties, dysphagia (difficulty swallowing), and Alzheimer's disease. The 12/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making. He required partial to moderate assistance with eating and received a mechanically altered diet. A Care Plan, dated 7/15/24 and reviewed on 12/4/24, indicated the resident was at nutritional risk associated with dysphagia diet due to dysphagia and Parkinson's disease causing impaired dexterity and movement, history of significant weight changes (7/12/24) and the diagnosis of protein calorie malnutrition. Interventions included, but were not limited to, diet as ordered by the physician and monitor diet acceptance and intake. A Dietary Note, dated 1/27/25, indicated the resident had a significant weight loss of 6.3% within the last 30 days. The Food Consumption Logs for the months of February and March 2025, located in the Task section of the electronic medical record, indicated the following: - There was no documentation of breakfast intake on 2/8/25 - There was no documentation of dinner intake on 2/21/25 and 2/27/25 - There was no documentation of food intake for all three meals on 2/10/25, 2/11/25, 2/19/25, 2/22/25, and 3/3/25 During an interview on 3/5/25 at 2:25 p.m., the Unit Manager indicated the resident's food intake should have been documented. 10770 2. The record for Resident 176 was reviewed on 3/3/25 at 2:40 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, wedge compression fracture of T11 and T12 vertebra, anxiety disorder, chronic pain, adult failure to thrive, severe protein calorie malnutrition, and atrial fibrillation. The 2/14/25 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required set up assistance with eating. The resident had no oral problems and weighed 73 pounds with no weight loss. A Care Plan, dated 2/11/25, indicated the resident was at risk for nutritional deficits related to underweight status. The approaches were to monitor by mouth intakes. A Care Plan, dated 2/11/25, indicated the resident had a nutritional problem or a potential nutritional problem related to serve protein calorie malnutrition. The approaches were to monitor weight and food intake. A Registered Dietitian (RD) Progress Note, dated 2/17/25, indicated the resident was at an underweight status with a body mass index of 14.7. The resident's admission weight was 73 pounds and her weight was 72 pounds on 2/24/25. The Food Consumption Log, in the CNA Task Section, indicated breakfast was not documented on 2/10/25, 2/11/25, 2/22/25, 2/26/25, and 2/27/25. Lunch was not documented on 2/10/25, 2/11/25, 2/22/25, 2/26/25, and 2/27/25, and dinner was not documented on 2/10/25, 2/11/25, 2/17/25, and 2/18/25. During an interview on 3/5/25 at 2:00 p.m., the Unit Manager indicated meal consumptions should be completed before the end of each CNA's shift. The current and undated Food Acceptance Methods of Measurement policy, provided by the Administrator on 3/6/25 at 9:00 a.m., indicated determining food intake by facility staff and family was an important part of monitoring the food consumed by residents. Comparing food intake over time was a way to evaluate trends in a resident's nutritional status such as low intake and possibility of changes in the weight. 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure a resident was free from pain related to pain medications and transportation to the pain clinic not being available for 1 of 1 resident reviewed for pain. (Resident 36) Finding includes: During an interview on 3/2/25 at 11:44 a.m., Resident 36 indicated she did not get her medications on time or at all, as they were always running out of them. The record for Resident 36 was reviewed on 3/5/25 at 9:10 a.m. Diagnoses included, but were not limited to, rheumatoid arthritis, anemia, anxiety disorder, end stage renal disease, and osteoarthritis of the hip. The Quarterly Minimum Data Set (MDS) assessment, dated 2/7/25, indicated the resident was cognitively intact for daily decision making and received an opioid medication. The resident indicated she had frequent pain that interfered with her sleep and activities of daily living. Her pain was a five out of 10 on the pain scale. A Care Plan, revised on 1/27/25, indicated the resident had behaviors of making false accusations related to stating she does not receive her medications. A Care Plan, revised on 2/25/25, indicated the resident had arthritis, a fractured right foot and chose to go to another pain clinic. The approaches were to anticipate the need for pain relief and respond immediately and encourage the resident to call for assistance when in pain. A Physician's Order, dated 12/30/24, indicated Methocarbamol (a type of muscle relaxant that works by calming overactive nerves in your body and treats muscle pain and stiffness) tablet 500 milligrams (mg), give one tablet by mouth two times a day. A Nurse's Note, dated 12/31/24 at 9:56 a.m., indicated the Methocarbamol had not arrived to the facility. The 1/2025 Medication Administration Record (MAR) indicated the Methocarbamol tablet 500 mg was coded with a 16, meaning see nurse's notes, at 8:00 a.m. on 1/1/25, 1/2/25, 1/3/25, 1/4/25, 1/5/25, and 1/6/25 and at 8:00 p.m. on 1/1/25, 1/2/25, 1/4/25, and 1/5/25. Nurse's Notes, dated 1/1/25, 1/2/25, 1/3/25, 1/4/25, 1/5/25 and 1/6/25, indicated the Methocarbamol had not arrived to the facility. A Nurse's Note, dated 1/13/25 at 2:49 p.m., indicated a message was left for the pain clinic to reschedule the resident's appointment due to the transportation company canceled the pick up. A Nurse' Note, dated 1/13/25 at 4:03 p.m., indicated the pain clinic called back with a new appointment on 1/28/25 at 11:30 a.m. A Physician's Order, dated 1/1/25, indicated Oxycodone 10 mg, give one tablet four times a day for pain. The 2/2025 MAR indicated the Oxycodone was coded with a 16 on 2/15/25 at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. and on 2/16/25 at 12:00 p.m. and 6:00 p.m. Nurse's Notes for the above dates indicated the medication was not available and they were awaiting it from pharmacy. Nurse's Notes, dated 2/26/25 at 7:33 p.m., indicated the resident missed the pain clinic appointment due to transportation. A phone call was placed to the clinic to reschedule. The 3/2025 MAR indicated the Oxycodone was coded with a 16 on 3/4/25 at 12:00 p.m. and 6:00 p.m. and on 3/5/25 at 12:00 a.m. Nursing Notes for the above dates indicated the medication was not available and they were awaiting it from pharmacy. During an interview on 3/5/25 at 2:00 p.m., the Unit Manager indicated the resident had missed two pain clinic appointments due to no transportation because they canceled. She was aware the resident had missed doses of pain medication, however, the pharmacy only supplied a limited amount of medication in the EDK (emergency drug kit) box, therefore sometimes nursing staff could not give her the medication due to not having enough in the EDK box. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure proper medication storage related to medicated creams not stored securely for 2 of 2 residents randomly observed. (Residents 58 and 13) Findings include: 1. During random observations on 3/2/25 at 11:49 a.m. and 3:12 p.m., Resident 58 was observed in bed. At those times there was a tube of Bacitracin medicated cream on the dresser. During random observations on 3/3/25 at 9:32 a.m. and 1:03 p.m. and on 3/4/25 at 9:44 a.m., the Bacitracin medicated cream remained on top of the dresser in the resident's room. On 3/4/25 at 2:00 p.m., LPN 2 was observed in the room. At that time, the LPN was shown the medicated cream on top of the dresser. During an interview at that time, LPN 2 indicated the Bacitracin was to be locked in the treatment cart and not left in the resident's room. The record for Resident 58 was reviewed on 3/4/25 at 9:30 a.m. Diagnoses included, but were not limited to, chronic kidney disease, chronic migraines, atrial fibrillation, high blood pressure, major depressive disorder, anxiety, joint disorder, and obsessive compulsive disorder. The 1/29/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 2/27/25, indicated Bacitracin Ointment 500 units, apply to right shin and right lower leg open blisters one time a day. There was no order to keep the medicated cream at the bedside in the resident's room. During an interview on 3/4/25 at 3:20 p.m., the Unit Manager indicated the Bacitracin cream should not have been left in the resident's room on the dresser. 43293 2. During random observations on 3/02/25 at 9:05 a.m. and 11:08 a.m., a tube of Medihoney (a topical wound medication) was observed on Resident 13's dresser. During an interview on 3/5/25 at 11:31 a.m., the Unit Manager was informed of the findings and offered no further information. A policy titled, Storage of Medications and Biologicals, received as current on 3/6/25 at 10:30 a.m. from the Unit Manager, indicated, . The facility is required to secure all medications in a locked storage area and to limit access to only authorized or licensed personnel consistent with state or federal requirements and professional standards of practice . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on record review and interview, the facility failed to ensure a care plan meeting was conducted at least quarterly for 1 of 5 residents reviewed for care planning. (Resident 4) Finding includes: The record for Resident 4 was reviewed on 3/4/25 at 9:05 a.m. Diagnoses included, but were not limited to, pneumonia and hypertensive heart disease. The 12/27/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A review of the care plan notes indicated the last care plan meeting conducted was on 3/14/24. The resident declined a care plan meeting on 9/18/24. There was no documentation of subsequent care plan meetings conducted or refused. During an interview on 3/5/25 at 4:05 p.m. the Social Service Director indicated care plan meetings normally would take place at least quarterly, with each MDS assessment. A policy titled, Care Plans, Comprehensive Person - Centered, received as current from the Director of Nursing on 3/6/25 at 9:00 a.m. indicated, . The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The Interdisciplinary Team must review and update the care plan: . At least quarterly, in conjunction with the required quarterly MDS assessment . 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to ensure pressure ulcer treatments were completed as ordered by the physician for 1 of 4 residents reviewed for pressure ulcers. (Resident 10) Finding includes: During an interview on 3/2/25 at 11:55 a.m., Resident 10 indicated his pressure ulcer treatment was completed one time a week and was just changed on the midnight shift and that has never happened. On 3/4/25 at 2:00 p.m., the resident refused to have the surveyor observe the pressure ulcer and the treatment. The record for Resident 10 was reviewed on 3/4/25 at 11:40 a.m., Diagnoses included, but were not limited to, stroke, left hemiplegia, abnormal posture, heart failure, heart disease, pain in the left wrist anxiety and major depressive disorder. The 2/25/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had one Stage 3 (full-thickness tissue loss where subcutaneous fat was visible within the wound, but bone, tendon, or muscle were not exposed) unhealed pressure ulcer. The Care Plan, revised on 2/6/25, indicated the resident had an impairment to his skin integrity. The approaches were for nursing to provide the treatment as ordered by the physician. The Care Plan, dated 9/17/24, indicated the resident had an actual Stage 3 pressure ulcer. The approaches were to apply the treatment as ordered. A Physician's Order, dated 10/16/24, indicated to clean the coccyx wound with normal saline, pat dry, apply moistened collagen powder and cover with a bordered gauze daily. The 11/2024 Treatment Administration Record (TAR) indicated the treatment was not signed out as being completed on 11/7/24, 11/8/24, 11/9/24, 11/10/24, 11/21/24, and 11/29/24. A Physician's Order, dated 12/9/24, indicated to clean the coccyx wound with normal saline, pat dry, apply moistened collagen matrix sheet and cover with a bordered gauze every night shift. The 12/2024 TAR indicated the treatment was not signed out as being completed on 12/11/24, 12/19/24, 12/23/24, and 12/29/24. The 1/2025 and 2/2025 TARs indicated the treatment was not signed out as being completed on 1/2/25, 1/9/25, and 2/3/25. A Physician's Order, dated 2/17/25, indicated to clean the coccyx wound with normal saline, pat dry, apply collagen to the wound bed and skin prep to the periwound and cover with a bordered gauze every night shift. The 2/2025 and 3/2025 TAR indicated the treatment was not signed out as being completed on 2/20/25, 2/27/25, and 3/2/25. The last documented Wound Nurse Practitioner (NP) note, dated 2/28/25, indicated the wound was improving and smaller in size. The pressure ulcer measured 1.2 centimeters (cm) in length, 0.4 cm in width, and 0.3 cm in depth and had 90% granulation tissue with 10% slough (dead tissue). There was documentation in nursing notes for the month of 1/2025 and 2/2025 the resident had refused to lay down during the day as he wished to stay up and smoke. During a phone interview on 3/4/25 at 2:00 p.m., the Wound NP indicated the resident refused debridement all the time, and was noncompliant with lying down daily as he indicated he wanted to smoke and was not going to bed during the day. During an interview on 3/5/25 at 2:00 p.m., the Unit Manager indicated treatments were to be completed as ordered by the physician. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure an orthotic device was in place for a resident with a limited range of motion to the hand for 1 of 2 residents reviewed for range of motion. (Resident 10) Finding includes: During an interview on 3/2/25 at 11:54 a.m., Resident 10 indicated he used to wear a splint on his left hand, but now he did not. The resident's left hand was observed to be flaccid (soft and limp characterized by a decrease in or absence of muscle tone) and he was not able to open the left hand on his own, he used his right hand to open the hand. During random observations on 3/3/25 at 1:04 p.m., and on 3/4/25 at 9:35 a.m. and 12:00 p.m., the resident was observed seated in his wheelchair. At those times, his left hand was flaccid and there was no orthotic device observed in that hand. During an interview on 3/4/25 at 2:05 p.m., the resident indicated he had not seen his hand splint in a long time. The record for Resident 10 was reviewed on 3/4/25 at 11:40 a.m. Diagnoses included, but were not limited to, stroke, left hemiplegia, abnormal posture, heart failure, heart disease, pain in the left wrist anxiety and major depressive disorder. The 2/25/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had a range of motion impairment to one side for his upper extremity. A Care Plan, revised on 1/16/24, indicated the resident had an ADL (activities of daily living) self care performance deficit related to hemiplegia affecting his left side. A Care Plan, revised on 1/16/24, indicated the resident was at risk for falls related to left-sided paralysis. The approaches were to wear the left wrist orthotic device as ordered. A Physician's Order, dated 12/20/22, indicated left wrist/hand orthotic device to be donned and doffed as the resident tolerated or requested every day and night shift. The Treatment Administration Record (TAR) for 11/2024 indicated the orthotic device lacked documentation of it being signed out on the night shift on 11/7/24, 11/8/24 and 11/29/24 and on the day shift on 11/10/24. The TAR for the month of 12/2024 indicated there were no documented refusals of the resident not wearing the orthotic device. The device lacked documentation of it being signed out on the night shift on 12/11/24, 12/23/24 and 12/31/24. The 1/2025, 2/2025 and 3/2025 TAR indicated the orthotic device was signed out as being donned for day and night shift with no documentation of refusals. During an interview on 3/4/25 at 3:20 p.m., the Unit Manager indicated the orthotic device was attached to his motorized wheelchair and he no longer used that wheelchair. The order for the device should have been discontinued a long time ago. 3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 2 of 3 residents reviewed for oxygen. (Residents 7 and 58) Findings include: 1. During a random observation on 3/2/25 at 9:09 a.m., Resident 7 was observed seated in her wheelchair. At that time, she was wearing oxygen per a portable tank via nasal cannula at 2.5 liters per minute. On 3/2/25 at 12:12 p.m. and 3:04 p.m., the resident was observed seated in her wheelchair. At those times she was wearing oxygen per a portable tank via nasal cannula at 2 liters per minute. During random observations on 3/3/25 8:55 a.m., 1:00 p.m., and 3:00 p.m., the resident was observed seated in her wheelchair. At those times she was wearing oxygen per a portable tank via nasal cannula at 2 liters per minute. During random observations on 3/4/25 at 9:40 a.m., 11:00 a.m., 11:49 a.m., and 1:59 p.m., the resident was observed seated in her wheelchair. At those times she was wearing oxygen per the portable tank via nasal cannula at 2.5 liters per minute. On 3/4/25 at 3:00 p.m., the Unit Manager was in the main dining room where the resident was seated. The Unit Manager was asked to look at the oxygen setting and verified it was set to 2.5 liters per minute. The record for Resident 7 was reviewed on 3/3/25 at 1:15 p.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), asthma, bronchitis, dementia, heart failure, heart disease, and high blood pressure. The 1/27/25 Annual Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for decision making and used oxygen while a resident. The revised 3/17/23 Care Plan, indicated the resident has asthma, COPD and has shortness of breath while lying flat and was at risk for complications. The approaches were to provide oxygen per the doctor's orders. A Physician's Order, dated 4/13/23, indicated oxygen at 3 liters per minute continuously. During an interview on 3/4/25 at 3:00 p.m., the Unit Manager indicated the oxygen rate should have been set to 3 liters per minute. 2. During random observations on 3/2/25 at 11:49 a.m. and 3:12 p.m., Resident 58 was observed in bed. At those times, she was wearing oxygen on the room concentrator via nasal cannula at 1.5 liters per minute. During random observations on 3/3/25 at 9:32 a.m., and 1:03 p.m., on and 3/4/25 at 9:44 a.m., the resident was observed in bed. At those times she was wearing oxygen on the room concentrator via nasal cannula at 1.5 liters per minute On 3/4/25 at 2:00 p.m., LPN 2 was observed in the room and was asked to look at the oxygen level. At that time, she verified the oxygen was not at 2 liters, as the middle of the ball was below the 2 on the concentrator. The record for Resident 58 was reviewed on 3/4/25 at 9:30 a.m. Diagnoses included, but were not limited to, chronic kidney disease, chronic migraines, atrial fibrillation, high blood pressure, major depressive disorder, anxiety, joint disorder, and obsessive compulsive disorder. The 1/29/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was not receiving oxygen. A Care Plan, dated 2/7/25, indicated the resident was at risk for alterations in oxygen levels due to diagnosis of pneumonia. The approaches were to set the oxygen at 2 liters per minute. A Physician's Order, dated 2/6/25, indicated oxygen at 2 liters per minute. During an interview on 3/4/25 at 3:20 p.m., the Unit Manager indicated the oxygen was to be at 2 liters per minute. 3.1-47(a)(6)

Based on observation and interview, the facility failed to ensure the call light system in a resident's room and the call light system at the nurses' station was properly functioning during random call light observations. (Residents 38 & 18) Findings include: 1. During an observation on 3/2/25 at 12:00 p.m., Resident 38's call light button was pushed. The light inside the room on the wall was observed to be functioning. At 12:27, there was no staff response to the resident's light. The call light in the hallway outside the resident's room was observed and was not activated. At 12:29 p.m., the nurse indicated that the call light was not working, and she would notify the Maintenance Director. 2. On 3/3/25 at 9:24 a.m., Resident 18 indicated her call light lit up outside of her room, but did not work at the nurse's station. She said the staff would only know if her light was going off if they looked down the hall for it. During the environmental tour with the Maintenance Director and the Administrator on 3/6/25 at 2:49 p.m., the Maintenance Director tested the call light in Resident 18's room then observed the call light system at the nurses' station and found the call light system was not functioning properly. During an interview on 3/6/25 at 3:10 p.m., the Maintenance Director indicated he knew the call light at the nurses' station was not operating properly. He contacted the repair technician on 3/6/25 to come and repair the system. 3.1-19(u)(1)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) for 3 of 3 wound care treatments observed. (Residents 3, 6, and 226) Findings include: 1. On 3/5/25 at 11:30 a.m., the Assistant Director of Nursing (ADON) was observed performing the treatment to Resident 3's sacral pressure area. The ADON entered the resident's room and proceeded to wash her hands with soap and water. She donned a pair of gloves, repositioned the resident in bed, and removed the dressing to the resident's sacrum. She was not wearing a gown when she repositioned the resident and removed the dressing. The ADON proceeded to remove her gloves, used hand sanitizer, donned new gloves and a gown and completed the resident's treatment to her sacrum. The record for Resident 3 was reviewed on 3/5/25 at 11:21 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, chronic kidney disease stage 4, and hypertensive heart disease. The Quarterly Minimum Data Set (MDS) assessment, dated 12/2/24, indicated the resident was moderately impaired for daily decision making and she had one Stage 4 pressure area (the wound extends through all layers of the skin, reaching the underlying muscle, tendon, or bone). A Care Plan, reviewed on 12/2/24, indicated the resident was in enhanced barrier precautions (EBP) due to a wound to the coccyx area. The March 2025 Physician's Order Summary (POS) indicated EBP (a set of infection control measures that used gowns and gloves to reduce the spread of multidrug-resistant organisms) was to be maintained due to the resident's sacral wound. During an interview on 3/5/25 at 3:00 p.m., the ADON indicated she should have worn a gown when removing the resident's dressing to the sacrum. 2. On 3/5/25 at 2:34 p.m., the Assistant Director of Nursing (ADON) was observed performing wound care for Resident 6. The ADON entered the resident's room, she washed her hands with soap and water and donned a gown and gloves. She removed the dressing to the resident's left heel. The dressing to the resident's sacrum was already removed due to receiving incontinence care. After changing gloves, sanitizing her hands, and donning new gloves, the ADON completed the treatment to the resident's sacrum. The ADON removed her gown and gloves and left the resident's room to retrieve more supplies from the treatment cart. Upon entering the room, the ADON washed her hands, donned a pair of gloves, and proceeded to complete the treatment to the resident's left heel. She was not wearing a gown at that time. During an interview on 3/5/25 at 3:00 p.m., the ADON indicated she should have worn a gown while completing the treatment to the resident's left heel. The record for Resident 6 was reviewed on 3/4/25 at 12:22 p.m. Diagnoses included, but were not limited to, Alzheimer's disease and Stage 4 pressure ulcer to the left buttock. The 12/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making. He was identified as having one Stage 3 (full thickness tissue loss) pressure ulcer, one Stage 4 (the wound extends through all layers of the skin, reaching the underlying muscle, tendon, or bone) pressure ulcer, and four Deep Tissue Injuries (a type of pressure ulcer that occurs when prolonged pressure or shear forces damage to the underlying soft tissues, such as muscles and bones). A Physician's Order, dated 3/2/25, indicated to maintain EBP (a set of infection control measures that used gowns and gloves to reduce the spread of multidrug-resistant organisms) related to wounds. 43293 3. During an observation on 3/3/25 at 9:05 a.m., Resident 226 was observed resting in bed. She had a dressing on her left lower leg. An EBP (enhanced barrier precautions) sign was on her door. At that time, the resident indicated the Assistant Director of Nursing (ADON) only wore gloves, not a gown, when performing the daily dressing change on her leg. During an observation of wound care on 3/5/25 at 2:03 p.m., the ADON removed the resident's dressing to her leg, and reached over her uncovered wound to get her tablet. She then put on a gown, cleansed the wound, and applied the dressing. The record for Resident 226 was reviewed on 3/4/25 at 11:31 a.m. Diagnoses included, but were not limited to, cerebral infarction and hypertension. The 2/19/25 Nursing Admission Evaluation Assessment indicated the resident was cognitively intact for daily decision making and required limited assistance from staff with ADLs and transfers. A Care Plan, revised on 3/2/25, indicated the resident required EBP due to her wound. A Physician's Order, dated 3/2/25, indicated the EBP were to be in place because the resident had a wound. During an interview on 3/5/25 at 2:20 p.m., the ADON indicated she forgot to put a gown on before beginning wound care. A policy titled, Enhanced Barrier Precautions, received as current from the Unit Manager on 3/6/25 at 10:30 a.m. indicated, . Gloves and gown are applied prior to performing the high contact resident care activity . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . wound care . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure dependent residents received timely assistance with ADL's (activities of daily living) related to incontinence care for 2 of 4 residents reviewed for ADL's. (Residents C and F) Findings include: 1. On 11/12/24 at 5:38 a.m., Resident C was observed lying in bed asleep. The room had a strong urine odor that could be smelled from the doorway. CNA 1 checked on the resident and asked if care could be provided. When CNA 1 pulled the sheet up from the resident's body, there was stool and urine that had leaked onto the bed sheet. The resident's brief was soiled through with urine and stool. During an interview at the time, CNA 1 indicated the resident was not soiled when she came in at 11:00 p.m. CNA 1 had not checked the resident for incontinence since 11:00 p.m. on 11/11/24. The Record for Resident C was reviewed on 11/12/24 at 12:33 p.m. Diagnosis included, but were not limited to, Alzheimer's, depression, anxiety, anemia, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/24, indicated the resident was moderately impaired for daily decision making. The resident had impairment on both sides of the lower extremities. Toileting hygiene and personal hygiene required substantial/maximum assistance and the resident was always incontinent of bowel and urine. A Care Plan, dated 10/17/24, indicated the resident was incontinent of urine. Interventions were to identify incontinence patterns, establish a toileting plan, provide incontinence care as needed, and provide preventative skin care with each incontinent episode. A Care Plan, dated 10/17/24, indicated the resident was incontinent of bowel. Interventions were to identify incontinence patterns, establish a toileting plan, and provide preventative skin care with each incontinent episode. A Care Plan, dated 10/17/24, indicated the resident had an ADL self-care performance deficit related to general weakness, Alzheimer's, and impaired cognition. Interventions indicated the resident required 1-2 staff members for toilet use. During an interview on 11/12/24 at 1:45 p.m., the Administrator indicated Resident C should not have been soiled, and should have been changed and repositioned every 2 hours. 2. On 11/12/24 at 5:50 a.m. and 6:39 a.m., Resident F was observed awake lying in bed. The resident indicated the brief they were wearing was soaked. The resident pulled the covers over and showed the soiled brief. During an interview at the time, Resident F indicated the brief was last changed the previous day on 11/11/24 at 3:00 p.m. The record for Resident F was reviewed on 11/13/24 at 9:55 a.m. Diagnosis included, but were not limited to, respiratory failure, oxygen dependence, weakness and difficulty walking. The Admission Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was cognitively intact for daily decision making. The resident was occasionally incontinent of urine and always incontinent of bowel. Toileting required substantial/maximum assistance and the resident was dependent with lower body dressing. A Care Plan, dated 10/11/24, indicated Resident F was incontinent of bowel. Interventions were to provide peri care after each incontinent episode and to provide peri skin care. A Care Plan, dated 10/11/24, indicated the resident had an ADL self care performance deficit related to impaired mobility. Interventions indicated the resident was totally dependent on staff for toilet use and the resident required 2 staff participation for bed mobility. During an interview on 11/12/24 at 1:48 p.m., the Administrator indicated Resident F should not have been soiled, and should have been changed every 2 hours. This citation relates to Complaint IN00445328. 3.1-38(a)(2)(C)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 3) when providing care to a resident (Resident E) who was in Enhanced Barrier Precautions (EBP) and failed to ensure hand hygiene was completed by a staff member (CNA 2) after the care had been completed, for one random observation for infection control. Finding includes: During an observation on 11/12/24 from 5:37 a.m. through 5:59 a.m., the following was observed: At 5:37 a.m., Resident E was lying in bed. She indicated she had been incontinent of a bowel movement. A urinary catheter drainage bag was observed positioned on the the side of the bed. A sign posted above the bed indicated Enhanced Barrier Precautions were to be used during care. At 5:40 a.m., CNA 3 entered the room and indicated she would need to have another staff member assist her with the incontinence care. CNA 3 donned gloves, retrieved a plastic measuring container from the bathroom, and started to empty out the urinary catheter drainage bag. CNA 3 was stopped prior to starting the task. She indicated the resident required EBP, then continued to empty the urine into the measuring container without the the correct PPE applied (gown). She indicated there was 900 milliliters of urine drained from the bag and emptied the measuring container in the toilet. CNA 3 then donned a gown over her uniform. At 5:55 a.m., CNA 2 entered the room and asked CNA 3 why the gown was worn. CNA 3 indicated the resident was on EBP due to the urinary catheter. CNA 2 indicated she was unaware the resident required EBP. At 5:59 a.m., incontinent care was completed. Resident E requested fresh water for her tumbler. CNA 2 removed one glove, pulled the trash bag out of the trash can and tied the bag, then picked up the tumbler and walked to the door. She then removed the gown and the other glove and rolled it in a wad, and exited the room, while holding the tumbler and the closed trash bag. She then obtained a new trash bag located on the side of the Medication Cart, sitting outside the room in the hall, and placed the gown and glove in the bag and tied the bag up and started to walk down the hallway. CNA 2 was stopped. She indicated the hand gel in the hallway was, old and she would wash her hands. She delivered the trash bags to the soiled utility room, walked out of the room then entered the pantry with the tumbler and washed her hands in the pantry's sink. Resident E's record was reviewed on 11/12/24 at 7:47 a.m. The diagnoses included, but were not limited to, cystitis and lung cancer. A Quarterly Minimum Data Set assessment, dated 8/27/24, indicated an intact cognitive status, was dependent for toileting and bed mobility, and had an indwelling catheter. A Care Plan, dated 4/4/24, indicated a suprapubic urinary catheter was present and EBP was required. The interventions included, the EBP would be used and appropriate hand washing procedures would be completed after care was completed. A Physician's Order, dated 8/27/24, indicated EBP was to be used due to the suprapubic catheter. A facility EBP policy, dated 8/2022 and received as current from the Director of Nursing (DON) on 11/13/24 at 8 a.m., indicated a gown and gloves were to be used during high contact resident care activities. Face protection may be used if there was a risk of splashing or spray. The examples of high contact activities included hygiene, brief change, and device care (urinary catheter). The communication for EBP included signage would be used. A facility hand hygiene policy, dated 11/28/2016 and received from the DON as current, indicated hand hygiene was the final step after removing and disposing of personal protective equipment. 3.1-18(b)

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 67 of 67 residents who resided in the facility. Finding includes: The staffing schedules for 9/1-9/20/23 and 1/1-1/31/24 were reviewed on 2/7/24 at 8:40 a.m. There were currently 2 RN's who worked in the facility as a floor nurse. The other RN's who were employed at the facility, were the Director of Nursing (DON) and the MDS Coordinator. Nursing time cards were reviewed on 2/7/24 at 9:25 a.m., and the following was noted: There was no RN coverage for 7/22/23. There was no RN coverage for 9/2/23. There was no RN coverage for 9/3/23. There was no RN coverage for 9/16/23. There was no RN coverage for 9/17/23. There was no RN coverage on 1/6/24. During an interview on 2/7/24 at 12:10 p.m., the Administrator indicated that they did not have an RN working on the dates above. 3.1-17(b)(3)

Based on observation and interview, the facility failed to keep the resident's environment in good repair, related to marred walls, doors, and door frames, gouged walls, missing baseboards, and non-skid strips peeling off the floor, for 2 of 4 units in the facility. (100 and 200 Hall). Findings include: During the Environmental tour on 2/12/24 at 10:53 a.m., the following was observed: 1. Hall 100 a. room [ROOM NUMBER] - The resident room and bathroom doors were marred as well as the frames. The corner by the closet and bathroom door was gouged and missing the baseboard. There was 1 resident who resided in the room and used the bathroom. b. room [ROOM NUMBER] - The resident room and bathroom doors were marred, as well as the door frames. The walls in the bathroom and in the room were marred. The floor around the toilet was rusty. Two residents resided in the room and used the bathroom. c. room [ROOM NUMBER] - The walls in the room were marred. There was 1 resident who resided in the room. 2. Hall 200 a. room [ROOM NUMBER] - The non-skid strips were peeling next to bed 2 and in the bathroom in front of the toilet. There were 2 residents in room and both residents used the bathroom. b. room [ROOM NUMBER] -The edge of the wall next to the closet was scratched and marred. The wall was marred underneath the grab bar next to the toilet. There were 2 residents in the room and used the bathroom. During the interview on 2/12/24 at 11:15 a.m., the Maintenance Director indicated he was currently training an assistant, and they were currently going through the building to verify and make repairs. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored, for 3 of 4 residents reviewed for skin conditions (non-pressure related), and signs and symptoms of constipation were monitored, for 1 of 1 residents reviewed for constipation. (Residents 56, 22, 166, and 217) Findings include: 1. During a random observation on 2/7/24 at 9:25 a.m., a circular fading reddish/purple bruise was observed on Resident 56's left forearm. During an interview at that time, the resident indicated he noticed the bruise after staff had helped him put on his shirt. The record for Resident 56 was reviewed on 2/7/24 at 1:35 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), intestinal obstruction, weakness, and surgical aftercare following surgery on the digestive system. The Quarterly Minimum Data Set (MDS) assessment, dated 12/5/23, indicated the resident was cognitively intact. He required extensive assistance with bed mobility and transfers. There was no Physician's Order to monitor the bruising to the resident's left forearm. The Weekly Skin Review, dated 1/31/24, indicated the resident's skin was intact. There was no documentation related to bruising. The Weekly Skin Review, dated 2/7/24, indicated the resident's skin was intact. There was no documentation related to bruising. During an interview on 2/9/24 at 1:02 p.m., the Assistant Director of Nursing indicated the resident told her that he had the bruise for a while. She indicated the bruise should have been identified on the weekly skin assessment. 10770 2. On 2/6/24 at 10:29 a.m., Resident 22 was observed sitting in a wheelchair in his room watching television. At that time, both lower arms were observed with red and purple areas of bruising, and the right arm had an old skin tear that was scabbed. The record for Resident 22 was reviewed on 2/9/24 at 11:10 a.m. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes, dependence on renal dialysis, major depressive disorder, heart failure, and high blood pressure. The 11/25/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. A Care Plan, revised on 4/24/23, indicated the resident had potential for further skin integrity impairment related to vision loss and fragile skin. The approaches were to follow facility protocols for treatment and injury. There was no documentation in Nursing Progress Notes prior to 2/6/24 regarding the bruises on both arms. A Nurses' Note, dated 2/7/24 at 10:27 a.m., indicated the resident was noted with multiple bruises and scabbed areas to his hands, arms, and legs. Physician's Orders, dated 2/7/24 at 10:35 a.m., indicated monitor bruising to bilateral arms and right toes until resolved every day and night shift. During an interview on 2/9/24 at 1:15 p.m., the Director of Nursing indicated there was no assessment or documentation of the bruises prior to 2/7/24. 3. During an interview on 2/6/24 at 2:42 p.m., Resident 166 indicated she had trouble with constipation. The record for Resident 166 was reviewed on 2/8/24 at 10:05 a.m. Diagnoses included, but were not limited to, cervical disc degeneration, morbid obesity, anxiety, major depressive disorder, high blood pressure, and seizures. The 12/5/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and was always incontinent of bowel. There was no Care Plan for constipation. Physician's Orders, dated 1/21/23, indicated Polyethylene Glycol powder, give 17 grams by mouth one time a day for constipation. Dissolve 1 capful (17 GM) in 6-8 ounces of liquid. Physician's Orders, dated 11/30/23, indicated Percocet 5-325 milligrams (mg) (Oxycodone with Acetaminophen), give 1 tablet by mouth every 8 hours as needed for pain. There was no prn (as needed) medication ordered for the resident for constipation. The bowel movements (bm) log for the month of 12/2023, indicated, on 12/20 it was blank and not completed. On 12/21 and 12/22 0 was entered, on 12/23 it was blank and not completed, on 12/24 0 was entered, on 12/25 it was blank and not completed, on 12/26 0 was entered and on 12/27-12/29/23 were blank and not completed. The bm log for the month of 1/2024, indicated, on 1/15 it was blank and not completed. On 1/16-1/19/24 a 0 was entered. The bm log for the month of 2/2024, indicated a 0 was entered on 2/2, 2/3, 2/4, and on 2/5 the resident had a small bowel movement. On 2/6/24 another 0 was entered. The Medication Administration Record (MAR) for the month of 1/2024, indicated the resident was administered the Percocet on 1/14, 1/19 times 2, 1/21, 1/24, 1/26, and 1/27/24. During an interview on 2/9/24 at 1:30 p.m., the Director of Nursing indicated staff were not documenting in the point of care when the resident had a bowel movement. 48055 4. On 2/6/24 at 10:49 a.m., Resident 217 was observed with multiple bruise like appearances on the right and left dorsal side of her hands. The record for Resident 217 was reviewed on 2/6/24 at 9:15 a.m. Diagnoses included, but were not limited to, chronic ulcer of the left ankle, right below the leg amputation, squamous cell carcinoma of the skin, peripheral vascular disease, and atherosclerotic heart disease. The resident was admitted to the facility on [DATE]. The Minimum Data Set (MDS) assessment was not completed. A Care Plan, dated 2/6/24, indicated the resident was on anticoagulant therapy of Plavix and Aspirin. An Admission Nursing Assessment Evaluation, dated on 2/5/24, indicated the resident was admitted with areas of non-pressure ulcers to the left distal ankle. There was an old PEG tube scar, as well as a healed wound to the left foot. There was no documentation of bruise like marks on the right and left hand. A Skin Observation Assessment, dated 2/6/24 through 2/7/24, indicated no scratches, red areas, discoloration, skin tear, or open areas noted. During an interview on 2/9/24 at 3:21 p.m., the Director of Nursing (DON) indicated she did not see the marks on the resident's hands, and the nurses missed the bruises to her hand on the Admission Assessment. A facility policy titled, Skin and Wound Management System, provided as current by the Administrator on 2/9/24 at 2:39 p.m., indicated . An assessment of skin integrity is to be performed on each resident upon admission to the center by completing . a.) A head to toe physical evaluation of the skin condition. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to not flushing the PICC line with the correct amount of saline, and a lack of documentation the saline and heparin flushes were administered as ordered, for 1 of 1 residents observed with a PICC line during medication pass. (Resident 62) Finding includes: On 2/9/24 at 11:55 a.m., RN 1 was observed passing medication to Resident 62. He prepared the intravenous (IV) medication of Ceftriaxone 2 grams (gm) and primed a new IV tubing. The RN cleaned the left upper arm access lumen with an alcohol swab, flushed the PICC line with 4 milliliters (ml) of normal saline, attached the tubing containing the Ceftriaxone, and started the IV infusion. At 1:08 p.m., RN 1 was observed disconnecting the IV tubing after the medication had completed infusing. He flushed the PICC line with 4 ml of normal saline, followed with 5 ml of Heparin (an anticoagulant), and applied a new cap to the lumen. Interview with RN 1 on 2/9/24 at 12:05 p.m., indicated he did not know how much of the saline flush to administer prior to connecting the IV. Resident 62's record was reviewed on 2/6/24 at 1:00 p.m. Diagnoses included, but were not limited to, infection following a procedure, disruption of wound, fracture of the left lower leg, open wound, and skin infection. A Physician's Order, dated 1/6/24, indicated IV Ceftriaxone 2 gm one time a day for 40 days. A Physician's Order, dated 1/5/24, indicated flush IV with 10 ml of normal saline followed by 5 ml of Heparin at 10 units/ml every 12 hours. The Medication Administration Record (MAR), dated 2/2024, indicated there was no documentation the saline or Heparin flushes had been administered through the PICC line before and after the IV antibiotic. During an interview, on 2/12/24 at 11:40 a.m., the Director of Nursing (DON) indicated the nurse should have followed the Physician's Order related to the amount of saline used to flush the PICC line, and the saline and Heparin flushes were not on MAR for the nurse to sign they had been administered before and after the IV antibiotic. 3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident with a suprapubic foley catheter received foley catheter care, and catheter bags and tubing were kept off the floor, for 2 of 3 residents reviewed for catheters. (Residents B and D) Findings include: 1. During an interview on 2/6/24 a 10:55 a.m., Resident B indicated nursing staff were not cleaning around his suprapubic foley catheter. At that time, the resident lifted up the bed linens, so his catheter site could be observed. The area around the catheter was red with dried blood noted. There was no split gauze sponge around the ostomy. On 2/6/24 at 1:30 p.m., the resident was observed in bed. At that time, the catheter bag and tubing were observed on the floor. At 3:30 p.m., the catheter bag was now hanging on the side of the garbage can and the bottom of the bag was touching the floor. On 2/7/24 at 9:06 a.m., the resident was observed in bed. At that time, he lifted up the bed linens, so the suprapubic catheter stoma could be observed. There was no bandage noted around the ostomy, and the area was red with dried blood. The catheter bag was touching the floor. On 2/7/24 at 3:40 p.m., the resident was observed in bed. The catheter bag was not attached to anything, and was laying directly on the floor. The record for Resident B was reviewed on 2/7/24 at 2:05 p.m., Diagnoses included, but were not limited to, quadriplegia, neuromuscular of the bladder, anxiety, alcohol abuse, stroke, major depressive disorder, and high blood pressure. The Quarterly Minimum Data Set (MDS) assessment, dated 1/29/24, indicated the resident was cognitively intact and had a suprapubic catheter and an ostomy. The Care Plan, revised on 9/26/23, indicated the resident had an urinary tract infection. The Care Plan, revised on 10/10/23, indicated the resident had a suprapubic catheter. Physician's Orders, dated 9/21/23, indicated cleanse suprapubic catheter site with soap and water and apply a split sponge dressing every night shift for infection control and hygiene. A Physician's Order, dated 12/19/23, indicated Sulfamethoxazole-Trimethoprim (an antibiotic) tablet 800-160 milligrams (mg), give 1 tablet by mouth two times a day for an urinary tract infection for 10 days. The Medication and Treatment Administration Records (MARS/TARS) for the months of 10/2023, 11/2023, 12/2023, 1/2024 and 2/2024, indicated there was no documentation the foley catheter care was being done daily and a sponge dressing was being applied. During an interview on 2/7/24 at 3:45 p.m., the Director of Nursing indicated she was unaware there was no place on the MAR or TAR to sign out the foley catheter care to ensure it was being completed as ordered. The foley catheter bag and tubing was not to be on the floor. The revised and current 10/2010 Suprapubic Catheter Care policy, provided by the Administrator on 2/9/24 at 3:25 p.m., indicated nursing staff were to wash around the catheter site with soap and water. If the resident had a drainage sponge around the stoma site, remove the sponge before washing with soap and water. Document in the resident's medical record the date and time the procedure was performed. 48055 2. On 2/6/24 at 10:30 a.m., Resident D was observed in bed with an indwelling foley catheter. At that time, the bed was low to the floor, and the bag and catheter tubing were observed on the floor. On 2/7/24 at 10:10 a.m., the resident was observed in bed, and the catheter bag was touching the floor. On 02/09/24 at 9:40 a.m., the resident was observed in bed. At that time, the catheter bag was hanging on the bed rail, and the tubing was laying on the floor next to the resident's bed. The record for Resident D was reviewed on 2/6/24 at 9:13 a.m. Diagnoses included, but were not limited to, stroke, hemiplegia, muscle weakness, and aphasia. The State Optional Minimum Data Set (MDS) assessment, dated 1/17/24, indicated the resident was severely impaired for cognitive decision making. A Care Plan indicated the resident was incontinent of bowel and bladder. A Physician's Order indicated foley catheter care was to be administered to the resident every shift and as needed. During an interview, on 2/9/24 at 10:45 a.m., the Director of Nursing (DON) indicated the resident's catheter bag or tubing should not be on the floor. A facility policy titled, Catheter Care Urinary, Infection Control, provided as current by the Administrator on 2/9/24 at 2:39 p.m., indicated . Be sure the catheter tubing and drainage bag are kept off of the floor . This citation relates to Complaint IN00423048. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications, and an assessment to self-administer their own medications, for 3 of 3 residents reviewed for self-administration of medication. (Residents 56, 22, and 54) Findings include: 1. During a random observation on 2/6/24 at 10:24 a.m., two small bottles of Tylenol were observed in a plastic bin containing denture supplies, located on Resident 56's bedside table. During random observations on 2/7/24 at 9:26 a.m., 1:24 p.m., and 3:05 p.m., the bottles of Tylenol remained in the plastic bin. During random observations on 2/8/24 at 9:57 a.m. and 3:04 p.m., the bottles of Tylenol remained in the plastic bin. During a random observation on 2/9/24 at 10:16 a.m., the bottles of Tylenol remained in the plastic bin on the resident's bedside table. The record for Resident 56 was reviewed on 2/7/24 at 1:35 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing) and intestinal obstruction. The Quarterly Minimum Data Set (MDS) assessment, dated 12/5/23, indicated the resident was cognitively intact. The resident did not have a current Care Plan related to self administration of medications. A Physician's Order, dated 10/21/23 and listed as current on the February 2024 Physician's Order Summary (POS), indicated the resident was to receive Tylenol 325 milligrams (mg), 2 tablets every 6 hours as needed for pain. There was no order for the resident to self-administer the medication and a Self-Administration of Medication Assessment had not been completed. During an interview on 2/9/24 at 10:42 a.m., the Director of Nursing (DON) indicated the resident's family would bring in medications for him without telling anyone. She indicated the Tylenol would be removed from the resident's room. 10770 2. On 2/9/24 at 12:40 p.m., Resident 22 was observed in a wheelchair in his room watching television. At that time, there was a large bottle of Tums tablets on his dresser. During an interview at that time, the resident indicated he takes them all the time. On 2/6/24 at 2:13 p.m., on 2/7/24 at 9:30 a.m. and 3:30 p.m., and on 2/8/24 at 9:57 a.m. and 11:08 a.m., the container of Tums was still on his dresser. The record for Resident 22 was reviewed on 2/9/24 at 11:10 a.m. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes, dependence on renal dialysis, major depressive disorder, heart failure, and high blood pressure. The 11/25/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact and needed set up help for eating. There was no Care Plan for the resident to self-administer his own medications. There was no Physician's Order for the Tums, nor was there an order for the resident to self-administer his own medications. There was no Self-Administration of Medication Assessment completed for the resident. During an interview on 2/8/24 at 2:00 p.m., the Director of Nursing indicated there was no Physician's Order for the Tums tablets and there was no Self-Administration of Medication Assessment for the resident to give his own medications. 48383 3. On 2/6/24 at 10:40 a.m., the resident was observed in her room. There was a labeled facility box, which contained a hand held inhaler of Albuterol sulfate, on the resident's bedside table, along with a bottle of Tums. The resident indicated she used the inhaler and Tums when she needed them. On 2/07/24 at 9:08 a.m., Resident 54 was observed in her room. The bottle of Tums and the inhaler were observed on the bedside table. The record for Resident 54 was reviewed on 2/8/24 at 11:00 a.m. Diagnoses included, but were not limited to, hypertension (high blood pressure), heart failure, cancer, respiratory failure, stroke and chronic obstructive pulmonary disease (restricted airway). The Quarterly Minimum Data Set (MDS) assessment, dated 1/22/24, indicated the resident was cognitively intact for daily decision making. The Care Plan, dated 1/22/24, indicated the resident required oxygen therapy due to chronic obstructive pulmonary disease. The interventions were to administer oxygen and puffers as ordered. A Physician's Order, dated 6/16/23, indicated inhale 2 puffs of Albuterol sulfate (inhaler) orally every 6 hours as needed for wheezing. There was no Physician's Order for the Tums. There was no Care Plan to self-administer her medications. There was no Self-Administration of Medication Assessment completed for the resident. During an interview on 2/8/24 at 10:49 a.m., the Director of Nursing (DON) indicated the resident did not have a Self-Administration of Medication Assessment completed. A policy titled Self Administration of Medications, dated 12/2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . 3.1-11(a)

Based on record review and interview, the facility failed to ensure a resident admitted with a pressure ulcer received the necessary treatment and services to prevent further breakdown related to providing preventative measures, the lack of documentation of turning, repositioning, and transferring the resident out of bed which resulted in an unstageable necrotic pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: The closed record for Resident C was reviewed on 9/29/22 at 11:00 a.m. The resident was admitted to the facility on [DATE] from the hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 4/29/22, indicated the resident was rarely understood and rarely understands. The resident was an extensive assist with a 2 plus person physical assist for bed mobility, and toilet use. The resident had 1 unhealed pressure ulcer which was a deep tissue injury (DTI) that was present on admission. A Braden Pressure Scale assessment, dated 4/28/22, indicated the resident was at risk for pressure ulcers. The resident was slightly limited with cognition, was occasionally moist, and required an extra linen change approximately once a day. The resident was slightly limited with mobility and made frequent, though slight changes in body or extremity position independently. The resident's nutrition was adequate. A Braden Pressure Scale assessment, dated 5/5/22, indicated the resident at moderate risk for pressure ulcer. The resident now required moderate to maximum assistance in moving. Complete lifting without sliding against sheets was impossible, frequently slides down in bed or chair requiring frequent repositioning with maximum assistance. A Care Plan, dated 4/22/22, indicated the resident had potential/actual impairment to skin integrity. A Care Plan, dated 4/22/22, indicated the resident had an Activities of Daily Living self care performance deficit related to a stroke. The approaches were to assist with turning and repositioning as needed. A Care Plan, dated 4/22/22, indicated the resident had a chronic foley catheter. A Nursing Evaluation Admission Assessment, dated 4/22/22, indicated the resident had a scab below the left knee and bruising to the abdomen. A Nurses' Note, dated 4/25/22 at 11:15 a.m., indicated a head to toe skin assessment was completed. The resident had a scab to the right knee and a deep tissue injury (pressure ulcer) to the elbow. Physician's Orders, dated 4/25/22, indicated right elbow cleanse with normal saline, pat dry and apply skin prep daily. May apply as needed every shift. one time a day for wound care and every 12 hours as needed. A Wound Observation, dated 4/25/22, indicated the resident was admitted with a deep tissue injury (pressure ulcer) to the right elbow. The ulcer measured 5 centimeters (cm) by 4 cm. A Wound Observation, dated 5/9/22, indicated the right elbow pressure ulcer measured 4 cm by 3 cm. The area was healed on 5/16/22 A Registered Dietitian's (RD) Note, dated 4/28/22 at 11:35 a.m., indicated the resident was a new admission. The resident was NPO (nothing by mouth) and was receiving an enteral feeding through the peg tube (a tube inserted directly into the stomach for nutrition). The enteral feeding provided 100% of nutrition and hydration for the resident. The RD indicated there were no pressure injuries and his weight was 181 pounds with a body mass index of 26.7. The resident would have weekly weights and would be monitored by NAR (Nutrition at Risk). An RD Note, dated 5/4/22 1:39 p.m., indicated the resident remained NPO and enteral feedings were adequate. There were no new recommendations. There was no information regarding any pressure ulcers. Physician's Orders, dated 4/25/22, indicated 16 Fr (French) foley catheter with 10 cc (cubic centimeters) balloon. May change as needed for leakage, dislodgement or occlusion. Physician's Orders, dated 4/28/22, indicated [MEDICATION(S)] 1.5 bolus (237 milliliters) every 4 hours. Nurses' Notes, dated 5/11/22 at 8:28 a.m., indicated the resident was observed with a pressure ulcer to the left buttock. A Wound Observation, dated 5/11/22, indicated an acquired pressure ulcer to left buttock that measured 7 cm by 5 cm. The pressure ulcer was described as unstageable with 100% black necrotic tissue. A Nurses' Note, dated 5/11/22 a 10:53 a.m., indicated the Interdisciplinary Team (IDT) met to review the pressure ulcer to the left buttock. The Physician and family were made aware. New orders were received for the Wound Physician to evaluate and treat, an air mattress was applied to the bed, the RD was consulted and orders for liquid protein received. The Wound Nurse was to follow. There were no Physician's Orders for a liquid protein supplement or a specialty air mattress prior to the development of the unstageable pressure ulcer on 5/11/22. The 5/20/22 Bed Mobility (turning and repositioning) Task for ADLs indicated there was no documentation the resident was turned or repositioned on the day shift on 5/1, 5/2, 5/8, and 5/9/22. There was no documentation on the evening shift on 5/5, 5/7, and 5/11 and on the midnight shift on 5/1, 5/5, 5/9 and 5/10/22. The Bed Mobility Task was only signed out 1 time during the day on 5/3-5/8/22, on evening shift 5/1-5/4, 5/6, and 5/8-5/10/22, and on the midnight shift on 5/2, 5/3, and 5/6-5/8/22 The 5/20/22 Transfer Task for ADLs for all three shifts was coded with an 8 indicating the task did not occur. A Wound Physician Note, dated 5/16/22, indicated it was an initial visit for an unstageable left medial buttock pressure ulcer. The ulcer measured 5 cm by 2.5 cm by unstageable and had 100% thick adherent necrotic tissue. Interview with the Wound Nurse on 9/29/22 at 2:50 p.m., indicated she was livid when she saw the resident had a black necrotic unstageable pressure sore. The facility staffed with mostly Agency Staff and she cannot 100% say the resident was being turned and repositioned every 2 hours. The resident had an indwelling foley catheter and was NPO and received all nutrition through the peg tube. The resident did not speak but could let his needs be known by pointing or nodding. The Wound Nurse indicated barrier cream after each incontinent episode was to be applied and the RD would see the resident when they were high risk for break down. Interview with the Director of Nursing on 9/29/22 at 2:50 p.m., indicated all of the regular mattresses were pressure reducing. The air mattress was ordered for the resident on 5/11/22. Staff were to reposition, check and change the resident every 2 hours, and she could not say that was being done all the time with all of the Agency Staff in the building. Interview with the Wound Nurse on 9/29/22 at 3:30 p.m., indicated she had dropped the ball and did not order the air mattress until 5/11/22. This Federal tag relates to Complaint IN 759 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident's fluid intake was sufficient to maintain proper hydration, related to a resident's decreased fluid intake and facility did not implement new interventions to increase the resident's fluid intake and did not notifying the resident's Physician of the decreased intakes. The resident was transferred and admitted into the hospital with a [DIAGNOSES REDACTED]. (Resident #B) The Immediate Jeopardy began on 12/17/15 when the resident had increased swallowing problems and fluid intake decreased. The resident exhibited signs of dehydration (poor skin turgor and decreased output) on 12/19/15, 3 days prior to the resident's Physician being notified of the signs and symptoms of the dehydration and 5 days prior to the resident being transferred to the emergency room . The resident was admitted into the Intensive Care Unit at the hospital with [DIAGNOSES REDACTED]. The Administrator and Director of Nursing (DoN) were notified of the Immediate Jeopardy on 12/30/15 at 3:28 p.m. Finding includes: Resident #B's record was reviewed on 12/23/15 at 2:00 p.m. The resident's [DIAGNOSES REDACTED]. The resident had a State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, signed by the HCR (Health Care Representative) on 03/05/14, which indicated the resident chose not to have cardiopulmonary resuscitation administered. The Advance Directive Information, signed by the HCR on 10/19/12, indicated the resident did not have a Living Will. An Admission Minimum Data Set assessment, dated 12/10/15, indicated the resident's cognition had not been assessed. The resident's decision making skills were severely impaired. The resident was dependent on staff for eating and all other activities of daily living. The resident did not have swallowing disorders. A Dehydration Assessment, dated 12/01/15, indicated the resident was at risk for dehydration with a score of 12 (higher than 10 at risk) and had swallowing difficulty, required assistance with food and fluids, Received thickened liquids, and was unable to ask for fluids. A care plan, dated 12/17/15, indicated the resident was a risk for dehydration related to a poor oral intake. The goal indicated the resident would exhibit no signs and symptoms of dehydration. The interventions included, Encourage to consume all fluids offered at mealtime .Observe for s/sx (signs and symptoms) dehydration (i.e. (example): dry oral mucosa/lips, skin tenting, dark/foul smelling urine), Offer and encourage between meal fluid consumption An undated dietary care plan, indicated the resident required a therapeutic diet with thickened fluids. The interventions included, provide diet/fluids as prescribed, supplements, record meal consumption and report signs and symptoms of swallowing problems. The Registered Dietitian's Full Assessment, dated 12/14/15, indicated the resident's estimated milliliters (ml) of fluid needs of 2004 ml daily. The Medication Administration Record, [REDACTED]. The Carnation Instant Breakfast intake was as follows: 12/17/15-60 milliliters (ml) for breakfast and lunch and 10 ml for supper 12/18/15-60 ml for breakfast and lunch and 80 ml for supper 12/19/15-60 ml for breakfast, 20 ml for lunch, and 20 ml for supper 12/20/15-50 ml breakfast, sips for lunch and supper 12/21/15-50 ml breakfast and sips for lunch and supper 12/22/15-none was taken for breakfast The four ounces of pudding was not consumed at bedtime from 12/16/15 through 12/21/15. The Dietary Consumption Records, dated 12/15/15 through 12/22/15, indicated the following intakes of food: 12/15/15-(B) 51-75%, (L) 26-50%, (S) 51-75% 12/16/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/17/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/18/15-(B) refused, (L) 0-25%, (S) 0-25% 12/19/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/20/15- (B) 0-25%, (L) 51-75%, S) 0-25% 12/21/15- (B) 0-25%, (L) 0-25%, (S) 0-25% 12/22/15- (B) refused The fluid intakes for December 2015, indicated the following milliliters per day: 12/4/15- 240 12/6/15- 240 12/10/15- 840 12/11/15- 720 12/12/15- 960 12/13/15- 690 12/14/15- 570 12/15/15-1080 12/16/15- 480 12/17/15- 360 12/18/15- 135 12/19/15- 360 12/20/15- 360 12/21/15- 240 A Speech Therapy Note, dated 12/15/15, indicated, .Dietary spoke with therapist today regarding patient's progress with current diet .Therapist also informed dietary that amount consumed by patient is decreased d/t (due to) difficulty initiating swallow .which creates concern for patient meeting daily nutritional/hydration needs. A Speech Therapy Note, dated 12/17/15, indicated, Therapist education to LPN (Licensed Practical Nurse) (LPN #3) as patient was placed in a semi laying position in an attempt to feed her. This was being done to prevent anterior spillage to increase intake. Unfortunately, irregardless of position, the patient was unable to consume an adequate amount of food for nutrition/hydration. Consulted with nursing on feeding techniques including the possible use of a controlled bolus via a syringe. Nursing to track intake for the next 4 days and will speak with family about alternative feeding if patient continues to display an inability to swallow sufficiently to maintain weight and hydration .This appears to be related to an overall decline in medical status related to advancing dementia. The Nurses' Progress Notes indicated: 12/17/15 at 7:54 p.m.- resident consumed 0-25% of her evening meal 12/18/15 at 2:01 p.m.- (Written by LPN #1) Resdient (sic) did not eat at am (morning) meal, kept pushing food out of her mouth. Resident did eat approx. (approximately) 50% of noon meal. 12/18/14 at 10:06 p.m.- (Written by RN, Registered Nurse, #4) Res. (resident) ate only a couple of bites at dinner. She pushes food out of her mouth and takes in very little. 12/19/15 at 4:04 p.m.- (Written by LPN #1) Resident ate approx 50% of am meal, at noon meal resident did not swallow any food writer put in her mouth, resident held head down and food slid out of mouth. 12/19/15 at 10:16 p.m.- (Written by RN #4) Res. had poor food consumption this shift. She ate only bites at dinner even with many attempts to get her to eat. Res. had some sips of liquid but only very little. Res. had a dry brief at the end of shift .Res. has poor skin turgor as evidenced by tenting (skin pinched up) of the hands and sternum greater than a (sic) 3 second return (amount of time it takes for skin to return to normal after being pinched up) (test for dehydration); fluids were offered and resident did not drink well 12/20/15 at 2:26 a.m.- (Written by RN #5) No food consumption on this shift. She did take sips of fluids this shift She has poor skin turgor as evidenced by tenting of the hands and sternum greater than 3 seconds return 12/20/15 at 12:52 p.m.- (Written by LPN #1) REsident (sic) ate and swallowed a few bites for am meal, resident took and swallowed meds (medications), at noon meal resident opened mouth to take food but would not swallow the food, writer attempted to encourage resident to swallow but she did not, writer had to remove the food from residents mouth. 12/21/15 at 2:50 a.m.- (no progress note from 12:52 p.m. to this note) (Written by RN #6) Refused intake this shift. No output 12/21/15 at 2:39 p.m.- (Written by LPN #1) REsident (sic) ate 3 bites including medication for am meal, after the first three bites, resident just held food in her mouth and would not swallow, any fluids attempted to be administered ran back out of her mouth. Resident ate two bites at noon meal and then would not swallow any more food, any fluids attempted to be administered ran back out of residents mouth. 12/21/15 at 10:34 p.m.- (Written by RN #4) Two staff assisted resident with her dinner. One staff helped hold up resident's head while the other staff attempted to feed resident. Res. took only a few bites before the food began to fall back out of her mouth. Res. was given several spoons of liquid to encourage her to drink more fluids. Res. did swallow some. Mostly the liquids drained out of her mouth even with her head up. Res. had a wet brief after dinner and her skin turgor was less than 3 seconds on her hands and sternum .MD (Medical Doctor) was contacted just to give him report about the resident and situation. MD aware. 12/22/15 at 4:33 a.m.- (Written by RN #5) Resident took in sips of water and did void one time so far this shift .Skin turgor was less than 3 seconds on her hands and sternum 12/22/15 at 11:15 a.m.- (Written by LPN #3) Resident resting in bed at this time. Resident continues to not eat or drink fluids offered by staff at meal times. Resident was unable to take meds this AM and medications rolled out of mouth. MD called and informed of residents (sic) status. New orders received and noted to send to (Hospital Name) for evaluation and treatment . 12/22/15 at 12:10 p.m.- Resident left facility at this time in stable condition. Report called to (Hospital ER). The emergency room Physician's Note, dated 12/22/15 at 1:01 p.m., indicated the resident had an associated [DIAGNOSES REDACTED]. The laboratory tests, dated 12/22/15 at 3:56 p.m., indicated the resident's white blood count was 14.9 (normal 4.8-10.8), urine was yellow and cloudy, negative for glucose (sugar), [MEDICATION NAME] (made when body breaks down fat for energy), and leukocytes (white blood cells). The resident's sodium was 181 (normal 135-147), potassium was 4.1 ( normal 3.5-5), BUN (kidney function) 156 (normal 7-22), and Creatinine (kidney function) 3.6 (normal 0.4-1.5). The hospital History and Physical, dated 12/23/15, indicated the resident had severe [MEDICAL CONDITION] (elevated sodium), lethargy/metabolic [MEDICAL CONDITION] (disease of the brain), severe dehydration/AKI (acute kidney injury) (kidney failure), and leukocytosis (elevated white cells). The plan indicated intravenous fluids, do not want to lower the Na (sodium) to acutely (cerebral [MEDICAL CONDITION] would be a concern) During an interview on 12/23/15 at 1 p.m., the Hospital Physician indicated the resident was very dehydrated upon admission to the ICU. He indicated this was due to not enough fluid intake. During an interview on 12/23/15 at 3:22 p.m., the Assistant Director of Nursing (ADoN) indicated the resident's Physician and POA should have been notified when the resident's food and fluid consumption had decreased and when the resident first started showing signs of dehydration. During an interview on 12/23/15 at 4:07 p.m., the Dietary Manager indicated the Registered Dietician saw the resident on 12/14/15, and the resident had received supplements which she had consumed. During an interview on 12/23/15 at 4:07 p.m., the ADoN indicated she was unsure why the resident's Physician and POA were not called when the resident had started to decline and exhibited symptoms of dehydration. During an interview on 12/28/15 at 8:26 a.m., LPN #1 indicated the first few days the resident was at the facility she ate well, then she started pushing the food out of her mouth and the last few days she was at the facility she would spit the food out or it would drool from her mouth. LPN #1 indicated no one had reported she wasn't eating. LPN #1 indicated the last week before she was sent out was when he found out the resident was not eating. LPN #1 indicated the Physician and/or POA had not been notified when he was aware the resident had not been eating or drinking well. During an interview on 12/28/15 at 9:28 a.m., Speech Therapist (ST) #2 indicated she had spoke with the nurse (LPN #3) when the resident was first declining and informed the nurse intake of food/fluid consumption would be needed and also to contact the family/POA to determine what they would like done and to explain the progression of the disease process. ST #2 indicated they always spoke to the nurse taking care of the resident, so they can contact the family/POA and then contact the Physician. During an interview on 12/28/15 at 9:52 a.m., LPN #3 indicated she added the resident to the board so everyone would know they needed to document intakes. LPN #3 indicated ST said they would notify the family. LPN #3 indicated usually with a change in condition the Nurse would call the Physician and family/POA. LPN #3 indicated she had contacted the family on 12/22/15. During an interview on 12/28/15 at 10:24 a.m., the Dietary Manager indicated the resident was reviewed by the Nutrition at Risk (NAR) committee. A note received from the Dietary Manager, dated 12/18/15, indicated, the resident was starting to have a decrease in food/fluid consumption and to have the staff monitor and notify the family in a few days for their decision for either a feeding tube or for comfort measures. During an interview on 12/28/15 at 11:22 a.m., RN #4 indicated she had not initiated interventions for the decrease of food and fluid intake. She indicated she had not known if it was a change. She indicated she kept an eye on the resident. RN #4 indicated she had been informed by the past Director of Nursing (DoN) that if a resident was showing signs of dehydration, she no longer had to call the Physician and only document if the resident accepted or did not accept fluids. RN #4 indicated she was told the State doesn't require us to call the Physician. RN #4 indicated she had passed the information on to the next shift on 12/19/15 to ensure the staff attempted to give the resident fluids. RN #4 indicated when she worked on 12/21/15 she reported to the Social Service Director the resident was not eating or drinking enough and had attempted to notify the resident's family/POA and was unable to. RN #4 indicated she then notified the resident's Physician and informed the Physician the resident was not eating or drinking at all and the Physician indicated he would be in the building the next morning to see the resident. During an interview on 12/28/15 at 11:38 a.m., LPN #3 indicated the resident's Physician had not been in to see the resident prior to her being transferred to the hospital. A Hospital Physician's Progress Note, dated 12/28/15, indicated, .[MEDICAL CONDITION] (elevated sodium) from severe water deficit-now better. Severe azotemia (elevated BUN and creatinine levels) and AKI (acute kidney injury) on admit from volume depletion A Hospital Physician's Progress Note, dated 12/29/15, indicated, .[MEDICAL CONDITION] .AKI: improving; Likely prerenal azotemia and possible ATN (acute tubular necrosis) from poor oral intake A facility policy, dated 10/2012, titled, Acute Hydration at Risk, received from the Director of Nursing as current, indicated, To assure each resident receives adequate fluids to prevent dehydration to the extent the resident's condition makes this possible .Each resident shall be assessed for risk factors for dehydration within 72 hours of admission .A resident shall be deemed 'Hydration at Risk' under the following conditions: .Acute decline in fluid intake that lasts > (over) 48 hours. d. Presentation of signs/symptoms of dehydration .The Hydration at Risk/Nutrition at Risk committee will meet weekly and review those residents designated 'Hydration at Risk' for response to the developed Hydration at Risk plan of care . The immediate jeopardy that began on 12/17/15 was removed on 12/31/15 when the facility reviewed all resident records to identify residents at risk for dehydration. All residents' in the facility were assessed for dehydration. Facility Nurses' were inserviced on ensuring physician notification for residents exhibiting signs and symptoms of dehydration and decreased fluid intake. All direct care staff were inserviced related to provision of care. The facility inserviced staff for physician notification and hydration. Staff were interviewed and were knowledgeable of the policies and protocols. The Nurses are to make rounds at least daily to ensure residents needs are being met and an audit tool will be utilized to assure services to are being provided, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility will continue to audit all residents with changes of condition and decreased food and fluid intakes and to ensure the policies are followed and the residents at risk for dehydration are treated with sufficient fluid intake to prevent dehydration. This Federal Tag relates to Complaint IN 580. 3.1-27(a)(3)

Based on record review and interview, the facility failed to ensure a resident's care was not neglected related to, not implementing new interventions when a resident's food and fluid intake decreased, the resident exhibited increased swallowing problems, not following Speech Therapy's recommendations of notifying the family for directions on alternate ways for food and fluid consumption, and not notifying the resident's Physician and Health Care Representative (HCR) in a timely manner of the decrease in food and fluid intake for 1 of 7 residents reviewed for neglect in a total sample of 5 and extended sample of 4. (Resident #B). The Immediate Jeopardy began on 12/17/15 when the resident had increased swallowing problems and food and fluid intake decreased. The resident exhibited signs of dehydration (poor skin turgor and decreased output), on 12/19/15, 3 days prior to the resident's Physician being notified of the signs and symptoms of the dehydration and 5 days prior to the resident being transferred to the emergency room . The resident was admitted into the Intensive Care Unit at the hospital with [DIAGNOSES REDACTED]. The Administrator and Director of Nursing (DoN) were notified of the Immediate Jeopardy on 12/29/15 at 9:14 a.m. Finding includes: Resident #B's record was reviewed on 12/23/15 at 2:00 p.m. The resident's [DIAGNOSES REDACTED]. The resident had a State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, signed by the HCR (Health Care Representative) on 03/05/14, which indicated the resident chose not to have cardiopulmonary resuscitation administered. The Advance Directive Information, signed by the HCR on 10/19/12, indicated the resident did not have a Living Will. An Admission Minimum Data Set assessment, dated 12/10/15, indicated the resident's cognition had not been assessed. The resident's decision making skills were severely impaired. The resident was dependent on staff for eating and all other activities of daily living. The resident did not have swallowing disorders. A care plan, dated 12/17/15, indicated the resident was a risk for dehydration related to a poor oral intake. The goal indicated the resident would exhibit no signs and symptoms of dehydration. The interventions included, Encourage to consume all fluids offered at mealtime .Observe for s/sx (signs and symptoms) dehydration (i.e. (example): dry oral mucosa/lips, skin tenting, dark/foul smelling urine), Offer and encourage between meal fluid consumption An undated dietary care plan, indicated the resident required a therapeutic diet with thickened fluids. The interventions included, provide diet/fluids as prescribed, supplements, record meal consumption and report signs and symptoms of swallowing problems. The Registered Dietitian's Full Assessment, dated 12/14/15, indicated the resident's caloric needs were 1670-2004 calories per day and an estimated milliliters (ml) of fluid needs of 2004 ml daily. The resident had fair to poor meal intakes 25-50% for breakfast, 25-75% for lunch and 0-75% at supper. Supplements were in place and the resident would continue to be monitored for weights and status. The Medication Administration Record, [REDACTED]. The intake of the Magic Cup, at lunch, dated 12/17/15 and 12/18/15, was 25% and, 12/19/15 through 12/22/15, the resident had not consumed any of the Magic Cup. The intake at supper, indicated on 12/17/15 through 12/21/15 the resident had not consumed the Magic Cup. The Carnation Instant Breakfast intake was as follows: 12/17/15-60 milliliters (ml) for breakfast and lunch and 10 ml for supper 12/18/15-60 ml for breakfast and lunch and 80 ml for supper 12/19/15-60 ml for breakfast, 20 ml for lunch, and 20 ml for supper 12/20/15-50 ml breakfast, sips for lunch and supper 12/21/15-50 ml breakfast and sips for lunch and supper 12/22/15-none was taken for breakfast The four ounces of pudding was not consumed at bedtime from 12/16/15 through 12/21/15. The Dietary Consumption Records, dated 12/2/15 through 12/14/15, indicated the average intake for breakfast (B) was 26-50%, lunch (L) was 26-50%, and supper (S) was 26-75%. The Dietary Consumption Records, dated 12/15/15 through 12/22/15, indicated the following intakes of food: 12/15/15-(B) 51-75%, (L) 26-50%, (S) 51-75% 12/16/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/17/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/18/15-(B) refused, (L) 0-25%, (S) 0-25% 12/19/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/20/15- (B) 0-25%, (L) 51-75%, S) 0-25% 12/21/15- (B) 0-25%, (L) 0-25%, (S) 0-25% 12/22/15- (B) refused The fluid intakes for December 2015, indicated the following milliliters per day: 12/4/15- 240 12/6/15- 240 12/10/15- 840 12/11/15- 720 12/12/15- 960 12/13/15- 690 12/14/15- 570 12/15/15-1080 12/16/15- 480 12/17/15- 360 12/18/15- 135 12/19/15- 360 12/20/15- 360 12/21/15- 240 A Speech Therapy Note, dated 12/15/15, indicated, .Dietary spoke with therapist today regarding patient's progress with current diet .Therapist also informed dietary that amount consumed by patient is decreased d/t (due to) difficulty initiating swallow .which creates concern for patient meeting daily nutritional/hydration needs. A Speech Therapy Note, dated 12/17/15, indicated, Therapist education to LPN (Licensed Practical Nurse) as patient was placed in a semi laying position in an attempt to feed her. This was being done to prevent anterior spillage to increase intake. Unfortunately, irregardless of position, the patient was unable to consume an adequate amount of food for nutrition/hydration. Consulted with nursing on feeding techniques including the possible use of a controlled bolus via a syringe. Nursing to track intake for the next 4 days and will speak with family about alternative feeding if patient continues to display an inability to swallow sufficiently to maintain weight and hydration .This appears to be related to an overall decline in medical status related to advancing dementia. The Nurses' Progress Notes indicated: 12/17/15 at 7:54 p.m.- resident consumed 0-25% of her evening meal 12/18/15 at 2:01 p.m.- (Written by LPN #1) Resdient (sic) did not eat at am (morning) meal, kept pushing food out of her mouth. Resident did eat approx. (approximately) 50% of noon meal. 12/18/14 at 10:06 p.m.- (Written by RN, Registered Nurse, #4) Res. (resident) ate only a couple of bites at dinner. She pushes food out of her mouth and takes in very little. 12/19/15 at 4:04 p.m.- (Written by LPN #1) Resident ate approx 50% of am meal, at noon meal resident did not swallow any food writer put in her mouth, resident held head down and food slid out of mouth. 12/19/15 at 10:16 p.m.- (Written by RN #4) Res. had poor food consumption this shift. She ate only bites at dinner even with many attempts to get her to eat. Res. had some sips of liquid but only very little. Res. had a dry brief at the end of shift .Res. has poor skin turgor as evidenced by tenting (skin pinched up) of the hands and sternum greater than a (sic) 3 second return (amount of time it takes for skin to return to normal after being pinched up) (test for dehydration); fluids were offered and resident did not drink well 12/20/15 at 2:26 a.m.- (Written by RN #5) No food consumption on this shift. She did take sips of fluids this shift She has poor skin turgor as evidenced by tenting of the hands and sternum greater than 3 seconds return 12/20/15 at 12:52 p.m.- (Written by LPN #1) REsident (sic) ate and swallowed a few bites for am meal, resident took and swallowed meds (medications), at noon meal resident opened mouth to take food but would not swallow the food, writer attempted to encourage resident to swallow but she did not, writer had to remove the food from residents mouth. 12/21/15 at 2:50 a.m.- (no progress note from 12:52 p.m. to this note) (Written by RN #6) Refused intake this shift. No output 12/21/15 at 2:39 p.m.- (Written by LPN #1) REsident (sic) ate 3 bites including medication for am meal, after the first three bites, resident just held food in her mouth and would not swallow, any fluids attempted to be administered ran back out of her mouth. Resident ate two bites at noon meal and then would not swallow any more food, any fluids attempted to be administered ran back out of residents mouth. 12/21/15 at 10:34 p.m.- (Written by RN #4) Two staff assisted resident with her dinner. One staff helped hold up resident's head while the other staff attempted to feed resident. Res. took only a few bites before the food began to fall back out of her mouth. Res. was given several spoons of liquid to encourage her to drink more fluids. Res. did swallow some. Mostly the liquids drained out of her mouth even with her head up. Res. had a wet brief after dinner and her skin turgor was less than 3 seconds on her hands and sternum. Res. sons (Son #1 and #2) were called to give them an update on how the resident was doing and to let them know she was not eating or drinking much. (Son #1's Name) phone would not accept calls. (Son #2's Name) phone was not answered and his mailbox was not set up. So neither son could be contacted. MD (Medical Doctor) was contacted just to give him report about the resident and situation. MD aware. 12/22/15 at 4:33 a.m.- (Written by RN #5) Resident took in sips of water and did void one time so far this shift .Skin turgor was less than 3 seconds on her hands and sternum 12/22/15 at 11:15 a.m.- (Written by LPN #3) Resident resting in bed at this time. Resident continues to not eat or drink fluids offered by staff at meal times. Resident was unable to take meds this AM and medications rolled out of mouth. MD called and informed of residents (sic) status. New orders received and noted to send to (Hospital Name) for evaluation and treatment. This nurse attempted to contact (Son #1 and #2's Name). (Son's #1's Name) number stated that it was unable to receive incoming calls and (Son #2's Name) number stated that there was no voicemail box set up. 12/22/15 at 12:10 p.m.- Resident left facility at this time in stable condition. Report called to (Hospital ER). 12/22/15 at 12:19 p.m.- Writer (Social Service Director) called and spoke with resident's POA (Power of Attorney) (Son #1) on the telephone to inform him that his mother will be transported to (Hospital Name). He was then transferred to the nurse for clinical information. 12/22/15 at 12:30 p.m.- (Written by LPN #3) .This nurse writer gave son (Son #1) update on mothers (sic) condition .then asked son for direct phone number where he could be reached to be updated on mothers (sic) condition a the hospital but the son refused to give this nurse the number. The Weight and Vitals Summary in the record, indicated resident's weights were 12/02/15-147 pounds, 12/09/15-146.8 pounds, 12/16/15-144.6 pounds at the facility. The emergency room Admission Notes, dated 12/22/15 at 1:01 p.m. indicated the residents weight was 144 pounds. The emergency room Physician's Note, dated 12/22/15 at 1:01 p.m., indicated the resident had an associated [DIAGNOSES REDACTED]. The laboratory tests, dated 12/22/15 at 3:56 p.m., indicated the resident's white blood count was 14.9 (normal 4.8-10.8), urine was yellow and cloudy, negative for glucose (sugar), [MEDICATION NAME] (made when body breaks down fat for energy), and leukocytes (white blood cells). The resident's sodium was 181 (normal 135-147), potassium was 4.1 ( normal 3.5-5), BUN (kidney function) 156 (normal 7-22), and Creatinine (kidney function) 3.6 (normal 0.4-1.5). The hospital History and Physical, dated 12/23/15, indicated the resident had severe [MEDICAL CONDITION] (high sodium level), lethargy/metabolic [MEDICAL CONDITION] (disease of the brain), severe dehydration/AKI (acute kidney injury) (kidney failure), and leukocytosis (elevated white blood cells). The plan indicated intravenous fluids, do not want to lower the Na (sodium) to acutely (cerebral [MEDICAL CONDITION] would be a concern) During an interview on 12/23/15 at 1 p.m., the Hospital Physician indicated the resident was very dehydrated upon admission to the ICU. He indicated this was due to not enough fluid intake. During an interview on 12/23/15 at 3:22 p.m., the Assistant Director of Nursing (ADoN) indicated the resident's Physician and POA should have been notified when the resident's food and fluid consumption had decreased and when the resident first started showing signs of dehydration. During an interview on 12/23/15 at 4:07 p.m., the Dietary Manager indicated the Registered Dietician saw the resident on 12/14/15, and the resident had received supplements which she had consumed. During an interview on 12/23/15 at 4:07 p.m., the ADoN indicated she was unsure why the resident's Physician and POA were not called when the resident had started to decline and exhibit symptoms of dehydration. During an interview on 12/28/15 at 8:26 a.m., LPN #1 indicated the first few days the resident was at the facility she ate well, then she started pushing the food out of her mouth and the last few days she was at the facility she would spit the food out or it would drool from her mouth. LPN #1 indicated no one had reported she wasn't eating. LPN #1 indicated the last week before she was sent out was when he found out the resident was not eating. LPN #1 indicated the Physician and/or POA had not been notified when he was aware the resident had not been eating or drinking well. During an interview on 12/28/15 at 9:28 a.m., Speech Therapist (ST) #2 indicated she had spoke with the nurse (LPN #3) when the resident was first declining and informed the nurse intake of food/fluid consumption would be needed and also to contact the family/POA to determine what they would like done and to explain the progression of the disease process. ST #2 indicated they always spoke to the nurse taking care of the resident so they could contact the family/POA and then contact the Physician. During an interview on 12/28/15 at 9:52 a.m., LPN #3 (ST spoke to) indicated she added the resident to the board so everyone would know they needed to document intakes. LPN #3 indicated ST said they would notify the family. LPN #3 indicated usually with a change in condition the Nurse would call the Physician and family/POA. LPN #3 indicated she had contacted the family on 12/22/15. During an interview on 12/28/15 at 10:24 a.m., the Dietary Manager indicated the resident was reviewed by the Nutrition at Risk (NAR) committee. A note received from the Dietary Manager, dated 12/18/15, indicated, the resident was starting to have a decrease in food/fluid consumption and to have the staff monitor and notify the family in a few days for their decision for either a feeding tube or for comfort measures. During an interview on 12/28/15 at 11:22 a.m., RN #4 indicated she had not initiated interventions for the decrease of food and fluid intake. She indicated she had not known if it was a change. She indicated she kept an eye on the resident. RN #4 indicated she had been informed by the past Director of Nursing (DoN) that if a resident was showing signs of dehydration, she no longer had to call the Physician and only document if the resident accepted or did not accept fluids. RN #4 indicated she was told the State doesn't require us to call the Physician. RN #4 indicated she had passed the information on to the next shift on 12/19/15 to ensure the staff attempted to give the resident fluids. RN #4 indicated when she worked on 12/21/15 she reported to the Social Service Director the resident was not eating or drinking enough and had attempted to notify the resident's family/POA and was unable to. RN #4 indicated she then notified the resident's Physician and informed the Physician the resident was not eating or drinking at all and the Physician indicated he would be in the building the next morning to see the resident. During an interview on 12/28/15 at 11:38 a.m., LPN #3 indicated the resident's Physician had not been in to see the resident prior to her being transferred to the hospital. A Hospital Physician's Progress Note, dated 12/28/15, indicated, .[MEDICAL CONDITION] from severe water deficit-now better. Severe azotemia (elevated BUN and creatinine levels) and AKI (acute kidney injury) on admit from volume depletion A Hospital Physician's Progress Note, dated 12/29/15, indicated, .[MEDICAL CONDITION] .AKI: improving; Likely prerenal azotemia and possible ATN (acute tubular necrosis) from poor oral intake An undated Facility Policy, titled, Abuse Prevention Program, received from the Director of Nursing as current on 12/29/15 at 10 a.m., indicated, .It is the policy of this facility to prevent resident abuse, neglect .On a regular basis, supervisors will monitor the ability of the staff to meet needs of residents, staff understanding of individual resident care needs and situations .Neglect/Mistreatment: means the failure to provide or willful withholding of adequate medical care .personal care or assistance with activities of daily living that is necessary to avoid physical harm The immediate jeopardy that began on 12/17/15 was removed on 12/31/15 when the facility reviewed all resident records to identify changes in condition and physician and family notifications. All residents' in the facility were assessed for changes in conditions and potential neglect. Facility Nurses' were inserviced on ensuring physician notification of any change in condition and neglect. All direct care staff were inserviced related to provision of care to residents and change in condition. The facility inserviced staff for neglect, physician notification, hydration, and nutrition. Staff were interviewed and were knowledgeable of the policies and protocols. An audit tool was reviewed to ensure physician and family notifications were being completed, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility will continue to audit all residents with changes of condition and decreased food and fluid intakes to ensure the policies are followed and the residents are not neglected. This Federal Tag relates to Complaint IN 580. 3.1-27(a)(3)

Based on record review and interview, the facility failed to ensure a resident maintained an acceptable nutritional status, related to a decrease in dietary intake with no new interventions initiated, which caused weight loss for 1 of 4 residents reviewed for nutrition in a total sample of 5 and extended sample of 4. (Resident #B) Finding includes: Resident #B's record was reviewed on 12/23/15 at 2:00 p.m. The resident's [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment, dated 12/10/15, indicated the resident's cognition had not been assessed. The resident's decision making skills were severely impaired. The resident was dependent on staff for eating and all other activities of daily living. The resident did not have swallowing disorders. An undated dietary care plan, indicated the resident required a therapeutic diet with thickened fluids. The interventions included, provide diet/fluids as prescribed, supplements, record meal consumption and report signs and symptoms of swallowing problems. The Registered Dietitian's Full Assessment, dated 12/14/15, indicated the resident's caloric needs were 1670-2004 calories per day and an estimated milliliters (ml) of fluid needs of 2004 ml daily. The resident had fair to poor meal intakes 25-50% for breakfast, 25-75% for lunch and 0-75% at supper. Supplements were in place and the resident would continue to be monitored for weights and status. The Medication Administration Record, [REDACTED]. The intake of the Magic Cup, at lunch, dated 12/17/15 and 12/18/15, was 25% and, 12/19/15 through 12/22/15, the resident had not consumed any of the Magic Cup. The intake at supper, indicated on 12/17/15 through 12/21/15 the resident had not consumed the Magic Cup. The Carnation Instant Breakfast intake was as follows: 12/17/15-60 milliliters (ml) for breakfast and lunch and 10 ml for supper 12/18/15-60 ml for breakfast and lunch and 80 ml for supper 12/19/15-60 ml for breakfast, 20 ml for lunch, and 20 ml for supper 12/20/15-50 ml breakfast, sips for lunch and supper 12/21/15-50 ml breakfast and sips for lunch and supper 12/22/15-none was taken for breakfast The four ounces of pudding was not consumed at bedtime from 12/16/15 through 12/21/15. The Dietary Consumption Records, dated 12/2/15 through 12/14/15, indicated the average intake for breakfast (B) was 26-50%, lunch (L) was 26-50%, and supper (S) was 26-75%. The Dietary Consumption Records, dated 12/15/15 through 12/22/15, indicated the following intakes of food: 12/15/15-(B) 51-75%, (L) 26-50%, (S) 51-75% 12/16/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/17/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/18/15-(B) refused, (L) 0-25%, (S) 0-25% 12/19/15-(B) 0-25%, (L) 0-25%, (S) 0-25% 12/20/15- (B) 0-25%, (L) 51-75%, S) 0-25% 12/21/15- (B) 0-25%, (L) 0-25%, (S) 0-25% 12/22/15- (B) refused A Speech Therapy Note, dated 12/15/15, indicated, .Dietary spoke with therapist today regarding patient's progress with current diet .Therapist also informed dietary that amount consumed by patient is decreased d/t (due to) difficulty initiating swallow .which creates concern for patient meeting daily nutritional/hydration needs. A Speech Therapy Note, dated 12/17/15, indicated, Therapist education to LPN (Licensed Practical Nurse) as patient was placed in a semi laying position in an attempt to feed her. This was being done to prevent anterior spillage to increase intake. Unfortunately, irregardless of position, the patient was unable to consume an adequate amount of food for nutrition/hydration. Consulted with nursing on feeding techniques including the possible use of a controlled bolus via a syringe. Nursing to track intake for the next 4 days and will speak with family about alternative feeding if patient continues to display an inability to swallow sufficiently to maintain weight and hydration .This appears to be related to an overall decline in medical status related to advancing dementia. The Nurses' Progress Notes indicated: 12/17/15 at 7:54 p.m.- resident consumed 0-25% of her evening meal 12/18/15 at 2:01 p.m.- (Written by LPN #1) Resdient (sic) did not eat at am (morning) meal, kept pushing food out of her mouth. Resident did eat approx. (approximately) 50% of noon meal. 12/18/14 at 10:06 p.m.- (Written by RN, Registered Nurse, #4) Res. (resident) ate only a couple of bites at dinner. She pushes food out of her mouth and takes in very little. 12/19/15 at 4:04 p.m.- (Written by LPN #1) Resident ate approx 50% of am meal, at noon meal resident did not swallow any food writer put in her mouth, resident held head down and food slid out of mouth. 12/19/15 at 10:16 p.m.- (Written by RN #4) Res. had poor food consumption this shift. She ate only bites at dinner even with many attempts to get her to eat. Res. had some sips of liquid but only very little . 12/20/15 at 2:26 a.m.- (Written by RN #5) No food consumption on this shift . 12/20/15 at 12:52 p.m.- (Written by LPN #1) REsident (sic) ate and swallowed a few bites for am meal, resident took and swallowed meds (medications), at noon meal resident opened mouth to take food but would not swallow the food, writer attempted to encourage resident to swallow but she did not, writer had to remove the food from residents mouth. 12/21/15 at 2:50 a.m.- (no progress note from 12:52 p.m. to this note) (Written by RN #6) Refused intake this shift . 12/21/15 at 2:39 p.m.- (Written by LPN #1) REsident (sic) ate 3 bites including medication for am meal, after the first three bites, resident just held food in her mouth and would not swallow, any fluids attempted to be administered ran back out of her mouth. Resident ate two bites at noon meal and then would not swallow any more food, any fluids attempted to be administered ran back out of residents mouth. 12/21/15 at 10:34 p.m.- (Written by RN #4) Two staff assisted resident with her dinner. One staff helped hold up resident's head while the other staff attempted to feed resident. Res. took only a few bites before the food began to fall back out of her mouth. Res. was given several spoons of liquid to encourage her to drink more fluids. Res. did swallow some. Mostly the liquids drained out of her mouth even with her head up .Res. sons were called to give them an update on how the resident was doing and to let them know she was not eating or drinking much. (Son #1's Name) phone would not accept calls. (Son #2's Name) phone was not answered and his mailbox was not set up. So neither son could be contacted. MD (Medical Doctor) was contacted just to give him report about the resident and situation. MD aware. 12/22/15 at 11:15 a.m.- (Written by LPN #3) Resident resting in bed at this time. Resident continues to not eat or drink fluids offered by staff at meal times .MD called and informed of residents (sic) status. New orders received and noted to send to (Hospital Name) for evaluation and treatment . The Weight and Vitals Summary in the record, indicated resident's weights were 12/02/15-147 pounds, 12/09/15-146.8 pounds, 12/16/15-144.6 pounds at the facility. The emergency room Admission Notes, dated 12/22/15 at 1:01 p.m. indicated the residents weight was 144 pounds. The emergency room Physician's Note, dated 12/22/15 at 1:01 p.m., indicated the resident had an associated [DIAGNOSES REDACTED]. The laboratory tests, dated 12/22/15 at 3:56 p.m., indicated the resident's [MEDICATION NAME] (protein in the blood) was 3.0 (normal 3.2-4.5). During an interview on 12/23/15 at 3:22 p.m., the Assistant Director of Nursing (ADoN) indicated the resident's Physician and POA should have been notified when the resident's food and fluid consumption had decreased. During an interview on 12/23/15 at 4:07 p.m., the Dietary Manager indicated the Registered Dietician saw the resident on 12/14/15, and the resident had received supplements which she had consumed. During an interview on 12/28/15 at 8:26 a.m., LPN #1 indicated the first few days the resident was at the facility she ate well, then she started pushing the food out of her mouth and the last few days she was at the facility she would spit the food out or it would drool from her mouth. LPN #1 indicated no one had reported she wasn't eating. LPN #1 indicated the last week before she was sent out was when he found out the resident was not eating. LPN #1 indicated the Physician and/or POA had not been notified when he was aware the resident had not been eating or drinking well. During an interview on 12/28/15 at 9:28 a.m., Speech Therapist (ST) #2 indicated she had spoke with the nurse (LPN #3) when the resident was first declining and informed the nurse intake of food/fluid consumption would be needed and also to contact the family/POA to determine what they would like done and to explain the progression of the disease process. ST #2 indicated they always spoke to the nurse taking care of the resident so they could contact the family/POA and then contact the Physician. During an interview on 12/28/15 at 9:52 a.m., LPN #3 indicated she added the resident to the board so everyone would know they needed to document intakes. LPN #3 indicated ST said they would notify the family. During an interview on 12/28/15 at 10:24 a.m., the Dietary Manager indicated the resident was reviewed by the Nutrition at Risk (NAR) committee. A note received from the Dietary Manager, dated 12/18/15, indicated, the resident was starting to have a decrease in food/fluid consumption and to have the staff monitor and notify the family in a few days for their decision for either a feeding tube or for comfort measures. During an interview on 12/28/15 at 11:22 a.m., RN #4 indicated she had not initiated interventions for the decrease of food and fluid intake. She indicated she had not known if it was a change. She indicated she kept an eye on the resident. RN #4 indicated when she worked on 12/21/15 she reported to the Social Service Director the resident was not eating or drinking enough and had attempted to notify the resident's family/POA and was unable to. RN #4 indicated she then notified the resident's Physician and informed the Physician the resident was not eating or drinking at all and the Physician indicated he would be in the building the next morning to see the resident. A Hospital Physician's Progress Note, dated 12/29/15, indicated, .[MEDICAL CONDITION] (high sodium) .AKI (acute kidney injury): improving; Likely prerenal azotemia (elevated blood urea nitrogen and serum creatinine levels) and possible ATN (acute tubular necrosis) from poor oral intake A facility policy, dated 05/2011, titled, Nutritional Supplements, received from the Director of Nursing as current, indicated, .The following are examples of conditions/symptoms that may necessitate placing the resident on the NAR (Nutrition at Risk) program: .Residents who consume less than 50% of food served for 1 week .These residents and overall consumption of meals as well as nutritional supplements will be reviewed no less than bi-weekly during the facility's interdisciplinary NAR review meeting. 6. If a resident is not consuming the nutritional supplement or has poor tolerance to the product this will be reviewed and an alternative product will be provided . This Federal Tag relates to Complaint IN 580. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided for a resident related to lack of follow up monitoring to concerns of allegation of resident to resident physical contact and aggressive physical behaviors displayed. This resulted in a resident to resident altercation with a resident being hit multiple times with the leg rest of a wheelchair resulting in bruising, skin tears, and laceration requiring sutures. (Residents #D and #F) (CNA's #1 & #3) (RN #1 and RN #2) Finding include: 1. The record for Resident #F was reviewed on 12/1/14 at 6:35 a.m. The resident's [DIAGNOSES REDACTED]. The 10/21/14 Minimum Data Set quarterly assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (11). A score of (11) indicated the resident's cognitive patterns were moderately impaired. The assessment also indicated the resident required limited assistance of one staff member for bed mobility and transfers and was able to walk in the room with supervision and set up up help by staff. The assessment also indicated the resident had received anti-depressant medication (7) days in the (7) day reference period of the assessment. The assessment also indicated the resident had no behaviors, delusions, or hallucinations. An Incident Report Form completed on 11/6/14 was also reviewed. This form indicated a female resident reported that Resident #F who resided on the same hall had inappropriately touched her as they were both coming out of their rooms. An investigation was initiated and Resident #F was moved to to another room on a different hall on 11/6/14. This room was noted to be the room Resident #D resided in. An "Incident Report Form" dated 11/25/14 was reviewed on 12/1/14 at 8:00 a.m. The form was completed by the facility. The report indicated an incident involving Residents #D and #F occurred on 11/25/14 at 12:15 a.m. The report indicated both residents resided in the same room. A CNA heard yelling and entered the room of the residents and upon entering observed Resident #F with the foot rest of a wheelchair in his hand and about to hit Resident #D. The CNA called for help while removing the wheelchair foot rest out of Resident #F's hand. The CNA then noted blood on Resident #D's face and Resident #F stated he thought Resident #D was his uncle an called him a different name. Resident #D was assessed and transported to the hospital with facial injuries. Resident #F was put on 1:1's with a staff member until he was sent out to the hospital for a Psychiatric evaluation. Resident #F had sustained a skin tear to his right hand. A facility "Resident Abuse Investigation Report" dated 11/25/14 was also reviewed. The form indicated Residents #D and #F were involved in a resident to resident altercation. The report indicated Resident #D sustained facial injuries and Resident #F sustained a skin tear to the right hand. The report indicated CNA #1 was the first staff member reporting the incident. The report indicated the IDT review of the incident indicated a causative factor was Resident #F was hallucinating. The report also indicated Resident #F would not be returning to the facility. Staff interviews completed during the Investigation of the above incident were reviewed. A written statement completed by RN #1 indicated CNA #3 came to the Nurses's station on 11/24/14 at 10:45 p.m. and told her and RN #3 that Resident #F had thrown his oxygen tank. Resident #F was brought to the RDR (Restorative Dining Room) for 1:1 care. At 12:00 a.m., the resident requested to go back to bed and CNA #1 took him back to bed. CNA #1 later answered another resident's call light and heard noises from Resident #F's room. She went to the room and observed Resident #F sitting in his wheel chair with a foot rest above his head. When RN #1 entered the room the foot rest was on the floor and was "bloody". Resident #D's face and arm were covered in blood and his left orbital area was swollen and his left eye was swollen shut. The resident had multiple lacerations to the face and the right arm. 911 and the Physician were called. A statement form CNA #3 was reviewed. There was no documentation in this statement related to the resident throwing his oxygen tank or any other behaviors. This statement indicated the CNA entered Resident #D's room and saw blood all over his upper body and staff waited with him until the ambulance arrived. A statement from RN #3 indicated on 11/24/14 at 10:45 p.m. CNA #3 informed her that Resident #F had "threw his portable O2 (oxygen) tank". The statement also indicated the local Police were at the facility and they spoke with both family members and also Resident #D. The Police officer saw the TV screen was busted and Resident #D wanted to press charges. The resident's Care Plans were reviewed. A Care Plan initiated on 8/1/2013 indicated the residents received an anti-depressant medication for a [DIAGNOSES REDACTED]. Care Plan interventions included to encourage group activities to increase socialization , monitor for mood and behaviors, notify the Physician and the family of any changes, and monitor for adverse reactions. The above interventions were all initiated on 8/1/2013. No further interventions were added after 8/1/2013. A Care Plan initiated on 11/6/2014 indicated the resident displayed socially inappropriate behavior. Care Plan interventions on 11/6/2014 included, to educate the resident on what was and was not appropriate and to validate the resident's feelings. No further interventions were added after 11/6/2014. Review of a Nurse Practitioner Progress Note completed on 11/13/14 indicated the resident had been re-located to another hall due to inappropriate sexual behavior with another resident. The Progress Note also indicated "today again inappropriately touched male room mate" and patient exposed himself. Recommendations on the Progress Note included for a Urinalysis and Culture & Sensitivity test and a Complete Blood Count laboratory test to be completed. The November 2014 Behavior/Interventions Monthly Flow Record was reviewed. Two behaviors were listed on the flow record. They were "s/s (signs/symptoms of depression) and "any behaviors concerns". There was a number (1) marked under the section "any other behaviors" for the number of behaviors on the 11/6/14 day shift for the resident. The outcome for the above was marked with a (+) which indicated improved. There was writing column for # of Behavior Episodes in the box for the Day shift on 11/7/14 for "any other behaviors". The writing was not legible with a (1) marked under the writing. An (+) was marked under the outcome of this behavior on 11/7/14. No behaviors were marked 11/8/14 thru 11/23/14. One "any other behaviors" was marked on the day shift on 11/24/14 and one was marked on the evening shift on 11/24/14- both of the above noted a (+) which indicated improved. A (+) was marked in the "any other behaviors" section on the night shift on 11/24/14 with nothing documented in the outcome section. When interviewed on 12/1/14 at 5:15 a.m., RN #1 indicated she worked the night shift starting on 11/24/14 into 11/25/14 when Resident #F hit his roommate (Resident #D). The RN indicated she was not assigned to care for these residents that shift. RN #1 indicated a CNA had walked into the room and observed Resident #F sitting in a wheelchair next to Resident #D's bed and was holding the foot rest from his wheelchair in his hand. The CNA removed the resident from the room. The RN indicated both she and the other Nurse came to the room and observed Resident #D in his bed and he was covered in blood on his face, arm, and neck. Resident #D also had abrasions on his face and his left orbital area was swollen. Lacerations were also present to the Resident #D's left lower lip and left eye areas. RN #1 indicated first aid was given and 911 was called and Resident #D was sent to the hospital. RN #1 indicated Resident #D told her Resident #F just came over and started hitting him and the resident asked her why he did that. When interviewed again on 12/1/14 at 9:25 a.m., RN #1 indicated at the start of the night shift on 11/24/14, she and another Nurse were counting narcotics at the Nurses' station. RN #1 indicated she recalled hearing CNA #3 saying something about Resident #F throwing his oxygen tank but did not hear anything more. The RN indicated she was not assigned to care for Resident #F and did not know anything more then that. When interviewed on 12/1/14 at 5:45 a.m. CNA #1 indicated she was assigned to care for Residents #D and #F on the night shift beginning on 11/24/14 at 10:30 p.m. The CNA indicated when she came in that night Resident #F was sitting up in unit dining room with other CNA's sitting with him. The CNA she unusually works the night shift and had been assigned to care for Resident #F several times on her shift. CNA #1 indicated it was unusual to see Resident #F sitting up at the start of her shift. The CNA indicated the Evening Shift CNA's reported to her that everything was fine and did not tell her why Resident #F was up in the chair in the dining room. The CNA also indicated no one had told her about Resident #F having any behaviors. CNA #1 indicated she asked Resident #F if he wanted to go to bed and then transferred him to his room and into bed. The CNA indicated when she left the room Resident #F was in bed. She then left the room and went to help a another resident and heard the resident's roommate (Resident #D) yelling for help. The CNA indicated when she went to the room, Resident #F was sitting in his wheelchair with the leg rest from the wheel chair in his hand and she removed it from his hand and took him out of the room. The other CNA's and Nurses were coming into the room also. When interviewed by telephone on 12/1/14 at 10:19 a.m., RN #2 indicated he had heard something from a staff member in the facility about Resident #F touching his roommate (Resident #D) inappropriately. The RN indicated he could not recall when he heard this information and stated he heard it in " passing". The RN indicated he was under the impression this was already documented because he did not observe it and it did not occur on his shift. The RN indicated he did not observe any documentation of this in the resident's record. RN #2 indicated he did not report this to anyone. When interviewed on 12/1/14 at 9:10 a.m., the DON (Director of Nursing) indicated an incident occurred between Residents #F and Resident #D at 12:15 a.m. on 11/25/14. The DON indicated the residents were roommates. The DON indicated she was called and came to the facility. The staff reported that Resident #F had been observed in the room with the foot rest of his wheelchair in his hand and Resident #D was observed in bed with injuries to his face. The DON indicated she was not aware of any other reported incidents between the roommates and stated the roommates seemed to get along. The DON indicated earlier that day Resident #F had pushed a vase off the table around lunch time and later in the day had made a statement about the people on the TV talking. The DON indicated these two behaviors were unusual for Resident #D. The DON indicated Resident #F was out to the hospital on [DATE] for a psychiatric evaluation and would not be returning to the facility. Continued interview with the DON indicated the 11/25/14 incident was reviewed and interviews with staff did note Resident #F threw his portable oxygen tank earlier in the evening of 11/24/14 and was taken to the Rehab unit dining room for 1:1 supervision. The DON indicated the CNA later put him to bed and stayed with him and he fell asleep. The DON and the facility Administrator were interviewed on 12/1/14 at 9:30 a.m. The DON indicated she did not know any other details of the event noted on the written statement about Resident #F throwing his oxygen tank in the evening of 11/24/14. The DON indicated there was no documentation of this in Resident #F's record and no incident report was completed. The DON indicated she did not further investigate the above. The DON indicated staff were supposed to document behaviors and incidents. When interviewed on 12/1/14 at 10:10 a.m., LPN #1 indicated she unusually worked the Day shift. The LPN indicated she worked on 11/12/14 and 11/13/14. The LPN indicated she was not aware of any inappropriate behaviors for either Resident#D or Resident #F on those dates. The LPN indicated she was aware of the incident which recently occurred between these two residents. The LPN indicated she spoke with the Nurse Practitioner on 11/13/14 about Resident #F not acting like himself, sleeping more, and being confused to questions. The LPN indicated she was not aware of Resident #F inappropriately touching any other male resident. When interviewed on 12/1/14 at 11:05 a.m., the facility Administrator indicated he recalled speaking to a family member of Resident #D. The Administrator indicated he believed this was on Wednesday before Thanksgiving (11/26/14). The Administrator indicated the family member had said something asking him if he knew Resident #D had been "groped" by Resident #F.. The Administrator indicated he did not ask the family member how they knew about this or any other details. The Administrator indicated no report was written about the above statement. The Administrator indicated he recalled the family member also stating RN #2's name. The Administrator indicated he did not talk to RN #2 until Friday (11/28/14). The Administrator also indicated the same family member spoke with him again on Friday and that was when he spoke to RN #2 The Administrator indicated he had no other written information or report on the above allegation made to him on 11/26/14. The Administrator indicated he spoke with RN #2 and the RN did mention an incident of touching but did not have the information documented. The Administrator indicated he was not aware of the 11/13/14 Nurse Practitioner Progress Note made in Resident #F's chart related to inappropriately touching his roommate. The Administrator indicated the Nurse Practitioner did not inform him nor did any staff member on 11/13/14. When interviewed on 12/1/14 at 11:20 a.m., the Director of Nursing indicated she also had not been aware of the 11/13/14 Nurse Practitioner note and no staff had informed her about any occurrence of Resident #F touching his roommate Resident #D. When interview via telephone on 12/1/14 at 11:30 a.m., the Nurse Practitioner who completed the 11/13/14 Progress Note for Resident #D was interviewed via phone. She recalled a staff nurse informed her of the residents behavior and with the then male roommate. The Nurse Practitioner indicated she had been aware the resident had a recent room change due to a previous behavior with another resident on the other hall. The Nurse Practitioner indicated she did not recall the name of the Nurse who told her the above. 2. On 12/1/14 at 6:00 a.m., Resident #D was observed sitting in a wheel chair in his room. Dark ecchymotic (bruised) areas were noted under the resident's left eye, the left cheek area towards the jaw line, and under the jaw to the neck area. There were small scattered scab areas to the forehead also noted. The record for Resident #D was reviewed on 12/1/14 at 6:15 a.m. The resident's [DIAGNOSES REDACTED]. The 10/1/14 Minimum Data Set quarterly assessment indicates the resident's BIMS (Brief Interview for Mental Status) score was (8). A score of (8) indicated the resident's cognitive patterns were moderately impaired. The assessment indicated the resident did not display any signs of delirium or acute mental status changes and had no behaviors. The assessment also indicated the resident required extensive assistance (resident involved in activity, staff provide weight bearing support) of one staff member for bed mobility, personal hygiene, and dressing. The assessment indicated the resident required extensive assistance of two or more staff members for transfers and had impairment in range of motion in one upper and one lower extremity. The 11/2014 Nursing Progress Notes were reviewed. An entry made on 11/25/14 at 4:32 a.m. indicated a CNA heard a noise in the resident's room and upon entering the room saw the resident's room mate (Resident #F) with his leg rest from his wheelchair over the resident. The CNA noted blood to the resident's face and arms and called for help. Nurse entered the room and observed blood to the face, arms, and hands and lacerations and skin tears to the resident's arms and hands. The Physician was called at 12:30 a.m., 911 was called at 12:35 a.m. 911 arrived at 12:45 a.m. and was accompanied by a Police Officer. 911 left at 12:50 a.m. The next entry in the Nursing Progress Notes was made on 11/25/14 at 4:40 a.m. This entry indicated the hospital called to give report to the Nurse and the resident was to be transferred back to the facility via ambulance. The resident returned to the facility at 4:25 a.m. The resident's family was present and the resident was placed into bed. Sutures to the the left side of the mouth and the left orbital (area around the eye) areas were observed. Purple bruising was noted to the left side of the face and jaw. Multiple cuts were noted over the face. A dressing was in place to the right arm. The resident had some discomfort and was given something for the pain. Continued review of the 11/2014 Nursing Progress Notes indicated there were no entries made on 11/24/14, 11/23/14, or 11/22/14. There was one entry made on 11/21/14 at 1:47 a.m. This entry indicated a treatment continued to the right lower extremity and the dressing in place was clean, dry, and intact. There were no entries made in 11/2014 related to any altercations or incidents of inappropriate touching occurring between the resident and his new room mate (Resident #F) on any days in November. Review of the 11/25/14 hospital emergency room hospital "After Visit Summary" records indicated the resident's "[DIAGNOSES REDACTED]. A Skin/Wound Note was completed on 11/251/4 at 8:00 a.m. The note was completed by an LPN. The note indicated the resident was noted to have a laceration just below the left eye and another laceration to the left outer mouth area. Both the lacerations had sutures in place. The note also indicated red and purple bruising was noted to the left peri-orbital area and dark purple and red bruising was noted to the the resident's left cheek and jaw line down the left neck. The left cheek and jaw area was also edematous (swollen). A skin tears were noted to the back of the right hand, the right upper forearm, and the right inner forearm with no active bleeding. Red, blue, and purple scattered bruising was noted to the right chest. The back of the resident's left hand was noted with 11 cm (centimeters) x 7 cm purple bruising. Weekly Skin Assessment sheets were initiated on 11/25/14. A total of (9) sheets were completed as follows: 11/25/14 at 8:00 a.m.- left periorbital laceration to the face which measured 0.1 cm x 2 cm. Two sutures were present and dark purple and red bruising was toed to the left peri-orbital area. The resident did state the area was "tender to touch." 11/25/14 at 8:03 a.m.- left outer mouth laceration with two sutures intact. The bruising to surrounding tissue was dark purple and red bruising and edema noted. The resident did state his face was tender to touch. 11/25/14 at 8:18 a.m.- skin tear to the back of right hand measuring 3 cm x 3 cm x 0.1 cm with no active bleeding. Some purple bruising and edema noted to the right middle finger. 11/25/14 at 8:23 a.m.- skin tear to the right outer forearm measuring 3 cm x 2 cm x 0.1 cm. No active bleeding. Dark purple bruising to the peri-wound tissue noted. 11/25/14 at 8:45 a.m.- scattered small skin tears bridged together on the left forearm. 11/25/14 at 8:51 a.m.- skin tear to the right upper forearm measuring 2.5 cm x 3.5 cm x 0.1 cm. Surrounding tissue dark purple bruising. 11/25/14 at 8:55 a.m.- scattered bruising to the right chest area. Bruising blue, red, and purple. 11/25/14 at 9:04 a.m.- scattered small abrasion to the right scalp. 11/25/14 at 8:51 a.m.- skin tear noted to the right upper forearm measuring 2.5 cm x 3.5 cm x 0.1 cm. An IDT (Interdisciplinary Team) note was completed by Social Services on 11/25/14 at 9:46 a.m. The note indicated the Social Service visited with the resident's and he was eating breakfast in his room. The resident was asked what happened and the resident stated "The guy hit me." Review of a 11/26/14 physician progress notes [REDACTED]. The resident sustained [REDACTED]. The Progress Note indicated a CT scan of the head had been completed on 11/25/14 and was negative for a bleed. The Progress Note also indicated CT scans of the facial bones were negative for fractures, and a MRI was positive for a deviated septum. The "Behavior Management Psychotropic Medication Protocol" policy was reviewed on 12/2/14 at 1:50 p.m. There was no date on the policy. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated "Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well-being or that of other residents, or behaviors that can have the potential for harm to self or others will be assessed with [REDACTED]." The policy also indicated when established residents have a new onset of adverse behaviors the behaviors were to be documented and communicated to the Social Service. The resident was to be placed on the 24 hour report documentation record. Social service was to assess the resident and complete a Monthly Flow Records. Staff were to notify the attending Physician to rule out possible medical causes. The resident's Care Plan was to be updated to include the problem behavior, goals, and approaches. The problem behavior, approaches, and goals were to be included on the Care Plan. The documentation was to be reviewed by the Behavior Committee to determine a plan. This Federal tag relates to Complaint IN 170. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to monitor and manage pain for a dependant resident with known risk factors for pain, for 1 out of 1 residents reviewed for pain related to not assessing and medicating a resident prior to a shower resulting in the resident grimacing and complaining of pain. (Resident #B) Findings include: On 12/31/31 between 8:10 and 9:00 a.m., care of Resident #B was observed with CNA's #1 and #2. The CNA's transferred the resident from the bed into a bath chair with a Hoyer lift (mechanical lifting device). CNA #2 indicated to CNA #1 to be careful of the resident 's feet as they were sensitive. When the resident was lowered into the bath chair she began to grimace and complain her buttocks hurt. CNA #2 adjusted the chair and attempted to seat her again, the resident continued to complain of her buttocks hurting. The CNA's repositioned her in the chair by adjusting the back. The resident continued to complain she was in pain. CNA #2 put a pillow under the resident's buttock, and then the resident indicated that felt better. The resident then complained her feet were hurting her. The CNA uncrossed her feet. Approximately one minute later, the resident started to grimace and complain her feet were hurting again. Her feet were again repositioned. She was then taken to the shower room. When she returned to the room, the CNA's transferred the resident back into bed with the Hoyer lift. The resident was grimacing and complained her legs hurt during the transfer. The resident's record was reviewed on 12/31/13 at 9:00 a.m. The resident was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A Minimum Data Set annual assessment dated [DATE] indicated the resident had a BIMS (Brief Interview for Mental Status) score of 06, which indicated cognitive impairment. Her functional status indicated she was totally dependent for transferring and bathing assistance. The December 2013 Physician order [REDACTED]. There was no other pain medication on the POS. A Care Plan dated 11/6/2013 indicated the problem of potential for pain related to arthritis and [MEDICAL CONDITION]. The goal was the resident should have pain relieved within one hour of pain medication. The interventions included to assess pain medication effectiveness; and to monitor for verbal and non-verbal signs of pain. Interview with CNA #2 on 12/31/13 at 9:25 a.m., she indicated the resident complained of pain during care, "all the time." She indicated she would notify the nurse when that occurred. She further indicated she had notified the nurse today that the resident was having pain during care. Interview with CNA #1 on 12/31/13 at 10:15 a.m., indicated the resident frequently complained of pain during care. Interview with LPN #1 on December 31, 2013 at 9:27 a.m., indicated the CNA had notified her the resident was having pain and that she had given the resident a Tylenol. Further interview with the LPN indicated the resident did not have a PRN (as needed) order for pain medication, and she had not given the resident Tylenol, she indicated she would call the Physician for an order. Further record review at 12:00 p.m. on 12/31/13., indicated an order had been received from the Physician for Tylenol 650 milligrams every six hours as needed for pain or fever. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure therapists communicated with the nursing staff of a resident who was displaying pain during therapy, nursing staff failed to assess and treat a resident for pain in a timely manner who was displaying facial grimacing, restlessness, and yelling in her room and/or in public view for 1 out of 7 residents reviewed and failed to ensure nursing staff notified the therapy department with a resident who had an increase in positioning problems for 1 out of 36 residents reviewed. (Resident #123 and #26) Findings include: 1. On 5/13/13 from 12:00 p.m. to 12:30 p.m., Resident #123 was observed to be restless and was yelling out in the skilled dining room. The resident had facial grimacing. During this time, the DoN was observed walking over to the resident, patted her hand, reassured her, and then walked away. The resident was not asked if she was in pain. No other nurse or CNA had addressed the resident's yelling. On 5/13/13 at 2:30 p.m., Resident #123 was heard yelling out from her room. On 5/14/13 at 10:30 a.m., Resident #123 was heard yelling out from her room. The resident was observed to have facial grimacing and was restless in her geri chair. On 5/15/13 at 12:00 p.m., Resident #123 was observed yelling out in the skilled dining room. On 5/16/13 at 8:15 a.m., Resident #123 was observed in her room, partially sitting up in her geri chair, moving her legs up and down. The resident indicated she was in pain and she hurt all over. LPN #1 was informed, chuckled, and indicated the resident did get pain medication ordered last evening. On 5/16/13 at 9:20 a.m., Resident #123 was observed in her room, in her geri chair, partially sliding down with her right knee bent and left leg crossed over the right knee. The resident continued to have facial grimacing. The resident indicated her pain was not better. The resident indicated she wanted to go to bed. A CNA on the unit was informed. Resident #123 record was reviewed on 5/15/13 at 2:10 p.m. The Resident [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. A care plan for pain related to impaired cognition was initiated on 5/10/13. The approach/intervention indicated to give pain medications as ordered. The May 2013 Physician Recapitulation orders and May 2013 MAR (Medication Administration Record) did not indicate pain medication had been ordered. An OT (Occupational Therapy) initial evaluation dated 5/2/13, indicated the resident had periodic pain but was unable to rate. The evaluation indicated the resident grimaced at the end of range of motion exercises to the bilateral upper extremities, especially the shoulders. A PT (Physical Therapy) initial evaluation dated 5/2/13, indicated the resident was unable to rate her pain. The evaluation indicated the resident had grimaced at the end of the range of motion to the bilateral lower extremities. A FACES scale was rated at 4/10 (0 being no pain and 10 being a lot of pain). Resident #123 record was reviewed again on 5/16/13 at 8:35 a.m. A physician order [REDACTED]. An OT daily therapy note dated 5/13/13, indicated the resident was "calling out at times." The treatment [DIAGNOSES REDACTED]. An OT daily therapy note dated 5/14/13, indicated during range of motion to all upper extremely joints, the resident was "calling out at the end range of shoulder joints." The treatment [DIAGNOSES REDACTED]. A PT progress note dated 5/15/13, indicated the resident would holler (yell) while performing ROM (range of motion) to BLE (bilateral lower extremities) but was unable to rate the pain and unable to describe her symptoms. An OT progress note dated 5/15/13, indicated "Pt (Patient) calling out at times...Pt. grimaces at end range PROM (passive range of motion) BUE's (bilateral upper extremities), esp. (especially) shoulders, though is unable to rate type or level of pain. Pt. generally has few verbalizations, but occasionally responds appropriately to simple questions." The treatment [DIAGNOSES REDACTED]. An OT daily therapy note dated 5/16/13, indicated resident "calls out at times." The treatment [DIAGNOSES REDACTED]. On 5/13/13 at 12:00 p.m., staff indicated the resident had been yelling out since admission. On 5/16/13 at 8:25 a.m., the DoN stated "that is how the resident communicates." In clarification, the DoN indicated when Resident #123 yells, it was how she communicated and the ADoN indicated the resident would yell out her answers when staff had asked her questions. On 5/16/13 at 9:45 a.m., PT #12 indicated the therapists would inform nursing staff of the resident's progress or anything significant to their daily care, but they do not inform them of their pain because they were already being assessed for their pain medication. On 5/16/13, at 11:45 a.m., LPN #1 indicated the resident had pre senile dementia and this contributed to her yelling out versus the resident being in pain. LPN #1 was not aware of the resident having pain during therapy. LPN #1 indicated the coccyx wound was superficial and shouldn't be painful and he had asked the resident in the past if she was in pain when she would yell out. LPN #1 indicated the resident would first say yes to pain and then a few minutes later she would say no, so she was "wishy washy" and due to her dementia, he didn't know if she was in pain. LPN #1 indicated the resident was not on pain medication in the hospital. LPN #1 also indicated the staff would need to maintain the residents dignity, as in keeping the resident in bed all day versus putting her to bed when she was in pain or uncomfortable. LPN #1 indicated the spouse informed him, the resident did not have [MEDICAL CONDITION] but a patch of [MEDICAL CONDITION] and he was upset with the [MEDICAL CONDITION] diagnosis, so the pain would not [MEDICAL CONDITION] related. LPN #1 indicated he did not clarify the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Upon reviewing the resident's behavior record on 5/16/13 at 2:00 p.m., the DoN indicated, again, the resident did not have behaviors and it was the way she communicated. The DoN initiated the behavior monitoring record on 5/15/13 for socially inappropriate/disruptive behavior/sounds. The option to manage pain was not selected as an intervention. During an interview with the Administrator and the DoN on 5/17/13 at 9:00 a.m., the DoN indicated resident #123 had weekly pain assessments which indicated the resident did not have pain. The DoN also indicated communication between therapy and nursing was good and was not aware of therapy not informing the nursing staff reports of pain from residents. 2. On 5/13/13 at 11:45 a.m., Resident #26 was observed in the skilled dining room, reclined in a geri chair, with his head off to the right side of the chair. The resident received his meal at 12:05 p.m., and was being fed by a family member, while his head remained off the right side of the chair. At 12:18 p.m., the resident's family member indicated Resident #26's head always had to be repositioned by the staff frequently. During this time, the DoN and CNA #2 repositioned the resident. On 5/13/13 at 12:40 p.m., Resident #26's head had fallen back off to the right side of the geri chair. CNA #2 was at the table sitting across the resident, feeding another resident. The wife continued to feed the resident in this position. There were other staffing personnel observed in the dining room, who did not attempt to repositioned the resident. On 5/15/13 at 9:00 a.m., Resident #26 was observed in his room, reclined in his geri chair, with his head on metal edge of the chair. The resident was observed to have had a concave cushion for his head that was flattened, a concave trunk cushion and was sitting on a pommel cushion. On 5/15/13 at 10:00 a.m., Resident #26 was observed in bed. Resident #26 continued to favor his head to the right side, near the wall. On 5/15/13 at 3:45 p.m., Resident #26 was observed in bed with the top of his head was pressed against the wall. The touch pad call light was on the bedside table, which was located at the foot of the bed and the bed pad alarm was observed to be unplugged. The resident's door was half way shut, and the resident could not be seen from the hallway. Two large pillows was observed to be fluffed and tucked under the fitted sheet, preventing the resident from getting out of bed. Resident #26's record was reviewed on 5/15/13 at 9:00 a.m. Resident #26's [DIAGNOSES REDACTED]. A care plan for risk for fall was initiated on 1/11/13. The approaches/interventions were not dated, but indicated to "reinforce safety awareness, resident lays self on floor to fix wheel chair at times-wiggles out. Wife aware-risk and benefits explained. Falling star program to increase supervision." An OT (Occupational Therapy) note dated 1/24/13, indicated the resident had "an impairment of decreased postural awareness - slumped sitting posture and decreased cardiopulmonary condition - limited tolerance for activity." An OT note dated 1/25/13, indicated the resident was positioned in layback chair; was not able to tolerate an incrediback (concave fitting) wheel chair and was sliding out due to increased extensor tone. A Side Rail Assessment Screen dated 2/6/13, indicated the resident was not able to get out of bed unassisted, was not able to turn from side to side unassisted while in bed, did not attempt to get out of bed unassisted, and the resident did have alterations in safety awareness due to cognitive decline. An OT discharge note dated 2/8/13, indicated Resident #26 needed total assistance during meals. The resident had been in a "layback" chair, leans to the right at times and was observed to have had an increased extensor tone with a need for repositioning to improve posture and interaction with environment. The note also indicated the staff had been instructed on appropriate positioning and feeding, with a good understanding demonstrated. A Fall Risk assessment dated [DATE] and 4/19/13, indicated the resident was a high risk for falls and the resident had fallen 1-2 times in the past three months. A care plan for physical mobility impaired due to [DIAGNOSES REDACTED]. The approaches/interventions indicated "therapy per order, staff assist as indicated, educate on call light use and asking for assist, contact MD and family as indicated." A nursing note dated 4/19/13 at 11:30 a.m., indicated the resident was found on floor in front of the window, lying on his back, trying to fix his chair. The note indicated the resident stated, "I wiggled out of my chair to fix the wire under it." A nursing note dated 4/19/13 at 8:30 p.m., indicated Resident #26 had "wiggled out of chair and had a fall. Res. (resident) needs to be positioned frequently and will "wiggle an wiggle." A nursing note dated 5/10/13 at 7:00 p.m., indicated the resident was in his geri chair in his room, was "wiggling", and caught his leg and received a 7 cm (centimeter) by 2 cm abrasion to his front lower right leg. A CNA care plan was provided by the DoN on 5/16/13 at 1:00 p.m. The CNA care plan indicated the resident had a bed alarm only. An interview with LPN #10 on 5/15/13 at 8:15 a.m., indicated the staff had tried multiple things with the resident for positioning and have been unsuccessful. LPN #10 indicated that if the resident was able to get his fingers to the end of the arm of the chair, he would pull himself down. LPN #10 indicated the geri chair had worked best for the resident and he did need frequent repositioning due to his continued "squirming". LPN #10 indicated a bariatric bed was used for the resident due to his "squirming." An interview with the SSD (Social Service Director) on 5/15/13 at 10:30 a.m., indicated Resident #26's wife did not want him moved closer to the nurses station. SSD indicated the staff was on alert about the resident's frequent position changes. An interview with OT #11 on 5/15/13 at 11:30 a.m., indicated she had not been made aware of the resident's positioning problems. OT #11 indicated therapy did try an incrediback wheel chair (concave fitting) but was unsuccessful. OT #11 indicated no other cushions had been attempted. OT stated, "Resident may need to be re-screened if they are having to reposition him often". An interview with PT #12 on 5/15/13 at 11:45 a.m., indicated he had not been made aware of the resident's positioning problems. PT #12 indicated a high back wheel chair was borrowed from a resident (who wasn't using his) was attempted and failed. PT #12 indicated the resident was stiff and rigid. PT #12 indicated the Broada (prevents head from falling off chair) chair had not been attempted due to no availability of a chair. PT #12 indicated the staff had not informed therapy of the resident's positioning problems and with meal service. PT #12 indicated he would look to re-evaluate the resident. The DoN on 5/15/13 at 11:55 a.m., indicated the resident was being discussed in the morning meeting on "Tuesday" for a Broda chair. The DoN indicated the resident was constantly being repositioned, had head bolsters in his wheelchair, this was his third time being in the facility, and the resident's spouse can be interviewed about the frequent repositioning. The DoN indicated their corporation owns the equipment company. An interview with CNA #13 on 5/15/13 at 4:00 p.m., indicated other CNAs had told her to put pillows under the fitted sheets to keep the resident's legs in bed because he "squirms" so much. CNA #13 indicated she was not aware of the call light not being within the resident's reach or the bed alarm not being plugged in. CNA #13 indicated she was in the resident's room approximately 15 minutes prior and had cleaned the resident. CNA #13 indicated she frequently checks on the resident. An interview with the resident's spouse on 5/16/13 at 11:15 a.m., indicated she was not aware of the facility looking into ordering a Broda chair for the resident. An interview with CNA #14 on 5/16/13 at 11:30 a.m., indicated she was new to the facility and this was her first week on her own on the unit. CNA #14 indicated she was told by the night shift CNA, not to put pillows under the fitted sheet since it was considered a restraint. CNA #14 indicated other CNAs had been putting the pillows under the fitted mattress. 3.1-37(a)

Based on record review and interview, the facility failed to identify non-compliance with investigations and reporting of all allegations of abuse, resident choices in relation to bathing, assessments for side rails, gradual dose reductions, the use of an antipsychotic medication versus assessing for pain, and communication between the therapy department and the nursing department in relation to pain and safety in relation to positioning through the quality assurance protocol. Findings include: An interview with the Administrator and DoN on 5/17/12 at 9:00 a.m., indicated the facility's Quality Assurance Committee meets quarterly and consists of himself, the Director of Nursing, Assistant Director of Nursing, Department Heads, Pharmacy, as well as the Medical Director. The DoN indicated there was no action plan in place at this time with Quality Assurance. The DoN indicated all the month end reports of all the care areas are brought in for the quarterly meeting to review for trends. The DoN indicated, if there was a trend, an action plan would be developed, care plan would be updated as needed, the nursing staff would be notified by a 24 hour board and the nursing staff would give the CNA reports. The DoN indicated she had thought about making changes to choices with showers. The DoN indicated when she would receive the GDR from the pharmacy, she would notify the physicians and social service. The DoN indicated she was planning on involving the SSD more with GDR due to behavior management. The DoN indicated resident #123 had weekly pain assessments which indicated the resident did not have pain. The DoN also indicated communication between therapy and nursing was good and was not aware of therapy not informing the nursing staff reports of pain from residents. The Administrator indicated he was not aware of the policy indicating unsubstantiated allegations of abuse would not be reported to the state agency and he would review it with the corporation. 1. During an interview on 5/13/13 at 11:35 a.m., Resident #47 indicated she had been treated roughly by staff. She indicated the situation had been handled by the Administrator, and the CNA involved had been terminated. Interview with the Administrator on 5/15/13 at 10:55 a.m. indicated there had been an allegation of rough treatment by Resident #47 involving a CNA dropping the resident versus lowering her to the floor during a transfer on 03/15/13. The Administrator did not indicate a date for the rough treatment allegation. The Administrator indicated the CNA was terminated. During an interview with Administrator and Director of Nursing (DoN) on 5/15/13 at 2:33 p.m., the DoN (Director of Nursing) indicated on 3/15/13, Resident #47 was transferred from a wheelchair to the bed and the resident's leg gave out and the CNA lowered the resident to the floor. The DoN indicated Resident #47 transferred with one assist. The DoN indicated about a month later, on 4/12/13, Resident #47 requested that the CNA no longer care for her. The DoN indicated she did not know why the resident did not want the CNA to care for her. The DoN indicated the CNA had cared for the resident after the fall until the request was made on 04/12/13. The DoN indicated the first time the resident voiced a concern about the CNA was on 4/12/13. The DoN indicated no investigation had been completed after the resident had requested the CNA no longer take care of her. Further interview with the Administrator indicated the CNA refused to switch assignments and was terminated on 4/12/13. The Administrator was not sure why Resident #47 no longer wanted the CNA to care for her on 4/12/13 and indicated an investigation had not been completed and the Indiana State Department of Health (ISDH) had not been notified of the rough treatment. Resident #47's record was reviewed on 5/16/13 at 9:03 a.m. A nursing note dated 3/15/13 at 9:30 p.m. indicated "Res (Resident) was being transferred from chair to bed and res stated that her legs were giving out. CNAs assisted res to floor. Total body assessments completed. No injuries noted." During an interview with the DoN on 5/16/13 at 10:29 a.m., the DoN indicated there was no investigation completed because there was no fall. The DoN indicated Resident #47 had been lowered to the floor, she did not fall. During an interview with Resident #47 on 5/15/13 at 3:37 p.m., Resident #47 indicated the CNA was transferring her from wheelchair to her bed and she slid down the CNA's leg to the floor. Resident #47 indicated she felt she was dropped by the CNA. Resident #47 indicated she told the CNA she felt she was dropped during the transfer. Resident #47 indicated no one interviewed her following the situation. Further interview with Resident #47 indicated a few weeks later she heard a rumor the CNA called off the day following the incident because Resident #47 fell on her leg. Resident #47 indicated at that time she no longer wanted the CNA to care for her and immediately reported the situation to the Administrator. Resident #47 indicated she met with Administrator on 04/12/13 and discussed her concerns and informed the Administrator she had been dropped. She (Resident #47) asked the Administrator why she had not been interviewed regarding the CNA dropping her. Resident #47 indicated the Administrator told her she had not been interviewed regarding the previous incident because he was told she fell instead of Resident #47's claim that she was dropped. Resident #47 indicated the Administrator handled the situation promptly that day and the CNA was terminated. Resident #47's record was reviewed on 5/16/13 at 9:03 a.m. The Resident's admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. A facility policy on Abuse dated 7/1/11, and received as current from the Administrator, indicated "...The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The Administrator or the designee who is in charge of the facility, shall report any instances of suspected abuse, neglect, or misappropriation of resident property to the Department of Health as required...Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative as required by state guidelines..." 2. An interview with Resident #14 on 5/13/13 at 2:53 p.m., indicated the resident was not able to choose how many times a week she could take a bath or shower. An interview with Resident #14 on 5/15/13 at 10:17 a.m., indicated the staff had offered her showers on certain days but she was unable to choose if she would like to take a shower or not on that day. Resident #14 indicated that she was not able to choose the days she would like to take a shower. She indicated she had not requested her shower to be on a different day or at a different time and the choice was not offered to her by staff. Resident #14's record was reviewed on 5/14/13 at 3:44 p.m. The Resident's Admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was cognitively intact and it was very important for her to choose between a tub bath, bed bath, or shower. 3. During an interview on 5/13/13 at 2:13 p.m., Resident #83 indicated, she did not get to choose how many times a week she would like to take a bath or a shower. The resident indicated she received a shower twice a week and would like to take one everyday. On 5/15/13 at 8:15 a.m., the Minimum Data Set (MDS) Annual assessment dated [DATE] was reviewed. The MDS indicated it was very important to the resident to choose daily preferences and the resident was cognitively intact. An interview with the Social Services Director on 5/15/13 at 8:42 a.m., indicated nursing puts the residents on a bathing schedule. An interview with the Director of Nursing (DON) on 5/15/13 at 9:00 a.m., indicated residents would have a set schedule for bathing by room number. 4. An observation of Resident #67's bed on 5/13/13 at 12:34 p.m., indicated the bed was made and empty. The quarter side rails were in the up position in the mid section of the bed on both sides. On 5/15/13 at 1:35 p.m., the resident was observed in bed with the side rails up, in the mid section of the bed on both sides. On 5/16/13 at 8:51 a.m., the resident was observed in bed lying on her right side, sleeping with side rails up in the mid section of bed on both sides. On 5/16/13 at 9:33 a.m., the resident was observed sleeping in her bed, The side rails were up in the mid section of bed on both sides. On 5/16/13 at 10:29 a.m., the resident was observed sleeping in the bed, with the side rails up in the mid section of bed on both sides. On 5/16/13 at 11:22 a.m., Certified Nursing Assistants (CNA) #16 was observed raising one side rail on the bed, then raised the bed up and lowered the head of bed. CNA #15 and #16 turned the resident from side to side to check for incontinence and to place a mechanical lift pad under the resident. The resident was then lifted from the bed to the geri-chair. The resident did not assist in any of the bed movement or the transfer to the geri-chair. Resident #67's record was reviewed on 5/16/13 at 8:23 a.m. Resident #67's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had severe cognitive impairment, was totally dependent for all activities of daily living (ADLS), required one person for assistance for bed mobility, and no side rails were being used. A side rail assessment dated [DATE], indicated the resident was to have 1/2 side rails for positioning and support. There was no side rail care plan in the resident's record. An interview with CNA #15 on 5/15/13 at 1:46 p.m., indicated the resident used the side rails so she would not fall out of bed, and did not use them for positioning or support. An interview with CNA #16 on 5/16/13 at 8:55 a.m., indicated she did not know why the resident had side rails and the resident always had them up while in bed. She indicated the resident did not use them for positioning or support and the resident did not move around in bed. An interview with the Director of Nursing on 5/6/13 at 10:32 a.m., indicated that the resident did not have a care plan for side rails since the resident would hold onto the side rails when the staff turned her. An interview with CNA #16 on 5/16/13 at 11:25 a.m., indicated the resident's arms are always pulled to her chest and the resident did not use side rails to grab for positioning or support when turning or transferring from bed. 5. Resident #37's record was reviewed on 5/15/13 at 3:15 p.m. The resident was admitted into the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Annual MDS (Minimal Data Set) Assessment, dated 2/21/13, indicated the resident was cognitively intact, had no mood or depression signs or symptoms, no behaviors, and received an antidepressant the past seven days. The care plan, dated 2/28/13, indicated the resident had [MEDICAL CONDITION] and received an antidepressant. The interventions included, reduce lighting, reduce noise level, offer snacks, offer neck/back massage, observe medication reactions, and gradual dose reduction (GDR) per policy. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The resident's Physician's Recapitulation Orders, dated 4/13, indicated the resident was still receiving the trazadone 75 mg at bedtime for sleep. The Psychological Consult, dated 7/24/12, 8/28/12, 9/25/12, and 12/4/12, indicated the resident received the trazadone 75 mg every night for chronic sleep disturbance, and the area for GDR was checked to indicate the GDR was clinically contraindicated to prevent worsening function. There was a lack of documentation to indicate why a GDR would worsen the resident's functioning. The Psychological consult, dated 1/15/13, indicated the resident was on trazadone 75 mg every night for chronic sleep disturbance and resident was improving, and the consults, dated 2/19/13, 3/19/13, and 4/15/13, indicated the resident received the trazadone 75 mg every night for chronic sleep disturbance, and the area for GDR was checked to indicate the GDR was clinically contraindicated to prevent worsening function. There was a lack of documentation to indicate why a GDR would worsen the resident's functioning. The Physician's/Nurse Practitioner progress notes, dated Dr./NP progress notes, dated December 5, 12, 19, 2012, January 2, 9, 23, 30, 2013, February 6, 13, 24, 20, 27, 2013, March 20 and 28, 2012, April 3, 10, 17, 2013, and May 1 and 15, 2013, lacked documentation for the reason for the trazadone or why a GDR was not completed. The Physician's progress note, dated March 13, 2013 indicated the resident had [MEDICAL CONDITION]. The Pharmacy recommendations, received from the Medical Records Clerk as the only recommendations since 06/13, indicated recommendations on 12/27/12, 1/25/13, 3/4/13 and 3/20/13. The Pharmacy recommendations lacked documentation for a recommendation to GDR the trazadone. The Nurses' Notes, dated 4/23/13 at 9 p.m., indicated the resident received antidepressants related to [MEDICAL CONDITION] and gets 6-8 hours sleep per night, without signs and symptoms of fatigue. During an interview on 5/16/13 at 7:45 a.m., the Director of Nursing indicated she had notified the resident's Physician about the trazadone and the Physician indicated the trazadone was for appetite not for sleep. During an interview on 05/16/13 at 9:03 a.m., the Social Service Director indicated the Director of Nursing monitors the [MEDICAL CONDITION] mediations. She indicated she just monitors for resident behaviors, which the resident had no behaviors. She indicated she was not involved with the [MEDICAL CONDITION] medications. 6. Resident #83's record was reviewed on 5/15/13 at 2:33 p.m. Resident #83's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated 4/5/13, for Resident #83 indicated resident was cognitively intact and received Antianxiety and Antidepressant medication 7 times within the last 7 days. Mood interview conducted and indicated resident had no symptoms of feeling down or depressed, having trouble concentrating on things, and not feeling fidgety or restless. The behavior assessment indicated the resident had no symptoms of [MEDICAL CONDITION] and there were no behavioral, verbal or physical symptoms indicated. A care plan dated 4/5/13, indicated Resident #83 became anxious when she gets short of breath (SOB), and resident was to receive [MEDICATION NAME] (antianxiety) as ordered. A pharmacy recommendation dated 9/26/12, indicated the [MEDICATION NAME] was being given to the resident without a supporting diagnosis. The physician indicated on 10/3/12, the resident had anxiety. A pharmacy recommendation dated 2/27/13, indicated the resident had been on [MEDICATION NAME] 0.5 mg (milligrams) twice a day since 7/18/12, and recommended a gradual dose reduction (GDR). The physician indicated on 3/10/13, he disagreed with the recommendation and indicated the resident had chronic [MEDICAL CONDITION] (congestive obstructive [MEDICAL CONDITION] disease) and [MEDICAL CONDITION]. There was a lack of documentation to indicate why a GDR was contraindicated. On 5/15/13 at 2:49 p.m., the Social Service Director was interviewed and indicated there have been no behaviors reported to her and also indicated the facility does not monitor anyone receiving an anti-anxiety medication. An interview with the DON (Director of Nursing) on 5/15/13 at 3:30 p.m., indicated the resident was taking [MEDICATION NAME] for [MEDICAL CONDITION] exacerbation and had not had any anxiety since being on the medication. The DON indicated the facility did not monitor the effectiveness unless the resident was having problems and the physician did not want to do a GDR. The DON reviewed Resident #83's record and had no further information regarding why the reduction of the [MEDICATION NAME] was contraindicated. 7. On 5/13/13 from 12:00 p.m. to 12:30 p.m., Resident #123 was observed to be restless and was yelling out in the skilled dining room. The resident had facial grimacing. During this time, the DoN was observed walking over to the resident, patted her hand, reassured her, and then walked away. The resident was not asked if she was in pain. No other nurse or CNA had addressed the resident yelling. On 5/13/13 at 2:30 p.m., Resident #123 was heard yelling out from her room. On 5/14/13 at 10:30 a.m., Resident #123 was heard yelling out from her room. The resident was observed to have facial grimacing and was restless in her geri chair. On 5/15/13 at 12:00 p.m., Resident #123 was observed yelling out in the skilled dining room. On 5/16/13 at 8:15 a.m., Resident #123 was observed in her room, partially sitting up in her geri chair, moving her legs up and down. The resident indicated she was in pain and she hurt all over. LPN #1 was informed, chuckled and indicated the resident did get pain medication ordered last evening. On 5/16/13 at 9:20 a.m., Resident #123 was observed in her room, in her geri chair, partially sliding down with her right knee bent and left leg crossed over the right knee. The resident continued to have facial grimacing. The resident indicated her pain was not better. The resident indicated she wanted to go to bed. A CNA on the unit was informed. Resident #123's record was reviewed on 5/15/13 at 2:10 p.m. Resident #123's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. A care plan for pain related to impaired cognition was initiated on 5/10/13. The approach/intervention indicated to give pain medications as ordered. The May 2013 Physician Recapitulation orders and May 2013 MAR (Medication Administration Record) did not indicate pain medication had been ordered but had indicated to give 0.2 ml (milliliters) of [MEDICATION NAME] 0.5 mg/2 ml, IM (intramuscular) every 6 hours as needed for agitation. Resident #123's record was reviewed again on 5/16/13 at 8:35 a.m. A physician order [REDACTED]. A Behavior/Check off list for behaviors exhibited was completed on 5/13/13 at 7:30 a.m. The form indicated the resident was "yelling out..bucking in geri chair." The interventions attempted before [MEDICATION NAME] was given at 6:30 a.m., was the resident was removed from the environment. At 7:00 a.m., "TV". No time indicated, but different staff tried to intervene. The [MEDICATION NAME] was given at 7:30 a.m. At 9:00 a.m., the resident began to calm down. An OT daily therapy note dated 5/13/13, indicated the resident was "calling out" at times. An OT daily therapy note dated 5/14/13, indicated range of motion to all upper extremely joints, with the resident "calling out at the end range of shoulder joints." A Behavior Check off list for behaviors exhibited was completed on 5/14/13 at 10:00 p.m. The form indicated the resident was "excessive yelling and high amount of anxiety." The interventions attempted before [MEDICATION NAME] was given at 8:00 p.m., was the resident was removed from the environment, at 8:15 p.m., "TV", at 8:30 p.m., different staff tried to intervene, and at 9:00 p.m., a snack was provided. Other interventions included repositioning and her brief was changed. The [MEDICATION NAME] was administered at 9:00 p.m., and the resident was asleep by 10:00 p.m. A PT progress note dated 5/15/13, indicated the resident would holler (yell) while performing ROM (range of motion) to BLE (bilateral lower extremities) but was unable to rate the pain and unable to describe her symptoms. An OT progress note dated 5/15/13, indicated "Pt (Patient) calling out at times...Pt. grimaces at end range PROM (passive range of motion) BUE's (bilateral upper extremities), esp. (especially) shoulders, though is unable to rate type or level of pain. Pt. generally has few verbalizations, but occasionally responds appropriately to simple questions." The treatment [DIAGNOSES REDACTED]. An OT daily therapy note dated 5/16/13, indicated resident "calls out at times." The treatment [DIAGNOSES REDACTED]. On 5/13/13 at 12:00 p.m., a CNA indicated the resident yells out all the time and had been doing it since admission. An interview with the SSD (Social Service Director) on 5/15/13 at 10:20 a.m., indicated she believed nursing was looking at the resident's pain. The SSD indicated Psych was recently referred due to her being a new admit. On 5/16/13 at 8:25 a.m., the DoN stated "that is how the resident communicates." In clarification, the DoN indicated when Resident #123 yells, that was how she communicated and the ADoN indicated the resident would yell out her answers when staff would ask her questions. On 5/16/13 at 9:45 a.m., PT #12 indicated the therapists would inform nursing staff of the resident's progress or anything significant to their daily care, but they do not inform them of their pain because they were already being assessed for their pain medication. On 5/16/13, at 11:45 a.m., LPN #1 indicated the resident had pre senile dementia and this contributed to her yelling out versus the resident being in pain. LPN #1 was not aware of the resident having pain during therapy. LPN #1 indicated the coccyx wound was superficial and shouldn't be painful and he had asked the resident in the past if she was in pain when she would yell out. LPN #1 indicated the resident would first say yes to pain and then a few minutes later she would say no, so she was "wishy washy" and due to her dementia, he didn't know if she was in pain. LPN #1 indicated the resident was not on pain medication in the hospital. LPN #1 also indicated having to maintain the residents dignity, as in keeping the resident in bed all day versus putting her to bed when she was in pain or uncomfortable. LPN #1 indicated the spouse informed him, the resident did not have [MEDICAL CONDITION] but a patch of [MEDICAL CONDITION] and he was upset with the [MEDICAL CONDITION] diagnosis, so the pain would not [MEDICAL CONDITION] related. LPN #1 indicated he did not clarify the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Upon reviewing the resident's behavior record on 5/16/13 at 2:00 p.m., the DoN indicated, again, the resident did not have behaviors and her yelling was the way she communicated. The DoN initiated the behavior monitoring record on 5/15/13 for socially inappropriate/disruptive behavior/sounds. The interventions/approaches were to move the resident to a quiet area, hold hand, turn on TV, turn off TV, and/or lay down for a nap. The option to manage pain was not selected. The psychoactive medication indicated was [MEDICATION NAME]. [MEDICATION NAME] 0.5 mg/ml, inject 0.2 ml every six hours as needed, was not listed as a psychoactive medication. A facility policy, dated 08/01/10, titled, "Behavior Management [MEDICAL CONDITION] Medication Protocol", received from the Director of Nursing as current, indicated, "...Residents who receive antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest, lowest dosage necessary to manage the resident's condition. Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications and will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs..." 8. On 5/13/13 at 11:45 a.m., Resident #26 was observed in the skilled dining room, reclined in a geri chair with his head off to the right side of the chair. The resident received his meal at 12:05 p.m., and was starting to be fed by a family member while his head remained off the right side of the chair. At 12:18 p.m., the resident's family member indicated Resident #26's head never stays up and the staff has to reposition the resident frequently. During this time, the DoN and CNA #2 repositioned the resident. On 5/13/13 at 12:40 p.m., Resident #26's head had fallen back off to the right side of the geri chair. CNA #2 was at the table sitting across the resident, feeding another resident. The wife continued to feed the resident in this position. There were other staffing personnel observed in the dining room, who did not attempt to repositioned the resident. On 5/15/13 at 9:00 a.m., Resident #26 was observed in his room, reclined in his geri chair with his head on metal edge of the chair. The resident was observed to have a concave cushion for his head which was flattened, a concave trunk cushion and was sitting on a pommel cushion. On 5/15/13 at 10:00 a.m., Resident #26 was observed in bed. Resident #26 continued to favor his head to the right side, near the wall. The resident's bed was observed not to be in the lowest position. On 5/15/13 at 3:45 p.m., Resident #26 was observed down in his bed with the top of his head pressed against the wall. The bed pad alarm was observed to be unplugged. The resident's door was half way shut, and the resident could not be seen from the hallway. Two large pillows was observed to be fluffed and tucked under the fitted sheet, preventing the resident from getting out of bed. Resident #26's record was reviewed on 5/15/13 at 9:00 a.m. Resident #26's [DIAGNOSES REDACTED]. A care plan for risk for fall was initiated on 1/11/13. The approaches/interventions were not dated, but indicated to "reinforce safety awareness, resident lays self on floor to fix wheel chair at times-wiggles out. Wife aware-risk and benefits explained. Falling star program to increase supervision." An OT (Occupational Therapy) note dated 1/24/13, indicated the resident had "an impairment of decreased postural awareness - slumped sitting posture and decreased cardiopulmonary condition - limited tolerance for activity." An OT note dated 1/25/13, indicated the resident was positioned in layback chair; was not able to tolerate an incrediback (concave fitting) wheel chair and was sliding out due to increased extensor tone. A Side Rail Assessment Screen dated 2/6/13, indicated the resident was not able to get out of bed unassisted, was not able to turn from side to side unassisted while in bed, did not attempt to get out of bed unassisted, and the resident did have alterations in safety awareness due to cognitive decline. An OT discharge note dated 2/8/13, indicated Resident #26 needed total assistance at meals. The resident had been in a "layback" chair, leans to the right at times and was observed to have had an increased extensor tone with a need for repositioning to improve posture and interaction with environment. The note also indicated the staff had been instructed on appropriate positioning and feeding, with a good understanding demonstrated. The resident was referred to restorative program. A Fall Risk assessment dated [DATE] and 4/19/13, indicated the resident was a high risk for falls and the resident had fallen 1-2 times in the past three months. A care plan for physical mobility impaired due to [DIAGNOSES REDACTED]. The approaches/interventions indicated "therapy per order, staff assist as indicated, educate on call light use and asking for assist, contact MD and family as indicated." A nursing note dated 4/19/13 at 11:30 a.m., indicated the resident was found on floor in front of the window, lying on his back trying to fix his chair. The note indicated the resident stated, "I wiggled out of my chair to fix the wire under it." A nursing note dated 4/19/13 at 8:30 p.m., indicated Resident #26 had "wiggled out of chair and had a fall. Res. (resident) needs to be positioned frequently and will "wiggle an wiggle."(sic) A nursing note dated 5/10/13 at 7:00 p.m., indicated the resident was in his geri chair in his room, was "wiggling", and caught his leg and received a 7 cm (centimeter) by 2 cm abrasion to his front lower right leg. A CNA care plan was provided by the DoN on 5/16/13 at 1:00 p.m. The CNA care plan indicated the resident had a bed alarm only. An interview with LPN #10 on 5/15/13 at 8:15 a.m., indicated the staff had tried multiple things with the resident for positioning and had been unsuccessful. LPN #10 indicated that if the resident was able to get his fingers to the end of the arm of the chair, he would pull himself down. LPN #10 indicated the geri chair had worked best for the resident and he did need frequent repositioning due to his continued "squirming". LPN #10 indicated a bariatric bed was used for the resident due to his "squirming." An interview with the SSD (Social Service Director) on 5/15/13 at 10:30 a.m., indicated Resident #26's wife did not want him to be moved closer to the nurses station. SSD indicated the staff was on alert about the resident's frequent position changes. An interview with OT #11 on 5/15/13 at 11:30 a.m., indicated she had not been made aware of the resident's positioning problems. OT #11 indicated therapy did try an incrediback wheel chair (concave fitting) but was unsuccessful. OT #11 indicated no other cushions had been attempted. OT #11 stated, "Resident may need to be re-screened if they are having to reposition him often". An interview with PT #12 on 5/15/13 at 11:45 a.m., indicated he had not been made aware of the resident's positioning problems. PT #12 indicated a high back wheel chair was borrowed from a resident (who wasn't using his) was attempted and failed. PT #12 indicated the resident was stiff and rigid. PT #12 indicated the Broada (prevents head from falling off chair) chair had not been attempted due to no availability of a chair. PT #12 indicated the staff had not informed therapy of the resident's positioning problems and with meal service. PT #12 indicated he would look to re-evaluate the resident. The DoN on 5/15/13 at 11:55 a.m., indicated the resident was being discussed in the morning meeting on "Tuesday" for a Broda chair as well as two other residents. The DoN indicated the resident was constantly being repositioned, had head bolsters in his wheelchair, this was his third time being in the facility, and the resident's spouse can be interviewed about the frequent repositioning. The DoN indicated their corporation owned the equipment company. An interview with CNA #13 on 5/15/13 at 4:00 p.m., indicated other CNAs had told her to put pillows under the fitted sheets to keep his legs in bed where he "squirms" all the time. CNA #13 indicated she was not aware of the call light not being within reach to the resident or the bed alarm not being plugged in. CNA #13 indicated she was in the resident's room approximately 15 minutes prior and had cleaned the resident. CNA #13 indicated she frequently checks on the resident. An interview with the resident's spouse on 5/16/13 at 11:15 a.m., indicated she was not aware of the facility looking into ordering a Broda chair for the resident. An interview with CNA #14 on 5/16/13 at 11:30 a.m., indicated she was new to the facility and this was her first week on her own on the unit. CNA #14 indicated she was told by the night shift CNA, not to put pillows under the fitted sheet that it was considered a restraint. CNA #14 indicated other CNAs had been putting the pillows under the fitted mattress. An interview with the DoN on 5/17/13 at 9:00 a.m., indicated she did not have a fall policy and the Falling Star program was for residents who had a history of [REDACTED]. 3.1-52(a) 3.1-52(b)