Every finding on record at Clinton House Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to ensure a resident received scheduled showers for 1 of 2 residents reviewed for ADL (activities of daily living) care. (Resident D)Findings include:A confidential email, dated 6/11/26, indicated Resident D had not received adequate care at the facility and had only received two (2) showers in 2 weeks.The clinical record for Resident D was reviewed on 7/27/26 at 11:48 a.m. The diagnoses included, but were not limited to, orthopedic aftercare, Charcot's joint (a progressive and destructive condition of the bone structure) of right ankle and foot, and acquired absence of the left leg below the knee.A Brief Interview for Mental Status (BIMS) score, dated 5/22/26, indicated Resident D was cognitively intact.A care plan, dated 5/28/26, indicated Resident D was at risk for ADL self-care deficits related to right mid-foot osteotomy (surgical bone repair) and external fixation (a surgical treatment used to stabilize bones using pins and wires inserted through the skin into the bone, and connected to an external frame outside the body). Interventions included, but were not limited to, bathing and showers were preferred on Monday's and Thursday 's day shift and could fluctuate throughout the day and Resident D was dependent on staff.Resident D's care plan did not include a documented history of refused care for ADL needs, including showers.Resident D had eight (8) bathing opportunities from his admission on [DATE] to his discharge on [DATE].In May 2026, according to Resident D's Monday and Thursday shower schedule, Resident D should have received a shower on 5/25 and 5/28.The CNA task for bathing did not have documentation on 5/25, a refusal was documented on 5/27, and resident unavailable was documented on 5/28.There was no shower sheets provided for the month of May.In June 2026, according to Resident D's Monday and Thursday shower schedule, Resident D should have received a shower on 6/1, 6/4, 6/8, 6/11, 6/15 and 6/18.The CNA task for bathing did not have documentation for 6/1 or 6/4, a refusal was documented for 6/8, a bed bath was documented on 6/11, a shower was documented on 6/15, and a refusal was documented on 6/18.Facility shower sheets were provided for 6/1 and 6/4 but did not include the Resident D's signature. Shower sheets were not provided for the documented refusals on 6/8 and 6/18.A progress note, dated 6/4/26, indicated Resident D's friend called the facility after Resident D reported to his friend, he had not had a shower since being admitted to the facility.A progress note, dated 6/7/26, indicated Resident D's friend came to the facility wanting to know when Resident D's last shower was. The nurse told Resident D's friend the resident was not allowed to have a shower due to the pins in his legs rusting and he had been offered bed baths with rags and water. Resident D's friend asked if family and friends could help give the resident a bed bath. The staff member indicated the friend would need to ask the DON or Executive Director (ED).There was no documentation to indicate Resident D was unable to take a shower due to the external fixator in the progress notes, physician's notes, podiatrist (foot specialist) notes, wound care notes, resident assessments, or the resident's care plan.A progress note indicated on 6/13/26, Resident D had complained about not receiving a shower. Resident D was told he had been out of the facility for the entirety of the day and into the night on the day of his scheduled shower, showers must be done on the schedule he chose when admitted , and if he wanted to change his shower schedule he would need to speak with management on Monday (6/15/26).During an interview, on 7/28/26 at 10:15 a.m., the DON (Director of Nursing) indicated Resident D often refused showers.During an interview, on 7/28/26 at 11:13 a.m., LPN (Licensed Practical Nurse) 4 indicated when a resident refused a shower, the CNA (certified nursing assistant), the nurse and the resident would sign the shower sheet to prove several attempts were made and all attempts were refused.A facility shower sheet indicated .Each resident must be offered care a total of three times. If the resident is still refusing after these attempts, 2 staff members (CNA/QMA/Nurse) MUST witness the third refusal.The resident is also required to sign, unless deemed cognitively or medically unable.A current facility policy, titled Activities of Daily Living Support, dated 9/11/23 and received from the DON on 7/28/26, indicated .Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to complete activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with.Hygiene (bathing, dressing, grooming, and oral care).A current facility policy, titled Resident Rights Policy, dated 11/1/21 and received from the DON on 7/28/26, indicated .Residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.Residents have the right to be treated with consideration, respect, and recognition of their dignity and individuality.This citation relates to Intake 3041286.410 IAC (Indiana Administrative Code) 3.1-38(a)(2)(A)410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(A)410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(B)410 IAC (Indiana Administrative Code) 3.1-38(b)(2)410 IAC (Indiana Administrative Code) 3.1-38(b)(3)410 IAC (Indiana Administrative Code) 3.1-38(f)

Based on observation, interview and record review, the facility failed to ensure PPE (personal protective equipment) was worn correctly and to establish a clean field for wound care supplies for 1 of 6 residents reviewed for infection control. (Resident 21)Finding includes:During an observation, on 8/14/25 at 9:32 a.m., Unit Manager (UM) 2 gathered wound care supplies, which included, an antiseptic wound cleanser, gauze pads, calcium alginate with silver (an antimicrobial dressing), and a foam bordered dressing, in preparation to perform a wound care treatment for Resident 21. After gathering the wound care supplies, UM 2 then put on PPE (a gown and gloves). UM 2 did not tie the gown closed around her waist. UM 2 then placed the wound care supplies on Resident 21's bedside table and opened them. UM 2 was not observed to have cleaned the surface of the bedside table prior to placing the wound care supplies on the table and opening them. The wound care supplies were observed to have been placed on the bedside table next to a urinal with approximately 200 milliliters of urine in it. After completing the wound care treatment, UM 2 placed the bedside table within Resident 21's reach and asked Resident 21 if he would like her to empty the urinal before leaving the room.During an interview, on 8/14/25 at 9:43 a.m., UM 2 indicated she was not aware the gown had ties for the waist section, and the gown should have been tied around the waist. UM 2 also indicated the urinal should have been removed from the bedside table prior to performing the wound care treatment.The clinical record for Resident 21 was reviewed on 8/14/25 at 3:04 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, rhabdomyolysis, and cognitive communication deficit.A physician's order, dated 8/5/25, indicated Resident 21 required the use of enhanced barrier precautions (EBP) with a sign posted to communicate to staff to ensure a gown and gloves were used during identified high contact care activities.During an interview, on 8/14/25 at 11:40 a.m., the Director of Nursing (DON) indicated UM 2 emptied the urinal prior to the wound care treatment. The DON indicated UM 2 said after she put on her gown and gloves, she noticed the urinal had been used again and she did not want to change gloves again, so UM 2 offered to empty the urinal after the treatment. If the gown had ties around the waist, the gown should have been tied.A current facility policy, titled Clean Dry Dressing Change, dated 8/1/23 and received from the DON on 8/14/25 at 12:00 p.m., indicated .Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs.The following equipment and supplies will be necessary when performing this procedure.Personal protective equipment [(e.g., gowns, gloves.)].Clean bedside stand. Establish a clean field.Place the clean equipment on the clean field.A current facility policy, titled Enhanced Barrier Precautions, dated 11/1/23 and received from the DON on 8/14/25 at 12:00 p.m., indicated .It is the policy of the facility to ensure that Enhanced Barrier Precautions [(EBPs)] are utilized to prevent the spread of multi-drug resistant organisms [(MDROs)] to residents.Enhanced barrier precautions [(EBPs)] are used as an infection prevention and control intervention to reduce the spread of multi=drug resistant organisms.to residents.3.1-18(b)

Based on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed within 14 days of admission for 1 of 4 residents reviewed for MDS assessments. (Resident 12)Finding includes:The clinical record for Resident 12 was reviewed on 8/11/25 at 2:42 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), dementia, and congestive heart failure.Resident 12 had an entry MDS assessment completed on 6/30/25.An admission MDS assessment, with an Assessment Reference Date (ARD) date of 7/13/25, was still in progress and was not completed as of 8/12/25.During an interview, on 8/12/25 at 2:42 p.m., the MDS Coordinator indicated the admission comprehensive MDS assessment was overdue by 30 days. The assessment should have been completed by 7/13/25.During an interview, on 8/12/25 at 2:45 p.m., the MDS Coordinator indicated the facility followed the Resident Assessment Instrument (RAI) manual for their policy.An RAI manual, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, effective October 1, 2024, indicated .When admitting a resident from another nursing home, regardless of whether or not it is a transfer within the same chain, a new admission assessment must be done within 14 days.By statute, the RAI must be completed within 14 days of admission. As an integral part of the RAI, CAAs must be completed and documented within the same time frame.3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed every 3 months for 3 of 4 residents reviewed for MDS assessments. (Resident 17, 30, and 59)Findings include:1. The clinical record for Resident 17 was reviewed on 8/11/25 at 3:15 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, moderate vascular dementia with psychotic and mood disturbance, and anxiety disorder.The first quarterly assessment after the annual comprehensive Minimum Data Set (MDS) assessment for Resident 17 was completed on 4/6/25. The next quarterly assessment was completed 4 months later (127 days), on 8/11/25.2. The clinical record for Resident 30 was reviewed on 8/11/25 at 3:20 p.m. The diagnoses included, but were not limited to, hydrocephalus, paraplegia, and mild dementia with mood disturbance.The first quarterly assessment after the annual comprehensive Minimum Data Set (MDS) assessment for Resident 30 was completed on 4/8/25. The next quarterly assessment was completed 4 months later (122 days), on 8/8/25.3. The clinical record for Resident 59 was reviewed on 8/11/25 at 3:35 p.m. The diagnoses included, but were not limited to, autistic disorder and epilepsy without status epilepticus.The first quarterly assessment after the annual comprehensive Minimum Data Set (MDS) assessment for Resident 30 was completed on 4/10/25. The next quarterly assessment was completed over 3 months later (120 days), on 8/8/25.During an interview, on 8/12/25 at 2:45 p.m., the MDS Coordinator indicated the facility followed the Resident Assessment Instrument (RAI) manual for their policy. The quarterly assessment should have been completed within 3 months according to the manual.An RAI manual, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, effective October 1, 2024, indicated the Assessment Reference Date (ARD) is no later than the ARD of the previous OBRA assessment of any type + 92 calendar days. The MDS Completion Date of the Quarterly Assessment must be no later than 14 days after the ARD (106 days). 3.1-31(d)(3)

Based on interview and record review, the facility failed to ensure the physician was notified of high blood glucose levels within the physician's ordered call parameters for 1 of 1 resident reviewed for quality of care. (Resident 53)Findings include: The clinical record for Resident 53 was reviewed on 8/11/25 at 2:00 p.m. The diagnoses included, but were not limited to, morbid obesity, type 2 diabetes, and hypertension.A physician's order, dated 7/22/25, indicated to give Admelog injection (insulin lispro) per sliding scale. If the blood glucose was 401 or more, give 9 units and call the Medical Doctor (MD).The following blood glucose readings were over 401 with no documentation the MD was called:a. On 7/23/25 at 11:29 a.m., the blood glucose reading was 496 with no documentation the MD was called.b. On 7/31/25 at 4:40 p.m., the blood glucose reading was 401 with no documentation the MD was called.c. On 8/6/25 at 9:18 p.m., the blood glucose reading was 417 with no documentation the MD was called.d. On 8/7/25 at 8:43 p.m., the blood glucose reading was 416 with no documentation the MD was called. During an interview, on 8/12/25 at 2:09 p.m., the Director of Nursing (DON) indicated notification to the physician would be scanned into the miscellaneous tab in the electronic record and would be documented in the notes.During an interview, on 8/12/25 at 2:14 p.m., the DON indicated notification could also be attached to the order and would show up in the administration record. She would look for those dates to see if there was notification. During an interview, on 8/12/25 at 2:36 p.m., the DON indicated she could not locate documentation of the notifications for the high blood glucose readings in the record.During an interview, on 8/15/25 at 10:30 a.m., Licensed Practical Nurse (LPN) 4 indicated the MD should have been notified if there were call orders and the notification should have been documented in the resident's record.A current facility policy, titled Notification of Resident's Change in Condition, with an effective date of 9/11/23 and received from the DON on 8/15/25 at 8:44 a.m., indicated .The nurse will notify the resident's attending physician or physician on call when there has been a(an).Specific instruction to notify the physician of changes in the resident's condition.3.1-37(a)

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for at least 8 consecutive hours 7 days a week for 2 of 21 days reviewed for staffing. (7/20/25 and 8/3/25)Findings include:The as worked staffing schedules were reviewed on 8/11/25 at 1:35 p.m. A RN was not scheduled to work on Sunday, 7/20/25. A RN was not scheduled to work on Sunday, 8/3/25. The facility assessment, dated 3/17/25, indicated the facility had 2 residents who required IV (Intravenous) medications on average. Staff with specialized training such as RNs were to be assigned to areas with residents with higher acuity needs.During an interview, on 8/15/25 at 10:19 a.m., the Director of Nursing indicated there was no RN present in the facility on 7/20/25 and 8/3/25. The facility followed the CMS guidelines for staffing, and an RN should have been present on those dates for at least 8 consecutive hours.The facility did not provide a staffing policy prior to exit. 3.1-17(b)(3)

Based on interview and record review, the facility failed to ensure the daily nurse staffing data was posted at the beginning of each shift on 1 of 6 survey observation dates. (8/10/25)Findings include:During an observation, on 8/10/25 at 12:21 p.m., the posted nurse staffing data sheet was dated for 8/8/25.During an interview, on 8/11/25 at 12:55 p.m., the Director of Nursing (DON) indicated the scheduler created the daily nurse staffing data forms and posted it each morning. On the weekends, she created it ahead of time, and the manager on duty was supposed to post it each morning. The Saturday and Sunday sheets were placed in the posting frame behind Friday's sheet to be pulled forward over the weekend. If there were call-ins or changes, it would not reflect those on the weekend or night shifts after she went home. The staffing should be posted each morning, even during the weekend. If the posted sheet was dated 8/8/25, then the nurse staffing data sheet for 8/9/25 must not have been pulled forward on Saturday and Sunday's sheet was not pulled forward at the beginning of the shift.The facility did not provide a policy on nurse staffing data posting prior to exit.3.1-17(a)

Based on observation, interview and record review, the facility failed to ensure baseline care plans were completed within 48 hours after admission for 2 of 2 residents reviewed for baseline care plans. (Resident B and 34) Findings include: 1. During an observation, on 9/3/24 at 10:51 a.m., Resident B was wearing oxygen at 3 liters. The clinical record for Resident B was reviewed on 9/5/24 at 1:25 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. The resident was admitted on [DATE]. While reviewing the resident's care plan, the resident did not have a baseline care plan for the use of oxygen. During an interview, on 9/6/24 at 2:31 p.m., the Chief Nursing Officer (CNO) indicated there was not a respiratory baseline care plan for the resident. The policy was for the baseline care plan to be started within 48 hours of admission. 49891 2. The clinical record for Resident 34 was reviewed on 9/4/24 at 2:39 p.m. The diagnoses included, but not limited to, pneumonia, acute on chronic systolic congestive heart failure, major depressive disorder, chronic kidney disease stage 3, and anxiety disorder. The resident's initial admitted was 7/18/24. The baseline care plan meeting date was recorded as occurring on 7/22/24 at 10:30 a.m. The resident was discharged to the hospital on 7/23/24. The resident was readmitted to the facility again on 7/27/24. The clinical record did not include a new baseline care plan meeting. During an interview, on 9/6/24 at 2:05 p.m., the Social Services Director indicated the baseline care plan meetings were recorded in the clinical record. A current facility policy, titled Baseline Care Plan, dated 10/20/23 and received from the Interim Executive Director on 9/6/24 at 2:40 p.m., indicated .Upon admission, the admission nurse will initiate the development of the baseline care plan as part of the admission assessment. The baseline care plan will continue to be developed by the interdisciplinary team and be completed within 48 hours of admission. 3.1-35(a)

Based on interview and record review, the facility failed to administer an as needed medication for weight gain, to notify the physician of a weight gain and to hold insulin doses per the physician's orders for 2 of 2 residents reviewed for quality of care. (Resident 34 and 68) Findings include: 1. The clinical record for Resident 34 was reviewed on 9/4/24 at 2:39 p.m. The diagnoses included, but were not limited to, pneumonia, acute respiratory failure with hypoxia (absence of enough oxygen to sustain bodily functions), acute on chronic systolic congestive heart failure (heart is unable to pump blood as well as it should), and chronic kidney disease stage 3. A physician's order, dated 7/28/24, indicated to weigh the resident daily and to notify the physician if the resident had a weight gain of 3 pounds in a day or 5 pounds in a week for congestive heart failure. A physician's order, dated 7/28/24, indicated to give furosemide (a diuretic medication) 40 milligrams (mg) by mouth every 24 hours as needed (PRN) for a greater than 3-pound weight gain. The vitals record in the electronic medical record indicated the resident's weights included, but were not limited to, a. On 8/4/24, the weight was 152 pounds and on 8/5/24 the weight was 155.5 pounds. This was a documented increase of 3.5 pounds in a day. b. On 8/10/24, the weight was 149.9 pounds and on 8/16/24 the weight was 161 pounds. This was a gain of 11.1 pounds in a week. c. On 8/11/24, the weight was 150 pounds and on 8/12/24 the weight was 156.5 pounds. This was an increase of 6.5 pounds in a day d. On 8/13/24, the weight was 156.5 pounds and on 8/14/24 the weight was 162 pounds. This was a gain of 5.5 pounds in a day. e. On 8/28/24, the weight was 158.5 pounds and on 8/30/24 the weight was 162 pounds. There was no weight found for 8/29/24. This was a gain of 3.5 pounds. The vitals record had multiple dates of missing weights. The Medication Administration Record (MAR), dated 8/1/24 through 8/31/24, indicated there had been no administrations of the furosemide PRN dose for a weight gain greater than 3 pounds. The electronic medical record did not indicate the physician had been notified of any weight gain greater than 3 pounds in a day or greater than 5 pounds in a week. During an interview, on 9/3/24 at 12:15 p.m., the resident indicated her main issue was with her breathing and feeling short of breath. She indicated the oxygen, and breathing treatments did not take away her discomfort of feeling short of breath on some days. The resident indicated her legs hurt more when they were more swollen. During an interview, on 9/6/24 at 2:25 p.m., the Director of Nursing (DON) indicated there had been no PRN furosemide doses documented as being given with the weight gain of greater than 3 pounds. She also indicated the provider had not been notified of weight gains as it occurred. 2. The clinical record for Resident 68 was reviewed on 9/6/24 at 1:32 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus with hyperglycemia and diabetic neuropathy, Parkinson's disease, gastroparesis, vascular dementia with mood disturbance, mild cognitive impairment, long term current use of insulin, depression, anxiety disorder, visual hallucinations, and tremor. A physician's order, dated 3/11/24 and discontinued 6/9/24, indicated to inject 28 units of insulin glargine-yfgn subcutaneously two times a day for diabetes and to hold if the blood glucose was less than 200. A physician's order, dated 6/9/24, indicated to inject 34 units of insulin glargine-yfgn subcutaneously two times a day for diabetes and to hold if the blood glucose was less than 200. A MAR, dated 6/1/24 through 6/30/24, indicated insulin glargine-yfgn 34 units was given with a documented blood glucose level less than 200 on 6/2/24 for the a.m. and p.m. doses, 6/4/24 for the a.m. dose, 6/7/24 for the p.m. dose, 6/11/24 for the a.m. dose, 6/13/24 for the a.m. and p.m. doses, 6/13/24 for the a.m. and p.m. doses, 6/14/24 for the a.m. dose, 6/16/24 for the a.m. dose, 6/18/24 for the a.m. dose, 6/21/24 for the p.m. dose, 6/22/24 for the a.m. dose, 6/28/24 for a.m. dose, and 6/30/24 for the a.m. dose. The documented blood glucose range was 115 to 197 for the doses given against the order to hold for a blood glucose less than 200. A MAR, dated 7/1/24 through 7/31/24, indicated insulin glargine-yfgn 34 units was given with a documented blood glucose level less than 200 on 7/4/24 for the a.m. and p.m. doses, 7/5/24 for the a.m. dose, 7/6/24 for the a.m. dose, 7/8/24 for the a.m. dose, 7/9/24 for the a.m. dose, 7/13/24 for the a.m. and p.m. doses, 7/14/24 for the a.m. dose, 7/16/24 for the a.m. dose, 7/17/24 for the a.m. dose, 7/20/24 for the a.m. and p.m. doses, 7/22/24 for the a.m. dose, 7/23/24 for the a.m. dose, 7/28/24 for the a.m. dose, and on 7/30/24 for the a.m. dose. The documented blood glucose range was 107 to 197 for the doses given against the order to hold for a blood glucose less than 200. A MAR, dated 8/1/24 through 8/31/24, indicated insulin glargine-yfgn 34 units was given with a documented blood glucose level less than 200 on 8/2/24 for the a.m. dose, 8/4/24 for the a.m. dose, 8/5/24 for the a.m. dose, 8/8/24 for the p.m. dose, 8/10/24 for the a.m. dose, 8/11/24 for the a.m. dose, 8/13/24 for the a.m. dose, 8/14/24 for the a.m. dose, 8/15/24 for the a.m. dose, 8/16/24 for the a.m. and p.m. doses, 8/22/24 for the a.m. dose, and 8/23/24 for the a.m. and p.m. doses. The documented blood glucose range was 149 to 198 for the doses given against the order to hold for a blood glucose less than 200. A MAR, dated 9/1/24 through 9/30/24, indicated insulin glargine-yfgn 34 units was given on 9/1/24 for the a.m. dose with a blood glucose of 134, on 9/2/24 for the a.m. dose with a blood glucose of 199, on 9/3/24 for the a.m. dose with a blood glucose of 187, and on 9/6/24 for the a.m. dose with a blood glucose of 195. During an interview, on 9/6/24 at 2:06 p.m., Licensed Practical Nurse (LPN) 7 indicated a medication was given if there was a check mark and initials on the MAR. There would be a code with initials when the medication was not given. LPN 7 indicated the insulin doses had been given on 9/1/24, 9/2/24, 9/3/24, and 9/6/24 with blood glucose levels less than 200. During an interview, on 9/6/24 at 2:21 p.m., the DON indicated the insulin doses were given against the hold order on multiple occasions. A current facility policy, titled Change in Condition/Physician Notification Guidelines, dated 11/23 and received from the DON on 9/10/24 at 12:00 p.m., indicated .physician notification is based on assessment findings and is to be documented in the medical record A current facility policy, titled Medication Administration Policy, dated 6/1/22 and received from the DON on 9/10/24 at 11:58 a.m., indicated .Check for vital signs or other tests to be done during or prior to medication administration A current facility policy, titled Subcutaneous Insulin, undated and received from the Clinical Support Nurse on 9/10/24 at 1:00 p.m., indicated .Administer to resident .as ordered . 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure staff stored a nebulizer mask and a CPAP/BiPap mask in a sanitary manner, failed to sanitize a CPAP/BiPap mask after it was found on the floor, and failed to ensure a resident receiving oxygen supplement therapy had an order for the oxygen for 3 of 3 residents reviewed for respiratory care. (Resident 58, 27 and B) Findings include: 1. During an observation, on 9/3/24 at 10:20 a.m., Resident 58 was resting in bed. A nebulizer mask was found lying on top of the nebulizer machine. It was not stored in a bag. The clinical record for Resident 58 was reviewed on 9/3/24 at 12:26 p.m. The diagnoses included, but were not limited to, history of traumatic brain injury, acute respiratory failure with hypoxia, and other diseases of the bronchus. A physician's order, initiated on 10/21/23, indicated to administer albuterol sulfate (a respiratory medication) 2.5 milligrams in 3 milliliters via nebulizer every six (6) hours as needed for shortness of breath and/or wheezing. During an interview, on 9/3/24 at 10:38 a.m., CNA 5 indicated the mask should not be stored on top of the nebulizer machine. During an interview, on 9/3/24 at 11:25 a.m., the Director of Nursing indicated the nebulizer mask was not stored appropriately. 2. During an observation, on 9/3/24 at 10:35 a.m., Resident 27 was sitting up in bed. A mask for a CPAP/BiPap (machine used to assist with breathing while sleeping) was noted to be on the floor. During an observation, on 9/3/24 at 10:36 a.m., CNA 5 entered the room, picked up the CPAP/BiPap mask from the floor and placed it on top of the machine. CNA 5 indicated the mask was not stored in a sanitary manner. She was not observed to have cleaned the mask prior to exiting the room. The clinical record for Resident 27 was reviewed on 9/10/24 at 10:56 a.m. The diagnoses included, but were not limited to, unspecified asthma, chronic respiratory failure with hypoxia, and obstructive sleep apnea. The resident did not have an order for a CPAP/BiPap machine. The resident did not have a care plan addressing the use of a CPAP/BiPap machine. During an interview, on 9/10/24 at 12:33 p.m., Resident 27 indicated he used the machine every night and nursing staff put the mask on him. During an interview, on 9/3/24 at 11:26 a.m., the Director of Nursing indicated the mask should have been sanitized and placed in a bag with a new date. During an interview, on 9/10/24 at 12:05 p.m., the Director of Nursing (DON) indicated Resident 27 needed to have an order for the CPAP. During an interview, on 9/10/24 at 12:32 p.m., RN 6 indicated when the resident admitted to the facility he had an order for the CPAP. The order was discontinued in October of 2023 when he went out to the hospital. 48525 3. During an observation, on 9/3/24 at 10:51 a.m., Resident B was wearing oxygen at 3 liters. The clinical record for Resident B was reviewed on 9/3/24 at 1:25 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. The resident was admitted on [DATE]. While reviewing the resident's physician's orders, the resident did not have an order for the use of oxygen. During an interview, on 9/3/24 at 3:01 p.m., the DON indicated she was not aware the resident did not have an order for oxygen. During an interview, on 9/10/24 at 12:00 p.m., the DON indicated they did not have a policy for physician's orders. A current facility policy, titled CPAP/BiPap CLEANING POLICY, dated as last revised and received from the Director of Nursing on 9/10/24 at 11:58 a.m., indicated, .Nebulizer/BiPap/CPAP mask and oxygen tubing is to be stored in plastic bag when not in use 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure assessments were completed and a consent was obtained prior to the use of side rails for 2 of 3 residents reviewed for accident hazards. (Resident O and 63) Findings include: 1. During an observation, on 9/3/24 at 9:34 a.m., 9/3/24 at 10:49 a.m., 9/4/24 at 9:19 a.m., 9/5/24 at 2:42 p.m., 9/6/24 at 1:40 p.m., 9/9/24 at 2:54 p.m., and 9/10/24 at 10:47 a.m., a side rail was in the raised position and in use on Resident O's bed. The clinical record for Resident O was reviewed on 9/4/24 at 2:02 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, unsteadiness on feet, weakness, lack of coordination, difficulty in walking, peripheral vascular disease, anxiety disorder, chronic pain syndrome, hypertension, and major depressive disorder. A side rail assessment, completed on 7/24/23, indicated Resident O did not need a side rail to assist in bed mobility. The electronic record did not have documentation showing the risks and benefits were explained to Resident O or a consent was obtained prior to the use of side rails. A physical therapy treatment note, dated 6/25/24, indicated Resident O completed transfers using the bedside rail during his therapy session. 2. During an observation, on 9/3/24 at 9:37 a.m., 9/4/24 at 9:29 a.m., 9/5/24 at 1:23 p.m., and 9/9/24 at 2:54 p.m., a side rail was in place on Resident 63's bed. The clinical record for Resident 63 was reviewed on 9/4/24 at 2:03 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, lack of coordination, difficulty in walking, bipolar disorder, generalized anxiety disorder, seizures, gastroesophageal reflux, hypertension, pain in right knee, pain in left knee, and age-related physical debility. A side rail assessment was completed on 2/20/24 at 1:09 p.m. The assessment had the following question, Risks & Benefits have been explained & agreed to bed rail utilization, and indicated one of the following should be selected: 1. Resident representative notified and agreed or 2. Resident notified and agreed. Neither option was selected. The electronic record did not have documentation showing the risks and benefits were explained to Resident 63 or a consent was obtained prior to the use of side rails. A facility document, titled Admission Packet, was found in the electronic record for Resident O and 63. The document indicated .Prior to installing a side or bed rail, the Facility will attempt to use appropriate alternatives. If the Facility determines it is necessary to use a bed or side rail, the Facility will (1) assess the Resident for risk of entrapment from bed rails prior to installation; (2) review the risks and benefits of bed rails with the Resident, Resident Representative and/or Resident Representative and obtain informed consent prior to installation . A current policy, titled Policy and Procedure Subject: Bedrails, dated 11-22 and received from the Clinical Support nurse on 9/5/24 at 9:00 a.m., indicated .when bed/side rails are requested .the admitting nurse will complete the Side Rail Evaluation .When bed/side rails are deemed to be appropriate for the resident, upon completion of the Side Rail Evaluation, the admitting nurse will review risks and benefits and obtain informed consent. 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication was not ordered beyond 14 days or the attending physician documented their rationale in the resident's medical record to indicate the duration for the PRN order for 2 of 5 residents reviewed for unnecessary medications. (Resident K and 183) Findings include: 1. The clinical record for Resident K was reviewed on 9/5/24 at 10:54 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, fibromyalgia, type 2 diabetes mellitus with hyperglycemia, recurrent major depressive disorder with psychotic symptoms, insomnia, unspecified affective mood disorder, anxiety disorder, post-traumatic stress disorder, and unspecified psychosis not due to a substance or known physiological condition. A physician's order, dated 2/9/24, indicated to give 1 tablet of alprazolam (an anti-anxiety medication) 0.25 mg (milligrams) by mouth every 12 hours as needed for anxiety with a 90 day stop date of 5/9/24. A physician's order, dated 5/16/24, indicated to give 1 tablet of alprazolam 0.25 mg by mouth every 12 hours as needed for anxiety with a 90 day stop date of 8/14/24. A physician's order, dated 8/15/24, indicated to give 1 tablet of alprazolam 0.25 mg by mouth every 12 hours as needed for anxiety with no end date given. During an interview, on 9/9/24 at 9:22 a.m., the Director of Nursing (DON) indicated she had not noticed the current PRN alprazolam order did not have a stop date. She could not find any documentation of a clinical reasoning from the physician for the extended duration of the PRN orders. 48525 2. The clinical record for Resident 183 was reviewed on 9/4/23 at 2:36 p.m. The diagnoses included, but were not limited to, severe bipolar disorder with psychotic features, type 2 diabetes, and irritable bowel syndrome. A physician's order, with a start date of 8/23/24, indicated to give clonazepam (an anti-anxiety medication) 0.5 mg every 12 hours as needed. The order for the clonazepam did not have an end/stop date. During an interview, on 9/9/24 at 2:03 p.m., the DON indicated she did not see a stop date for the PRN order. During an interview, on 9/9/24 at 2:34 p.m., the Clinical Support nurse indicated as needed psychotropics should have stop dates within 14 days. A current policy, titled Psychotropic Drug Policy. Gradual Dose Reduction, PRN Psychotropics, not dated and received from the Clinical Support nurse on 9/10/24 at 9:35 a.m., indicated .PRN Psychotropics hypnotics, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN use of the medication 3.1-48(a)(2)

Based on observation, interview and record review, the facility failed to ensure food was being served at proper (safe and appetizing) temperature for 1 of 1 kitchen reviewed for safe food temperatures. Findings include: During an interview, on 9/3/24 at 11:22 a.m., Resident E indicated room trays were often delivered late, and the food was cold. The posted mealtimes were as followed: Breakfast: 7:00 a.m. to 8:00 a.m. Lunch: 12:00 p.m. to 1:00 p.m. Dinner: 5:00 p.m. to 6:00 p.m. During a continuous dining observation, on 9/3/24 from 12:17 p.m. to 12:57 p.m., 30 residents in the dining room were served lunch. During a continuous dining observation, on 9/3/24 from 12:57 p.m. to 1:08 p.m., room trays were delivered to residents on the 200 hall and 400 hall. During a continuous dining observation, on 9/3/24 from 1:08 p.m. to 1:20 p.m., room trays were delivered to residents on the 500 hall and 600 hall. During the delivery of the room trays on the 500 hall, at 1:17 p.m., a food temperature check was requested on the last room tray. During an observation and interview, on 9/3/24 at 1:17 p.m., the Dietary Manager checked the temperature of the meal and indicated the hot foods should be served at 120 degrees Fahrenheit and the cold foods should be served at 45 degrees Fahrenheit. The Dietary Manager indicated if the food did not meet the recommended temperatures, the food would be reheated. The temperatures of the last room tray were as followed: a. The cheeseburger was 106 degrees Fahrenheit. b. The potato salad was 51 degrees Fahrenheit. c. The watermelon was 65 degrees Fahrenheit. During an observation, on 9/3/24 at 1:20 p.m., the last room tray was delivered with the hot food below the recommended temperature (greater than 135 degrees Fahrenheit) and the cold food was above the recommended temperature (less than 41 degrees Fahrenheit). During an interview, on 9/4/24 at 10:39 a.m., Resident C indicated the food being served was bland, cold, and the meal trays brought to the resident's room were delivered late. During an interview, on 9/6/24 at 1:31 p.m., Resident F indicated if they ate in the main dining room, the food temperatures were not a concern. If they ate the meals in their rooms, the food was cold when it was delivered. Resident F indicated complaints about the food had been discussed in the monthly resident council meetings. During an interview, on 9/6/24 at 1:33 p.m., Resident G indicated meal portions were not consistent, the food was bland, and if they chose to eat in their room, the food was cold when it was delivered. During an interview, on 9/9/24 at 2:35 p.m., the Interim Executive Director (ED) indicated he was aware of the ongoing complaints about the food. The concern had been discussed at resident council meetings almost every month. A current facility policy, titled Food and Nutrition Services, dated as revised 11/22 and received from the Clinical Support nurse indicated .The facility will provide each resident with a nourishing, palatable, well-balanced diet . A facility document, titled .Quick Resource Tool: Safe Food Handling . dated 9/1/2021 and received from the Director of Nursing (DON) on 9/10/24 at 10:40 a.m., indicated .The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that the food items are exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit, or per state regulation .All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as state regulation requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding .Temperature for Time/Temperature Control for Safety (TCS) foods will be recorded at time of service and monitored periodically during meal service periods . This citation relates to Complaint IN00441593. 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was placed in contact isolation immediately after being tested and while waiting for the results for Clostridium Difficile (C-Diff) for 1 of 1 resident reviewed for antibiotic use. (Resident B) Finding includes: During an observation, on 9/3/24 at 10:51 p.m., Resident B was on enhanced barrier precautions. The clinical record for Resident B was reviewed on 9/5/24 at 1:25 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. A nursing progress note, dated 9/2/24, indicated the resident had an episode of bowel movement which was foul smelling and mucus in appearance. The physician was notified. A physician's order, dated 9/2/24 at 11:30 a.m., indicated to obtain a stool sample. A physician's order, dated 9/2/24, indicated the Medical Doctor (MD) started Resident B on Flagyl (an antibiotic) 500 mg (milligram) by mouth three times per day for diarrhea to rule out C-Diff (a highly contagious bacteria which causes diarrhea and inflammation of the colon). A physician's order, dated 9/3/24 at 6:00 p.m., indicated the resident was to be in contact isolation every shift until C-Diff was ruled out. The resident was not placed into contact isolation immediately while being tested for C-Diff. Resident B was not in contact isolation for over 24 hours after being tested . During enhanced barrier precautions, personal protective equipment (PPE) was not required to be put on every time when entering the room. Contact isolation required PPE every time when entering a room. During an interview, on 9/3/24 at 3:01 p.m., the Director of Nursing (DON) indicated when you get an order for a stool sample to rule out C-Diff, a resident should be put in contact isolation until they get the results back. A current policy, titled Clostridium Difficile, dated as effective 6/14/24 and received from the DON indicated .Resident with diarrhea and suspected CDI are placed on contact precautions while awaiting laboratory results 3.1-18(j)

Based on observation, interview and record review, the facility failed to ensure the refrigerator did not contain employee drinks, the dishwasher was washing at the recommended temperature and the sanitizing solution bucket levels were in range. This deficient practice had the potential to affect 77 of 77 residents who received food from the kitchen. Findings include: During the kitchen observation, on 8/27/23 at 11:06 p.m., with the Dietary Manager (DM) the following were observed: a. The reach-in refrigerator contained a medium size fast-food cup with a brown drink and a straw. b. The red sanitizer bucket was tested twice. The DM placed a test strip into the bucket and the strip did not change colors. She tested the bucket again using a strip from a different container and the strip did not change color. c. The dishwasher was put through the wash and rinse cycle twice. The first time the rinse temperature was 117 degrees Fahrenheit and the second time the rinse temperature was 116 degrees Fahrenheit. An Installation and Operation Manual from [name of appliance company] indicated the water requirements for the dishwasher rinse was a minimum of 120 degrees Fahrenheit and a recommended temperature of 140 Fahrenheit. During an interview, on 8/27/23 at 11:06 a.m., the DM indicated the fast-food cup was a staff's drink. The refrigerator should not contain staff food or drinks. During an interview, on 8/27/23 at 11:10 a.m., the DM indicated the red bucket contained sanitizing solution (used to wipe tables and surfaces). None of the testing strips turned colors and the test strip should change to green to indicate the amount of sanitizer was appropriate for cleaning surfaces. The green color would indicate a range of 200-400. During an interview, on 8/27/23 at 11:20 a.m., the DM indicated the temperature of the dishwasher should be above 120 degrees and the temperatures were 116 and 117 degrees. The dishwasher not reaching the right temperature and could leave bacteria on the dishes. A current policy, titled QRT Warewashing, dated 9/1/21 and received from the Clinical Support Nurse on 8/27/23 at 3:14 p.m., indicated .All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. A current policy, titled Resident Food-Safe Storage, revised 11/20/22 and received from the Clinical Support on 8/27/23 at 3:14 p.m., indicated .Employee food items shall be placed in the employee refrigerator A current policy, titled How to Sanitize, not dated and received from the Clinical Support on 8/27/23 at 3:14 p.m., indicated .Buckets should be changed every 2-4 hours or more as needed to keep the water clean and the sanitizer effective in use .Buckets that are easily identifiable (e.g. red buckets) and not used for any other purposes do not require labels .Replace solutions when the concentration gets weak or when the solution becomes cloudy .Quaternary Ammonia (QUAT) per manufacture instructions usually 0-500 PPM .The test strip should be in the range of 200 to 400). 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure the reconciliation of controlled drugs in 3 of 3 medication carts reviewed for controlled drugs and to maintain insulin medication integrity for 2 of 2 residents reviewed for insulin medication distribution. (Residents 15 and 4) Findings include: 1a. During the record review of controlled drug records, on 8/30/2023 at 3:01 p.m., the Medication Cart 200, Shift Change Controlled Substance Inventory Count Sheet (narcotic count record- reconciliation) was incomplete for the Month of August 1 through 27, 2023. The narcotic count record -reconciliation sign in and sign out documentation record for August 1 through 27, 2023 was missing 48 of 124 entries. b. During the record review of controlled drug records, on 8/30/2023 at 3:08 p.m., the Medication Cart 400, Shift Change Controlled Substance Inventory Count Sheet (narcotic count record- reconciliation) was incomplete for the Month of August 1 through 27, 2023. The narcotic count record -reconciliation sign in and sign out documentation record for August 1 through 27, 2023 was missing 13 of 104 entries. c. During the record review of controlled drug records, on 8/30/2023 at 3:15 p.m., the Medication Cart for the Memory Care Unit (MCU), Shift Change Controlled Substance Inventory Count Sheet (narcotic count record- reconciliation) was incomplete for the Month of August 1 through 27, 2023. The narcotic count record -reconciliation sign in and sign out documentation record for August 1 through 27, 2023 was missing 37 of 108 entries. During an interview, on 8/28/2023 at 11:40 a.m., LPN 2 indicated the staff were to sign in and out each shift when they did a narcotic count to verify the correct narcotic count for the shift. The reconciliation records for controlled drugs were signed when you count the controlled drugs before each shift and after the shift was over. The count must be conducted with another nurse/QMA and must be accurate or it was reported to the supervisor. She indicated the staff must have forgotten to do the documentation. During an interview, on 8/28/2023 at 11:55 a.m., QMA 3 indicated the staff were to sign in and out each shift when they did a narcotic count to verify the correct narcotic count for the shift. The reconciliation records for controlled drugs were signed when you count the controlled drugs before each shift and after the shift was over. The count must be conducted with another nurse/QMA and must be accurate or it was reported to the supervisor. She indicated the staff must have forgotten to do the documentation. During an interview, on 8/28/2023 at 1:40 p.m., the Director of Nursing (DON) indicated the staff were to sign in and out each shift when they did a narcotic count to verify the correct narcotic count for the shift. The reconciliation records for controlled drugs were signed when you count the controlled drugs before each shift and after the shift was over. The count must be conducted with another nurse/QMA and must be accurate or it was reported to her. She indicated the staff must have forgotten to do the documentation. During an interview, on 8/28/2023 at 3:10 p.m., QMA 4 indicated the staff were to sign in and out each shift when they did a narcotic count to verify the correct narcotic count for the shift. The reconciliation records for controlled drugs were signed when you count the controlled drugs before each shift and after the shift was over. The count must be conducted with another nurse/QMA and must be accurate or it was reported to the supervisor. She indicated the staff must have forgotten to do the documentation. 2. During an observation of the medication cart on the Memory Care Unit, three insulin medications were observed to be in the cart, unopened, and not refrigerated. The manufacture label indicated the medication was to be refrigerated until opened. a. The record for Resident 15 was reviewed on 8/30/2023 at 4:05 p.m. Diagnoses included, but were not limited to, atrial fibrillation, depression, anxiety, and type 2 Diabetes Mellitus. The Medication Administration Record (MAR) for Resident 15 indicated the resident was to receive Insulin Glargine Solution 100 UNIT/ML inject 15 unit subcutaneous at bedtime for diabetes. The resident's medication was found unopened and in the MCU cart on 8/28/2023 at 3:11 p.m. b. The record for Resident 4 was reviewed on 8/30/2023 at 4:15 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus (DM), cardiac pacemaker, dementia, mood disturbance, and anxiety. The Medication Administration Record (MAR) for Resident 4 indicated the resident was to receive Insulin Glargine Solution 100 UNIT/ML inject 28 unit subcutaneous in the morning for diabetes. The MAR for Resident 4 indicated the resident was to receive Insulin Aspart FlexPen 100 UNIT/ML solution pen-injector inject as per sliding scale subcutaneous three times a day for or DM. The resident's medication was found unopened and in the MCU cart on 8/28/2023 at 3:11 p.m. During an interview, on 8/28/2023 at 3:15 p.m., RN 6 indicated the insulin medications for Residents 4 and 15 should have remained in the refrigerator until the medication was to be opened and utilized. During an interview, on 8/28/2023 at 4:22 p.m., the DON indicated the medications had been removed from the refrigerator the morning of 8/28/2023 for utilization. The medications had not yet been utilized and should have been returned to the refrigerator when they were not given to the residents. A current policy, titled Controlled Medication Storage, effective 2/1/2018 and received on 8/30/2023 at 4:18 p.m., from the DON indicated .physical inventory of all controlled medication(s), including emergency supply is completed at each shift change of two (2) licensed nurses and is documented on the controlled medication accountability record per facility procedure A current policy, titled Insulin Storage, effective 11/2020 and received on 8/30/2023 at 9:15 a.m., from the DON indicated .All insulins are sensitive to temperatures that are too high or too low. Once you receive your insulin prescription, you should store all supplies you've received in the refrigerator .Keep an insulin pen refrigerated until you open it; after that, you can store at room temperature 3.1-25(e)(2) 3.1-25(e)(3) 3.1-25(m)

Based on observation, record review and interview, the facility failed to ensure a resident was dressed in her own clothing, a resident's bed was not in the lowest position and sitting on the floor and a resident was assisted to eat with the staff sitting next to her for 3 of 3 residents reviewed for dignity. (Resident 14, 52 and 40) Finding includes: 1. During an observation, on 8/27/23 at 3:18 p.m., Resident 14 was lying in bed with her eyes closed and the bed was so low to the floor it was almost touching the floor with only about one inch between the floor and bed. The bed appeared like it was floor level and the resident appeared to be lying on the floor. The record for Resident 14 was reviewed on 8/3/23 at 11:49 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, osteoarthritis, major depressive disorder, and a mood disorder. A care plan, dated 7/11/23, indicated the resident was at a risk for impaired safety and injury related to a fall risk. The interventions included, but were not limited to, keep the bed in the lowest position. During an interview, on 9/1/23 at 10:09 a.m., LPN 14 indicated the bed position when a care plan indicated for the bed to be in the lowest position would depend on the resident. The beds placed in the lowest position which was almost touching the floor would prevent a resident from falling out of the bed. Other beds were placed in a low position although not close to touching the floor. 2. During an observation, on 8/27/23 at 3:45 p.m., Resident 52 was lying in bed and was wearing a hospital gown. During an observation, on 8/28/23 at 12:29 p.m., the resident was lying in bed in her room and was wearing a hospital gown. During an observation, on 8/29/23 at 11:28 a.m., the resident was lying in bed in her room, her eyes were closed, and she was wearing a hospital gown. During an observation, on 9/1/23 at 10:10 a.m., Resident 52 was lying in bed. The bed was so low it appeared as though the resident was sleeping on the floor. The record for Resident 52 was reviewed on 8/30/23 at 2:29 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with agitation, chronic kidney disease and depression. A care plan, dated 6/13/23, indicated the resident had an activities of daily living (ADL) self-care deficit and was at a risk for functional declines related to depression, impaired mobility, and dementia. The interventions included, but were not limited to, encourage participation in daily care and provide positive reinforcement for activities attempted and/or partially achieved. The care plan did not include the resident would wear a hospital gown. A care plan, dated 6/13/23, indicated the resident was at a risk for impaired safety/injury related to being a fall risk. The interventions included, but were not limited to, keep the bed in the lowest position. The care plan did not indicate if the lowest position was at the floor level or in the regular lower bed position (not elevated position for when staff provided care). An Activity Preferences form, dated 7/30/23, indicated it was somewhat important for the resident to be choose her clothes. During an interview, on 8/29/23 at 12:26 p.m., RN 12 indicated the resident always wore a hospital gown. There were a few times the resident would wear regular clothes. During an interview, on 8/30/23 at 3:39 p.m., the Clinical Support Nurse indicated she was not able to locate documentation in the electronic health record (EHR) for the reason the resident always wore a hospital gown. The preferences were not marked for wearing a hospital gown and the care plan did not include wearing a hospital gown. During an interview, on 8/31/23 at 10:39 a.m., the Social Services Designee (SSD) indicated the resident was combative with care at times and she assumed the resident would not let staff change her clothes. The resident did have her own clothing. During an interview, on 8/31/23 at 4;15 p.m., the Executive Director (ED) indicated she was not aware the residents' beds were in such a low position at the floor level. The beds were not in the lowest position to keep the resident's from getting up and were not supposed to be on the floor. 46961 3. During an observation, on 8/27/23 at 12:33 p.m., QMA 7 was standing next to Resident 40 feeding her. CNA 8 took over feeding the resident and she remained standing until the resident finished. During an observation, on 8/29/23 at 12:33 p.m., the Activity Director was assisting the resident to eat while she was standing next to her. She kneeled on the floor beside the resident at 12:36 p.m., then stood back up to assist her to eat. The record for Resident 40 was reviewed on 8/27/23 at 1:00 p.m. Diagnoses included, but were not limited to, dysphagia and Alzheimer's disease. A care plan, dated 8/15/23, indicated eating may fluctuate throughout the day, but usual performance was supervision or touching assistance. During an interview, on 8/30/23 at 3:30 p.m., the Activity Director, who was also a CNA, gave a copy of the items reviewed in the state approved curriculum for dining assistants (used to train feeding assistants to assist residents to eat). She indicated the staff were taught to sit next to the resident and not across from them. She was not sure why this was not listed on the state approved curriculum for dining assistants. During an interview, on 8/31/23 at 2:47 p.m., CNA 10 indicated when she fed a resident, she would sit on the affected side at eye level with the resident. She was taught to sit next to the resident when feeding them during the CNA training. A current policy, titled Castle Healthcare Fall Prevention Program, reviewed on 6/9/21 and received from the ED on 9/1/23 at 4:30 p.m., indicated .It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible .Standard Fall/Safety Precautions For All Residents .The bed will be maintained in a position appropriate for resident transfers A current policy, titled Resident Rights, revised on 11/2022 and received from the Director of Nursing (DON) on 9/1/23 at 12:30 p.m., indicated .To promote the exercise of rights for each resident, including any who face barriers [such as communication problems, hearing problems and cognition limits] in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability .These rights include the resident's right to .Retain and use personal possessions to the maximum extent that space and safety permit 3.1-3(t)

Based on interview and record review, the facility failed to update the care plan for a resident after acquiring a pressure ulcer on his heel for 1 of 3 residents reviewed for pressure ulcers. (Resident 73) Finding includes: The record for Resident 73 was reviewed on 8/29/23 at 10:02 a.m. Diagnoses included, but were not limited to, severe calorie malnutrition, traumatic brain injury, need for assistance with personal care, anemia, and lower back wound. A skin and wound progress note, dated 6/28/23 at 12:32 p.m., indicated Resident 73 had developed a new pressure ulcer on his right heel. A care plan, dated 6/15/23, indicated to monitor the progress of the resident's skin condition, notify the nurse of new areas of skin breakdown, provide a pressure redistribution mattress to the bed, and provide incontinence care as needed. The care plan did not include the new pressure ulcer on the right heel. During an interview, on 9/1/23 at 9:47 a.m., the Clinical Support Nurse indicated there was no care plan with revisions for the resident's new pressure ulcer for his right heel. During an interview, on 9/1/23 at 11:07 a.m., the Director of Nursing (DON) indicated the facility did not have a care plan with revisions for the resident's new pressure ulcer for his right heel. A current policy, titled CARE PLANS PROTOCOL, received from the DON on 9/1/23 at 12:30 p.m., indicated .The care plan should be revised on an on-going basis to reflect changes in the resident and the care the resident is receiving. The care plan is an interdisciplinary communication tool the comprehensive care plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be periodically reviewed and revised, and the services provided or arranged must be in accordance with each resident's written plan of care 3.1-35(d)(1)

Based on observation, record review and interview, the facility failed to ensure a resident was getting her teeth brushed twice daily as ordered by the dentist for 1 of 1 resident reviewed for dental care. (Resident 40) Finding includes: During an observation, on 8/28/23 at 12:25 p.m., Resident 40 was talking and there was a very foul odor noted from the resident's mouth. The record for Resident 40 was reviewed on 8/29/23 at 11:30 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), anxiety, Alzheimer's disease, and age-related cataract. A dental note, dated 4/4/23, indicated the resident's oral hygiene was poor. A dental note, dated 7/18/23, indicated the resident had heavy generalized plaque (a sticky film coating teeth which contains bacteria), heavy calculus (hardened dental plaque) and generalized bleeding. The gingival (tissue surrounding the teeth) tissue was red and inflamed. The instructions included for the staff to please assist the resident to brush her teeth twice daily and to focus on the gumlines. A care plan, dated 8/15/23, indicated the resident had an activities of daily living (ADL) self-care deficit. The resident's oral hygiene may fluctuate throughout the day and usual performance was supervision or touching assistance. The care plan did not include the instructions from the dentist for the staff to assist the resident with brushing her teeth twice daily or to focus on the gumlines. The daily documentation of ADL care from the CNAs did not include if the resident's teeth were brushed. During an interview, on 8/30/23 at 2:30 p.m., RN 12 indicated it was hit or miss if the resident would let staff assist with oral care. She was not aware of the recommendations from the dentist. During an interview, on 8/30/23 at 2:47 p.m., the Clinical Support Nurse indicated the resident's care plan did not include the recommendations from the dentist and should be updated. Social services would usually read the dental notes and acknowledge the recommendations from the dentist. During an interview, on 8/31/23 at 10:30 a.m., the Social Services Designee (SSD) indicated she would tell the nurse the recommendation from the dentist and then it was out of her hands. It would be up to the nurses to make a task for the Certified Nursing Assistants (CNAs) to complete the task. The nursing staff would also need to update the care plan since teeth brushing would be a nursing care plan. A current policy, titled Dental Services and Loss or Damage of Dentures, dated 11/28/17 and received from the Executive Director (ED) on 9/1/23 at 4:38 p.m., indicated .The facility will, if necessary or requested by the resident, assist with scheduling appointments for dental services A current policy, titled Physician Orders Policy/Guidelines, revised on 11/2022 and received form the Clinical Support Nurse on 8/28/23 at 2:00 p.m., indicated .Physician orders are reviewed and noted accordingly per licensed nursing staff A current policy, titled Activities of Daily Living [ADLS] Maintain Abilities, revised on 11/2022 and received from the ED on 9/1/23 at 4:40 p.m., indicated .It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs .The facility will provide care and services for the following activities of daily living .hygiene-bathing, dressing, grooming, and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene 3.1-38(a)(2)(A) 3.1-38(b)(1)

Based on observation, interview and record review, the facility failed to ensure assessments and documentation of care were completed for a resident with sutures after a surgical procedure, assessments were completed for a resident with a head injury after a fall, and the physician was notified of weight changes for a resident with congestive heart failure for 2 of 2 residents reviewed for skin conditions and 1 of 1 resident reviewed for congestive heart failure. (Resident 42, 66, and 33) Finding includes: 1. During an observation, on 8/27/23 at 3:06 p.m., Resident 42 had a scabbed area on the right side of his mouth about 2 inches in length. During an observation, on 8/31/23 at 11:07 a.m., the resident was sitting up in the recliner in the common area, the scabbed area to the right side of the mouth remained the same and was about 2 inches in length. The record for Resident 42 was reviewed on 8/30/23 at 2:33 p.m. Diagnoses included, but were not limited to, Alzheimer's disease and basal cell carcinoma of the skin of the nose. A care plan, initiated on 11/20/2020 and revised on 2/22/21, indicated the resident had a potential for impairment to his skin integrity related to fragile skin. The interventions included, but were not limited to, document location, size and treatment of skin injury and report failure to heal. A dermatology visit note, dated 8/22/23, indicated the resident had surgery to his right cheek to repair a flap. The total repair area was 4.04 cm (centimeters) by 2 cm. The wound was closed with sutures and a petrolatum and pressure dressing was applied. The suture removal would be in 14 days. A physician's order, dated 8/22/23, indicated no ointments or creams aside from Vaseline should be applied to the surgery, hold baby(?) for 5 days after surgery. The physician order did not include the site of the surgery or indicated there were sutures from the surgery. There was no explanation of what hold the baby indicated. A weekly skin review, dated 8/26/23, indicated the resident had skin impairment to the face. The weekly skin review did not include the location on the face or the size of the skin impairment. It also did not include the resident had sutures to the right side of his mouth. During an interview, on 8/31/23 at 11:12 a.m., Certified Nursing Assistant (CNA) 13 indicated the resident had seen a dermatologist and there were sutures to the right side of his mouth with a big, scabbed area. During an interview and observation, on 9/1/23 at 12:28 p.m., LPN 14 indicated the resident had 5 sutures to the right side of his mouth. The electronic health record (EHR) did not include the resident had sutures and if treatment was supposed to be done to the sutures or when the sutures would need to be removed. During an interview, on 9/1/23 at 2:19 p.m., the Director of Nursing (DON) indicated the resident's skin condition to the right side of his mouth was not listed in the EHR, there were no measurements of the skin condition, no physician orders for care of the sutures and no information on when the sutures were to be removed. The sutures were placed on 8/22/23 and the follow up appointment with the dermatologist was scheduled for 9/5/23. The skin assessment completed, on 8/26/23, did not include the sutures or the measurements of the skin condition and should have included them. The word baby on the physician order should have been hold bathing for 5 days after surgery. 2. The record for Resident 66 was reviewed on 8/29/23 at 2:26 p.m. Diagnoses included, but were not limited to, dementia without a behavioral disturbance, type 2 diabetes mellitus, cerebral infarction, peripheral vascular disease, chronic obstructive pulmonary disease, and congestive heart failure. A care plan, dated 7/8/23, indicated the resident was at a risk for impaired safety and injury related to a fall risk. The goal was for the resident to have a minimized risk for falls and minimized injuries related to falls. A progress note, dated 8/9/23 at 1:55 p.m., indicated at 6:15 a.m., the resident was yelling from the bathroom and requesting help. The staff found the resident lying on her stomach in the bathroom. She had a 5-centimeter (cm) bump on her right forehead which was starting to bruise. A progress note, dated 8/9/23 at 1:56 p.m., indicated the resident was sent to the emergency room for evaluation and treatment. A 72-hour fall follow up, dated 8/10/23, indicated the resident had a fall, there was a bump to the right forehead. The follow up did not include measurements to the bump on the right forehead and did not include if the bump was resolving or worsened. A Nurse Practitioner (NP) note, dated 8/10/23, indicated the resident was seen for follow up after a fall and emergency room visit. The resident fell and hit her head. The NP note did not include any information about a bump to the right forehead. An Interdisciplinary Team (IDT) note, dated 8/10/23 at 9:34 a.m., indicated the resident had a fall during a self-transfer, was sent to the emergency room for evaluation, and had a bump on her forehead with slight bruising. The IDT note did not include the measurement of the bump to the forehead. The electronic health record (EHR) did not include when the bump on the forehead had resolved. During an interview, on 8/30/23 at 2:57 p.m., the Clinical Support Nurse indicated the resident had a fall on 8/9/23, went to the emergency room (ER), and returned to the facility. The ER notes indicated the resident had a contusion although the location of the contusion and the measurements were not documented. The facility did not have further documentation of the bump on the resident's forehead including when it was resolved. 44598 3. During an observation, on 8/29/23 at 3:40 p.m., Resident 33 was sitting in her wheelchair, in the dining room, her legs were dangling to the floor and both lower legs were swollen. During an observation and interview, on 8/31/23 at 9:55 a.m., the resident indicated her legs were swollen and they were heavy. The resident's legs appeared to have edema. The record for Resident 33 was reviewed on 8/29/22 at 12:12 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic kidney disease, and hypertension. A care plan, dated 6/22/22, indicated the resident had an alteration in her nutritional status related to congestive heart failure. The interventions included, but were not limited to, obtain weight as indicated and report to the Registered Dietician, Physician, and family of significant weight changes. A physician's order, dated 6/14/21, indicated to call the Cardiologist if the resident had a 5 or more-pound (lb.) weight gain in one week. The resident was to be weighed on Mondays and before breakfast. A physician's order, dated 7/17/22, indicated to give furosemide (a diuretic) tablet 40 milligram (mg), 1 tablet in the morning. The resident's weights were reviewed and indicated the following: a. On 8/21/22, the resident weighed 191.6 pounds. On 8/28/22, the resident weighed 206.6 pounds. This was a weight gain of 15 pounds in week. b. On 10/3/22, the resident weighed 215 pounds. On 11/1/22, the resident weighed 235.0 pounds. This was a weight gain of 20 pounds within the month. There was no documentation the resident's medical record to indicate the Cardiologist was notified of the weight increases as ordered. During an interview, on 8/31/23 at 12:03 p.m., the Director of Nursing (DON) did not know if the cardiologist was notified of the weight increases. The cardiologist should be notified according to the order. During an interview, on 8/31/23 at 1:50 p.m., the Clinical Support Nurse indicated the resident went to the cardiologist in July and they discussed weights. She was not sure if the Cardiologist was notified of the August weight increase. A current policy, titled Wound Documentation Policy, dated 2022 and received from the Executive Director on 9/1/23 at 4:30 p.m., indicated .Process .Wounds will be assessed weekly and documented on the skin pressure and/or non pressure UDAs [user defined assessment] until healed by a Licensed Nurse .When a skin impairment is healed the MD and family will be notified and plan of care updated. The skin pressure and/or non pressure UDA[s] will be completed to note healing of the wound[s] by Licensed Nurse .If areas are identified after admission the licensed nurse will assess the area and complete applicable skin pressure and/or non pressure UDA[s]. The Licensed Nurse will notify the Medical provider for orders, notify the resident/resident representative, and implement applicable new care plan interventions .Weekly Skin Assessment will be complete by a licensed nurse and documented in the medical record MAR/TAR and/or weekly skin observation UDA A current policy, titled Physician Orders Policy/Guidelines, revised 11/2021 and received from the DON on 8/29/23 at 2:21 p.m., indicated .Medical care problems are communicated to the attending physician in a timely, concise, and thorough matter .The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical intervention .Should the physician not be available, the alternate physician should be contacted .If neither of these physicians are available, the Medical Director should be notified 3.1-37(a)

Based on interview, observation and record review, the facility failed to ensure the emergency brake was engaged before assisting a resident off the facility bus (Resident 63) and to ensure a resident was secured in the wheelchair during transport in the facility bus (Resident 43) for 2 or 5 residents reviewed for falls. Resident 63 sustained a hematoma to her left knee and a fractured pelvis. Findings include: 1. During an interview, on 08/26/22 at 9:17 a.m., Resident 63 indicated she fell while being transported in the facility bus to the hospital for a scheduled echocardiogram (an ultrasound of the heart). CNA 11 was driving the bus, pulled up to the emergency room door and then stopped the bus. The resident stood up from her seat and walked to the lift at the back of the bus. CNA 11 was not able to open the lift door and went back into the bus. The resident was still standing in the back of the bus by the lift door. She saw CNA 11 at the front of the bus. CNA 11 was doing something with the emergency brake. The bus started to shake, she lost her balance and fell on the floor. She was on her left side and unable to move. CNA 11 left the resident alone in the bus, went inside the hospital and returned to the bus with 2 security guards. CNA 11 and the 2 security guards assisted the resident into the emergency room . The resident had severe pain and bruising to her left side. X-ray's were completed and the resident had a large hematoma on her left lateral knee and a fractured pelvis. A Facility Reported Incident (FRI), dated 5/8/22, indicated Resident 63 was in the parking lot of [name of hospital]. CNA 11 was applying the parking brake when the bus jerked and the resident fell . The resident was taken to the emergency room (ER) to be evaluated. The resident had an abrasion, a hematoma on her left knee and a fractured pelvis. The facility provided education to the transport personnel to ensure residents did not rise or exit the bus until it came to a complete halt. The record for Resident 63 was reviewed on 8/25/22 at 3:34 p.m. Diagnoses included, but were not limited to, fracture of the right and left pubis, type 2 diabetes mellitus, [CONDITION(S)] (inflammation) of left lower limb, anxiety disorder, cardiac pacemaker, [CONDITION(S)] and hypertension. A BIMS (Brief Interview for Mental Status) assessment, dated 8/5/22, indicated the resident was cognitively intact. A [name of hospital] ER record, dated 5/8/22, indicated the resident had a large hematoma on the left lateral knee and a acute fracture of the pelvic (a sturdy ring of bones located at the base of the spine). A progress note, dated 5/19/2022 at 3:44 p.m., indicated the resident stood up from the bus seat. The driver engaged the emergency brake and the resident lost her balance and fell . The driver was educated. A Driver Safety Regulations Inservice, dated 5/8/22 and signed by CNA 11, indicated the driver and all occupants were required to wear safety belts when the vehicle was in operation or while riding in a vehicle. The driver was responsible for ensuring passengers wear their seatbelts. During an interview, on 8/31/22 at 3:24 p.m., CNA 11 indicated she was driving Resident 63 to a appointment at the hospital. She left the bus engine running and exited the bus to put the lift down. The resident was standing by the lift and the lift would not go down. She returned inside the bus to put the emergency brake on. When she put the emergency brake on the bus shook hard. The resident fell behind the back seats. She remained inside the bus, tried to assist the resident up from the bus floor and the resident refused. She left the resident alone on the bus, went into the hospital to get assistance. Two security guards went back to the bus with her and assisted the resident into a wheelchair. The resident was evaluated in the emergency room . CNA 11 did not request the resident to remain seated and indicated, Residents take their seatbelts off all the time. 2. The record for Resident 43 was reviewed on 08/31/2022 at 9:23 a.m. Diagnosis included, but were not limited to, metabolic [CONDITION(S)] (a [CONDITION(S)] brain disease), [CONDITION(S)] disease, cerebral infarction (stroke), diabetes mellitus and below the knee amputation of the left leg. Progress notes, dated 03/08/2022, indicated the following: 4:25 p.m., the doctor spoke with the DON (Director of Nursing) post fall and gave orders for an X-ray of the bilateral hips and pelvis due to a fall. 5:45 p.m., a summary of the IDT (Interdisciplinary Team) meeting indicated during transport, the resident's cushion slid with the resident forward and out of his wheelchair. The staff were re-education on seat belt use. All approved drivers received re-education. The bus was inspected to verify proper functioning. X-rays revealed no fractures and no additional injuries were documented. An incident report, dated 03/08/2022 at 2:20 p.m., indicated the following: The transportation driver was taking the resident to his appointment when she heard the resident make a noise. The driver indicated the resident slid half way out of his wheelchair. The driver then stopped the bus and went to help the resident when his cushion and himself slid out from under his seat belt and onto his buttocks. The driver called the DON and 2 CNAs to meet her at bus. The DON assessed the resident for injuries and obtained vitals. The staff assisted the resident back into his wheelchair, contacted the family and doctor. The resident was then brought back to facility and assessed further for injuries. Vitals were taken again when resident returned to facility. The resident denied any pain and no bruising or skin issues were noted. A current facility policy, titled Policy and Procedure for Bus Driver Operation, undated and received from the Assistant Director of Nursing (ADON) on 08/31/2022 at 3:49 p.m., indicated .Seat belts must be worn by the driver and the resident. If the resident refuses to wear a seat belt they will not be transported 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure an anticoagulant medication was transcribed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident F). This resulted in Resident F not receiving the medication from admission on 08/25/2021 through discharge to the emergency roiagnom on [DATE], experiencing a Stroke. The Immediate Jeopardy began on 08/25/2021, when Resident F received one dose of [MEDICATION(S)] (an anticoagulation) at his previous facility. He was admitted to this facility, on 8/25/21, with orders for [MEDICATION(S)]. [MEDICATION(S)] was not ordered for the resident. The resident did not receive the medication from 8/25/21 through 10/11/21. He was sent to the hospital on 10/11/21 for a left Middle Cerebral Artery (MCA) stroke (A stroke which occurs when the MCA was blocked or ruptured and the blood flow to the MCA's territory was interrupted) as confirmed with an Magnetic Resonance Imaging (MRI). The Executive Director (ED) and the Director of Nursing (DON) were notified of the immediate jeopardy at 4:19 p.m., on 02/08/2022. The immediate jeopardy was removed on 02/09/2022, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding include: During an interview, on 02/07/22 at 11:41 a.m., Resident F's family member indicated the resident had back surgery at a hospital on 08/02/21, was discharged to a rehabilitation hospital on 08/04/21, and then was admitted to another long term care facility on 08/20/21. He had received [MEDICATION(S)] (a medication used to prevent blood clots) at both the rehab hospital and the prior long term care facility. She was concerned with the blood pressure medications he was receiving at the prior long term care facility so she reached out to the Director of Nursing (DON) at this long term care facility wanting to have him discharged from the previous facility and admitted there. He was admitted on [DATE] at 6:00 p.m. On 10/11/21, she received a call from the facility indicating the resident was found on the floor, his heart rate was elevated and he was cold and clammy. The facility sent him out to the emergency room (ER) via Emergency Medical Services (EMS) immediately. At the hospital, she indicated the ER nurse asked her when was the last time he had received his [MEDICATION(S)]. She called the facility to get this answer and found out he was not on [MEDICATION(S)] and had not received the medication during his entire admission. She became upset and told the nurse he needed this medication, had chronic [CONDITION(S)] (an irregular heart rhythm) and had been taking it for years. The record for Resident F was reviewed on 02/07/22 at 9:10 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . If a blood clot in the left upper chamber (left atrium) breaks free from the heart area, it can travel to the brain and cause a stroke). A document, titled [name of rehabilitation hospital] .history and physical form, dated 08/06/21, indicated .Past Medical History .A-Fib [[CONDITION(S)]] .medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .Discharge Summary/Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Hospital Course .Patient is anticoagulated on [MEDICATION(S)] .discharged medications .[MEDICATION(S)] 5 mg by mouth twice daily A document, titled [Name of Facility] Healthcare Continuity Of Care, dated 08/25/21, indicated .Discharge instructions: physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The last documented dose administered was 08/25/21 at 8:38 a.m., at the prior facility. An Admission MDS (Minimum Data Set) assessment, dated 8/31/21, indicated the resident was cognitively intact, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 08/26/21, indicated the resident did have an altered cardiovascular status related to [CONDITION(S)]. Interventions included, but were not limited to, monitor for side effects of anticoagulant use. The MAR (Medication Administration Record) for August, September and October 2021, was reviewed and there was no documentation the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a reconciliation of the resident's discharge medications from the previous facility with the residents admitting medication orders from the Medical Director at the admitting facility, it was noted the only medications not transcribed from the previous facility's discharge orders onto the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] (a blood pressure medication) and [MEDICATION(S)]. A facility physician's progress note, dated 09/12/21, indicated Impression/Recommendation .chronic anticoagulation because of A-Fib continue Xa inhibitor [Factor Xa inhibitors are a type of anticoagulant that work by selectively and reversibly blocking the activity of clotting factor Xa, preventing clot formation] .Past Medical History .Chronic A-fib .Scheduled meds .[MEDICATION(S)] 5 mg .b.i.d. (twice daily). During an interview, on 02/08/22 at 11:41 a.m., the facility pharmacist indicated [MEDICATION(S)] was a Xa inhibitor. A summary note for providers, dated 10/11/21 at 3:14 p.m., indicated the resident had a fall and the physical assessment after the fall indicated the resident had a change in condition, he had increased confusion, disorientation, and general weakness. A neurological assessment after the fall indicated the resident had an altered level of consciousness. A nurses note, dated 10/11/21 at 3:15 p.m., indicated the resident was sent to the ER after a fall. When the nurse entered the room, the resident presented with blue lips, sweaty and clammy. His blood pressure was 179/76, his heart rate was in the 120's and irregular, and his respiratory rate was 26. His speech was slurred and weakness was noted and the resident was sent to the hospital via EMS. A nurses note, dated 10/11/21 at 3:31 p.m., indicated EMS called the facility and stated the resident was diverted to a larger hospital related to a new right sided weakness. A document, titled [name of hospital] patient documentation, dated 10/22/22, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was given TPA (Tissue [MEDICATION(S)] Activator) (a medication to break up blood clots) for a suspected stroke and admitted to the ICU. The resident had acute hypoxic (lack of oxygen) respiratory failure due to this with concern for possible pneumonia and had to be intubated (a tube placed in your airway and connected to a ventilator). Imaging was suggestive of a left MCA stroke. Neurology recommended to hold [MEDICATION(S)] and start Aspirin due to the size of the stroke. It was documented the resident had known A-fib but was off [MEDICATION(S)] at his nursing home for some reason. The resident was supposed to be anticoagulated on [MEDICATION(S)] as an outpatient but was reportedly not getting it at his nursing home. An MRI of the resident's brain, taken on 10/15/21, indicated a large evolving left MCA infarction. During an interview, on 02/07/22 at 12:39 p.m., the Medical Director indicated if a resident was admitted on an anticoagulant he would not discontinue it related to the high risk it would place the resident to have a stroke. During an interview, on 02/07/22 at 4:19 p.m., the DON indicated Resident F's daughter contacted her because she was concerned with the medications he was receiving at prior facility, indicating he was not acting like himself. She wanted to have him admitted to this facility. The resident was admitted on [DATE] and she was the nurse who admitted him. He came with discharge instructions including a list of medications from the previous facility. She called the resident's daughter at the time of admission and discussed each medication the resident was discharged on . The daughter indicated to her which of the medications she wanted her father to receive and which she wanted to discontinue. The daughter asked her to call the resident's family physician to get his approval for these medications, which the DON indicated she had done. She talked with the nurse and went over all the medications the daughter wanted her father to be on. She never actually talked with the physician but the nurse discussed the call with him and she was given the approval for the medications discussed. She then put the medications discussed with the family physician and the daughter in the resident's MAR. During an interview, on 02/08/2022 at 8:41 a.m., Resident F's daughter indicated she did not remember discussing a medication list with the DON on her father's admission to the facility. She would not have told the DON to discontinue her father's [MEDICATION(S)] as she was aware of how important the medication was to help prevent her father from having a stroke. Her concerns with the medications her father was given at the previous facility were related to his blood pressure medication. She asked the DON to call Dr [name], her father's family medical doctor to discuss the blood pressure medications, it was nothing to do with his [MEDICATION(S)]. Dr [name] faxed over a list of her father's current medication to the facility a couple days after her father was admitted . During an interview, on 02/08/22 at 9:07 a.m., the resident's family medical physician's nurse indicated she was the nurse the DON spoke with on 08/26/21. The DON called to discuss and clarify the resident's blood pressure medications. The resident's blood pressure was low and she had questions related to the resident's order for [MEDICATION(S)] 10 mg once a day and [MEDICATION(S)] 40 mg once a day (both medications were used to treat high blood pressure). She relayed the concerns to the physician and the physician approved and made changes. The changes were faxed to the facility. During an interview, on 02/08/22 at 9:48 a.m., the DON indicated she had not received a list of medications faxed from the resident's family medical physician. During an interview, on 02/08/22 at 9:53 a.m., the resident's family medical physician's nurse indicated the resident's daughter called the physician's office and requested a medication list to be sent the facility. A document, titled [name] healthcare, dated 02/08/22, indicated on 8/24/21, Resident F's daughter contacted the resident's family medical physician. She had a concern with the way the resident had been acting. He was acting very bizarre and moody. She compared it to when the resident had an episode of [CONDITION(S)] (low blood pressure). She was concerned with the resident's blood pressure medications he was receiving at the previous facility he was admitted to. At that point, there was not any documented concerns with any other medications, and no other medications were discussed. On 08/25/21, the daughter indicated she was moving the resident out of the previous facility and into this facility and she requested a medication list to be faxed to the new facility. On 08/26/21, the DON of the admitting facility reached out to the resident's family medical physician and discussed the resident's blood pressure medications on the discharge medication list from the first facility. At that time, the only medications which were discussed with the nurse were [MEDICATION(S)] and [MEDICATION(S)]. During an interview, on 02/08/22 at 1:16 p.m., Resident F's family medical physician's nurse indicated the resident had not been seen in the office since 04/2021 and his list of medications at that time would have been what she faxed to the facility. At the time of the last office visit, the resident was given a prescription for [MEDICATION(S)] with 11 refills. His family physician was not aware he was not receiving [MEDICATION(S)] and because of the resident's medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A document, titled [name of physician] Family Medicine, faxed from Resident F's family medicine physician on 02/08/22 at 3:11 p.m., indicated the resident was taking [MEDICATION(S)] 5 mg by mouth twice daily and had been on this medication since 10/25/19. During an interview, on 02/08/21 at 4:08 p.m., the Medical Director indicated he was not aware the resident had not received [MEDICATION(S)] 5 mg twice daily from admission on 08/25/21 through discharge on 10/11/21. He did not discontinue the [MEDICATION(S)] and he thought the resident was given this medication as ordered. A current facility policy, titled Resident Admission Procedure, undated and provided by the DON on 02/08/22 at 4:14 p.m., indicated .1. When the facility is notified of a potential admission .the admission coordinator or designee should enter the resident .list of anticipated transfer medications .3. The responsible nurse will review the new admission medication list and should contact the physician .for acceptance as part of the normal admission process .5. Enter the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Immediate Jeopardy that began on 08/25/2021 was removed on 02/09/2022 when the facility completed the following: The ED and DON completed education for all licensed staff on the admission process. The Medical Director was also educated on review of new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents who were admitted in the last 30 days had their discharge medication orders reviewed for transcription accuracy. On 2/9/22, the DON/designee started one time weekly audits for four weeks to review with the Medical Director all new admissions and daily orders for order accuracy. Further audits were put into place including QAA (Quality Assessment and Assurance) monitoring for any trends. This Federal Tag relates to Complaints IN 598. 3.1-48(c)(2)

Based on interview and record review, the facility failed to provide adequate supervision, for a resident residing in the memory care unit, which resulted in her gaining access into a coded and locked shower room where she was left unattended for an undetermined time frame and was found on the floor, unresponsive for 1 of 3 residents reviewed for supervision. (Resident B). The immediate jeopardy began on [DATE] when the resident was found in a locked shower room, unresponsive, and had been unsupervised for an undetermined amount of time before she was found on the shower room floor. 911 was called and the resident later died at the hospital. The facility staff were unaware of how the resident was able to gain access to the locked shower room and how long she was in the shower room. The Executive Director, Regional Nurse Consultant and the Director of Nursing were notified of the Immediate Jeopardy at 4:02 p.m. on [DATE]. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: A report to the Indiana State Department of Health (ISDH), dated [DATE], indicated the resident fell in the Memory Care Unit (MCU) bathroom and was transferred to the emergency room (ER) and passed away due to a [MEDICAL CONDITION]. It indicated the resident received an abrasion to her left hand. The record for Resident B was reviewed on [DATE] at 9:45 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Initial Fall Occurrence note, dated [DATE] at 5:30 a.m., indicated the resident had an unwitnessed fall at 5:30 a.m. in the shower room of the MCU and she was noted to have abrasions to her left palm. A progress note, dated [DATE] at 6:44 a.m., indicated the nurse was alerted to the shower room in the MCU by the CNA who stated the resident had fallen while in the shower room and the resident was unresponsive. The nurse found the resident lying on her right side, on the floor, in front of the shower area. She was unresponsive but breathing. The nurse attempted to obtain vital signs and noted her oxygen saturation level was 95% on room air, her respirations were 12 per minute and her heart rate was weak at 49 beats per minute, but she was unable to obtain a blood pressure. The residents breathing was labored and she was noted to have periods of apnea (when breathing stops). Her pulse was weak. 911 was called and took over care for the resident at 5:50 a.m. An Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was a one person physical support with bathing. A care plan, dated [DATE], addressed the problem the resident had a self-care performance deficit in her Activities of Daily Living (ADL's). Interventions included, but were not limited to, the resident required supervision and assistance by one staff member with bathing and showering twice weekly and as necessary. A care plan, dated [DATE], addressed the problem the resident was at risk for falls related to hypertension and dementia. Interventions included, but were not limited to, to be sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. An Emergency Medicine report obtained from the hospital, dated [DATE], indicated the resident was left unattended in the shower and had fallen. The [DIAGNOSES REDACTED]. Due to the severity of the [MEDICAL CONDITION], cardiac interventions would likely not be beneficial. The resident's family was notified and decided to withdraw life support at 11:16 a.m. The time of death was declared at 11:54 a.m. During an interview, on [DATE] at 11:30 a.m., CNA 1 indicated she was working on the unit the morning the resident fell . She was providing care to another resident, when Resident B fell in the shower. She did not know how the resident obtained access to the shower room. She indicated the QMA working the unit with her was at her medication cart when she went to provide care. When she was done providing care, she took the dirty linen and trash to the shower room and found Resident B on the floor. The resident did not have clothes on and looked like she had just taken a shower. Her hair was wet and she had a towel around her. The last time she saw the resident was sometime between 4:30 and 5:00 a.m., and she was in the common living room area of the unit. The resident was unresponsive when she was found. During an interview, on [DATE] at 11:53 a.m., Laundry Staff 2 indicated she came in to work at 5:00 a.m. to help fold laundry from the day before. She started her day by walking with Laundry Staff 3 to collect soiled laundry. When they reached the MCU shower door, where the soiled linen was kept, the door was ajar less than two feet. She heard Laundry Staff 3 say sorry as she grabbed the laundry and at that time indicated a resident was in the shower. During an interview, on [DATE] at 12:15 p.m., Laundry Staff 3 indicated she was collecting the soiled linen from the MCU, the shower door was partially open. The resident was sitting in a shower chair and she was bent over like she was washing her legs. She thought she was washing her legs so she quickly grabbed the barrel and went out of the room because she was not allowed to collect the linen when residents were in the shower. She assumed another staff member was coming back to be with her. During an interview, on [DATE] at 12:56 p.m., Resident [NAME] indicated he used the shower room at the end of the hall to take his showers. Once or twice, the staff have had to leave the shower room to go do something but normally the staff stay in the room. There was a chair in the shower which he would sit on. During an interview, on [DATE] at 1:08 p.m., LPN 4 indicated she was the nurse on duty and she was on the east side of the building and was completing her charting. There was a CNA and a QMA assigned to the MCU. The CNA approached her and indicated they needed a resident assessed due to a fall in the in the shower room. The CNA told her the resident got in the shower room by herself. When she arrived, the resident was on the floor, laying on her right side kind of leaned over and she was breathing but was not responsive. She did a sternal rub and the resident did not respond but she was breathing. The resident had clean clothes located on her rolling walker and her dirty clothes were in the linen barrel. She was not assigned to the MCU and did not know how the resident obtained access to the shower room. During an interview, on [DATE] at 2:40 p.m., LPN 5 indicated the shower days in the MCU were assigned by room numbers. Resident B was alert enough she could ask for showers and if it was not her scheduled day, the staff would try to accommodate her. During an interview, on [DATE] at 1:39 p.m., the Director of Nursing (DON) indicated the staff called the Assistant Director of Nursing (ADON) and the ADON was the one who informed her of the fall. She did not know how the resident got into the shower room. Residents were assessed to determine the level of assistance needed and no resident should be left unattended in the shower room. Although an assessment determined their level of assistance needed, someone should be close by and in the same room. A current facility policy, titled Fall Prevention Program, dated as revised on [DATE], received from the Executive Director on [DATE] at 3:16 p.m., indicated .Residents who require assistance will not be left alone after being assisted to bathe, shower, or toilet . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility completed staff education/inservices on adequate supervision to prevent residents from having access to secured and locked areas, on what to do if a resident was found in a secure and locked area without supervision and all keypad safety codes were changed to the shower rooms. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated on adequate supervision to prevent residents from having access to secured and locked areas and on what to do if a resident was found in a secure and locked area without supervision. This Federal tag relates to Complaint IN 480. 3XXX,[DATE](a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident did not experience a significant weight loss. the failed to ensure the resident's weight was monitored and new interventions were implemented when weight loss continued resulting in a weight loss of 8.44 % in one month. (Resident 54). Finding includes: During an observation, on 07/30/19 at 10:37 a.m., Resident 54 was observed to be transported to a emergency transport cot by staff and the transport company staff. The resident was being sent to [MEDICAL TREATMENT]. The resident was not observed to have a lunch sent with him. The record for Resident 54 was reviewed on 08/02/19 at 8:51 a.m. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The physician's orders [REDACTED]. On 07/26/19, [MEDICATION NAME] (an antipsychotic) 5 mg give half a tablet at bedtime was added for depression and anxiety after the resident had a fall. A care plan, dated as last revised on 07/31/19, addressed the problem the resident used the antipsychotic medications [MEDICATION NAME] and [MEDICATION NAME] related to behavior management and agitation. Interventions included, but were not limited to, monitor for adverse reactions of [MEDICAL CONDITION] medications such as: unsteady gait, frequent falls, refusal to eat, depression, [MEDICAL CONDITION], loss of appetite and weight loss. A care plan, dated 06/24/19, addressed the problem the resident had the potential for a nutritional problem related to agitation, [MEDICAL CONDITIONS], depression, diarrhea, pain and anxiety. It indicated the resident was currently on hospice services. Interventions included, but were not limited to, provide and serve diet and supplements as ordered and to have RD evaluate as needed. The resident was not on hospice services. The nutritional care plan did not addressed the resident's end stage [MEDICAL CONDITION]. A care plan, dated 06/24/19, addressed the problem the resident received [MEDICAL TREATMENT] three times per week. Interventions included, but were not limited to, collaborate and communicate with [MEDICAL TREATMENT] center staff as needed, encourage compliance with diet as ordered and provide diet as ordered. The resident's Electronic Health Record (EHR) indicated the following weights: a. On 06/24/19, the resident weighed 153.8. b. On 07/05/19, the resident weighed 159.9. c. On 08/02/19, the resident weighed 146.4. The post [MEDICAL TREATMENT] weights recorded from the [MEDICAL TREATMENT] center indicated the following weights: a. On 06/26/19, the resident weighed 159.9. b. On 07/11/19, the resident weighed 159.0. c. On 07/20/19, the resident weighed 146.3. d. On 07/25/19, the resident weighed 147.6. e. On 08/01/19, the resident weighed 144.3. A nutrition assessment or progress note was not located in the resident's record. A review of the resident's intakes for (MONTH) indicated the following: a. 3 times the resident refused to eat. b. 29 times the resident consumed 0-25% of his meal. c. 18 times the resident consumed 26-50% of his meal. d. 7 times the resident consumed 51-75% of his meal. e. 12 times the resident consumed 76-100% of his meal. On Tuesdays, Thursdays and Saturdays, the resident went to [MEDICAL TREATMENT] and was not provided a lunch. During an interview, on 08/02/2019 at 10:18 a.m., the Kitchen Manager indicated the resident was on [MEDICAL TREATMENT] and a puree diet. He was not eating much. He was recently moved to the assist table. At breakfast, he fed himself. She indicated she had not been sending the resident a lunch to [MEDICAL TREATMENT] and she assumed he was receiving a nepro shake at [MEDICAL TREATMENT] although she was not for sure as she had not spoken with [MEDICAL TREATMENT]. The facility could send a puree sandwich, applesauce or cottage cheese with the resident. During an interview, on 08/02/19 at 1:31 p.m., the Minimum Data Set (MDS) assessment coordinator indicated she was aware of the facility weight policy to weigh new residents weekly and she was not sure why it was not completed. He should have been sent a sack lunch on [MEDICAL TREATMENT] days. During an interview, 08/02/19 at 2:00 p.m., the MDS coordinator indicated the resident had not been seen by the RD yet. A current agreement between the facility and the resident's [MEDICAL TREATMENT] center indicated .The Long Term Care Facility shall ensure that [MEDICAL CONDITION] Residents are prepared to spend an extended length of time at the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit and have received proper nourishment and any medications .before coming to the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit A current facility policy, titled Weight Measurement, not dated and received from Medical Records on 08/02/19 at 1:17 p.m., indicated .Resident's weights are taken upon admission, upon readmission and as indicated .A baseline weight will be established upon admission. The resident will be weighed weekly for (4) weeks after admission and monthly thereafter. Weekly weighing may be resumed if there is a significant change in condition, food intakes has declined over time or there is evidence of altered nutrition status 3.1-46(a)(1) 3.1-46(a)(2)

Based on interview, observation and interview, the facility failed to ensure a resident was not given [MEDICAL CONDITION] medications to chemically restrain him for 1 of 1 resident reviewed for chemical restraints (Resident 54). Resident 54 was given multiple [MEDICAL CONDITION] medications, had multiple falls after medication implementation and significant weight loss. Findings Include: During an interview, on 08/02/19 at 5:01 p.m., Resident 54's wife indicated the resident was still working in May, 2019. Before entering the hospital and the facility, the resident received an antianxiety and a depression medication. He had never received the other medications before then and since he had, his mind had been deteriorating. She indicated the facility started him on [MEDICATION NAME] at night so he would sleep better. During an observation, on 07/30/19 at 10:37 a.m., Resident 54 was transported to an emergency transport cot by staff and the transport company staff. On 08/02/19 at 10:24 a.m., Resident 54 was observed in bed and asleep. He had a full size mattress on the floor beside his bed and two quarter bilateral side rails in the up position. The record for Resident 54 was reviewed on 08/02/19 at 8:51 a.m. [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment, dated 07/01/19, indicated the resident was severely cognitively impaired. The physician's orders [REDACTED]. On 07/26/19, [MEDICATION NAME] (an antipsychotic) 5 mg give half a tablet at bedtime was added for depression and anxiety after the resident had a fall. The Medication Administration Record (MAR) indicated the resident was being monitored for depression, anxiety and agitation. The resident's Electronic Health Record (EHR) indicated the following weights: a. On 06/24/19, the resident weighed 153.8. b. On 07/05/19, the resident weighed 159.9. c. On 08/02/19, the resident weighed 146.4. A Fall Occurrence Note, dated 06/24/19 at 6:00 p.m., indicated the resident had an unwitnessed fall in the room next to his room. No injuries were noted and the new intervention of non-skid socks was added. A new order for [MEDICATION NAME] 1 mg every 6 hours routinely was added. A care plan, dated 06/24/19, addressed the problem the resident had depression related to dementia. Interventions included, but were not limited to, monitor and report adverse reactions to antidepressant therapy such as: hallucinations or delusions, gait changes, balance problems and falls. A care plan, dated 06/24/19, addressed the problem of anxiety. Interventions included, but were not limited to, monitor for significant side effects of the antianxiety medication use such as: drowsiness and dizziness. A [MEDICAL CONDITION] Medication Observation, dated 06/24/19, indicated the resident was alert with memory impairment and abnormal thinking. His behaviors were marked as friendly, non-compliant and restless. His current medications were listed as [MEDICATION NAME] and [MEDICATION NAME]. The [DIAGNOSES REDACTED]. The nursing progress notes indicated on 06/25/19 at 3:17 p.m., the resident had poor appetite and was anxious and restless. The nursing progress notes indicated on, 06/27/19 at 3:17 p.m., the resident was restless, fidgety and moved around more than usual. The nursing progress notes indicated on, 06/24/19 at 11:17 p.m., 06/27/19 at 7:17 a.m., 06/27/19 at 10:44 a.m., 06/27/19 at 2:44 p.m., 07/23/19 at 11:46 p.m., 07/24/19 at 9:00 p.m., 07/25/19 at 8:45 p.m. and 7/26/19 at 12:54 a.m., there were no concerns with the resident's mood or behaviors. No other behaviors were noted in the resident's progress notes. The CNA charting for Resident 54, from 07/04/19 to 08/01/19, indicated the resident had 15 episodes of delusions. There was no indication as to what the delusions were. No psychiatrist notes were located in the resident's record. A Fall Occurrence Note, dated 07/03/19 at 4:00 a.m., indicated the resident had an unwitnessed fall in his room. He had a 1 inch laceration to his left upper forehead. A new intervention of increased monitoring was added. A Fall Occurrence Note, dated 07/10/19 at 5:50 a.m., indicated the resident had a witnessed fall in the dining room. No injuries were noted and the new intervention of increased monitoring was added. A Fall Occurrence Note, dated 07/14/19 at 10:20 a.m., indicated the resident had an unwitnessed fall in the dining room. The resident sustained [REDACTED]. The resident was admitted to the hospital to undergo surgery to repair the [MEDICAL CONDITION]. A [MEDICAL CONDITION] Medication Observation, dated 07/18/19, indicated the resident received in-house therapy program, his sleep pattern fluctuated and his mental status was confused. He was marked as having delusions. His behaviors were marked as friendly, mood swings, restless and combative. His current medications were listed as [MEDICATION NAME] and [MEDICATION NAME]. The [DIAGNOSES REDACTED]. A Fall Occurrence Note, dated 07/21/19 at 2:20 p.m., indicated the resident had a witnessed fall in his room. The resident bumped his head on the floor and did not sustain any injuries. A new order was given to send to the emergency room . A [MEDICAL CONDITION] Medication Observation, dated 07/23/19, indicated the resident received in-house therapy program, his sleep pattern fluctuates and his mental status was confused. He was not marked as having psychotic features. His behaviors were marked as friendly, cooperative and calm. His current medications were listed as [MEDICATION NAME] and [MEDICATION NAME]. A Fall Occurrence Note, dated 07/24/19 at 8:40 p.m., indicated the resident had an unwitnessed fall in his room. No injuries were noted and a new intervention of 1:1 monitoring was added. An IDT (interdisciplinary team) Fall Note, dated 07/25/19, indicated the resident was found on the floor, on a mat next to his bed. The physician was contacted and [MEDICATION NAME] was added to his medication regimen. A [MEDICAL CONDITION] Medication Observation, dated 07/25/19, indicated the resident received in-house therapy program, he was up most of the night and he was confused. He was marked as having delusions, memory impairment and abnormal thinking. His behaviors were marked as friendly, agitated and non-complaint. His current medications were listed as [MEDICATION NAME] and [MEDICATION NAME]. A care plan, dated as last revised on 07/31/19, addressed the problem the resident used the antipsychotic medications [MEDICATION NAME] and [MEDICATION NAME] related to behavior management and agitation. Interventions included, but were not limited to, monitor for adverse reactions of [MEDICAL CONDITION] medications such as: unsteady gait, frequent falls, refusal to eat, depression, [MEDICAL CONDITION], loss of appetite and weight loss. The nursing progress notes indicated on, 07/29/19 at 6:15 a.m., the resident complained of being anxious all night and was unable to sleep. A new order for [MEDICATION NAME] 1 mg to be given then. A Fall Occurrence Note, dated 07/30/19 at 4:50 p.m., indicated the resident had an unwitnessed fall in his room. No injuries were noted. A new intervention of a mattress next to the bed was added. A Fall Occurrence Note, dated 07/31/19 at 4:10 p.m., indicated the resident had an unwitnessed fall in the activities room. No injuries were noted and new interventions of increased monitoring and every 2 toileting were added. During an interview, on 08/01/19 at 4:05 p.m., the Minimum Data Set (MDS) coordinator indicated the resident's behavior monitoring was on the MAR and the resident was being monitored for depression, anxiety and agitation. During an interview, on 08/02/19 at 1:05 p.m., the MDS coordinator indicated new interventions put into place after the resident's falls included non-skid socks, a concave mattress, a body pillow was tried for a while, he was moved from the memory care unit, and a mattress was placed on the floor next to his bed. After his fall on 07/25/19, a medication review was done and he was started on [MEDICATION NAME]. She indicated he said nonsensical things, which to her, were considered delusions. He was on the list to be seen by psychiatric services and had not been seen yet. During an interview, on 08/02/19 at 1:31 p.m., the MDS coordinator indicated she could not provide written documentation as to what his delusions were. A Nursing Drug Handbook 2019, indicated [MEDICATION NAME] had the potential for the adverse reactions of dizziness and unsteadiness and [MEDICATION NAME] had the potential for the adverse reactions of lethargy, [MEDICAL CONDITION], confusion, [MEDICAL CONDITION], agitation, anxiety and restlessness. [MEDICATION NAME] had a black box warning which indicated elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. An Admission Agreement, dated as revised 2019, received on entrance from the MDS coordinator indicated .You have the right to be treated with respect and dignity, including .The right to be free from any physical and chemical imposed for the purposes of discipline or convenience, and not required to treat your medical condition 3.1-3(x)

Based on observation, interview and record review, the facility failed to monitor weights and implement interventions which resulted in significant weight loss for 3 of 3 residents reviewed for nutrition (Residents G, F and E). Resident G had a 7.8 % weight loss in 19 days and Resident F had a 17.4 % weight loss in 30 days. Resident G and F were not weighted weekly as indicated in the plan of care and interventions were not implemented timely to prevent significant weight loss. Findings include: 1. On 05/22/2017 at 1:06 p.m., Resident G was observed to be in the dining room, at a table by herself without staff assistance. Her lunch consisted of country fried steak, mashed potatoes, and a vegetable blend with a fruit crisp for dessert. The resident ate less than 25% of her meal and then requested to leave to the dining room. On 05/23/2017 at 12:57 p.m., Resident G was observed to be in the dining room, at a table by herself with a staff member assisting her. Her lunch consisted of a hot dog, potato chips and baked beans. The resident ate 75% of her hot dog and baked beans and a few chips. Resident G's record was reviewed on 05/20/2017 at 11:15 a.m. [DIAGNOSES REDACTED]. The weight log indicated the following weights for Resident G: a. The resident was not weighed on admission. b. On 04/13/2017 the resident weighed 166 pounds. c. On 05/01/2017 the resident weighed 153 pounds which was a 13 pound or 7.8% weight loss in 19 days. No other weights were documented for the resident. No documentation of the Medical Doctor being notified of Resident G's weight loss was found during record review. An Admission MDS (Minimum Data Set) assessment dated [DATE], indicated the CAA (Care Area Assessment) of nutrition was identified. The CAA indicated .Resident triggered nutritional CAA related to having a BMI (Body Mass Index) too high or low. Staff will assess resident likes/dislikes and provide food/drink of resident choice. Staff will record daily intake with dietician review. Staff will weigh resident weekly and notify MD and dietician of any significant change Resident G's Care Plan dated 04/10/2017, addressed the problem of altered nutrition and hydration. Interventions included, but were not limited to .04/10/2017- diet as ordered mechanical level II. Offer HS (at bedtime) snack. Honor food/fluid preference. Liberalize diet. Monitor weight (monthly). Notify MD of significant weight loss. RD evaluation as needed A Dietary Note from the Registered Dietician (RD) dated 05/02/2017, indicated the Resident G's weight on May 1st was 152.7 pounds which indicated a 7.9% weight loss. Her current BMI was 23.2 and was slightly below the desirable range (24-27.5). Her intake was a regular diet. The resident had trended downward the past 2 weeks out of 4. The RD recommended Glucerna 1.2 (a dietary supplement) 1 can twice a day until weight had stabilize and to continue to monitor the resident's status and follow up as needed. A physician order [REDACTED].Glucerna 1.2 twice a day for a supplement due to decreased meal intakes and to support a stable weight During an interview on 05/23/2017 at 9:05 a.m., LPN 4 indicated all weights were recorded in the Electronic Medical Record (EMR) and there were no other weights for Resident G. During an interview on 05/23/2017 at 1:18 p.m., the Director of Nursing (DON) indicated newly admitted resident should be weighed on admission and weekly for the first 4 weeks after admission. During an interview on 05/23/2017 at 2:02 p.m., LPN 5 indicated the resident received Glucerna twice a day however the amount the resident consumed was not recorded. She indicated when the order was put into the EMR it was not set up to record the intake amount. During an interview on 05/24/2017 at 8:15 a.m., the DON indicated the amount of supplement consumed by the resident should have been documented. She indicated it could have been set up to do so in the EMR and staff needed educated on how to add supplemental documentation to an order. During an interview on 05/24/2017 at 1:45 p.m., the MDS Coordinator indicated there was no documentation found regarding the MD being notified of the residents weight loss. 2. The record for Resident F was reviewed on 5/22/17 at 2:37 p.m. [DIAGNOSES REDACTED]. The resident's admission weight on 1/4/17 was 114.8. On 2/3/17 the resident's weight was 95 pounds which was a 17.4 % weight loss in 30 days. A care plan dated 1/6/17, indicated the resident had altered nutrition and hydration and to notify the physician of a significant weight change and the registered dietician to evaluate as needed. A Minimum Data Set (MDS) care area assessment dated [DATE], indicated the resident was at risk for nutrition and would be weighed weekly. A physician order [REDACTED]. An RD (Registered Dietician) note dated 3/12/17, indicated the resident had 11.2 % weight loss over 2 months and the current BMI (body mass index) of 19.3 was very low. The resident's average oral intake was 69% and below the estimated needs of the resident. During an interview on 5/25/17 at 10:42 a.m., the DON indicated the resident should have been re-weighed on 2/3/17 due to the 20 pound weight loss. She also indicated the resident should have been weighed on a weekly basis for 4 weeks after admission and was not weighed weekly. The DON indicated the RD did not see the resident until March and did not address the weight loss until then. 3. The record for Resident E was reviewed on 5/22/2017 at 10:19 a.m. [DIAGNOSES REDACTED]. Weights included: a. On 2/1/2017 the resident weighed 109 pounds. b. On 2/13/2017 the resident weighed 105 pounds. c. On 2/18/2017 the resident weighed 104.2 pounds. d. On 3/3/2017 the resident weighed 99.2 pounds. e. On 3/6/2017 the resident weighed 99.2 pounds. f. On 4/2/2017 the resident weighed 102.8 pounds. g. On 4/10/2017 the resident weighed 98.8 pounds. h. On 5/1/2017 the resident weighed 96.4 pounds. The resident had a 4 pound weight loss from 4/2/2017 to 4/10/2017. A care plan for Resident E dated 12/31/2016, indicated interventions included, but were not limited to, Diet as ordered-puree .Monitor Weight: Every week on Thursday and monthly No other weights were documented for the resident. No documentation of the Medical Doctor being notified of the residents weight loss was located. During an interview on 5/25/2017 at 1:19 p.m., the DON indicated there was no documentation of the doctor being notified of the 4 pound weight loss 4/2/2017 and 4/10/2017. A current facility policy titled Weight Management dated 08/2014, received from the DON on 05/23/2017 at 10:35 a.m., indicated .Residents identified to be at risk for weight variance, will have routine assessment and care plan interventions implemented in accordance with Advanced Directives . 5. Licensed nurse to review electronic weight reports and schedule re-weights within 24 hours for significant weight variance: A five pound weight loss from previous weight. A 5% weight variance (loss/gain) in one month, 7.%% in three months, or 10% in 6 months. A three pound loss in one month for those weighing less than 100 lbs. 6. Weekly weight monitoring may be appropriate for: New admissions for one month. Significant unplanned weight loss/gain. Clinical conditions which may require more frequent monitoring. 7. Process for documentation of weight variance in medical record is completed in the electronic system by designated persons and includes communication to Licensed Nurse via AccuNurse . 15. For Quality Assurance, the DON/Interdisciplinary Team will monitor the prevalence of weight loss through analysis of weights recorded within EMR and Quality Measure reports. Results are reported at the QA&A (Quality Assessment & Assurance) meeting for quality improvement recommendations. 16. Facility will have routinely scheduled medical records audit process at least quarterly to identify compliance with electronic documentation of weights, assessment by licensed nurse and ID (interdiciplinary) team, physician and responsible party notification, and care plan process implementation with interventions 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure appropriate wound assessments were performed for 3 of 3 residents who developed pressure ulcers (Residents C, D and B), failed to follow pressure ulcer prevention interventions to prevent worsening of pressure ulcers for 2 of 3 residents reviewed for pressure ulcers (Residents D and B) and failed to implement a preventative intervention to prevent the development of a pressure ulcer for 1 of 3 residents who developed a pressure ulcer (Resident C). Resident C's right heel pressure ulcer progressed from a Suspected Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and shear. The area may be preceeded by tissue that was painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissues.) to an Unstageable ulcer (Full thickness tissue loss in, which the base of the ulcer was covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) with bone being probed in the center of the wound upon examination. Findings include: 1. Resident C's record was reviewed on 5/31/16 at 3:03 p.m. [DIAGNOSES REDACTED]. The resident's Electronic Medication Administration Record [REDACTED] 5/4/16--Cleanse the right heel ulcer with saline, then apply Silver Alginate (An antimicrobial dressing used to prevent a wound infection and it absorbed wound drainage and kept the wound bed moist). Cover the right heel ulcer with a heel foam dressing (a dressing specifically designed to fit the heel and typically used on pressure ulcers), then secure with kerlix wrap (a guaze type wrapping used to secure the dressing in place). Change the wound dressing daily. The resident's Admission MDS (Minimum Data Set) assessment dated [DATE], indicated he was 76 inches (6 feet 4 inches) tall and 321 pounds. Prior to the resident developing a pressure ulcer to his right heel his record did not indicate he had a specialty bed for his height or weight or any special equipment to accommodate his height. A Wound Assessment-V2 report dated 3/22/16, indicated the resident acquired a pressure ulcer to the right heel on 3/22/16. The original stage was a SDTI (Suspected Deep Tissue Injury). The highest stage was SDTI. The wound bed was dry and was an intact fluid filled blister. The ulcer measured 2.0 x 5.0 x 0 cm (centimeters). The periwound had slight redness. The report indicated this was the first observation of the ulcer. A Wound Assessment-V2 report dated 3/30/16, indicated the resident acquired a pressure ulcer to the right heel on 3/22/16. The original stage was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister.) The highest stage was a SDTI. The wound bed had [MEDICATION NAME] (pink) tissue present and was moist. The blister was broken and the skin was macerated (a softening or breaking down of tissue from constant dampness, which can be caused by exposure to anything wet (e.g.) perspiration, urine, wound exudate). The ulcer measured 8.0 x 10.5 x 0 cm. Special equipment or preventative measures put into place was an low air loss mattress and a bed extension was requested. A progress note dated 4/5/16 at 3:03 p.m., indicated the resident was found in bed without his heels floated. The resident had a right heel pressure ulcer with a 6.0 cm circumference of blue/black skin on bottom of his heel, which had a 2.0 x 1.5 cm area that was black. There was no open area noted in the blue/black area. The wound was draining a small amount of serosanguineous fluid from the skin under the busted blister. A Documents Review Report from (Name of Hospital) dated 4/18/16, indicated the resident had a right heel pressure wound with 100% black yellow color. The wound measured 4.0 x 6.0 cm. The wound was unstageable in the ulcer bed. There was moderate amount of serosanguineous drainage and the periwound had erytherma (redness). Additional comments indicated the resident's unstageable pressure ulcer was covered in yellow, black slough (Necrotic or avascular in the process of separating from viable tissue. Usually soft, moist and light in color; may be stringy). A Hospital Procedure Note from (Name of Hospital) dated 4/23/16, indicated the resident had a right heel decubitus and he had a debridement and irrigation of the right heel decubitus. He had wet eschar (thick, leathery necrotic or divitalized tissue, frequently black or brown in color) in the middle. The wound was debrided (dead tissue removed) and irrigated (flushed dead tissue from the wound) and he had a silver VAC dressing (Negative Pressure wound therapy) (helped promote healing of a wound at the cellular level) (had antimicrobial actions to help reduce infections to the wound) applied after the debridement of the wound. An Admission Nursing Assessment v3 dated 4/30/16, indicated the resident had a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle was not exposed. Slough may be present, but did not obscure the depth of tissue loss. May include undermining and tunneling) pressure ulcer to his right heel. The ulcer measured 6.0 x 5.2 x 0.1 cm. A progress note dated 5/3/16 at 11:27 a.m., indicated the wound on the resident's right heel measured 6.0 x 5.2 cm. The wound bed was red beefy tissue and had serosanguineous drainage on the dressing. A Wound Healing Clinic Consult from (Name of Hospital) dated 5/11/16, indicated the resident had a right heel ulceration. He developed the right heel ulceration secondary to being immobile in bed. He came to the clinic that day with no offloading of his right heel and indicated he had not been wearing his multi-Podus boot. He had a history of [REDACTED]. The ulcer measured 4.5 x 6.5 x 0.4 cm with a wound bed mixed with 80% fibrotic, yellowish, brownish tissue and 20% granular with some capillary bud formation. The ulceration probed to the bone in the center of the wound. An Admission Nursing Assessment v3 dated 5/23/16, indicated the resident had a right heel wound. A Progress note dated 5/23/16, indicated the resident refused to allow staff to remove the right heel dressing to assess the wound. Any additional wound assessments for the right heel pressure ulcer were requested from the Director of Nursing (DON) on 6/2/16 at 11:00 a.m. Any additional wound assessments, other than the wound assessments already received were requested on 6/2/16 at 3:27 p.m. By the end of the exit conference on 6/2/16, there was no additional wound assessments provided. During an interview on 6/2/16 at 3:27 p.m., the DON indicated the resident had a trapeze bar, which he was able to use to help reposition himself in the bed. She indicated he was 6 foot 4 inches tall and the bed he was in was too short for him and he would raise the head of his bed, then he would slide towards the foot of the bed. She indicated the resident was, so tall that his feet was flat against the end of the bed when he was laying in bed. She indicated the bed extension was not placed on the foot of the bed until after the resident developed the pressure ulcer to his right heel. She indicated he did not have multipodus boots to wear until he went to the Wound Clinic and they gave him a pair to wear. 2. On 5/31/16 at 2:10 p.m., Resident D was observed laying in a low bed on her right side with a pillow behind her back Her right heel was laying on the Genesis III alternating pressure pump mattress (a mattress with a pump that produced airflow with a 5 minute cycle time to alternate the pressure) with her left leg laying on top of her right leg and her left heel was laying on top of her right heel. The resident had blue non-skid socks on her feet. On 5/31/16 at 2:30 p.m., the resident's right heel was observed on the mattress with her left heel laying on top of her right heel with the MDS (Minimum Data Set) Coordinator in attendance. The resident had blue non-skid socks on her feet. The MDS Coordinator indicated when asked about the resident's heels needing to be floated the resident was on a low air loss mattress and covered her feet back up with the blankets and left the room. On 6/1/16 at 9:15 a.m., the resident was sitting in her broda chair in the hallway in front of the nurses station. She had blue non-skid socks on her feet laying on the footrest of the broda chair. On 6/1/16 at 9:42 a.m., LPN #1 and LPN #2 was observed changing the resident's right heel pressure ulcer dressing. The resident had a pressure ulcer to her right inner heel the size of a dime. The wound was a Stage II. The wound bed was 25% red and 75% pink tissue. LPN #1 indicated the wound was an UTD (Unable to determine). She indicated the facility was not allowed to downstage a wound. She measured the wound as 1.0 x 1.0 cm. After being asked what the depth measurement was, LPN #1 measured the depth of the wound as 0.1 cm. LPN #2 placed the residents blue non-skid socks back on her feet, which was laying on the broda chair footrest and took her into the hallway. During an interview on 6/1/16 at 9:59 a.m., LPN #1 indicated the wound assessments were performed weekly on one of the resident's shower days, by whoever the nurse was that had the resident that particular day. She indicated the facility no longer had a wound nurse. She indicated the DON overseen all the wound measurements after the wounds were measured weekly. On 6/1/16 at 11:10 a.m., Resident D was sitting in the hallway in her broda chair in front of the dining room with blue non-skid socks to her feet laying on the footrest of the broda chair. Resident D's record was reviewed on 6/1/16 at 1:00 p.m. [DIAGNOSES REDACTED]. Electronic Medication Administration Records (EMAR's) dated March, April, May and June 2016, included, but was not limited to, the following order: 3/14/16--Off load heels while in bed. None of the signature boxes on the EMAR's for this order for these time periods had initials in the boxes to indicate the resident's heels were offloaded while she was in bed. Wound Assessments-V2 for the following dates indicated the following regarding Resident D's acquired left heel pressure ulcer: 2/29/16--The date acquired was 2/28/16. The location was the left heel. The original stage was SDTI and the highest stage was SDTI. The wound bed had [MEDICATION NAME] tissue and was dry. It measured 1.0 x 3.5 x 0 cm. This was the first observation of the wound. Special equipment foam heel pads. 3/7/16--The acquired date was 2/28/16. The location was the left heel. The original stage was SDTI and the highest stage was a Stage II. The report indicated the Stage at the highest level could not be down-staged (the stage of the wound could not be changed to a lesser stage) as the wound healed. The wound bed had [MEDICATION NAME] tissue and was dry. The wound was a blood tinged fluid filled blister. The wound measured 1.0 x 3.5 x 0 cm. The wound was unchanged. Special equipment foam heel cushions. 3/14/16--The acquired date was 2/29/16. The location was the left inner heel. The original stage was Stage II and the highest stage was a Stage II. The wound was a blood tinged fluid filled blister. The wound measured 2.0 x 2.8 x 0 cm. The wound was worsening. 3/21/16--The acquired date was 2/27/16. The location was the left proximal heel. The original stage was Stage II and the highest stage was a Stage II. The wound bed had [MEDICATION NAME] tissue and was dry. The wound had dry skin covering the area from the old blister. The wound measured 1.5 x 2.5 x 0 cm. The wound was improving. Changes to treatment was to discontinue the foam heel pads and keep the purple foam booties on at all times except to shower. 3/30/16--The acquired date was 2/27/16. The location was the left heel. The original stage was SDTI and the highest stage was a Stage II. The wound bed had 25% necrotic tissue present and was dry. The wound measured 4.0 x 3.0 x 0 cm. The wound was worsening. Treatment change was to request a Physical Therapist to evaluate the wound for a possible treatment change. 4/6/16--The acquired date was 2/27/16. The location was the left heel. The original stage was SDTI and the highest stage was a SDTI. The wound bed had 50% necrotic tissue present and was dry. The wound measured 4.0 x 3.0 x 0 cm. The wound was unchanged. 4/11/16--The acquired date was 2/27/16. The location was the left heel. The original stage was Stage II and the highest stage was a Stage II. The wound bed was dry. The wound was a dried blister dark brown in color. The wound measured 4.0 x 3.0 x 0 cm. The wound was unchanged. 4/20/16--The acquired date was 2/27/16. The location was the left heel. The original stage was SDTI and the highest stage was a SDTI. The wound bed was not assessed. The wound measured 4.5 x 2.0 x 0 cm. The wound was unchanged. Treatment: Continue with the Vitamin A and D ointment and heel foam and offload the heels. 5/7/16--The acquired date was 2/27/16. The location was the left heel. The original stage was SDTI and the highest stage was a SDTI. The wound bed was not assessed. The wound measured 4.5 x 2.0 x 0 cm. The wound was unchanged. Treatment: Continue with the Vitamin A and D ointment and heel foam and offload the heels. 5/14/16--The acquired date was 2/28/16. The location was the left heel. The original stage was SDTI and the highest stage was a Stage II. The wound bed was [MEDICATION NAME] tissue and moist. There was a scant amount of serosanguineous (thin, watery and pink in color) drainage. The wound measured 4.5 x 3.5 x 0 cm. The periwound was macerated. The wound was improving. Treatment: [MEDICATION NAME] ointment (a ointment to treat wounds that absorbed light drainage). 5/24/16--The acquired date was 5/1/16. The location was the right heel. The original stage was UTD (Unable to determine) (Until enough slough or eschar was removed to expose the base of the ulcer, the true depth and therefore stage, cannot be determined. Stable dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels served as the body's natural (biological) cover and should not be removed) and the highest stage was a UTD. The wound bed had 30% slough tissue present. The wound measured 3.5 x 2.5 x 0 cm. There was a scant amount of serosanguineous amount of drainage. The wound was improving. A progress note dated 6/1/16 at 10:19 a.m., indicated the left heel ulcer measured 1.0 x 1.0 x 0.1 cm. The record lacked the stage and wound bed assessment. The 5/19/16 Wound Assessment V-2 was requested from the DON on 6/2/16 at 9:40 a.m. By the end of the exit conference on 6/2/16, the 5/19/16, wound assessment was not provided. During an interview on 5/31/16 at 10:00 a.m., the DON indicated she documented the right heel instead of the left heel as the pressure ulcer on the 5/24/16 wound assessment report and she also documented 5/1/16 instead of 2/27/16, as the acquired date for the left heel pressure ulcer. During an interview on 6/1/16 at 11:30 a.m., the DON indicated the facility's wound assessment forms indicated the nurses were not allowed to upstage a wound, so once a wound was a UTD it was always a UTD or a SDTI it had to always be a SDTI. She indicated the wound could be a healing UTD or healing SDTI. During an interview on 6/2/16 at 9:40 a.m., the DON indicated Resident D did not have her purple heel booties (protectors) placed on her until lunchtime on 6/1/16 and she should have them on at all times except to shower. She indicated the resident's left and right heel wound documentation was all the same. She indicated the right heel wound was a fluid filled blister, which went away, then was a dry callous. She indicated the facility nurses were not staging the wounds accurately. She indicated the offload heel order was an FYI (for your information) for the nurses like an order such as; May go LOA (leave of absence) with medications. She indicated there was no documentation to indicate the heels had been offloaded. She indicated she was the person who followed the progress of the wounds, since the wound nurse left. During an interview on 6/2/16 at 11:24 a.m.,, the DON indicated Physical Therapy did not assess the resident for the 3/30/16 recommendation for a treatment change for her left heel wound. She indicated she was not evaluated for a treatment change after the pressure ulcer got worse. 3. Resident B's record was reviewed on 05/31/2016 at 2:00 p.m. [DIAGNOSES REDACTED]. A physician order, dated 05/18/2016 at 10:46 a.m., indicated, [MEDICATION NAME] (a cream to treat wounds that absorbs light drainage) to area on buttock once daily x (times) 10 days then reeval (sic). A Care Plan dated, 01/06/2016, indicated Focus. Potential for pressure ulcer development r/t (related to) two assist, Impaired mobility, Cognitive deficits .Interventions .Pressure reducing cushion in wheelchair A document titled, Wound Assessment-V 2, dated 05/04/2016, indicated .B .1. Location: right buttock. 2 a. Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired. Date acquired: 05/04/2016, 3 a. Type: Pressure. 4. PRESSURE ULCER STAGE .4 a. Original 1 .4 b. Highest: 1 .8. WOUND MEASUREMENTS, 8 a. 1.0 cm 8 b. 1.2 cm 8 c. 0.1 cm A document titled, Skin Inspection Assessment, dated 05/05/2016, indicated .6. Identify any new skin issues: Site .Right buttock, Type: Pressure .Stage 3 A document titled, Clinical Interdisciplinary Assessment-V 2, dated 05/10/2016, indicated .B. SKIN: Skin Conditions 1. Skin intact A document titled, Wound Assessment-V 2, dated 05/18/2016, indicated .B .1. Location: right buttock. 2 a. Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired. Date acquired: 05/18/2016, 3 a. Type: Pressure. 4. PRESSURE ULCER STAGE .4 a. Original 1 .4 b. Highest: 1 .8. WOUND MEASUREMENTS, 8 a. 2.0 cm 8 b. 1 cm 8 c. 0.1 cm A document titled, Skin Inspection Assessment, dated 05/19/2016-05/26/2016, indicated .6. Identify any new skin issues: Site .Right buttock, Type: Pressure .Stage 3 A Treatment Administration Record dated, May 2016, lacked signatures for dates 05/18/2016-05/28/2016 for the following: [MEDICATION NAME] to area on buttock once daily x 10 days then reeval (sic). A document from the electronic charting system labeled (Name of Resident), Task: Pressure Redistribution Device, dated 05/31/2016, indicated .Was the pressure reducing device placed on the chair while the resident was in it? Day, Evening and Night shift had placed a check mark in the yes column to indicate the pressure relieving device was present for dates 05/18/2016 through 05/31/2016, with the exception of three night shifts on the dates 05/20/2016, 05/25/2016 and 05/26/2016. On those three night shifts there was a check mark placed in the Not Applicable column. The document lacked any information regarding if the device was inflated on those dates checked yes. On 05/31/2016 at 2:13 p.m., the resident was observed sitting in his room in a recliner with the foot rest elevated. He was frequently shifting in his seat, exhibited facial grimacing and tugged at the back of his slacks. The Roho cushion (a pressure relieving device) beneath the resident was flat and the chair alarm pad was positioned beneath the cushion. At that time, CNA #8 was asked to assist the resident. On 06/01/2016 at 08:55 a.m., CNA #6 and CNA #7 were observed standing Resident B. The resident's slacks and brief were removed, exposing his buttocks. A small amount of brown stool was noted on the brief. LPN #2 removed the dressing to the right buttock and cleansed the right buttock wound with a saline dampened gauze sponge. The center of the wound was open with a beefy red center. The peri wound was pale, macerated (softening or breaking down of tissue from constant dampness, which can be caused by exposure to anything we (e.g.) perspiration, urine, wound exudate) and approximately the size of a quarter. CNA #6 wiped the residents buttocks in an upward manner, over the open wound. LPN #2 cleansed the resident's wound once more with a saline dampened gauze sponge. LPN #2 applied [MEDICATION NAME] to the wound with a cotton tipped applicator and covered the wound with a foam dressing. The resident was cooperative with the dressing change. At that time, LPN #2 indicated she had previously assessed the wound to be a Stage 1. She indicated she guessed she did not stage it very well and did not have time to stage the wound properly due to the resident's history of combativeness. She indicated the wound was a 1 or 2. LPN #1 indicated you got him on a good day, and indicated the resident often hollers out and fights with treatments. At that time, LPN #2, CNA #6 and CNA #7 nodded in agreement. During an interview, on 5/31/2016 at 2:40 p.m., the DON (Director of Nursing) indicated the CNA's should verify and document the placement and inflation of the Roho cushion every shift. She indicated if the cushion was found deflated, she would hope the CNA's would notify her or somebody to fix it. During an interview on 5/31/2016 at 2:50 p.m., OT (Occupational Therapist) #9 indicated the Roho removed from the resident's room had a hole in it and he was unable to determine if the cushion could be used again. During an interview on 06/01/2016 at 8:50 a.m., LPN #2 indicated she had performed the dressing change to the right buttock the previous day and the wound was a stage 1. During an interview on 06/01/2016 at 4:22 p.m., the DON indicated no reassessment was performed for the resident's wound as ordered by the physician on 5/18/2016 after the [MEDICATION NAME] treatment was completed on 05/28/2016. During an interview on 06/02/2016 at 10:40 a.m., the resident's family member indicated when she visited last week, she found the resident sitting on the Roho cushion in the recliner and it was completely flat. She indicated she had taken the cushion to a staff member and told them it may have a hole in it. She indicated the staff member reinflated the cushion and gave it back to the resident. During an interview on 06/02/2016 at 11:10 a.m., the DON indicated if a new order was given for a treatment to the same area, the initial order should be discontinued. Additionally, she indicated it was standard practice to place the original order on hold, then revert back to it when a timed order was completed. She indicated the nurses would know to go back to the original order. She indicated the Treatment Administration Record lacked a written order to place the original order on hold. A current policy titled, (name of company) SKIN INTEGRITY STANDARD dated April 2015, provided by the DON on 06/01/2016, at 2:00 p.m., indicated, .If skin integrity issues are identified post-admission the following documented information is required: 1. Wound Specifics: a. Location of wound-as specifically as possible b. Size of the wound including length, width and depth in centimeters .d. Description of the wound bed: Presence of necrotic tissue (death of skin tissue) identified as eschar (thick, leathery necrotic or devitalized tissue, frequently black in color) or slough (Necrotic or avascular tissue in the process of separating from healthy tissue). Color .Moist or dry .i. Stages of Pressure: Stage 1-Nonblanchable [DIAGNOSES REDACTED] (abnormal redness of the tissues that does not blanch to pressure). Stage 2-Partial Thickness Skin Loss. Stage 3-Full Thickness Skin Loss .5. Care plan up-dated to reflect current status of the wound,, treatment plan, turning and positioning program, and additional interventions to promote healing. This Federal tag relates to Complaint IN 579. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review the facility failed to ensure a resident's right in self determination regarding implementation of the formulated advanced directive which resulted in death, in that when a resident made the determination for CPR (cardio-pulmonary resuscitation) in the event of unresponsiveness or [MEDICAL CONDITION], the Licensed Practical Nurse (LPN#4) failed to follow the resident's advanced directive and initiate CPR when he was found unresponsive. (Resident B). This deficient practice had the potential to affect all residents in the facility. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the nursing staff failed to provide medical intervention (CPR) to restore circulatory and respiratory function that had ceased. The Administrator and Regional Director of Clinical Operations were notified of the Immediate Jeopardy at 4:05 p.m., on [DATE]. Findings include: The record for Resident B was reviewed on [DATE]. [DIAGNOSES REDACTED]. The Resident was found in his recliner pulseless with no respirations on [DATE]. On admission to the facility on [DATE], the Resident's representative signed a form titled Indiana Physician order [REDACTED]. During a review of the progress notes dated [DATE], it was noted the physician of record ordered a 2-view chest x-ray in response to telephone interaction with nurse. Resident had complained of shortness of breath. During an interview with spouse of Resident B on [DATE] at 11:30 a.m., she indicated she was present when LPN#4 entered room and listened to her husband's chest. She indicated no one pushed on his chest. On [DATE], a written statement and signed statement was received from the x-ray technician. The statement indicated, the technician entered the room and spoke with spouse of the resident. The technician noticed no response from the resident with his mouth open and gray coloring of the skin. The technician left the room to get assistance from the nurse. The certified nurse aide (CNA#1) entered the room. The nurse entered the room with the technician. She checked for a pulse and checked for a heartbeat with stethoscope. The technician indicated no CPR was performed on the resident. The technician and LPN#4 both left the room. CNA#1 stayed in the room with the spouse. During an interview with CNA#1 on [DATE] at 1:45 p.m., he indicated he entered the room after the x-ray technician left to get the nurse. He stated he observed the nurse check for pulse and heartbeat. He stated no CPR was started at that time. He stated he stayed in the room to comfort spouse until he left to retrieve a bed to place Resident B and assist with post mortem care. During an interview with RN#2 on [DATE] at 2:10 p.m., she indicated she was working on east hall when she was requested by the LPN#4 on the west hall for assistance. She was asked to confirm a resident had passed away. She entered the room and visually assessed the resident as having sallow complexion, no chest movement, she listened to chest and took vital signs in both wrists. Resident's recliner was in the upright position. She indicated LPN#4 and myself left the room. RN#3 was certified in CPR. During an interview with CNA#4 on [DATE] at 2:30 p.m., she indicated she followed both nurses into the room of Resident B. She indicated she witnessed RN#3 checking resident for pulses. She noticed the recliner was in the upright position. She stayed to assist with post mortem care. During an interview with CNA#5 on [DATE] at 2:40 p.m., she indicated she was called into the room to assist other CNAs with hoyer lift to move Resident B from the recliner, which was in the upright position. The recliner had to be changed to the reclining position to place a hoyer pad under the resident to transfer him to a bed to perform post mortem care. During an interview with the Health Facility Administrator on [DATE] at 2:55 p.m., he indicated he was notified of the death of Resident B at 7 p.m., on [DATE]. He indicated he knew they did not follow policy. He and the Director of Nursing (DON) asked LPN#4 to finish charting and suspended her. He indicated the Staff Development came into the facility and started re-education on CPR policy on [DATE]. He started an investigation of the incident and reported to the Indiana State Department of Health on [DATE]. During a telephone interview with LPN#4 on [DATE] at 3:20 p.m., she indicated the x-ray technician came out of room and stated she needed the nurse in the room. She stated she checked for pulses and started compressions while the resident was in the recliner and the spouse yelled at her to stop, she spoke to the spouse to make sure she was talking about CPR. She indicated she stopped compressions because he was in a bad position for CPR and she had no help. He was flaccid with no expression, in the recliner. She left the room to call the doctor and the night shift supervisor. She also called the DON. LPN#4 was certified in CPR. A review of the Procedure 235A on [DATE], titled Cardiopulmonary Resuscitation (CPR), dated (MONTH) 2014. The procedure stated . Basic Responsibility . Licensed Nurse, Other Purpose: to ventilate and establish circulation for a resident with absence of respirations and pulse. Assessment Guidelines: May include but are not limited to: -Pulse rate or absence of pulse -Pulse rhythm -Pulse quality - Cyanosis -Respiratory distress -Respiratory rate or absence of respirations - Respiratory rhythm -Respiratory quality -Level of consciousness -Vital signs -allergies [REDACTED]. Equipment [MEDICAL CONDITION] board or hard surface Sphygmomanometer and stethoscope Airway Suction machine Disposable CPR mask, use per manufacturer's instructions Face mask with hand held portable pressure device use per manufacturer's instruction Procedure 1. CPR that is done properly or on a resident improperly or whose heart is still beating can cause serious injury. Do not perform CPR unless: a. The resident has stopped breathing or is breathing abnormally b. The resident is unresponsive and does not have signs of circulation and respirations c. No one with more training in CPR is present 2. Determine unresponsiveness by tapping or gently shaking resident and shouting ,Are you okay? If you suspect head or neck injury, do not shake. 3. If the resident does not respond, call out for help. 4. Delegate a specific individual to check resident's advance directives, orders and care plan for CPR, or no CPR (DNR) order; have specific individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 5. Do not start CPR if resident is breathing normally and has a pulse, Start emergency oxygen, delegate a specific individual to stay with the resident and monitor vital signs. Notify the attending physician of the resident's condition and request further orders for care, 6. Position the resident on a [MEDICAL CONDITION] board or hard surface by back as a unit, supporting head and neck. Circulation: 1. Determine pulselessness. Palpate the carotid artery gently to void compression the artery. Check circulation for no more than 10 seconds. 2. If the resident is unconscious with no normal breathing and no pulse,begin compressions. 3. Perform external chest compressions by placing heel of dominate hand on the center of the chest between nipples. The second hand should be placed directly on top of the first hand. 4. Depress sternum 2 inches. Give 30 chest compressions at a rate of at least 100 compressions per minute. Keep hands of sternum during upstroke. Airway: 1. Open airway using head tilt chin lift (by tilting the head back with one hand while lifting up the resident's chin with your other hand.) 2. Maintain an open airway. Look in the mouth to make sure the airway is clear. 3. If a foreign object is present, sweep it out right away. Breathing: 1. If the resident is breathless or has abnormal breathing, perform rescue breathing by gently placing the face mask over the resident's nose and mouth to create an airtight seal. 2. Deliver two breaths, each [MEDICATION NAME] one second. Pause between breaths. 3. Observe for chest rise and fall. The volume of each rescue breath should be sufficient to produce visible chest rise. a. Avoid delivering more breaths that recommended or breaths that are too large or too forceful. b. If the resident's chest does not rise when first breath delivered, perform the head tilt/chin lift again before giving second breath. 4. Allow chest deflation between breaths. 5. If there are signs of circulation, but no signs of breathing continue to give rescue breaths at the rate of one breath very five seconds or twelve breaths per minute. Repeat cycle of 30 compressions to 2 breaths. Continue uninterrupted until you are relieved by another knowledgeable about CPR, emergency life support arrives; a physician pronounces the resident expired or you are unable to continue. CPR Quick Reference Guide- Adults 1. Check the resident for responsiveness and normal breathing. 2. Call for help. If the resident is unresponsive delegate someone to call 911 emergency services. 3. Check pulse in the carotid artery of the neck 4. If the patient is unconscious with normal breathing and no pulse, begin chest compressions. 5. Locate the compression landmark: center of chest between nipples 6. Do chest compressions with two hands stacked; heel of one hand on sternum. Give 30 chest compressions 7. Open the airway. IF the resident is not breathing normally, begin rescue breathing: Give two full breaths at one second per breath. 8. Continue cycle ration of 30 compressions to 2 breaths. Total rate of 100 compressions per minute with compression depth of 2 inches. Documentation Guidelines: Documentation many include: Completion of CPR Change of Condition Form Notification of physician Notification of resident family or responsible party The Immediate Jeopardy that began on [DATE] was removed on [DATE], but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for ongoing staff training. The surveyor confirmed the following by observation, interview and record review: 1. The facility ensured the Advanced Directive forms were completed appropriately, and Physician ordered obtained and reflective of the resident's decision for end of life care. Resident care plans were reviewed and reflective of resident's end of life care. 2. The facility completed an inservice for all licensed and unlicensed staff on code response currently available in the facility was completed on [DATE]. Remaining staff would be required to be re-inserviced prior to next scheduled shift. 3. The facility performed Mock Code Drill to ensure staff's understanding of responsibilities during a code. This was completed on all three shifts on [DATE] and [DATE]. 4. A review of staff involved in Resuscitative efforts were CPR certified. CPR certification reviewed and verified by ISDH surveyors on [DATE]. 5. Through observation, record review, staff were interviewed to ensure they were aware of the facility policy and procedure and their responsibility in regard to code status. This Federal Tag relates to the Complaint IN 779. 3XXX,[DATE](a) 3XXX,[DATE](u)(3)

Based on interview and record review the facility failed to ensure a resident's right in self determination regarding implementation of the formulated advanced directive which resulted in death, in that when a resident made the determination for CPR (cardio-pulmonary resuscitation) in the event of unresponsiveness or [MEDICAL CONDITION], the Licensed Practical Nurse (LPN#4) failed to follow the resident's advanced directive and initiate CPR when he was found unresponsive. (Resident B). This deficient practice had the potential to affect all residents in the facility. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the nursing staff failed to provide medical intervention (CPR) to restore circulatory and respiratory function that had ceased. The Administrator and Regional Director of Clinical Operations were notified of the Immediate Jeopardy at 4:05 p.m., on [DATE]. Findings include: The record for Resident B was reviewed on [DATE]. [DIAGNOSES REDACTED]. The Resident was found in his recliner pulseless with no respirations on [DATE]. On admission to the facility on [DATE], the Resident's representative signed a form titled Indiana Physician order [REDACTED]. During a review of the progress notes dated [DATE], it was noted the physician of record ordered a 2-view chest x-ray in response to telephone interaction with nurse. Resident had complained of shortness of breath. During an interview with spouse of Resident B on [DATE] at 11:30 a.m., she indicated she was present when LPN#4 entered room and listened to her husband's chest. She indicated no one pushed on his chest. On [DATE], a written statement and signed statement was received from the x-ray technician. The statement indicated, the technician entered the room and spoke with spouse of the resident. The technician noticed no response from the resident with his mouth open and gray coloring of the skin. The technician left the room to get assistance from the nurse. The certified nurse aide (CNA#1) entered the room. The nurse entered the room with the technician. She checked for a pulse and checked for a heartbeat with stethoscope. The technician indicated no CPR was performed on the resident. The technician and LPN#4 both left the room. CNA#1 stayed in the room with the spouse. During an interview with CNA#1 on [DATE] at 1:45 p.m., he indicated he entered the room after the x-ray technician left to get the nurse. He stated he observed the nurse check for pulse and heartbeat. He stated no CPR was started at that time. He stated he stayed in the room to comfort spouse until he left to retrieve a bed to place Resident B and assist with post mortem care. During an interview with RN#2 on [DATE] at 2:10 p.m., she indicated she was working on east hall when she was requested by the LPN#4 on the west hall for assistance. She was asked to confirm a resident had passed away. She entered the room and visually assessed the resident as having sallow complexion, no chest movement, she listened to chest and took vital signs in both wrists. Resident's recliner was in the upright position. She indicated LPN#4 and myself left the room. RN#3 was certified in CPR. During an interview with CNA#4 on [DATE] at 2:30 p.m., she indicated she followed both nurses into the room of Resident B. She indicated she witnessed RN#3 checking resident for pulses. She noticed the recliner was in the upright position. She stayed to assist with post mortem care. During an interview with CNA#5 on [DATE] at 2:40 p.m., she indicated she was called into the room to assist other CNAs with hoyer lift to move Resident B from the recliner, which was in the upright position. The recliner had to be changed to the reclining position to place a hoyer pad under the resident to transfer him to a bed to perform post mortem care. During an interview with the Health Facility Administrator on [DATE] at 2:55 p.m., he indicated he was notified of the death of Resident B at 7 p.m., on [DATE]. He indicated he knew they did not follow policy. He and the Director of Nursing (DON) asked LPN#4 to finish charting and suspended her. He indicated the Staff Development came into the facility and started re-education on CPR policy on [DATE]. He started an investigation of the incident and reported to the Indiana State Department of Health on [DATE]. During a telephone interview with LPN#4 on [DATE] at 3:20 p.m., she indicated the x-ray technician came out of room and stated she needed the nurse in the room. She stated she checked for pulses and started compressions while the resident was in the recliner and the spouse yelled at her to stop, she spoke to the spouse to make sure she was talking about CPR. She indicated she stopped compressions because he was in a bad position for CPR and she had no help. He was flaccid with no expression, in the recliner. She left the room to call the doctor and the night shift supervisor. She also called the DON. LPN#4 was certified in CPR. A review of the Procedure 235A on [DATE], titled Cardiopulmonary Resuscitation (CPR), dated [DATE]. The procedure stated . Basic Responsibility . Licensed Nurse, Other Purpose: to ventilate and establish circulation for a resident with absence of respirations and pulse. Assessment Guidelines: May include but are not limited to: -Pulse rate or absence of pulse -Pulse rhythm -Pulse quality - Cyanosis -Respiratory distress -Respiratory rate or absence of respirations - Respiratory rhythm -Respiratory quality -Level of consciousness -Vital signs -allergies [REDACTED]. Equipment [MEDICAL CONDITION] board or hard surface Sphygmomanometer and stethoscope Airway Suction machine Disposable CPR mask, use per manufacturer's instructions Face mask with hand held portable pressure device use per manufacturer's instruction Procedure 1. CPR that is done properly or on a resident improperly or whose heart is still beating can cause serious injury. Do not perform CPR unless: a. The resident has stopped breathing or is breathing abnormally b. The resident is unresponsive and does not have signs of circulation and respirations c. No one with more training in CPR is present 2. Determine unresponsiveness by tapping or gently shaking resident and shouting ,Are you okay? If you suspect head or neck injury, do not shake. 3. If the resident does not respond, call out for help. 4. Delegate a specific individual to check resident's advance directives, orders and care plan for CPR, or no CPR (DNR) order; have specific individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 5. Do not start CPR if resident is breathing normally and has a pulse, Start emergency oxygen, delegate a specific individual to stay with the resident and monitor vital signs. Notify the attending physician of the resident's condition and request further orders for care, 6. Position the resident on a [MEDICAL CONDITION] board or hard surface by back as a unit, supporting head and neck. Circulation: 1. Determine pulselessness. Palpate the carotid artery gently to void compression the artery. Check circulation for no more than 10 seconds. 2. If the resident is unconscious with no normal breathing and no pulse,begin compressions. 3. Perform external chest compressions by placing heel of dominate hand on the center of the chest between nipples. The second hand should be placed directly on top of the first hand. 4. Depress sternum 2 inches. Give 30 chest compressions at a rate of at least 100 compressions per minute. Keep hands of sternum during upstroke. Airway: 1. Open airway using head tilt chin lift (by tilting the head back with one hand while lifting up the resident's chin with your other hand.) 2. Maintain an open airway. Look in the mouth to make sure the airway is clear. 3. If a foreign object is present, sweep it out right away. Breathing: 1. If the resident is breathless or has abnormal breathing, perform rescue breathing by gently placing the face mask over the resident's nose and mouth to create an airtight seal. 2. Deliver two breaths, each [MEDICATION NAME] one second. Pause between breaths. 3. Observe for chest rise and fall. The volume of each rescue breath should be sufficient to produce visible chest rise. a. Avoid delivering more breaths that recommended or breaths that are too large or too forceful. b. If the resident's chest does not rise when first breath delivered, perform the head tilt/chin lift again before giving second breath. 4. Allow chest deflation between breaths. 5. If there are signs of circulation, but no signs of breathing continue to give rescue breaths at the rate of one breath very five seconds or twelve breaths per minute. Repeat cycle of 30 compressions to 2 breaths. Continue uninterrupted until you are relieved by another knowledgeable about CPR, emergency life support arrives; a physician pronounces the resident expired or you are unable to continue. CPR Quick Reference Guide- Adults 1. Check the resident for responsiveness and normal breathing. 2. Call for help. If the resident is unresponsive delegate someone to call 911 emergency services. 3. Check pulse in the carotid artery of the neck 4. If the patient is unconscious with normal breathing and no pulse, begin chest compressions. 5. Locate the compression landmark: center of chest between nipples 6. Do chest compressions with two hands stacked; heel of one hand on sternum. Give 30 chest compressions 7. Open the airway. IF the resident is not breathing normally, begin rescue breathing: Give two full breaths at one second per breath. 8. Continue cycle ration of 30 compressions to 2 breaths. Total rate of 100 compressions per minute with compression depth of 2 inches. Documentation Guidelines: Documentation many include: Completion of CPR Change of Condition Form Notification of physician Notification of resident family or responsible party The Immediate Jeopardy that began on [DATE] was removed on [DATE], but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for ongoing staff training. The surveyor confirmed the following by observation, interview and record review: 1. The facility ensured the Advanced Directive forms were completed appropriately, and Physician ordered obtained and reflective of the resident's decision for end of life care. Resident care plans were reviewed and reflective of resident's end of life care. 2. The facility completed an inservice for all licensed and unlicensed staff on code response currently available in the facility was completed on [DATE]. Remaining staff would be required to be re-inserviced prior to next scheduled shift. 3. The facility performed Mock Code Drill to ensure staff's understanding of responsibilities during a code. This was completed on all three shifts on [DATE] and [DATE]. 4. A review of staff involved in Resuscitative efforts were CPR certified. CPR certification reviewed and verified by ISDH surveyors on [DATE]. 5. Through observation, record review, staff were interviewed to ensure they were aware of the facility policy and procedure and their responsibility in regard to code status. This Federal Tag relates to the Complaint IN 779. 3XXX,[DATE](a) 3XXX,[DATE](u)(3)

Based on record review, interview and observation the facility failed to ensure the safety of residents from a known verbally and physically aggressive resident (Resident #8). Resident # 8 had a history of [REDACTED]. Residents # 72, # 91, # 93, #30, # 21, and # 33 indicated they were fearful of resident #8 or had witnessed aggressive behavior from Resident # 8. They indicated they felt concerns to administration were not addressed. This deficit practice had the potential to affect 58 of 76 residents residing in the facility. An Immediate Jeopardy was identified on 3/11/14 at 5 p.m. The Immediate Jeopardy began on 3/11/14 with the indication during Resident #72, #91, #93, #30, #21, and #33 interviews that they were fearful of or had witnessed Resident #8's aggressive behavior. The Administrator was notified of the Immediate Jeopardy on 3/11/14 at 5 p.m. Findings include: During an interview on 3/6/2014 at 9:04 a.m., Resident #30 indicated Resident #8 often yelled at the staff members. Resident #30 also indicated Resident #8 ran his wheelchair into her hands. She was unable to recall the date of the incident and indicated she believed the act to be intentional. The resident indicated that her hands swelled and she was required to have x-rays. She indicated no injuries were noted at the time of the x-rays, but her hands hurt. On 3/6/2014 at 2:20 p.m., during an interview with Resident #91, he indicated he had issues with Resident #8. He indicated during dinner in the main dining room, he approached the table where Resident #8 was seated. Resident #8 asked him who he was and who told him he could eat at his table. Resident # 91 indicated Resident #8 then told him to go away, and he was cussing and swearing at him. During an interview with Resident #21, on 3/11/14 at 2:00 p.m., she indicated "Resident #8 does things and gets away with it. He cusses, pinches the aide's butts, is rude and threatens other residents. He runs into other resident with his wheelchair. His behaviors have not improved. Staff are afraid to report him he'll get them in trouble if they do. During an interview with LPN #1, on 3/11/14 at 3:25 p.m., she indicated Resident #8 will get them into trouble and he pats them on the butt and makes sexual remarks. She also indicated residents are afraid of him too. During an interview with Resident #93 on 3/11/14 at 3:29 p.m., the resident indicated Resident #8 often threatened other residents with physical harm. Resident #93 indicated she was standing near the entrance to the building on 3/11/14, and that Resident #8 approached her. She indicated Resident #8 had startled her and she told him she was startled. Resident #93 indicated Resident #8 then " ... yelled a bad comment to (her) and left." Resident #93 indicated Resident #8 cursed at her in the past. Resident #93 indicated that she would not want to be alone with Resident #8, " ... because he has that big wheelchair and he has things he can pick up off of the floor. If he wanted to, he could hurt me." Resident #93 indicated she had not reported the behaviors of Resident #8 because she didn't " ...want any trouble. If he (Resident #8) found out, he would be really mad." Resident #93 also indicated she witnessed Resident #8 touch nursing staff inappropriately. During an interview with Certified Nursing Assistant # 1 (CNA), on 3/11/14 at 3:45 p.m., she indicated Resident #8 was verbally aggressive and threw things at staff members at times. She indicated Resident #8 threw a urinal across his room on 3/11/14 at approximately 3:15 p.m. The CNA indicated Resident #8 was sometimes verbally abusive towards staff and sometimes made physical threats towards other residents. The CNA also indicated Resident #8 repeatedly tried tickling her on the ribs. The CNA indicated she was a little afraid to be alone with Resident #8 if he was in a bad mood. She indicated administrative staff had attempted to talk with Resident #8 regarding his behaviors towards staff and other residents, but she did not believe the intervention was effective. On 3/11/2014 at 3:45 p.m., during an interview with Resident #72, she indicated she recently complained to the Administrator regarding Resident #8 cursing and using f--- word in the main dining room during meals. Resident #72 sat at the far end of main dining room across the room from Resident #8. Resident #72 indicated she has seen Resident #8 with his fist raised at other residents and indicated she was fearful of this resident. Resident #72 indicated she had spoken to her son about Resident # 8's behavior and her fear. Resident # 72 indicated Resident # 8 could hurt her at any time with his wheelchair or coming into her room while sleeping, uninvited. Resident #72 indicated Administrator does nothing, so why say anything anymore. During an interview with Resident # 33, on 3/11/14 at 3:50 p.m., she indicated she was not afraid of Resident #8. " He comes in to get candy from me. I do want you to know, he's no angel." On 3/5/2014 at 4:50 p.m., while leaving the facility, Resident #8 was observed yelling loudly and cussing in main dining room. During interview at this time with unnamed CNA regarding yelling behaviors, she indicated resident always does this and he will be asked to leave dining room if the yelling does not stop. The record for resident #8 was reviewed on 3/10/14 at 1:30 p.m. This resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. IDT (Interdisciplinary Team) assessment dated [DATE], care plan discussion identified behaviors of cursing at another resident, behaviors noted in care plan meetings. A 5/17/13 careplan indicated a problem of behaviors including resident was yelling,cursing at other residents in the MDR, intervention included, but were not limited to, talk to resident as to why he is upset, staff to ask resident to remove himself from MDR if he continues to yell and curse. Nursing Notes indicated the following: 12/3/2013 resident is impatient with staff and makes comments about staff weight, verbally abusive and uncooperative 12/8/2013 verbally abusive to staff negative attitude/unpleasant mood, yelling out, aggressive to staff, inappropriate behavior 12/14/13 verbally abusive, yelling out 12/15/13 verbally abusive, fabricates stories, yelling at staff using inappropriate language, refusing treatments, inappropriate behavior, negative statements, anger toward staff 12/19/13 resident is uncooperative with care and meds, needs much encouragement to be cooperative 12/22/13 arguing with roommate, threatening to beat him up, then became verbally abusive toward CNAs, continues to propel throughout unit with w/c ignoring everyone, negative statements, anger towards others, inappropriate behavior 12/24/13 resident rude and demanding, acts as though staff is "STUPID" 12/26/13 therapy staff note resident is uncooperative with staff 12/28/2013 resident refuses meds, inappropriate with staff, rude to CNA and housekeeping 12/29/13 resident continues to be rude to staff demanding, says inappropriate things to staff 1/12/2014 verbally abusive to staff, yelling constantly at CNAs and ordering them around, throwing book and lotion into the hallway, when staff reminded resident he could hit or harm another resident with this behavior resident stated "I don't care" 2/2/2014 yelling at staff and peers, becoming angry, threatening staff saying, "I'll hurt you", rolling through hallways yelling at staff 3/8/2014 resident angry refused treatment, resident drove to dining room, when staff tried to redirect resident threatened multiple staff members, on multiple occasions, resident stated "If you do not stop bothering me, someone is going to get hurt, and that is a promise" 3/9/2014 in dining room, new resident entered room and resident was upset and told her she was not welcome to eat cake there with them in dining room, during the shift, resident made numerous rude comments to staff and other residents, resident threatened staff on multiple occasions, resident uncooperative with treatments and resistant to redirection On 3/11/2014 at 2:10 p.m., during record review of incident reports provided by the Administrator regarding resident # 8, no report from Resident #72 or Resident # 91 was found. Social services notes for resident #8 indicated: 7/31/2013 resident notified of new roommate/behavior poor began yelling at social service person 8/14/13 behaviors 8/13 and 8/14 discussed with resident not acceptable to yell and curse, threaten staff. Resident became defensive and yelled. DON aware of behaviors 8/22/13 resident behaviors present 8/22/13 discussed behaviors with resident not acceptable to be using curse words in dining room, resident became defensive and yelled "keep out of my business" attempted to redirect resident, DON aware 8/23/13 discussed behaviors with resident "These aids are d--m slow" indicated resident has issues with evening staff, attempted to redirect resident, DON aware 8/26/13 behavior on 8/25 discussed the report he "accidentally" hit a resident hand, resident stated "he is going to hit resident," educated resident on consequences of hitting other residents nurse reported altercation to DON, DON to report to state 8/27/13 behavior on 8/27 discussed with resident yelling at staff, DON aware of behavior 8/29/13 incident happened on 8/23/13 discussed with resident situation yelling at resident in hallway, felt he was ignored by resident, stated he did not hit resident but the wall, DON and Administrator notified and report to state 8/30/13 resident discussed going to (name of another nursing facility) resident denied request could not meet his needs, IDT discussed with resident verbal aggression and outburst does effect the other residents well being, Resident got upset and wheeled away from care plan meeting 8/30/13 discussed with resident situation he was yelling at another resident, resident denied, DON aware 9/4/13 resident was defensive during discussion on behavior, DON aware 9/10/13 discussed behavior yelling and threatening staff on 9/8 explained to resident threatening to hit staff is unacceptable, resident denied, DON aware, attempt to redirect resident 9/30/13 discussed with resident not appropriate to curse at residents, DON aware 10/2/13 discussed with resident calling nurse a b--ch not appropriate behavior resident denied, resident yelling at social service person and wheeled off refusing to listen 11/5/13 discussed with resident behavior 11/3 yelling with staff, tried to discuss with resident that cursing at staff is inappropriate 11/18/13 discussed 11/17 situation, resident reminded that cursing and threatening staff is not ok, resident became defensive and started yelling tried to redirect resident but he wheeled off in wheelchair, attempted to redirect resident, DON aware 12/30/2013 discussed behaviors for 12/28 and 12/29, resident yelling and making inappropriate comments, resident defensive, denied behavior "didn't do anything ...I am out of here!" attempted to explain yelling at staff and making inappropriate comments are not acceptable, resident wheeled off and refused to listen to anyone, DON aware 1/30/14 resident was verbally aggressive towards staff on 1/28, met with resident to explain that cursing hurts people's feelings 2/18/14 late entry for 2/4/14, resident was threatening staff and upset with another resident, advised if he continues to curse and yell in dining room he will be asked to leave, attempted to tell resident yelling and cursing is inappropriate resident wheeled away from social service person talking to him 2/18/14 late entry for 2/6/14 resident was verbally inappropriate towards staff during care. CNA told resident it was inappropriate to talk that way to others, resident got angry, upset and started yelling, social service person met with resident to discuss inappropriate behavior, resident rode off in wheelchair 3/3/13 resident was cursing and calling a resident names, incident with boxes and wheel chairs occurred, cursing and yelling occurred, resident was educated on dangers of wheelchair operation 3/5/14 discussed with ombudsman resident and staffing concerns with resident During an interview with the DON on 3/10/14 at 2:00 p.m., she indicated the behaviors of Resident #8 are addressed in the care plan and was reviewed and revised in 3/14. She indicated behaviors had improved with the intervention of an Ipad. Behavior was not recent, and has had no problems lately. During an interview with the Social Services Director on 3/11/14 at 2:13 p.m., she indicated Resident #8 was encouraged to go to staff to express his feelings. When she gets behavior reports, she would go to Resident #8 to get both sides of the story, many times there are different sides of the story, he demostrated defensive behavior. His behavior was discussed at morning meetings but not in recent past. Behaviors have improved, he is deeply involved in learning his Ipad. When he does act out, resident is asked to leave the area. Ombudsman has been helpful in directing activities for the resident and visits resident frequently. On 3/11/14 at 3 p.m., the administrator indicated he had no reportable occurrences related to the residents verbal or physical abusive behaviors. The Abuse and Crime Reporting Policies and Procedures, revised September 2011 was provided by the Adminsitrator on 3/5/14 and indicated: "...the policy of the facility is that every resident has the right to be free from verbal, sexual, physical, and mental abuse; neglect, corporal punishment, and involuntary seclusion... It is the responsibility of employees to promptly report to the facility administrator, local ombudsman (or local law enforcement agency) and to the State Licensing and Certification immediately or as soon as practically possible within 24 hours of detection, any incident of suspected or alleged neglect or resident abuse from other residents,staff,family or visitors; including injuries of unknown source and theft or misappropriation of resident property. Reports shall be thoroughly investigated in a timely manner... Purpose To protect the physical and emotional well-being and personal possessions of every resident... Definitions Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm,pain or mental anguish...Mental abuse includes but is not limited to humiliation,harassment, threats of punishment, or deprivation...Resident to Resident abuse mean the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident towards another...Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability... 4. Prevention The facility shall identify, analyze, and assess the following situations to minimize the likelihood of abuse, neglect, and/or missappropriation of resident property:... 5. Identification The facility will monitor the adequacy of assessment, care planning, and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse or neglect, such as: Physically aggressive or self injurious behaviors *verbally abusive behavior towards others *socially inappropriate or disruptive behaviors. 6. Investigation Injuries of unkknown source, suspected or alleged abuse, neglect, involuntary seclusion, and misappropriation of resident property or found, will be investigated with results reported in accordance with facility police, federal and state regulation's... 7. Protection To protect residents and employees from harm or regulation during investigations, the facility shall, take promptly measures to remove any resident from immediate harm or danger. The facility shall take reasonable measure to separate residents involved in alleged or witnessed Resident to Resident abuse... 6 (sic). Reporting Additionally, the facility requires that employees immediately report the facts of known or suspected instances of abuse and all allegations of abuse and suspicions of crime immediately to the facility Administrator (either directly or anonymously) so that facility's responsibility to protect residents and promptly investigate occurrences can be met. Failure to report in the required time frames may result in disciplinary action, including termination. The facility Administrator, or designee, will immediately, or as soon as practically possible with 24 hours of receiving an allegation or forming a suspicion, report the instance of abuse, neglect, or misappropriation of resident property to the local ombudsman or local law enforcement agency and to the Department of Health Services ( or appropriate State Agency) as required by law. The facility Administrator, or designee, shall report the findings of the internal investigation to officials in accordance with state law, including to the state survey and certification agency, within five working days of the incident...." The immediate jeopardy that began on 3/11/14 at 5 p.m., was removed on 3/12/14, when the facility placed Resident #8 on 1:1 care supervision by nursing staff, completed interviews of alert and oriented residents, and began all staff inserviceing on the facility abuse policy. The noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for ongoing staff training, resident education and family education on the abuse policy and procedure. 3.1-27(a)1 3.1-27(b)

Based on interviews, record review and observation the facility failed to investigate alleged verbal abuse and prevent further potential abuse from a known verbally and physically aggressive resident (Resident #8). Resident # 8 had a history of [REDACTED]. Residents # 72, # 91, # 93, #30, # 21, and # 33 indicated they were fearful of resident #8 or had witnessed aggressive behavior from Resident # 8. They indicated they felt concerns to administration were not addressed. This deficient practice had the potential to affect 58 of 76 residents residing in the facility. An Immediate Jeopardy was identified on 3/11/14 at 5 p.m. The Immediate Jeopardy began on 3/11/14 with the indication during Resident #72, #91, #93, #30, #21, and #33 interviews that they were fearful of or had witnessed Resident #8's aggressive behavior. The Administrator was notified of the Immediate Jeopardy on 3/11/14 at 5 p.m. Findings include: During an interview on 3/6/2014 at 9:04 a.m., Resident #30 indicated Resident #8 often yelled at the staff members. Resident #30 also indicated Resident #8 ran his wheelchair into her hands. She was unable to recall the date of the incident and indicated she believed the act to be intentional. The resident indicated her hands swelled and she was required to have x-rays. She indicated no injuries were noted at the time of the x-rays, but her hands hurt. On 3/6/2014 at 2:20 p.m., during an interview with Resident #91, he indicated he had issues with Resident #8. He indicated during dinner in the main dining room, he approached the table where Resident #8 was seated. Resident #8 asked him who he was and who told him he could eat at his table. Resident # 91 indicated Resident #8 then told him to go away, and he was cussing and swearing at him. During an interview with Resident #21, on 3/11/14 at 2:00 p.m., she indicated "Resident #8 does things and gets away with it. He cusses, pinches the aide's butts, is rude and threatens other residents. He runs into other residents with his wheelchair. His behaviors have not improved. Staff are afraid to report him he'll get them in trouble if they do." During an interview with LPN #1, on 3/11/14 at 3:25 p.m., she indicated Resident #8 will get them into trouble and he pats them on the butt and makes sexual remarks. She also indicated residents are afraid of him too. During an interview with Resident #93 on 3/11/14 at 3:29 p.m., the resident indicated Resident #8 often threatened other residents with physical harm. Resident #93 indicated she was standing near the entrance to the building on 3/11/14, and that Resident #8 approached her. She indicated Resident #8 had startled her and she told him she was startled. Resident #93 indicated Resident #8 then " ... yelled a bad comment to (her) and left." Resident #93 indicated Resident #8 cursed at her in the past. Resident #93 indicated she would not want to be alone with Resident #8, " ... because he has that big wheelchair and he has things he can pick up off of the floor. If he wanted to, he could hurt me." Resident #93 indicated she had not reported the behaviors of Resident #8 because she didn't " ...want any trouble. If he (Resident #8) found out, he would be really mad." Resident #93 also indicated she witnessed Resident #8 touch nursing staff inappropriately. During an interview with Certified Nursing Assistant # 1 (CNA), on 3/11/14 at 3:45 p.m., she indicated Resident #8 was verbally aggressive and threw things at staff members at times. She indicated Resident #8 threw a urinal across his room on 3/11/14 at approximately 3:15 p.m. The CNA indicated Resident #8 was sometimes verbally abusive towards staff and sometimes made physical threats towards other residents. The CNA also indicated Resident #8 repeatedly tried tickling her on the ribs. The CNA indicated she was a little afraid to be alone with Resident #8 if he was in a bad mood. She indicated administrative staff had attempted to talk with Resident #8 regarding his behaviors towards staff and other residents, but she did not believe the intervention was effective. On 3/11/2014 at 3:45 p.m., during an interview with Resident #72, she indicated she recently complained to the Administrator regarding Resident #8 cursing and using f--- word in the main dining room during meals. Resident #72 sat at the far end of main dining room across the room from Resident #8. Resident #72 indicated she has seen Resident #8 with his fist raised at other residents and indicated she was fearful of this resident. Resident #72 indicated she had spoken to her son about Resident # 8's behavior and her fear. Resident # 72 indicated Resident # 8 could hurt her at any time with his wheelchair or coming into her room while sleeping, uninvited. Resident #72 indicated Administrator does nothing, so why say anything anymore. During an interview with Resident # 33, on 3/11/14 at 3:50 p.m., she indicated she was not afraid of Resident #8. " He comes in to get candy from me. I do want you to know, he's no angel." The record for resident #8 was reviewed on 3/10/14 at 1:30 p.m. This resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. IDT (Interdisciplinary Team) assessment dated [DATE], care plan discussion identified behaviors of cursing at another resident, behaviors noted in care plan meetings. A 5/17/13 care plan indicated a problem of behaviors including resident was yelling, cursing at other residents in the MDR, intervention included, but were not limited to, talk to resident as to why he is upset, staff to ask resident to remove himself from MDR if he continues to yell and curse. Nursing Notes indicated the following: 12/22/13 arguing with roommate, threatening to beat him up, then became verbally abusive toward CNAs, continues to propel throughout unit with w/c ignoring everyone, negative statements, anger towards others, inappropriate behavior 1/12/2014 verbally abusive to staff, yelling constantly at CNAs and ordering them around, throwing book and lotion into the hallway, when staff reminded resident he could hit or harm another resident with this behavior resident stated "I don't care" 3/9/2014 in dining room, new resident entered room and resident was upset and told her she was not welcome to eat cake there with them in dining room, during the shift, resident made numerous rude comments to staff and other residents, resident threatened staff on multiple occasions, resident uncooperative with treatments and resistant to redirection On 3/11/2014 at 2:10 p.m., during review of incident reports provided by the Administrator regarding resident # 8, no report from Resident #72's concerns regarding Resident # 8 were provided. At this time, the Administrator indicated he was unaware of the above 12/22/13 event of Resident # 8 threatening to beat up his roommate. Social services notes for resident #8 indicated: 8/22/13 resident behaviors present 8/22/13 discussed behaviors with resident not acceptable to be using curse words in dining room, resident became defensive and yelled "keep out of my business" attempted to redirect resident, DON aware 8/26/13 behavior on 8/25 discussed the report he "accidentally" hit a resident hand, resident stated "he is going to hit resident," educated resident on consequences of hitting other residents nurse reported altercation to DON, DON to report to state 8/29/13 incident happened on 8/23/13 discussed with resident situation yelling at resident in hallway, felt he was ignored by resident, stated he did not hit resident but the wall, DON and Administrator notified and report to state 8/30/13 discussed with resident situation he was yelling at another resident, resident denied, DON aware 9/30/13 discussed with resident not appropriate to curse at residents, DON aware 12/30/2013 discussed behaviors for 12/28 and 12/29, resident yelling and making inappropriate comments, resident defensive, denied behavior "didn't do anything ...I am out of here!" attempted to explain yelling at staff and making inappropriate comments are not acceptable, resident wheeled off and refused to listen to anyone, DON aware 2/18/14 late entry for 2/4/14, resident was threatening staff and upset with another resident, advised if he continues to curse and yell in dining room he will be asked to leave, attempted to tell resident yelling and cursing is inappropriate resident wheeled away from social service person talking to him 3/3/13 resident was cursing and calling a resident names, incident with boxes and wheel chairs occurred, cursing and yelling occurred, resident was educated on dangers of wheelchair operation During an interview with the DON on 3/10/14 at 2:00 p.m., she indicated the behaviors of Resident #8 are addressed in the care plan and was reviewed and revised in 3/14. She indicated behaviors had improved with the intervention of an Ipad. Behavior was not recent, and has had no problems lately. During an interview with the Social Services Director on 3/11/14 at 2:13 p.m., she indicated Resident #8 was encouraged to go to staff to express his feelings. When she gets behavior reports,she would go to Resident #8 to get both sides of the story, many times there are different sides of the story, he demonstrated defensive behavior. His behavior was discussed at morning meetings but not in recent past. Behaviors have improved, he is deeply involved in learning his Ipad. When he does act out, resident is asked to leave the area. Ombudsman has been helpful in directing activities for the resident and visits resident frequently. The Abuse and Crime Reporting Policies and Procedures, revised September 2011 was provided by the Administrator on 3/5/14 and indicated: "...the policy of the facility is that every resident has the right to be free from verbal, sexual, physical, and mental abuse; neglect, corporal punishment, and involuntary seclusion... It is the responsibility of employees to promptly report to the facility administrator, local ombudsman (or local law enforcement agency) and to the State Licensing and Certification immediately or as soon as practically possible within 24 hours of detection, any incident of suspected or alleged neglect or resident abuse from other residents,staff,family or visitors; including injuries of unknown source and theft or misappropriation of resident property. Reports shall be thoroughly investigated in a timely manner... Purpose To protect the physical and emotional well-being and personal possessions of every resident... Definitions Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm,pain or mental anguish...Mental abuse includes but is not limited to humiliation, harassment, threats of punishment, or deprivation...Resident to Resident abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish by one resident towards another ...Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability... 4. Prevention The facility shall identify, analyze, and assess the following situations to minimize the likelihood of abuse, neglect, and/or misappropriation of resident property:... 5. Identification The facility will monitor the adequacy of assessment, care planning, and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse or neglect, such as: Physically aggressive or self injurious behaviors *verbally abusive behavior towards others *socially inappropriate or disruptive behaviors. 6. Investigation Injuries of unknown source, suspected or alleged abuse, neglect, involuntary seclusion, and misappropriation of resident property or found, will be investigated with results reported in accordance with facility police, federal and state regulation's... 7. Protection To protect residents and employees from harm or regulation during investigations, the facility shall, take promptly measures to remove any resident from immediate harm or danger. The facility shall take reasonable measure to separate residents involved in alleged or witnessed Resident to Resident abuse... The immediate jeopardy that began on 3/11/14 was removed on 3/12/14 at when the facility placed Resident #8 on 1:1 care supervision by nursing staff, completed interviews of alert and oriented residents, and began all staff inservice on the facility abuse policy. The noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for ongoing staff training, resident education and family education on the abuse policy and procedure. 3.1-28(d)

Based on interview, record review the facility failed to follow their abuse prevention policy and procedure to prevent verbal abuse of residents from a known verbally and physically aggressive resident (Resident #8). Resident # 8 had a history of [REDACTED]. Residents # 72, # 91, # 93, #30, # 21, and # 33 indicated they were fearful of resident #8 or had witnessed aggressive behavior from Resident # 8. They indicated they felt concerns to administration were not addressed. This deficient practice had the potential to affect 58 of 76 residents residing in the facility. An Immediate Jeopardy was identified on 3/11/14 at 5 p.m. The Immediate Jeopardy began on 3/11/14 with the indication during Resident #72, #91, #93, #30, #21, and #33 interviews that they were fearful of or had witnessed Resident #8's aggressive behavior. The Administrator was notified of the Immediate Jeopardy on 3/11/14 at 5 p.m. Findings include: During an interview on 3/6/2014 at 9:04 a.m., Resident #30 indicated Resident #8 often yelled at the staff members. Resident #30 also indicated Resident #8 ran his wheelchair into her hands. She was unable to recall the date of the incident and indicated that she believed the act to be intentional. The resident indicated her hands swelled and she was required to have x-rays. She indicated no injuries were noted at the time of the x-rays, but her hands hurt. On 3/6/2014 at 2:20 p.m., during an interview with Resident #91, he indicated he had issues with Resident #8. He indicated during dinner in the main dining room, he approached the table where Resident #8 was seated. Resident #8 asked him who he was and who told him he could eat at his table. Resident # 91 indicated Resident #8 then told him to go away, and he was cussing and swearing at him. During an interview with Resident #21, on 3/11/14 at 2:00 p.m., she indicated "Resident #8 does things and gets away with it. He cusses, pinches the aide's butts, is rude and threatens other residents. He runs into other resident with his wheelchair. His behaviors have not improved. Staff are afraid to report him he'll get them in trouble if they do. " During an interview with LPN #1, on 3/11/14 at 3:25 p.m., she indicated Resident #8 will get them into trouble and he pats them on the butt and makes sexual remarks. She also indicated residents are afraid of him too. During an interview with Resident #93 on 3/11/14 at 3:29 p.m., the resident indicated Resident #8 often threatened other residents with physical harm. Resident #93 indicated she was standing near the entrance to the building on 3/11/14, and Resident #8 approached her. She indicated Resident #8 had startled her and she told him she was startled. Resident #93 indicated Resident #8 then " ... yelled a bad comment to (her) and left." Resident #93 indicated Resident #8 cursed at her in the past. Resident #93 indicated she would not want to be alone with Resident #8, " ... because he has that big wheelchair and he has things he can pick up off of the floor. If he wanted to, he could hurt me." Resident #93 indicated she had not reported the behaviors of Resident #8 because she didn ' t " ...want any trouble. If he (Resident #8) found out, he would be really mad." Resident #93 also indicated she witnessed Resident #8 touch nursing staff inappropriately. During an interview with Certified Nursing Assistant # 1 (CNA), on 3/11/14 at 3:45 p.m., she indicated Resident #8 was verbally aggressive and threw things at staff members at times. She indicated Resident #8 threw a urinal across his room on 3/11/14 at approximately 3:15 p.m. The CNA indicated Resident #8 was sometimes verbally abusive towards staff and sometimes made physical threats towards other residents. The CNA also indicated Resident #8 repeatedly tried tickling her on the ribs. The CNA indicated she was a little afraid to be alone with Resident #8 if he was in a bad mood. She indicated administrative staff had attempted to talk with Resident #8 regarding his behaviors towards staff and other residents, but she did not believe the intervention was effective. On 3/11/2014 at 3:45 p.m., during an interview with Resident #72, she indicated she recently complained to the Administrator regarding Resident #8 cursing and using f--- word in the main dining room during meals. Resident #72 sat at the far end of main dining room across the room from Resident #8. Resident #72 indicated she has seen Resident #8 with his fist raised at other residents and indicated she was fearful of this resident. Resident #72 indicated she had spoken to her son about Resident # 8's behavior and her fear. Resident # 72 indicated Resident # 8 could hurt her at any time with his wheelchair or coming into her room while sleeping, uninvited. Resident #72 indicated Administrator does nothing, so why say anything anymore. During an interview with Resident # 33, on 3/11/14 at 3:50 p.m., she indicated she was not afraid of Resident #8. " He comes in to get candy from me. I do want you to know, he's no angel." The record for resident #8 was reviewed on 3/10/14 at 1:30 p.m. This resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. IDT (Interdisciplinary Team) assessment dated [DATE], care plan discussion identified behaviors of cursing at another resident, behaviors noted in care plan meetings. A 5/17/13 care plan indicated a problem of behaviors including resident was yelling, cursing at other residents in the MDR, intervention included, but were not limited to, talk to resident as to why he is upset, staff to ask resident to remove himself from MDR if he continues to yell and curse. Nursing Notes indicated the following: 12/22/13 arguing with roommate, threatening to beat him up, then became verbally abusive toward CNAs, continues to propel throughout unit with w/c ignoring everyone, negative statements, anger towards others, inappropriate behavior 1/12/2014 verbally abusive to staff, yelling constantly at CNAs and ordering them around, throwing book and lotion into the hallway, when staff reminded resident he could hit or harm another resident with this behavior resident stated "I don't care" 2/2/2014 yelling at staff and peers, becoming angry, threatening staff saying, "I'll hurt you", rolling through hallways yelling at staff 3/8/2014 resident angry refused treatment, resident drove to dining room, when staff tried to redirect resident threatened multiple staff members, on multiple occasions, resident stated "If you do not stop bothering me, someone is going to get hurt, and that is a promise" 3/9/2014 in dining room, new resident entered room and resident was upset and told her she was not welcome to eat cake there with them in dining room, during the shift, resident made numerous rude comments to staff and other residents, resident threatened staff on multiple occasions, resident uncooperative with treatments and resistant to redirection Social services notes for resident #8 indicated: 8/22/13 resident behaviors present 8/22/13 discussed behaviors with resident not acceptable to be using curse words in dining room, resident became defensive and yelled "keep out of my business" attempted to redirect resident, DON aware 8/26/13 behavior on 8/25 discussed the report he " accidentally" hit a resident hand, resident stated "he is going to hit resident," educated resident on consequences of hitting other residents nurse reported altercation to DON, DON to report to state 8/29/13 incident happened on 8/23/13 discussed with resident situation yelling at resident in hallway, felt he was ignored by resident, stated he did not hit resident but the wall, DON and Administrator notified and report to state 8/30/13 resident discussed going to (name of another nursing facility) resident denied request could not meet his needs, IDT discussed with resident verbal aggression and outburst does effect the other residents well being, Resident got upset and wheeled away from care plan meeting 8/30/13 discussed with resident situation he was yelling at another resident, resident denied, DON aware 9/30/13 discussed with resident not appropriate to curse at residents, DON aware 12/30/2013 discussed behaviors for 12/28 and 12/29, resident yelling and making inappropriate comments, resident defensive, denied behavior "didn't do anything ...I am out of here!" attempted to explain yelling at staff and making inappropriate comments are not acceptable, resident wheeled off and refused to listen to anyone, DON aware 2/18/14 late entry for 2/4/14, resident was threatening staff and upset with another resident, advised if he continues to curse and yell in dining room he will be asked to leave, attempted to tell resident yelling and cursing is inappropriate resident wheeled away from social service person talking to him 3/3/13 resident was cursing and calling resident names, incident with boxes and wheel chairs occurred, cursing and yelling occurred, resident was educated on dangers of wheelchair operation During an interview with the DON on 3/10/14 at 2:00 p.m., she indicated the behaviors of Resident #8 are addressed in the care plan and was reviewed and revised in 3/14. She indicated behaviors had improved with the intervention of an Ipad. Behavior was not recent, and has had no problems lately. During an interview with the Social Services Director on 3/11/14 at 2:13 p.m., she indicated Resident #8 was encouraged to go to staff to express his feelings. When she gets behavior reports, she would go to Resident #8 to get both sides of the story, many times there are different sides of the story, he demonstrated defensive behavior. His behavior was discussed at morning meetings but not in recent past. Behaviors have improved, he is deeply involved in learning his Ipad. When he does act out, resident was asked to leave the area. Ombudsman has been helpful in directing activities for the resident and visits resident frequently. On 3/11/2014 at 2:10 p.m., during review of incident reports provided by the Administrator regarding resident # 8, no report from Resident #72 was identified. He indicated he no state reportable incidents for Resident # 8 and he provided 3 resident concern worksheets, but these were related to Resident # 8's motorized wheelchair. The Abuse and Crime Reporting Policies and Procedures, revised September 2011 was provided by the Administrator on 3/5/14 and indicated: "...the policy of the facility is that every resident has the right to be free from verbal, sexual, physical, and mental abuse; neglect, corporal punishment, and involuntary seclusion... It is the responsibility of employees to promptly report to the facility administrator, local ombudsman (or local law enforcement agency) and to the State Licensing and Certification immediately or as soon as practically possible within 24 hours of detection, any incident of suspected or alleged neglect or resident abuse from other residents,staff,family or visitors; including injuries of unknown source and theft or misappropriation of resident property. Reports shall be thoroughly investigated in a timely manner... 5. Identification The facility will monitor the adequacy of assessment, care planning, and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse or neglect, such as: Physically aggressive or self injurious behaviors *verbally abusive behavior towards others *socially inappropriate or disruptive behaviors. 6. Investigation Injuries of unknown source, suspected or alleged abuse, neglect, involuntary seclusion, and misappropriation of resident property or found, will be investigated with results reported in accordance with facility police, federal and state regulation's... 7. Protection To protect residents and employees from harm or regulation during investigations, the facility shall, take promptly measures to remove any resident from immediate harm or danger. The facility shall take reasonable measure to separate residents involved in alleged or witnessed Resident to Resident abuse... 6 (sic). Reporting Additionally, the facility requires that employees immediately report the facts of known or suspected instances of abuse and all allegations of abuse and suspicions of crime immediately to the facility Administrator (either directly or anonymously) so that facility's responsibility to protect residents and promptly investigate occurrences can be met. Failure to report in the required time frames may result in disciplinary action, including termination. The facility Administrator, or designee, will immediately, or as soon as practically possible with 24 hours of receiving an allegation or forming a suspicion, report the instance of abuse, neglect, or misappropriation of resident property to the local ombudsman or local law enforcement agency and to the Department of Health Services ( or appropriate State Agency) as required by law. The facility Administrator, or designee, shall report the findings of the internal investigation to officials in accordance with state law, including to the state survey and certification agency, within five working days of the incident...." The immediate jeopardy that began on 3/11/14 at was removed on 3/12/14 when the facility placed Resident#8 on 1:1 care supervision by nursing staff, completed interviews of alert and oriented residents, and began all staff inservicing on the facility abuse policy. The noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of ongoing staff training, resident education and family education on the abuse policy and procedure. 3.1-28(a)

Based on record review and interview, the facility failed to prevent verbal abuse from staff to resident with the resident expressing fear of reprisal occurring for 2 of 5 allegations indicated during the annual survey process. (Resident #66 and #6) Findings include: 1. The "ABUSE PREVENTION, INTERVENTION, INVESTIGATION, & REPORTING POLICY" policy was provided by the Administrator on 3/22/11 at 7:10 p.m. This current policy indicated the following: "...POLICY * It is policy that every resident has the right to be free from verbal, sexual, physical, and mental abuse; neglect, corporal punishment, and involuntary seclusion. ...* All reports of alleged or suspected resident verbal, sexual, physical, and mental abuse; corporal punishment and involuntary seclusion; neglect; or misappropriation of resident property shall be reported promptly and thoroughly investigated by facility management in a timely manner. PURPOSE * to protect the physical and emotional well-being and personal possessions of every resident. ...DEFINITIONS Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. ...Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. PROCEDURES ...4. Identification * Residents, families, and staff shall be informed that they may report any concerns, incidents, or grievances without fear of reprisal or retribution. All persons making such reports are to be provided a non-threatening environment, and anonymity (if desired) to express identified concerns, with feed-back regarding the concerns expressed....." 2. On 3/21/11 at 8:30 a.m. during breakfast, Resident #65 indicated Resident #66 had an issue with a CNA last night which woke him up. On 3/21/11 at 9:05 a.m. during an interview, Resident #66 indicated last night she had asked for the bedpan. After she had finished, she indicated CNA #49 said she hadn't urinated. Resident #66 indicated she knew she had gone when CNA #49 said a "few drops." When Resident #66 was asked if she fear any reprisal, she indicated she was fearful. She indicated not very long ago she had smeared bowel movement on her brief and wanted it changed. She indicated CNA #49 "threw" the brief and said "Oh - - - - ." Also, Resident #66 indicated about 3 months ago she was in the shower with CNA #49 and another unidentified CNA, and they accused her of tearing 1 of the CNA's uniform top and scratching the other CNA. She indicated it was hard for her to stand in the shower and she needed to hold on to something and had held onto there uniform, which was all she had to pull up on. On 3/21/11 at the end of Resident #66's interview, the allegations were reported to the Administrator for investigation immediately. On 3/21/11 at 2:00 p.m. during an interview, the Administrator was informed concerning Resident #66's allegations. The Administrator indicated the Director of Nursing and Social Services had talked with the resident when first notified of the resident's allegations. On 3/21/11 during the initial investigation with the Director of Nursing and the Social Service Director, the resident indicated CNA #49 was continually rude to her and did not say anything because she feared she would be "on her list forever." She retold the incident with CNA #49 when she threw the brief and remarked "Oh s - - -." The immediate action taken was the suspension of CNA #49 pending investigation and inservicing of staff on the facility's abuse policy and procedures was began on 3/21/11. The disciplinary action notice, dated 3/22/11, was provided by the Administrator on 3/23/11 at 1:55 p.m. The summary of disciplinary action indicated suspension followed by termination of employment and CNA registry due to the report of abuse allegations. Resident #66's record was reviewed on 3/24/11 at 10:10 a.m. The resident [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment, dated 2/16/11, indicated the resident was alert and orientated. She required extensive assistance of 1 person for transfers and activities of daily living. 3. During review of a reportable occurrence on 3/22/11 at 6 p.m., it was indicated that on 3/21/11 during a care conference (exact time unknown) a family member of another resident heard CNA # 6 tell Resident # 6 if she continued to yell she would have to sit longer in her wheelchair. The CNA was suspended pending investigation on 3/21/11. 3.1-27(b)

Based on record review and interview, the facility failed to ensure pre-employment screening was completed for 2 of 7 employee records reviewed for pre-employment screening (CNA # 49 and CNA # 8). CNA # 49 did not have pre-employment reference checks completed and was terminated due to a substantiated allegation of verbal abuse which resulted in Resident # 66 being fearful and anxious. The facility failed to ensure the Abuse Prohibition policy indicated the Administrator would be notified immediately. Findings Include: 1. A March 2010 policy titled "Abuse Prevention, Intervention, Investigation, and Reporting Policy" was provided by the Administrator on 3/22/11 at 7:10 p.m., and deemed as current. The policy indicated "...Screening Applicants are required to pass a criminal background check...Applicants are required to provide references and references are checked per company policy...." 2. Due to an allegation of verbal abuse of Resident # 66 in which the resident was fearful and anxious after the event, the employee file for CNA # 49 was reviewed on 3/24/11 at 1 p.m. The file indicated the CNA did not have pre-employment reference checks completed. She was hired on 9/15/10. Additional information was requested from RN #5 on 3/24/11 at 1:10 p.m., regarding reference checks for CNA # 49. On 3/24/11 at 1:35 p.m., RN # 5 indicated the above reference checks had not been completed. 3. Employee file review was completed on 3/22/11 at 10 a.m. The review indicated CNA # 8 was hired on 1/24/11 and did not have a criminal history check or reference checks completed prior to employment. Additional information was requested on 3/22/11 at 7:30 p.m., from the Administrator, regarding the criminal history check and references for CNA # 8. On 3/24/11 at 10:45 a.m., LPN # 9 indicated she was unable to locate any additional information. 4. A review on 3/22/11 at 7:15 p.m., of the March 2010 policy titled "Abuse Prevention, Intervention, Investigation, and Reporting Policy" which was provided by the Administrator on 3/22/11 at 7:10 p.m., and deemed as current indicated "...the facility requires that employees promptly report there facts of known or suspected instances of abuse and all allegations of abuse to their direct supervisor, Administrator and or the Director of Nursing...." The policy did not indicate the Administrator must be notified immediately. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to have interventions in place and to change the interventions when falls occurred to prevent falls with injuries, which included bruises, lacerations with stitches and staples, skin tears, and a C 1 (neck fracture) fracture, for 2 of 3 resident with falls in a sample of 3 (Residents A and B). Findings include: 1. Resident B's closed clinical record was reviewed on 1/13/11 at 2:06 P.M. Resident B's [DIAGNOSES REDACTED]. Resident B was readmitted to the facility on [DATE]. Resident B's "Nursing Admission Assessment" dated 11/30/10 indicated she was full weight bearing and needed one person assist for transfers. She used a walker and wheelchair for mobility assistance. She had a history of [REDACTED]. The "Side Rail Assessment" dated 11/30/10 indicated low bed and soft mat on the floor where not checked indicating these interventions were not in place. The "Fall Risk Assessment" dated 11/30/10 indicated a total score of 18. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The "Medicare/HMO (health maintenance organization) Skilled Documentation Flow Sheet" dated 12/3/10 indicated Resident B was independent or assisted by request in the toilet. The "Change of Condition Report-Sustained or Suspected Fall" dated 12/3/10 at 2:50 A.M., indicated Resident B had a witnessed fall during a self-transfer in her bathroom. The resident said her legs "gave out" The preliminary investigation of possible contributing factors relating to the fall and additional circumstance related to this fall indicated she was barefoot. The resident had an external head injury. The "post-fall actions initiated were "vital signs and neurological assessment." The Post-Fall Documentation Flow Sheet dated 12/3/10 at 11:30 A.M., indicated Resident B had "swelling to the back of head." The physician's orders [REDACTED]." The Fall Risk Care Plan dated 11/30/10 had the problem of "At risk for falls and inturies (sic) R/T (related to): Medication: Diuretic meds, Cardiovascular meds. Medical Factors: Seizure disorder, Cognitive Impairment, Dementia, Poor safety awareness, Visual impairment, Weakness, Hx of falls. The interventions included, but were not limited to, keep call light within reach, Provide verbal safety cues, pressure sensor pad in (nothing marked). The interventions were updated on 12/3/10 with Pt. moved to MCU (Memory Care Unit). Gait belt to be utilized for all pt transfers et ambulation." The "IDT (interdisciplinary team) post-occurrence review" form dated 12/6/10 indicated the section for "Safety Risk" had no new safety issue identified. "Review safety devices in use or those potentially in need related to this occurrence" had wanderguard, chair alarm, and bed alarm checked. The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form indicated "On 12/3/10 Resident was standing in front of toilet stated 'knees became weak & wouldn't hold er' fell backwards. No (indicated by a circle with a line through it) apparent injury...." During an interview with the DON on 1/19/11 at 10:45 A.M. she indicated Resident B was instructed on safety and to use the call light when she needed to use the bathroom. The "Fall Risk Assessment" dated 12/7/10 indicated a total score of 19. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The "Medicare/HMO Skilled Documentation Flow Sheet" dated 12/12/10 at 9:05 P.M. indicated "Resident's alarm sounding, resident was sitting on the edge of her bed. Resident then scooted to end of bed attempting to reach her walker, couldn't reach it sat of floor.... witnessed by CNA...." During an interview with the DON on 1/19/11 at 10:48 A.M. she indicated there was no additional documentation regarding this fall. The "Fall Risk Assessment" dated 12/14/10 indicated a total score of 20. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The "Change of Condition Report-Sustained or Suspected Fall" dated 12/15/10 at 11:15 P.M., indicated Resident B had a witnessed fall as she was sitting on the toilet. She had an external head injury. She was unable to tell the staff what had happened. The preliminary investigation of possible contributing factors relating to the fall and additional circumstance related to this fall was blank. The "post-fall actions initiated were "neurological assessment and transfer to the hospital." The nurses' notes dated 12/15/10 at 11:15 P.M., indicated "Res. fell forward from toilet. Hit head on w/c. Laceration noted on scalp. Res. keeps falling asleep during assessment...." The physician's orders [REDACTED]." The ER report indicated on 12/16/10 was admitted to the ER. She had a laceration to her scalp which was closed with staples and she returned to the facility. The "Episodic Care Plan: Post-Fall" dated 12/15/10 had a problem of "sustained fall - fell from toilet - witnessed." There was a notation of 12/16/10 of "Res. falls asleep @ anytime." The goal was "Res. will have no falls r/t (related to) falling asleep while sitting in chair/toileting X 90 days. The interventions included, but were not limited to, "Do not leave res. unattended in BR. Be sure alarms are on when in bed or w/c. Alarmed seatbelt to be placed on w/c. When res. in room alone in w/c - keep bedside table in front of her. Keep call light in reach. Encourage using bed pan @ noc (night)." The physician's orders [REDACTED]. w/c for safety r/t falls." The "IDT (interdisciplinary team) post-occurrence review" form dated 12/20/10 indicated the section for "Review potential contributing factors related to this occurrence" indicated the "resident has dx dementia. will attempt self transfers." "Safety Risk" had no new safety issue identified. "Review safety devices in use or those potentially in need related to this occurrence" had bed alarm and self-releasing seat belt checked. Nite light and gripper socks was hand written on the form. The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form indicated "Resident was on toilet & fell forward, CNA unable to intervene...." The Fall Risk Care Plan dated 11/30/10 and updated on 12/20/10 had the problem of "At risk for falls...." The interventions were updated on 12/20/10 with the addition of "night light in BR (bathroom) and gripper socks @ HS (bedtime)." During an interview with the DON on 1/19/11 at 10:50 A.M. she indicated during the investigation of the fall the CNA told the DON she didn't know the resident had [DIAGNOSES REDACTED] and could fall asleep sitting up on the toilet. The "Fall Risk Assessment" dated 12/21/10 indicated a total score of 20. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The January 2011 physician's orders [REDACTED]. Check placement & function every shift" first written on 11/30/10, "May place a self release belt alarm on res wc for safety r/t falls" first written on 12/16/10. The nurses' notes dated 1/7/11 at 1:30 A.M. indicated "Res. alarm sounding. Writer ran to res. room.. Writer found res. on floor by bed laying in blood.... Writer asked res what happened. 'Res stated she rolled out of bed'.... her forehead hurt...." Review of the ER notes dated 1/7/11 indicated Resident B was admitted to the ER with "open wound of face." She complained of neck pain. A CT scan completed on 1/7/11 of her neck indicated at the C 1 (cervical vertebra 1) "probable nondisplaced transverse dens fracture (neck fracture)." She was transferred to a different hospital and admitted for treatment. 2. During the facility tour on 1/13/2011 at 11:50 A.M., with LPN # 1, Resident A was identified as being at risk for falls and having fallen in the past month. Resident A's clinical record was reviewed on 1/13/2011 at 12:25 P.M. Resident A's [DIAGNOSES REDACTED]. Resident A's daughter was her guardian. Resident A was observed in her room on 1/14/11 at 1:09 P.M. She was sitting in her wheelchair staring into space. There were anti-tipper bars on the front and the back of the wheelchair. The brakes on the wheelchair were locked and the resident was rocking the wheelchair back and forward as she talked. There was a seatbelt around the resident's waist. There was a mat on the floor next to the bed which had an alarm attached to it. The resident was asked about her falls. She answered that she doesn't use the call light because "it takes them 15-30 minutes to answer it." Resident A's "Fall Risk Care Plan" dated 3/29/10, 4/21/10, 5/22/10, 6/16/10, 7/8/10,, 7/23/10, 7/31/10, for the problem of "At risk for falls and inturies (sic) R/T (related to) Medications: antidepressants & antianxiety, incontinence, Parkinson's, unsteady gait, dementia, weakness, fall 4/3/10." The interventions included, but were not limited to, "provide adequate lighting, monitor side effects of meds, keep call light within reach, encourage use of call light, monitor for unsteady gait and balance, labs as ordered, assess toileting needs, provide verbal safety cues, keep personal belongings within reach, keep assistive devices within easy reach - wheelchair, provide non-skid footwear, PT eval and treat if indicated (dated 4/5/10), OT eval and treat if indicated (dated 4/5/10), pressure sensor pad in bed, w/c (d/c (discontinue) 4/5/10), pt to stay in common areas as much as poss (possible) (dated 8/1/10), visual checks x 3 days & psych eval (evaluation) (dated 7/31/10), motion sensor alarm ankel (sic) (dated 7/7/10), referred to OT for w/c (dated 7/7/10), staff instructed to lay pt down after meals (added 7/7/10), and Res. to amb. (ambulate) c (with) gait belt et assist x i (one) to et from meals (added 7/15/10), auto lock w/c brakes (added 7/23/10)." The "Fall Risk Assessment" dated 8/10/10 indicated a total score of 19. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The Nurses' Notes indicated: 8/19/10 9:00 P.M. "Resident fell at 3:30 P.M. Found on floor behind w/c (wheelchair) when alarm sounded, w/c was tipped over. No (indicated by a line crossed through a circle) signs of injury...." The physician's orders [REDACTED]." The care plan for falls had the addition of the "back anti-tippers" dated 8/19/10. The "Change of Condition Report-Sustained or Suspected Fall" dated 8/31/10 indicated Resident A had a suspected fall from her chair or wheelchair in her room at 10:45 A.M. The alarm was activated. She obtained a red area measuring 20 cm. to the left side of her forehead. The "IDT (interdisciplinary team) post-occurrence review" form dated 9/1/10 indicated on 8/31/10 the resident "fell from w/c while trying to stand alone. Alarm sounded, CNA witnessed res. fall. The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form indicated "Pt. sitting in w/c in rm (room) et was observed standing up (indicated by an arrow pointing up) from w/c alarm was sounding. Spoke c therapy r/t (related to) pt legs giving out. Therapy stated this will be a chronic problem. Pt placed on ambulation program to et from dining rm. (room)." The fall care plan dated 3/29/10 indicated the intervention of "Res. to amb. (ambulate) c (with) gait belt et assist x i (one) to et from meals." had been added on 7/15/10. Resident A's September 2010 "physician's orders [REDACTED]. "Motion sensor alarm on bed" 7/08/10 "Res. to ambulate with gait belt and assist of one to and from meals." 7/15/10 "Auto lock brakes to w/c." 7/23/10 "Back anti tippers to be placed on w/c." 8/19/10 There was a physician's orders [REDACTED]. D/C (discontinue) motion sensor alarm to bed. 2. Pressure sensitive pad to w/c et bed. Check functioning et placement Q. (every) shift." There was an "IDT (interdisciplinary team) post-occurrence review" form dated 9/9/10 which indicated the safety device in use was an "alarming mat @ bedside." The "Fall Risk Assessment" dated 9/23/10 indicated a total score of 18. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The quarterly MDS (minimum data set) assessment dated [DATE] indicated Resident A was moderately impaired with poor decisions; cues/supervision required. She needed extensive assistance of one person to transfer, walk in the room and hallway, eat, dress, bathe, and use the toilet. She was assessed as being unable to balance while standing, or sitting without physical help. She was assessed as having unsteady gait and having fallen in the past 31-180 days. The "Change of Condition Report-Sustained or Suspected Fall" dated 11/1/10 indicated Resident A had a suspected fall from her chair or wheelchair in her room at 9:15 A.M., during an assisted transfer. Resident A was leaning out of her chair and fell . The alarm was activated. She had no injuries. The "IDT (interdisciplinary team) post-occurrence review" form dated 11/1/10 indicated " was leaning forward in chair, fell out, hit head on bed c no sx (signs) of injury." The interventions in use were "pressure sensitive alarm to bed/chair. Mat on floor next to bed." The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form was blank. During an interview with the DON on 1/19/11 at 10:00 A.M., she indicated Resident A had a urinalysis and EEG (electroencephalogram) done after this fall. She was treated for [REDACTED]." The "Fall Risk Assessment" dated 11/10/10 indicated a total score of 18. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The "Change of Condition Report-Sustained or Suspected Fall" dated 11/11/10 indicated Resident A had a suspected fall from her chair or wheelchair in her room at 11:10 A.M., during a self- ambulation/self-transfer. The preliminary investigation of possible contributing factors relating to the fall and additional circumstance related to this fall indicated the alarm was not activated. There was a notation of "resident shut off" next to the alarm. She had no injuries. During an interview with the DON on 1/19/11 at 10:10 A.M., she indicated the facility investigation had determined the resident told the staff she had fallen. She told them she had turned off the alarm, gotten up, fallen, and gotten up and walked to the toilet where the CNA had found her. She indicated the facility's intervention was to re-educate the resident to call for assistance. The physician's orders [REDACTED]." The "Fall risk care plan" dated 3/29/10 had additional interventions dated 11/11/10 of "visual checks x 3 days and pt to be (I) (independent) c (with) assist x i (one)." The Nurses' notes indicated: 11/15/2010 8:10 P.M. "Resident was sitting in w/c watching t.v. as writer walked by alarm sounded, found resident sitting on floor with w/c tipped over.... Three small reddned (sic) areas on each elbow et base of neck...." The "Change of Condition Report-Sustained or Suspected Fall" dated 11/15/10 at 8:15 P.M. indicated Resident A had a suspected fall from her chair or w/c in her room while she was "trying to adjust the t.v. volume." The preliminary investigation of possible contributing factors relating to the fall and additional circumstance related to this fall was blank. The resident had no apparent injuries. The "IDT (interdisciplinary team) post-occurrence review" form dated 11/17/10 indicated the section for "Review safety devices in use or those potentially in need related to this occurrence:" had "front antitippers" written in the blank. The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form indicated "Resident was sitting in rm. in w/c watching TV alarm was sounding pt was sitting beside the bed c chair tipped over. Stated she was trying to adjust TV volume." The "Change of Condition Report-Sustained or Suspected Fall" dated 11/26/10 at 12:15 A.M., indicated Resident A had a suspected fall from her bed in her room reaching for an object. The alarm failed to sound. The resident had a laceration and was transported to the ER. The hand written note on the form indicated "Resident was found on the floor on (R) (right) side c a puddle of blood under her head. Res. stated 'I was leaning over to get a cough drop off the floor when I fell .' When asked stated 'I hit my head of the trash can.'" The physician's orders [REDACTED]. "Send to (name) ER for evaluation &tx. (treatment)." The nurses' notes indicated 11/26/10 9:00 A.M. "Returned from hospital at 7:30 A.M. Sutures to (R) temporal area. 2.6 cm. laceration...." The physician's orders [REDACTED]." The "Change of Condition Report-Sustained or Suspected Fall" dated 11/26/10 at 10:15 P.M., indicated Resident A had a suspected fall from her chair or w/c in her room reaching for an object. The alarm failed to sound or was removed. The resident slid to the floor with no apparent injuries. The hand written note on the form indicated "Resident was found lying on back on floor. Denies hitting head no (indicated by a circle with a line through it) bumps or discolorations noted. Resident stated 'I was going after another cough drop.'" During an interview with the DON on 1/19/11 at 10:20 A.M., she indicated the intervention was to make sure the residents trash can was within reach and the facility had gotten the resident a reacher. The "Fall risk care plan" dated 3/29/10 had an intervention of "Keep personal belongings within reach" on the care plan. The "Fall Risk Assessment" dated 11/27/10 indicated a total score of 21. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The "Change of Condition Report-Sustained or Suspected Fall" dated 11/30/10 at 4:00 P.M., indicated Resident A had a suspected fall from a sitting position from her w/c reaching for an object. The alarm sounded. She had no apparent injuries. The "IDT (interdisciplinary team) post-occurrence review" form dated 12/1/10 indicated the section for "Review safety devices in use or those potentially in need related to this occurrence" was blank. The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form indicated "On 11/30/10 Resident sitting in w/c - fell forward from sitting position. Alarm was activated & sounding - no (indicated by a circle with a line through it)...." The "Change of Condition Report-Sustained or Suspected Fall" dated 12/8/10 at 5:00 P.M., indicated Resident A had a suspected fall from her w/c during a self-transfer in her room as she was trying to stand. The alarm was sounding. She had no injuries. The "IDT (interdisciplinary team) post-occurrence review" form dated 12/9/10 indicated the section for "Review safety devices in use or those potentially in need related to this occurrence" had chair alarm and bed alarm checked. The notation was "bed & chair alarm intact & activated." The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form indicated "Resident c (with) poor safety awareness, h/o (history of) falls....NO (new order) to dc (discontinue) sensitive alarms & apply self releasing alarming seat belt." The physician's orders [REDACTED]." The "Change of Condition Report-Sustained or Suspected Fall" dated 12/11/10 at 2:03 P.M., indicated Resident A had a suspected fall from her chair or w/c in her room reaching for an object. She lost her balance. The alarm was activated. She had skin tears on the left hand. The post-fall actions initiated where "post fall neurological assessment, provided safety re-education, reinforced using call light for assistance, and oxygen saturation measured." The nurses' notes dated 12/11/10 at 2:03 P.M. indicated "Alarm sounding when arrive in res room, res was laying on floor on back. Res stated she was trying to open blinds & fell back on bed. The bed moved & she fell to the floor...." During an interview with the DON on 1/19/11 at 10:30 A.M. she indicated she had not reviewed that fall. During a second interview with the DON on 1/19/11 at 1:50 P.M. she indicated she had no additional information regarding interventions for the 12/11/10 fall. The "Fall Risk Assessment" dated 12/11/10 indicated a total score of 16. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The "Fall Risk Assessment" dated 12/21/10 indicated a total score of 16. The key for the assessment indicated "Total score above 10 represents HIGH RISK." The annual MDS (minimum data set) assessment dated [DATE] indicated Resident A was assessed as being moderately impaired for decision making with poor decisions and cues/supervision required. She needed extensive assistance of one person to transfer from the bed or chair to a standing position, walk in her room or the hallway, use the toilet, and bathe. She was assessed as being "not steady, only able to stabilize with human assistance for balance during transitions and walking. She had a walker and a wheelchair for assistive devices. The physician orders [REDACTED]. Pressure sensitive alarming mat @ bedside, check function et placement q. (every) shift. 2. Pressure sensitive alarm to wc, check placement et functioning every shift. 3. D/C (discontinue) orders for low bed c mat." The "Change of Condition Report-Sustained or Suspected Fall" dated 12/28/10 at 3:20 P.M., indicated Resident A had a suspected fall from her w/c in her room. The preliminary investigation of possible contributing factors relating to the fall and additional circumstance related to this fall was blank. The resident had a red scalp. The "post-fall actions initiated were "observation, safety re-education, reinforced using call light for assistance." There was a notation of "Resident stated, 'I was being negligent and popped wheeles (sic) in my w/c.'" The physician's orders [REDACTED]. Anti-tippers on rear of w/c." The "IDT (interdisciplinary team) post-occurrence review" form dated 12/29/10 indicated the section for "Review safety devices in use or those potentially in need related to this occurrence" had pressure alarm, chair alarm, and bed alarm checked. The notation was "back anti tippers placed." The "IDT notes/recommendations/targeted plan to prevent recurrence" section of the form indicated "Resident was sitting in w/c in room prior to being observed on the floor...." During an interview with the DON on 1/19/11 at 10:40 A.M. she indicated she did not know what had happened to the back anti-tippers, but she indicated they had not been on the wheelchair when Resident A had fallen and were placed after this fall. The care plan dated 12/29/10 for the problem of "At risk for falls and inturies (sic) r/t medication: psychotropic meds, cardiovascular meds, pain meds, antianxiety-antidepressants, incontinence, unsteady gait, pain, dementia, poor safety awareness, hx (history) of falls." The interventions included, but were not limited to, "provide adequate lighting, keep call light within reach, monitor for unsteady gait and balance, keep personal belongings within reach, keep assistive devices within easy reach, provide non-skid footwear, PT eval and treat if indicated, OT eval and treat if indicated, pressure sensor pad in w/c, floor, mat at bedside when in bed. antitippers on w/c, self-releasing alarm belt, auto locks w/c, and ambulate to meals." The January 2011 physician's orders [REDACTED]. "Res. to ambulate with gait belt and assist of one to and from meals" first written on 7/15/10, "Auto lock brakes to w/c" first written on 7/23/10, "Low bed with mat" first written on 11/26/10, "Self releasing alarm belt" first written on 12/09/10, "Pt to be independent ambulation with assist X one" first written on 11/11/10, "Anti-tippers rear of w/c, pressure sensitive alarming mat @ bedside, check functioning & placement q. shift, pressure sensitive alarm to wc, check placement & functioning q. shift," The "Change of Condition Report-Sustained or Suspected Fall" dated 1/12/11 at 12:00 P.M., indicated Resident A had a fall as she was being assisted to the bathroom with a CNA. The statement on the form indicated " CNA ambulating res. to BR (bathroom) - Res. lost balance et fell back, hit (L) (left) shoulder on door - causing red area 4 cm x 2.5 cm. res did not hit head...." The CNA assignment sheet dated 1/13/2011 indicated Resident A was to have "bed & chair alarms" and she was to have "Assist of 1 for ADLs (activities of daily living) and Transfers do not lock w/c when in rm (room). Interview with DON on 1/19/11 at 10:45 A.M. she indicated the CNA's on the day shift on the resident's hall were inserviced regarding the use of a gait belt for ambulation. Review of the policy and procedure for "Use of Gait Belt," dated 2008, provided by the administrator on 1/19/11 at 1:50 P.M., indicated: "Policy It is the policy of this facility that staff will help control and balance (by using a gait belt) residents who require assistance with ambulation and transfer. Purpose To help control and balance resident during assisted transfer or ambulation." Review of the "Falls Management," dated October 2010, provided by the administrator on 1/19/11 at 1:50 P.M., indicated: "Purpose. To evaluate risk factors and provide interventions to minimize risk, injury, and occurrences.... Fall Prevention Equipment may include, but is not limited to: Alarms, sensor mats, transfer poles, floor pads, non-skid mats, hand rails, grab bars, trapeze, adaptive equipment, transfer lifts, etc.... Regularly review, revise, and evaluate care plan effectiveness at minimizing falls and injuries...." This federal tag relates to complaint IN 499. 3.1-45(a)(2)