Every finding on record at Countryside Meadows

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP) (infection control measures requiring staff to wear gowns and gloves during high-contact care) were utilized during a dressing change for 1 of 5 residents reviewed for pressure ulcers (Resident D). Findings include: During an observation, on 3/18/26 at 3:15 p.m., Licensed Practical Nurses (LPNs) 6 and 7 completed Resident D's dressing change to her mid back. LPNs 6 and 7 wore masks and gloves for the dressing change but did not wear a gown. A sign above the resident's bed indicated the resident required EBP. LPN 6 assisted the resident with positioning and laying on her side, and LPN 7 completed the dressing change, but neither wore a gown during the care. During an interview, on 3/18/26 at 3:21 p.m., LPN 7 indicated she thought the resident had been removed from EBP because the resident just had a small wound. LPN 7 did not indicate why the EBP sign was in place above the resident's bed if EBP were not required. Resident D's record was reviewed on 3/19/26 at 12:30 p.m. The banner at the top of the resident's electronic record indicated the resident required EBP. Wound management documentation indicated the pressure ulcer to the resident's mid upper back was identified on 1/23/26. A care plan, initiated on 1/23/26, indicated the resident had impaired skin integrity related to a pressure ulcer to the mid upper back. Interventions included, but were not limited to, observe for signs or symptoms of infection. A care plan, last reviewed and revised on 1/28/26, indicated the resident was at risk of transferring or becoming colonized with a multi-drug resistant organism (MDRO) (bacteria or germs resistant to one or more classes of commonly used antibiotics, making infections difficult to treat) and required enhanced barrier precautions due to a chronic wound that required a dressing. Interventions included, but were not limited to, identify the resident needed EBP through signage and the medical record and wear gown and gloves prior to high contact resident care activities. A physician's order, dated 2/16/26, indicated cleanse the resident's wound to the mid upper back, pat dry, apply collagen (used to accelerate healing by providing a scaffold for new tissue growth, maintaining a moist environment, and stopping bleeding), and secure with a bordered dressing, change once daily and as needed if soiled or dislodged. A wound assessment, dated 3/9/26, indicated the resident's pressure ulcer to the mid upper back was classified as stage three (a severe, full-thickness wound extending through the skin layers into the subcutaneous fat, resulting in a deep, crater-like injury). The wound bed was granulation (highly vascularized connective tissue) tissue. On 3/19/26 at 12:18 p.m., the Executive Director (ED) provided a document titled, Enhanced Barrier Precautions [EBP], last revised in March 2025, and indicated it was the policy currently being used by the facility. The policy indicated, .ENHANCED BARRIER PRECAUTIONS (EBP): An intervention designed to reduce the transmission of resistant organisms that employs targeted use of gown and glove use during high contact resident care activities. Enhanced Barrier Precautions expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, it refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Enhanced barrier precautions are used for: Resident(s) with chronic wounds.regardless of their MDRO status.Chronic wound examples include: Pressure ulcers.Use of Personal Protective Equipment - Gown and Gloves: [NAME] gloves and gown prior to a high-contact care activity. Examples of high-contact resident care activities include.Wound care: any skin opening requiring a dressing.Discontinue of Enhanced Barrier Precautions.A resident may be removed from enhanced barrier precautions if they were placed on EBP solely because of the presence of a wound.when the wound heals. This citation relates to Intake 2742212. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(a).

Based on observation, record review, and interview, the facility failed to meet resident's preferences for 1 of 5 residents reviewed (Resident 82). Findings include:During an observation on 12/10/25 at 11:11 a.m., Resident 82's low air loss mattress was set to a setting of 8. He indicated his bed was supposed to be set at a setting of 4. He indicated that staff came in and provided care and bumped it up to a setting of 8 and left it at 8 after his care was completed. Resident 82 indicated he was supposed to have 2 handled cups with lids due to his rheumatoid arthritis (RA) which left him with contractures of all of his limbs and made it difficult for him to hold the Styrofoam cups. Resident 82 indicated he did not use the cups because staff did not remove them to wash them. He had to tell them to wash them, and they took the cups to wash them but never brought them back. He had 3 Styrofoam cups with straws in them on his bedside. During an observation on 12/11/25 at 10:32 a.m., Resident 82's bed settings were set to 8. He indicated his bed was not comfortable for him. He continued to have Styrofoam cups with straws in them at bedside. During an observation and interview on 12/12/25 at 12:46 p.m., Resident 82 was lying on his back. His tray was sitting out of reach of him. He could not pull his overbed table with tray on it to his person due to severe contractures of finger joints and hands. His bed settings were set to 8. He indicated he wanted the bed set to the setting of 4. During an observation on 12/12/25 at 1:26 p.m., Resident's bed setting was set to 8. He had Styrofoam cups with straws in them. On 12/16/25 at 10:51 a.m., Resident 82's bed settings were at 4. He had Styrofoam cups with straws in them next to bedside. During an observation and interview on 12/16/25 at 10:51 a.m., Resident 82 had his breakfast tray on his stomach. He had three regular Styrofoam cups in his room. His rheumatoid arthritis (RA) had left him with contractures of all of his limbs and that made it difficult for him to hold the Styrofoam cups. His bed settings were set at the setting of 4. On 12/12/25 at 12:31 p.m., a record review was completed for Resident 82. He had the following diagnosis which included, but were not limited to, cellulitis of lower legs (a spreading skin infection, most commonly of the lower leg), rheumatoid arthritis, chronic viral hepatitis, iron deficiency related to anemia secondary to blood loss, hypothyroidism, and depression. Resident 82 had a care plan, dated 7/1/25, that indicated to honor his food preferences of no pork. This was not reflected in his diet orders. His diet orders, dated 7/11/25, indicated he was to have a no salt diet, special instructions: no added salt diet. Resident to use two handled cups with sippy cup lid with spout for drinks at all meals daily. During an interview on 12/12/25 at 2:01 p.m., with the Director of Nursing Services (DNS) and Assisted Director of Nursing (ADNS), the ADNS indicated he just changed the resident's bed settings to 4. On 12/16/25 Resident 82's diet order was changed to include no pork. The order for the two handled cups was discontinued. A policy titled, Preference for Daily Routine, was provided by the Executive Director (ED) on 12/15/25 at 9:32 a.m. It indicated, .To identify and develop a plan of care that reflects a resident's past and current daily customary routines. This citation relates to Intake 2634043. 3.1-3(a)

Based on interview and record review, the facility failed to ensure effective communication with a hospice agency resulting in a delay in treatment for a resident who had a dislocated hip for 1 of 1 residents reviewed for hospice communication (Resident 94). Findings include:During a phone interview on 12/11/25 at 3:25 p.m. Resident 94's family indicated in February 2025 Resident 94 fell and broke her left hip, which resulted in a hemiarthroplasty (a half joint replacement surgery where only the femoral head is replaced with an artificial implant, leaving the natural hip socket intact). The resident's family indicated the resident had chronic nerve pain in her left leg and was on multiple pain medications to manage the pain. Resident 94's family indicated the resident was supposed to come to their house to celebrate Thanksgiving, but the resident was too tired, so they visited her in the evening at the facility. During that visit the resident's family member assisted Resident 94 to the bathroom and noticed that her left hip was bulging backward. The resident's family member indicated she mentioned her concern to hospice RN 11 and an unknown facility staff member and hospice ultimately ordered an x-ray. After the x-ray was ordered on 11/28/25 a whole slew of miscommunications happened. The family member and Resident 94's Power of Attorney (POA) were notified of the x-ray results on 12/1/25 or 12/2/25 she could not remember exactly, and she was told the facility was aware of the results as well. Hospice RN 11 was talking to the DON to arrange transportation to the orthopedic (ortho) clinic for them to evaluate and treat Resident 94, but the Hospice RN had a hard time getting ahold of the DON and no plan was set. Resident 94's family member indicated she went to the facility to check on the Resident on 12/3/25, and when she arrived she spoke with the Licensed Practical Nurse (LPN) who was caring for Resident 94 that shift and the LPN indicated they had no idea the resident's leg was dislocated or that she had even had an x-ray done. During that visit Resident 94's family member spoke with Hospice RN 11 who indicated the facility was claiming they did not receive notification of an order for her hip to be x-rayed nor the results of the x-ray. At that time Hospice RN 11 indicated she notified the facility at the same time as she notified the resident's family. By 12/4/25 hospice was still unable to get ahold of the DON to arrange transportation to the ortho clinic, so she decided she would take the resident herself in her personal vehicle. She called and told the facility she would be there to pick the resident up at 2:00 p.m. The DON called Resident 94's family member for a care conference meeting while she was already in the facility to pick the resident up. Resident 94's family member indicated the DON attempted to help arrange last minute transport with their activity bus but other residents were on an outing utilizing the bus. Once they got to the ortho clinic the staff there indicated all they were able to do was re-x-ray the resident's leg, and it was recommended that they go to the hospital immediately. Resident 94's family member indicated they took the resident to the ER where they re-x-rayed her hip and it showed that her hip was still dislocated, and to her understanding it had been dislocated for a few weeks. The resident's family member felt like they were not notified of every fall the resident had. Resident 94's family member indicated on 12/5/25 they received a phone call from the facility asking when they would be by to pick up the resident's things. At that time, they had not disclosed to the facility that they would be moving Resident 94 to a different facility. Shortly after that they received a letter in the mail saying the facility could no longer care for Resident 94 at that time. On 12/11/25 at 1:21 p.m. Resident 94's medical record was reviewed. She was a long-term care resident on hospice (end of life care) whose diagnoses included, but were not limited to, Alzheimer's disease and aftercare following hip joint replacement surgery. A progress note, dated 11/7/25, indicated Resident 94 had an unwitnessed fall and was found sitting on the floor with her back to the side of the bed. The note explained that the resident's wheelchair was tipped on its back next to the resident and Resident 94 indicated she was getting up to go to the bathroom when she grabbed her wheelchair and fell backward. The immediate intervention for that fall was to place a call before you fall sign in the resident's room. A call before you fall sign was the intervention for the fall on 5/27/25. An IDT note, dated 11/10/25, indicated the call before you fall sign was the only new intervention related to the fall Resident 94 had on 11/7/25. A progress note, dated 11/12/25, indicated Resident 94 had had a significant change in condition related to an overall decline. A progress note, dated 11/17/25, indicated Resident 94 had an unwitnessed fall and was found sitting on the floor facing the bed with her wheelchair behind her. That note explained Resident 94 indicated she was trying to transfer into her wheelchair to go to the bathroom when she fell. That note did not specify if the resident complained of pain or not. The immediate intervention for that fall was to place nonskid strips on the floor next to the bed. An IDT note, dated 11/18/25, indicated the immediate intervention for Resident 94's fall on 11/17 was to place nonskid strips at the bedside. That note indicated additional interventions were antiroll backs to be placed on the resident's wheelchair and a soft touch call light would be provided. Non-skid strips next to the bed were the intervention for Resident 94's fall on 4/13/25 and 10/11/25. Antiroll backs placed on the resident's wheelchair was the intervention for the fall Resident 94 had on 11/2/25. A progress note, dated 11/20/25, indicated Resident 94 had an unwitnessed fall and was found sitting on the floor next to her bed with her wheelchair next to her. That note explained that Resident 94 indicated she was reaching for her wheelchair when she slid off the bed. The note did not specify if the resident complained of pain or not. An IDT note, dated 11/20/25, indicated Resident 94 had an unwitnessed fall and was found sitting on the floor next to her bed. The note explained that the resident's family had attached her call light to the wall using hooks which contributed to an unsafe environment. The intervention for that fall was to remove the hooks from the wall. A progress note, dated 11/23/25, indicated Resident 94 had an unwitnessed fall and was found sitting on the floor. The note explained that Resident 94 was attempting to transfer herself from her wheelchair to her bed without assistance when she fell. That note indicated the resident's family were notified of that fall. During a phone interview on 12/11/25 at 3:25 p.m. Resident 94's family indicated they were not notified of the fall the Resident had on 11/23/25. An IDT note, dated 11/24/25, indicated the intervention for Resident 94's fall on 11/23/25 was to put a Dycem mat (non-slip mats for daily life and therapy) to her wheelchair seat. A hospice narrative note written by hospice RN 11, from a hospice progress note, dated 11/26/25 indicated, .PT [Patient] rates pain as moderate this visit. Small bruise to LLE [left lower extremity]. Patient requires assistance with all ADL's [Activities of Daily Living] except eating. sleeping up to 20 hours per day. Report given to facility Qualified Medication Aide [QMA12] . Progress notes, dated 11/27/25 and 11/28/25, indicated Resident 94 had no complaints of pain. Both progress notes were charted as a late entry on 12/4/25. A hospice nursing note, dated 11/28/25, indicated Resident 94 had moderate pain (4-6 on a pain scale of 1-10) at the time of the visit, the worst her pain had been in the 48 hours before the visit was an 8 out of 10 and the best it had been in that time was a 4 out of 10. The resident had periods of confusion, was drowsy and slept 18-20 hours a day. The note indicated the resident had limited range of motion and pain or stiffness in her lower left leg. The hospice narrative note written by hospice RN 11 indicated, . Patient rates pain as moderate this visit. patient requires assistance with all ADL's except eating. sleeping up to 20 hours per day. Report given to facility QMA [QMA 12] . SN [supervisory nurse] updated patients son.per son he and his wife are concerned about her left hip and requested an X-ray, SN communicated request to HMD [hospice medical doctor]. A hospice physician note, dated 11/28/25, indicated due to a fall, a new order for an x-ray of the left hip was placed to rule out fracture or dislocation. A progress note, dated 11/30/25, indicated Resident 94 had an unwitnessed fall and was found sitting on the floor of the bathroom after attempting to transfer herself from her wheelchair to the toilet. The note explained that Resident 94 was wearing fuzzy socks at the time of the fall, the Residents family were notified and no injuries were noted. That note did not specify if Resident 94 complained of pain or if hospice was notified of the fall. An IDT note, dated 12/1/25, indicated Resident 94 demonstrated full range of motion in all extremities and showed no signs or symptoms of injury. That note indicated the intervention for Resident 94's fall on 11/30/25 was to place nonskid strips in front of the toilet. During an interview on 12/16/25 at 12:57 p.m. Hospice RN 11 indicated hospice was not notified of the fall Resident 94 had on 11/30/25. Fall follow-up notes, dated 12/2/25 and 12/3/25, both indicated Resident 94's range of motion had no change. A hospice nursing note, dated 12/3/25, indicated Resident 94 had moderate pain (4-6 on a pain scale of 1-10) at the time of the visit, the worst her pain had been in the 48 hours before the visit was 8 out of 10 and the best it had been in that time was a 6 out of 10. The resident had periods of confusion, was drowsy and slept 18-20 hours a day. That note indicated the changes noted for Resident 94 were a dislocated left hip, multiple falls and some falls that were unreported. The hospice narrative note written by hospice RN 11 indicated, . X-ray results showed patient has dislocation of left hip.spoke with facility director of nursing [DON] Regarding X-ray results facility DON states she had not received results . Hospice would cover the cost for an ortho consult but not transportation. Facility DON stated they could get patient in a wheelchair and transport her; however, plans were not confirmed. Patients' [family member] informed .that patient had two unwitnessed falls on Sunday [11/30]. Neither of the falls were reported to Hospice staff. Patients daughter-in-law is very frustrated with patient safety, lack of communication. was unable to locate facility DON to further discuss transportation to an ortho consult.reached out via phone in the afternoon without response as well.spoke with patient's son . he states at this point he and his wife are happy to transport patient to ortho. to have consult done and will notify Hospice prior to taking the patient for the consult. gave report to facility nurse [QMA 12] . A progress note, dated 12/4/25 at 2:30 p.m., indicated Resident 94's family member was at the facility signing her out to take her to ortho clinic due to a left hip dislocation. The record lacked documentation of how or when Resident 94's left hip was dislocated, and x-ray orders or results. A progress note, dated 12/4/25 at 8:48 p.m., indicated Resident 94 had been transferred to the local hospital for further treatment. Hospital medical records, dated 12/4/25, indicated Resident 94 arrived at the emergency room (ER) complaining of left hip pain. The resident's son was at bedside and provided a medical history for the resident. He indicated to the ER staff that his wife noticed that the resident's left hip was swollen and was painful. The resident's son indicated that in the past 6 weeks she had been walking less, and he denied any prior dislocations. Her left lower extremity showed shortening, internal rotation and an X-ray confirmed a left hip dislocation. They were not sure when the dislocation happened. She had been falling more and had lost the ability to ambulate over the last 4 weeks. The orthopedics team recommended attempting a reduction (an urgent medical procedure to realign the femoral head and socket of the hip joint). ER staff attempted to reduce the dislocation, but it was unsuccessful. Resident 94's leg remained shortened and internally rotated. The orthopedics team recommended a Computed Tomography (CT) scan (an imaging test that uses X-rays and a computer to create detailed cross-sectional slices or 3D views of your bones.). The CT scan showed a superior dislocation of the left hip cranially by 6 centimeters (cm). The orthopedic team attempted a reduction in the Operating Room (OR) which was successful. Resident 94 was admitted to the hospital on [DATE] and was discharged and went to a rehabilitation facility on 12/10/25. A progress note, dated 12/5/25, indicated a bed hold policy was mailed to Resident 94's POA. Resident 94's hospice notes for the month of November were not available on the medical record until 12/16/25. On 12/12/25 at 10:22 a.m. the Executive Director (ED) and the DON provided a soft file containing the investigation into how Resident 94's leg became dislocated. In that soft file there was a timeline of events starting on 11/23/25 along with statements from staff. The timeline read as follows: Resident 94 had a fall on 11/23/26, the resident was assessed and had no change in condition noted. On 11/24/25, 11/25/25, and 11/26/25 no change of condition was noted. On 11/27/25 no change of condition was noted, but Resident 94's family member called hospice and told them she felt something was off. They indicated the resident's family member did not notify them of any concerns. On 11/28/25 the ED was present at the facility but was not notified of any concerns related to Resident 94. On 11/30/25 Resident 94 had a fall, no change in condition was noted. On 12/1/25 and 12/2/25 no change in condition was noted. On 12/3/25 no change in condition was noted, but the DON was notified of Resident 94's hip dislocation by the hospice nurse. They indicated the resident's family were aware of the x-ray results but wanted to take her to the ortho clinic the next day. On 12/4/25 Resident 94 was transferred to ortho clinic by the family member's personal vehicle. In a written statement, dated 12/11/25, the Facility ED indicated she spoke with the Hospice ED on 12/8/25 and questioned why the results of the x-ray were dated 11/29/25 but the facility was not notified until 12/3/25. The Hospice ED indicated to her that the results would not have been viewed by the hospice nurse until the next business day [12/1/25] because it was over a weekend. During an interview on 12/12/25 at 10:42 a.m. the Hospice ED indicated Hospice RN 11 visited Resident 94 on 11/28/25, and the family requested an x-ray of the Residents left hip. He indicated from what he could figure out after talking with the facility, Resident 94 received an x ray of her left hip on 11/29/25, the results were forwarded to Hospice RN 11 on 12/1/25, and she must not have seen the email until 12/3/25 when the facility was notified. The Hospice ED indicated it was the expectation of their nurses to notify facilities of test results immediately, and Hospice RN 11 was reeducated on that expectation. During an interview on 12/16/25 at 12:57 p.m. Hospice RN 11 indicated Resident 94 had had multiple falls and had become wheelchair bound over the last month or so. She indicated she had seen the resident on 11/28/25 and spoke with the Hospice MD to get an order to x-ray her left hip at the resident's family's request. On 11/29/25 the mobile x-ray company came in, and she saw the results on 12/2/25. Hospice RN 11 indicated she notified both the resident's family and the facility on 12/2/25; she was unable to recall who she spoke with at the facility. She spoke with the DON and the floor nurse for that shift on 12/3/25 to ensure they received the results of the x-ray, and they appeared shocked at that news. The DON and floor nurse indicated they were not aware the resident had an order for an x-ray. Hospice RN 11 indicated on 11/28/25 she gave report to QMA 12 and told her the x-ray had been ordered. On 12/16/25 at 2:10 p.m. a copy of a current facility policy titled, Hospice Policy dated 9/2024 was provided. That policy indicated, . It is the policy of this facility that when a resident elects the Hospice benefit, the contracted Hospice company and facility will coordinate to establish. a pattern of communication between the Hospice company, healthcare professionals, facility staff and resident/representative. Procedure:. 3. For residents who have elected the Hospice benefit, there will be. e. Hospice documentation available at the facility . 5. The social services director or designee will act as the Hospice coordinator which will be responsible for the following functions:. c. Ensuring that the facility communicates with the Hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the Hospice care with the medical care provided by other physicians. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure that a newly admitted resident, received meals prepared and served in accordance with the physician-ordered diet requirements, resulting in a significant weight loss of 6.38 percent within approximately 30 days for 1 of 4 residents reviewed for nutrition (Resident 151). Findings include:On 12/9/25 from 11:25 a.m. until 12:05 p.m., the following was observed during dining in the memory care (MC) unit. On 12/9/25 at 11:25 a.m., Resident 151 was in a wheelchair at the table in the dining room attempting to roll herself back and occasionally groaning. At 11:33 a.m., Resident 151 did not have a drink or food in front of her and was observed grabbing at Resident 65 next to her who had a drink and hitting at her. Resident 65 yelled for help and staff moved her to another table. At 11:38 a.m. Resident 151 was given chocolate milk and was repositioned at the table. She drank all her drink quickly. Once her drink was empty, Resident 151 started reaching for her tablemate's food and crying. She attempted to take a drink but was unable to get anything out of straw since it was empty and started crying. Staff delivered her food, which was a fish sandwich and thick fries. The staff cut her sandwich in half. Resident 151 took a couple bites of fries and a small bite of the fish on the sandwich. At 11:50 a.m., the staff came with sides for Resident 151, looked at the meal ticket in front of her, and went and exchanged the sides for pureed oranges and pureed coleslaw. The staff did not replace the uneaten fish sandwich or fries that were not pureed. Resident 151's meal ticket was observed in front of her and indicated the resident was to have bite sized food. Resident 151's meal tray was observed to have a fish sandwich only cut in half, thick fries, pureed coleslaw, and pureed oranges. Resident 151 had only ate a couple tiny bites of fish and bread, and a couple tiny bites of fries. At 11:54 a.m., staff got more chocolate milk for the resident and she immediately drank it. At 11:55 a.m. staff asked if Resident 151 was done eating. The resident said, no it looks good. Staff did not cut the resident's food or assist the resident to eat. At 11:59 a.m. Resident 151 was out of chocolate milk again. She took the lid off and kept shaking the empty cup. She was not observed to attempt to eat any of her food. At 12:01 p.m., a staff member sat down with the resident and attempted to help her eat her pureed foods. No additional amount of sandwich or fries were eaten. Her chocolate milk was refilled and she drank it immediately. Resident 151's record was reviewed on 12/9/25 at 2:54 p.m. She was a newly admitted resident with diagnoses which included, but were not limited to, dysphagia, (difficulty swallowing food or liquids), metabolic encephalopathy, (a broad term for brain dysfunction), and Alzheimer's disease (degenerative brain disease that affects memory and cognition) with severe cognitive impairment. She resided on the secured memory care (MC) unit. A physician order, dated 11/11/25, directed the resident to receive a regular, soft bite-sized diet. A comprehensive care plan, initiated on 11/18/25, indicated Resident 151 was identified as at risk for malnutrition and included interventions to provide diet per physician order of regular, soft bite-sized; monitor weights; and offer substitutions if intake was less than 50 percent (%). The record demonstrated inconsistent and/or incomplete documentation of meal intakes including, but were not limited to, the following: No documentation of intake for 12/6/25 or 12/7/25. Intake documentation, dated 12/8/25, indicated Resident 151 ate 26 to 50 % of dinner. No intake was documented for breakfast or lunch. Intake documentation, dated 12/9/25 at 1:47 p.m., indicated lunch was not taken. Resident 151's weights were reviewed and revealed the following weight loss: She was admitted on [DATE] and weighed 143 pounds (lbs). On 11/21/25 and 11/25/25, she weighed 141 lbs. A December weight obtained on 12/16/25 revealed she was down to 132 lbs. Resident 151 experienced a 6.38% weight loss within approximately 30 days, which was considered clinically significant. During several interviews on 12/16/25 around 2:00 p.m., nursing staff demonstrated inconsistent understandings of what a soft-bite-size diet consisted of. Registered Nurse (RN) 5 indicated soft bite size was similar to mechanical soft (texture-modified eating plan for people who have trouble chewing or swallowing, featuring foods that are pureed, ground, finely chopped, or naturally soft and moist, requiring minimal chewing to prevent choking and aspiration) and described it as kind of the new name of mechanical soft. Licensed Practical Nurse (LPN) 4 indicated for a soft-bite-size diet, the food should come from the kitchen in bite-size pieces. Certified Nursing Aide (CNA) 6 indicated when a resident's meal ticket indicated bite-sized, staff had to cut it up into bite-size pieces and that it did not come that way. During an interview on 12/16/25 at 2:20 p.m., Dietary Aide 7 indicated mechanical soft was no longer used and that soft bite-sized foods were the new term. She indicated it meant that food had to be small enough to go through the tines of a fork and that it was the kitchen's responsibility to send the meal that way. During an interview on 12/16/25 at 2:25 p.m., the Registered Dietician (RD) indicated soft and bite size replaced the national dysphagia (medical term for difficulty swallowing food and liquid) diet and was similar to mechanical soft or minced and moist. He indicated that if a resident's diet order specified soft bite size, the food should come from the kitchen already chopped or processed before being sent to the floor. He clarified that only when bite-sized instructions were listed under special instructions would floor staff be responsible for cutting food. On 12/6/25 at 3:07 p.m., the Administrator (ADM) provided a copy of the current facility policy titled Resident Weight Monitoring Policy, revised 9/2024. The policy indicated, .Upon admission, the resident's weight and height will be measured and recorded in the clinical record. The interdisciplinary team will place the following residents on weekly weights: New admission or readmission for a minimum of 4 weeks. Monthly weights will be obtained, verified for accuracy, and the weight variance report will be provided to the IDT by the 7th day of each month. Bi-Monthly Weights will be obtained at a minimum for the following residents: Residents who may be at risk for weight loss but have not experienced a significant weight loss, i.e., residents who have a pattern of decreased meal intake. Residents who have experienced a significant weight loss of 5% in 30 days. will have bi-monthly weights obtained at a minimum. The physician/health care practitioner and resident representative will be notified of unplanned significant weight loss. Any significant unexplained weight loss is considered a change in condition and must be addressed by the Interdisciplinary Team. 3.1-46

Based on observation, interview, and record review, the facility failed to ensure staff monitored a Gastrointestinal Tube (Gtube) (a feeding tube inserted through the belly directly into the stomach) feeding pump appropriately and ensured the resident received appropriate medications and positioning related to the Gtube for 1 of 1 residents reviewed for Gtube management (Resident 74). Findings include: On 12/10/25 at 9:37 a.m. Resident 74 was observed as he lay on his back in bed. He was unable to answer most questions, and he appeared to have limited mobility of his right side. As Resident 74 tried to speak, the inside of his mouth was observed. There appeared to be a thick yellow colored film over his teeth and tongue. Jevity (a brand of high-protein, fiber-fortified liquid nutrition) 1.5 kilocalories (k/cal) (the standard unit for measuring energy in food, often just called a calorie) was hanging and running at 50 milliliters per hour (ml/hr) along with a bag of free water for a flush. Upon observation of Resident 74's room, there was no Enhanced Barrier Precautions (EBP) sign outside of or on his side of the room, his call light was observed on the floor next to his bed and the head of his bed was raised to approximately 15 degrees. On 12/12/25 at 12:43 p.m. Resident 74 was observed as he lay in bed resting with his eyes closed. There was not an EBP sign outside of or on his side of the room. At this time the feeding pump was observed. Jevity 1.5 k/cal was hanging with a bag of free water, and the pump was beeping. There was an error message on the pump screen that indicated the pump had been idle for 10 minutes and to press continue. There was also a continue button in the bottom left side of the screen and an alarm bell symbol that had a line through it on the upper left side of the screen presumably to silence the alarm. The bottle of Jevity appeared to be nearly full and the tubing appeared to be empty or have only water in it. The tubing was connected to the resident's Gtube. Resident 74 woke when he was spoken to. When he yawned, he opened his mouth wide revealing a tick yellow substance caked on his gums and teeth, thick stringy mucus, and a yellow film on his tongue. On 12/12/225 at 12:50 p.m. Certified Nurse's Aide (CNA) 10 came in to check on Resident 74 and his roommate. CNA 10 indicated Resident 74 had an order of nothing by mouth (NPO). She indicated they did oral care with mouth swabs and water when he needed it done. CNA 10 indicated she would get some supplies to do oral care now. CNA 10 then adjusted Residen74's blankets and then went to the pump and appeared to touch something on the screen of the pump. At this time the pump stopped beeping. Before exiting the room, the pump began to beep again. CNA 10 walked out of the room and shut the door behind her, with the door shut you could not hear the beeping unless you stood right next to the door. CNA10 did not notify Resident 74's nurse that his pump was beeping. On 12/12/25 at 1:08 p.m. CNA10 was observed going back into Resident 74's room with oral care supplies. She closed the door behind her. On 12/12/25 at 1:11 p.m. CNA10 was observed as she came out of Resident 74's room with a bag of trash. She closed the door behind her and was observed walking out of view. She did not speak to any nurse. On 12/12/25 1:12 p.m. a staff member was observed pushing a food tray cart down the hall stopping at Resident 74's room. The staff member entered the room briefly and came out with Resident 74's roommates' lunch tray. She closed the door behind her. She did not notify anyone the pump was beeping. This staff member was not seen on the hallway again during this observation. This staff member was not in the room for a reasonable amount of time for her to have restarted the pump. On 12/12/25 at 1:14 p.m. CNA10 was observed speaking with the Assistant Director of Nursing (ADON) and two nurses. She did not notify them of any feeding pump issues. On 12/12/25 at 1:15 p.m. a continuous observation of Resident 74's room was initiated. During this observation no staff members went in or came out of Resident 74's room. On 12/12/25 at 2:14 PM Resident 74's feeding pump was observed, and it appeared to have been restarted and was running. The Jevity bottle appeared to have a noticeable decrease in amount. During an interview on 12/12/25 at 2:45 p.m. the Executive Director (ED) and the Director of Nursing (DON) indicated CNAs were not allowed to touch feeding pumps and should notify a nurse immediately if there were pump issues. They indicated they would investigate the issue and see if they could figure out who turned the pump back on and who the staff member with the food cart was. On 12/12/25 at 3:05 p.m. the ED indicated the staff member with the food cart was a Qualified Medication Aide (QMA). She indicated both CNA 10 and the QMA said they did not touch the pump. The ED indicated she was looking for their policy to see if the facility allowed QMAs to adjust feeding pumps. On 12/15/25 at 9:41 a.m. Resident 74's medical record was reviewed. He was a long-term care resident whose diagnoses included, but were not limited to, cerebral palsy (a permanent group of neurological conditions caused by non-progressive damage to a developing brain, affecting movement, posture, balance, and muscle coordination) and dysphagia (difficulty swallowing food or liquids). Resident 74 had an active order to be NPO, dated 9/30/25, with no stop date. Resident 74 had an active order for oral care every shift, dated 9/30/25, with no stop date. Resident 74 had an active order for the head of his bed to be at 30 degrees at all times, dated 9/30/25, with no stop date. Resident 74 had active orders for polyethylene glycol (MiraLAX) (a powder laxative), oxybutin chloride (a prescription medication used to treat symptoms of an overactive bladder), cholecalciferol (vitamin D) and aspirin that indicated to administer them orally all dated 9/30/25 with no stop dates. The medication orders lacked documentation indicating they could be placed in the Gtube. On 12/15/25 at 2:08 p.m. Resident 74 was observed as he lay in bed resting with his eyes closed. There was a cup of water on his bedside table on the right side of his bed, and there was an EBP sign taped to the wall above his bed. On 12/10/25 at 3:03 p.m. a copy of a current facility policy titled, Enhanced Barrier Precautions (EBP) dated 3/2025 was provided. This policy indicated, .Enhanced barrier precautions are used for: Resident(s) with. indwelling medical devices. Indwelling medical device examples include:.Feeding tube. On 12/15/25 at 9:29 a.m. a copy of a current facility procedure guide titled, Kangaroo ePump Enteral Feeding Pump Operations dated 3/2019 was provided. This procedure guide indicated, .Nursing Skills Competency. The policy lacked documentation that QMAs or CNAs could adjust feeding pumps. At the time of exit a policy pertaining to QMAs ability to adjust feeding pumps was not provided. 3.1-44(a)(1)3.1-44(a)(2)

Based on observations and interviews, the facility failed to ensure all medications were stored and dated properly and all medication labels were fully intact displaying the entire prescription in medication carts for 2 of 4 medication carts reviewed for medication storage. Findings include:On 12/16/25 at 10:53 a.m. the front 500 hall medication cart was reviewed with the Clinical Educator. Findings were as follows:1. There was a vial of lidocaine (a common local anesthetic that numbs specific body areas to block pain signals) for Resident 113 that had been opened. Upon review there was no open date on the bottle.On 12/16/25 at 11:00 a.m. the Clinical Educator indicated the lidocaine bottle shouldn't have been in the bag in which it was found in and it should have had an open date. She indicated she would dispose of it properly.On 12/16/25 at 11:15 a.m. the 300-hall medication cart was reviewed with the Clinical Educator. Findings were as follows:1. There was a bottle of pirfenidone (an oral antifibrotic medication used primarily to treat adults with idiopathic pulmonary fibrosis) for Resident 48, with half of its prescription label torn off so that only part of the prescription was visible.On 12/16/25 at 11:25 a.m. the Clinical Educator indicated she would let the Director of Nursing (DON) know and contact the pharmacy for a new prescription label.On 12/16/25 at 2:10 p.m. a copy of a current facility policy titled, Medication Storage and Expiration Policy dated 11/2024 was provided. This policy indicated, .The facility should store medications.consistent with applicable state and federal laws and regulations. 9. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) .10. c. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.The provided policy lacked guidance for torn or destroyed prescription labels.3.1-25(j)3.1-25(m)3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure the environment was free from the potential for accidents when a protective cap for a bedframe end-piece was missing which resulted in actual harm when a resident (Resident B) sustained an 18 centimeter (cm) long by 5 cm wide avulsion skin tear which required 6 sutures for 1 of 3 residents reviewed for accidents. Findings include:On 11/10/25 at 10:40 a.m., Resident B's room was observed with the Administrator (ADM) who indicated that during a transfer from her wheelchair to her bed, Resident B's leg was injured, by the metal bedframe, where there was an approximate 5-inch gap between the head of the bed frame, and the center frame. At the time of the observation, both end pieces of the frame had black protective caps in place. On 11/10/25 at 1:15 p.m., Resident B's family member indicated she had been notified of the injury but was shocked to see pictures of the extent of the injury. Resident B had sustained skins tears before, but nothing that extreme. She came to the facility the following morning to speak with staff and visit Resident B. She was told by the facility staff that upon their investigation, part of the bedframe rail had been missing an end-cap. So she went to Resident B's room, pulled off the end caps that had been replaced and could feel a jagged rough metal edge. On 11/10/25 at 1:30 p.m., Resident B's bed frame was observed. The specified end-cap was removed and there was a rough, jagged metal edge. The blue outer mattress covering also showed evidence of ripping/tearing from sitting directly over the uncapped jagged metal piece of the frame. During a confidential interview, it was indicated both caps from the bedframe were missing at the time of the accident. Resident B's leg got caught in between the gap, and the skin tore on the jagged metal edge. There was blood on the floor right under that area of the bedframe. During an interview on 11/10/25 at 1:50 p.m. the Maintenance Director indicated he was not in the facility at the time of the accident, but he and his assistant were told to do bed safety checks. During those checks, they found several other beds throughout the building that were missing the same end-cap protective pieces. The Maintenance Director called his assistant at this time, to confirm if caps were in place or not at the time of the accident. The Maintenance Assistant indicated when he checked Resident B's bed, two end-caps were missing and he replaced them immediately. The Maintenance Director was told to check and replace what was needed, but there was no plan moving forward related to continued monitoring that he was aware of at that time. On 11/10/25 at 2:40 p.m., Resident B's bedframe was observed for a final time with the Director of Nursing (DON) present. With the end cap removed, the jagged metal edge was felt and the evidence of it having been missing long enough to cause damage to the mattress cover was discussed. On 11/10/25 at 11:18 a.m. Resident B's record was reviewed. She was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, dementia, repeated falls and unsteadiness on feet. She was moved to the secured memory care unit on 9/8/25, and sustained a fall 9/9/25 which resulted in a lower extremity skin tear. An interdisciplinary team (IDT) progress note, dated 9/9/25 at 8:07 a.m., indicated Resident B had an unwitnessed fall in her room and sustained a skin tear on her lower extremity. The root cause of the fall was that the resident was trying to get up by herself, and the intervention was for her to have an Occupational Therapy evaluation. The record lacked follow-up or indication on how or where she sustained the skin tear. Upon Resident B's move to the secured memory care unit, a comprehensive care plan was initiated on 10/10/25 which indicated, Resident resides on a secured memory careunit related to diagnosis of unspecified dementia. an intervention for the plan of care was, Keep environment free from hazards. A Nurse Practitioner (NP) progress notes, dated 10/17/25 at 10:28 a.m., indicated Resident B had .dressings on her bilateral lower legs from some injuries that the nurse and staff are not aware of what could have caused it, the wound is just some scrapes that they have been changing daily right now. The record lacked follow-up or indication for how she sustained the skin tears. On 10/31/25 a new comprehensive care plan was initiated which indicated, Resident has skin tears to right knee and back of left knee. Interventions for this plan of care included, but were not limited to, Observe resident environment for potential to cause skin trauma. A nursing progress note, dated 11/5/25 at 10:27 a.m., indicated Resident B accidentally hit her left leg against the bed frame during a transfer and sustained a laceration on her left lower extremity with moderate bleeding. The nurse applied first aide and called 911 for her to be sent out to the emergency room (ER) for further evaluation and treatment. Corresponding ER documentation, dated 11/6/25 at 2:19 a.m., indicated patient from [facility] with large deep leg laceration to left lower leg. Staff reported they were transferring patient from wheelchair to bed when laceration occurred. Bleeding controlled. The wound was reapproximated in one layer with 6 simple interrupted sutures. Approximately 4 running sutures to approximate the areas in-between the simple interrupted sutures. On 11/10/25 at 3:00 p.m., The ADM and DON indicated there was no policy to address environmental hazards but they could provide a routine maintenance policy. On 11/10/25 at 3:19 p.m., the ADM provided a copy of current, but undated facility policy titled, Maintenance Procedure. The policy indicated, Beds: Frequency: semi-annual. Check bed casters to make certain brakes are locking, if so equipped. Check side rails to determine if they are working smoothly. Tighten nuts and bolts. Lubricate bed-adjusting mechanisms. This citation relates to Intake 2662177. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident D) with chronic Urinary Tract Infections (UTIs) and a nephrostomy tube (a thin, flexible tube inserted into the kidney to drain urine directly into a collection bag) had accurate medical orders and was receiving perineal care regularly for 1 of 1 residents reviewed for bowl and bladder concerns.Findings include:On 9/29/25 at 12:22 p.m. Resident D was observed as she lay in bed. Her bed did not have a fitted sheet, only a flat sheet, and all her pillows were without pillowcases. The resident indicated she had put her call light on at 8:00 a.m. to be changed but they had not come in to change her yet. Resident D was very tearful and indicated she was in so much pain and had told the facility about her concerns many times but nothing got better.On 9/29/25 at 12:47 p.m. Certified Nursing Assistant (CNA) 2 indicated to Resident D that she had gotten busy but was coming in now to change the resident's brief. As CNA 2 pulled back Resident D's sheet, the resident's brief and sheet were visibly soiled. As CNA 2 was changing Resident D, a strong ammonia urine smell permeated the room, and the brief was observed to be completely saturated with urine. Resident D had a nephrostomy tube on her left side with what appeared to be a blue bordered foam dressing. The dressing was dated 9/27. CNA 2 changed Resident D's brief, put down a dry towel underneath her and then left to get clean linen for her bed.On 9/29/25 at 1:00 p.m. Resident D's medical record was reviewed. She was a long term care resident whose diagnoses included but were not limited to cancer of the breast with metastasis and chronic urinary tract infections (UTI).Resident D had an active order to cleanse around the nephrostomy tube, apply betadine the area, apply a dry dressing, and monitor for signs and symptoms of infection once daily and as needed for soilage.A social services Minimum Data Set (MDS) assessment, dated 9/22/25, indicated the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. This score indicated intact cognition, meaning the individual's thinking and memory were functioning normally with no or very little impairmentResident D's Point of Care (POC) (the area in the Resident medical record where staff chart tasks performed by or for the Resident) history related to bowl and bladder care was reviewed for the month of September 2025. The POC history indicated 19 out of 28 days Resident D was incontinent 3 times per day, and 9 out of 28 days Resident D was incontinent 2 times per day. There were no continent toileting episodes charted. The documentation indicated the resident was receiving incontinent care only 2 to 3 times a day for the month of December.Resident D had a care plan related to her having chronic UTIs dated 1/20/25. The interventions for this care plan included, but were not limited to, assist with incontinent care.Resident D had a care plan related to her having a nephrostomy tube dated 1/20/25. The interventions for this care plan included, but were not limited, to change dressing as ordered, flush tube as ordered and keep the system a closed system as much as possible.Resident D had a care plan related to her needing assistance with toileting and incontinent care dated 1/20/25. The interventions for this care plan included, but were not limited to, assist with incontinent care as needed, and check and change every two hours and as needed for incontinence.At the time of exit there were no care plans or documentation in the record indicating Resident D had adverse behaviors related to refusal of incontinence care, toileting, personal hygiene or false accusations.During an interview on 9/29/25 at 1:27 p.m. the Director of Nursing (DON) indicated Resident D's nephrostomy tube was currently dislodged and would be replaced soon at the hospital. She indicated she was going to check Resident D's orders to see what the current orders were for the nephrostomy tube. The DON indicated the tube did not have a bag attached to it because it was not draining due to the dislodgment.During an interview on 9/29/25 at 1:36 p.m. the DON indicated she was going to clean up Resident D's orders, because the current order should have been to only change the dressing as needed for soilage and to flush the tube as needed.During an interview on 9/29/25 at 2:31 p.m. the Unit Manager (UM) indicated Resident D's current nephrostomy tube that was in place was a new tube and was working properly as far as she knew. She indicated she was just about to change the dressing for Resident D's nephrostomy tube, because to her knowledge the dressing was to be changed, and the tube was to be flushed daily and as needed. The UM indicated the nephrostomy tube was not connected to a bag at this time because her other kidney was functioning properly and she was urinating as normal, so the nephrostomy tube was not draining. She indicated if it did start to drain staff would then connect a drainage bag and account for the output from the tube. The UM also indicated Resident D was not on a bowel and bladder program because the resident did not know when she needed to go, she could only feel when she had already voided. She was on a standard two hour check and change schedule.During an interview on 9/29/25 at 3:00 p.m. the Administrator indicated the UM must have misspoke, because the current order for Resident D's nephrostomy tube was to be changed only as needed (PRN) and the tube was still dislodged.On 9/29/25 the administrator provided an electronic copy of a current facility policy titled, Bowel and Bladder Program, dated 5/2019. This policy indicated, .If a resident is totally incontinent and unable to be placed on a toilet or bedpan, resident should be checked and changed every two hours.This citation relates to Intake 2583736.3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 4 of 8 residents reviewed for call lights (Resident 25, 50, 52, and 72). Findings include: 1. On 10/4/24 at 11:55 a.m., Resident 25's call light was observed out of reach. Her diagnoses included, but were not limited to, right-sided hemiplegia (loss of strength or paralysis), atrial fibrillation (irregular heartbeat), hypertension (HTN) (high blood pressure), paroxysmal tachycardia (episodes of rapid heart rate), convulsions (sudden, violent, irregular movement of a limb or the body cause by involuntary contraction of the muscles), osteoporosis (OP) (bone disease that causes bones to become weak and more likely to break), and anxiety disorder (excessive and persistent feelings of fear, worry, or dread). A care plan, dated 8/27/15, indicated Resident 25 was at risk for falls due to her medications, atrial fibrillation, osteopenia (OP) (loss of bone density), decreased mobility, incontinence (lack of voluntary control of bladder and/or bowel), right-sided hemiplegia, hypertension, cerebral vascular accident (CVA), seizures (uncontrolled burst of electrical activity in the brain causing changes in behavior, movement and awareness), transient ischemic attack (TIA) (stroke), anxiety, hypoxic (oxygen deficiency) respiratory failure, chronic kidney disease (CKD) (impaired kidney-blood filtration), weakness, right-hand contracture (permanent tightening of the muscles, tendons, and skin), and history of respiratory failure. Interventions included to keep her personal items in reach and keeping her call light in reach. A care plan, dated 5/24/19, indicated Resident 25 was at risk for pathological fracture due to a diagnosis of osteopenia. Interventions included to remind the resident to ask for help, assist with transfers, and her call light in reach. 2. On 10/4/24 at 11:57 p.m., Resident 52's call light was observed not in reach. Her diagnoses included, but were not limited to, dementia, cerebral ischemia, encephalopathy (brain disease affect the function of the brain), HTN, paroxysmal atrial fibrillation, history of falls, cervical spondylosis (degeneration of the bones and discs in the neck), lumbar scoliosis (condition that causes an abnormal sideways curve in the lower back), postural lordosis (condition were the spine curves too much forward), anorexia (eating disorder), generalized anxiety disorder (GAD) (excessive, ongoing anxiety and worry), and weakness. A care plan, dated 8/8/24, indicated Resident 52 was at risk for falls due to decreased mobility, cognition, history of falls, medications, and related to cerebral ischemia (blockage in an artery restricts the delivery of oxygen rich blood to the brain, resulting in brain damage), a head injury related to a fall, dementia (loss of cognitive functioning such as thinking, remembering, and reasoning), encephalopathy, HTN, atrial fibrillation, cervical disc degeneration, cervical spondylosis, lumbar scoliosis, and postural lordosis. Interventions included keeping her personal items in reach and keeping her call light in reach. 3. On 10/4/24 at 11:59 a.m., Resident 72's call light was observed out of reach. His diagnoses included, but were not limited to, heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) (blood sugar disorder), cerebral infarction, TIA, angina pectoris (severe pain caused by an inadequate blood supply to the heart), cognitive communication deficit (brain injury that makes it difficult for a person to communicate), and osteoarthritis (OA) (degenerative joint disease that breaks down cartilage in the joint). A care plan, dated 10/9/23, indicated Resident 72 was at risk for falls due to decreased mobility, incontinence, history of falls, medications, visual impairments, and related to a diagnosis of heart failure, COPD, DM, CVA, TIA, angina pectoris, HTN, and chest pain. The goal was to reduce risk factors to prevent significant fall related injury. Interventions included keeping personal items in reach and her call light in reach A care plan, dated 10/13/23, indicated Resident 72 had impaired vision related to verbalizing that with his eyeglasses, he can only read large print. The goal was the resident will not experience negative consequences of vision loss as evidenced by remaining physically safe. Interventions included to be sure that the lenses of his eyeglasses were clean and keeping his call light in reach. 4. On 10/4/24 at 12:00 p.m., Resident 50's call light was observed out of reach. His diagnoses included, but were not limited to, paranoid schizophrenia (chronic mental disorder that affects how people think, feel, and behave), diabetes mellitus, pain in (unspecified) knee, HTN, acute kidney failure (AKF), TIA, and long term (current) use of antithrombotic (to prevent blood clots) / antiplatelets (to stop platelets from sticking together and forming blood clots) and muscle weakness. A care plan, dated 6/14/24, indicated Resident 50 was at risk for falls due to decreased mobility, incontinence, history of falls, medications and related to diagnosis of history of methicillin-resistant staphylococcus aureus (MSSA), history of sepsis (life-threatening emergency that occurs when the body's immune system had an extreme response to an infection or injury), DM, bacteremia (blood stream infection), colitis (inflammation of the lining of the colon), HTN, schizophrenia, bilateral knee pain, history of psychoactive (affecting the mind) drug use, history of CVA, and insomnia. The goal was to have fall factors reduced to avoid significant fall related injuries. Interventions included personal items in reach and keeping his call light in reach. A current policy, titled, IDT Comprehensive Care Plan Policy, dated 8/2023, was provided by the Director of Nursing (DNS) on 10/3/24 at 12:55 a.m. She indicated the facility did not have a call light policy and this policy was used for call lights. A review of the policy indicated, .The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being 3.1-3(v)(1)

Based on observation and record review, the facility failed to ensure medications were labeled and dated for 3 of 3 medication carts reviewed for medications (Resident 47, 49, 56, 83, 86, 106, 112, and 278). Findings include: On [DATE] at 1:53 p.m., the 500 back hall medication cart was observed with Qualified Medical Assistant (QMA) 11. The findings were: a The facility tuberculin serum was opened [DATE] and expired on [DATE]. b. Resident 83's was sent to the facility on [DATE] but had no opened date. c. Resident 86's had latanoprost was observed in the medication cart with only his name and date to indicate when it was opened d. Resident 112's had budesonide-formoterol with no date. The 500 front medication cart was observed with Registered Nurse (RN) 20. The findings were: a Resident 56's breyna ,d+[DATE].5 mcg (microgram) and fluticasone 50 mcg spray, had no open dates. b. Resident 47's had a nasal spray with no open date. The 100 front medication cart was observed with RN 12. The findings were: a Resident 278's lispro insulin was expired on [DATE]. b. Resident 49's lispro insulin had no prescription label or open date. c. Expired novolog with no name was opened on [DATE]. d. Resident 106's latanoprost 0.05% was sent on [DATE], it had no open date. e. Resident 106's dorzolamide-timolol drops did not have an open date. f. Resident 106's rhopressa 0.02% ophthalmic solution had no open date. A current policy, titled, LTC Facility Pharmacy Services and Procedures Manual, was provided by the Executive Director (ED), on [DATE] at 12:37 p.m. A review of the policy, indicated, .The facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .Facility staff should record the date opened on the primary medication container .when the medication has a shortened expiration date once opened 3XXX,d+[DATE](j)

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a resident's, (Resident 102) change of condition after a fall when he experienced break through pain and a decline in his ability to perform activities of daily living for 1 of 1 residents reviewed for notification of change of condition. Findings include: On 10/1/24 at 11:47 a.m., Resident 102 was observed. He was seated in a specialty wheelchair (WC) and was positioned slouched/slid down in his seat. He had a visitor who sat with him and waited for lunch. On 10/1/24 at 11:51 a.m., an unidentified nursing staff member and the visitor repositioned Resident 102 in his WC. They pulled him to an upright seated position. As they pulled him up, Resident 102 called out nonsensical words and grimaced his face. During an interview on 10/1/24 at 11:55 a.m., Resident 102's visitor identified herself as his sister and indicated she visited him almost every day. She indicated Resident 102 had Down's Syndrome (a genetic condition where a person is born with an extra chromosome which causes developmental and intellectual delays) and Alzheimer's dementia (a degenerative brain disease which affects cognitive function and memory). When asked about his positioning in the WC, his sister indicated, they (she and the facility's Interdisciplinary team [IDT]) had a difficult time finding a good fit wheelchair for his stature, posture, and fluctuating mobility. Resident 102 had always used a rollator walker, but since his last fall, which had resulted in a femur fracture and required surgery, he needed to use a WC because he had not been able to regained his ability to walk and had experienced a stark decline in his overall condition. On 10/3/24 at 9:48 a.m., Resident 102 medical record was reviewed. He was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, Down's Syndrome, slowness and poor responsiveness, and epilepsy (a chronic brain disease that causes seizures, which are episodes of abnormal electrical activity in the brain). A nursing progress note, dated 2/20/24 at 5:58 a.m., indicated Resident 102 was found on floor after an unwitnessed fall and he sustained a laceration to his right brow. The NP and Director of Nursing (DON) were notified. A nursing progress note, dated 2/24/24 at 1:20 p.m., indicated Resident 102 refused the morning meal and was resistant to care. He was gotten up and brought to the dining room for lunch. Resident 102 complained of pain and limped on his right lower extremity when ambulating, so he used a WC instead. The progress note lacked documentation the NP was notified of ongoing pain, and limping. A nursing progress note, dated 2/25/24 at 2:00 p.m., indicated, Resident 102 was very hostile and resisted morning care. He was aggressive towards staff and not easily redirected and was educated on kindness. The progress note lacked documentation the NP was notified of his change of behavior. An OT daily summary note dated 2/27/24 at 3:13 p.m., indicated Resident 102 refused to stand due to knee pain. Resident demonstrated full Functional Outcome Measure (FOM) of the right knee. When the therapist attempted to move Resident 102's leg similarly the resident reported pain and refused to move further. Resident 102 reported he needed to use the bathroom, but when taken to the bathroom he refused to transfer to toilet once in there. The note indicated nursing was notified. The record lacked documentation that nursing notified MD or NP of Resident 102's continuing breakthrough pain and refusal to transfer to the toilet. An OT daily summary note, dated 2/29/24 at 1:54 p.m., indicated, .patient performed therapeutic exercises using Omnicycle [the OmniCycle is a motorized therapeutic exercise system that can be used by patients with neurological, orthopedic, cardiac, or other challenges] . patient's response included 35% activity with multiple rest breaks . patient refused standing on this date The record lacked documentation the MD was notified that Resident 102 still refused to stand. On 10/4/24 at 12:15 p.m., the DON provided a copy of current facility policy titled, Resident Change of Condition Policy, revised, 11/2018. The policy indicated, .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place . acute medical change a. any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician Cross Reference F684. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure information reported on the Minimum Date Set (MDS) was accurate for 1 of 2 residents reviewed for MDS accuracy (Resident 61). Findings include: On 10/7/24 at 9:56 a.m., Resident 61's record was reviewed. She was admitted on [DATE]. Her diagnoses included, but were not limited to, paroxysmal atrial fibrillation (irregular heartbeat), long term use of antithrombotic (to prevent blood clots) / antiplatelets (prevent blood cells from sticking together), and dementia (brain disorder). Resident 61's medication order included, but was not limited to, aspirin (antiplatelet) 81 mg (milligram), chewable, once a day for paroxysmal atrial fibrillation. No physician order for an anticoagulant (blood thinner) was observed. Resident 61's care plan, dated 9/10/24, indicated she was at risk for bleeding and bruising related to use of antiplatelet medication. The goal was for her to remain free of adverse effects of antiplatelet medication. Resident 61's MDS, dated [DATE], was reviewed for medications. It indicated she was not on an antiplatelet. During an interview, on 10/7/24 at 10:51 a.m., the Regional Director of Clinical Services (RDCS) indicated Resident 61 was on was on Plavix (antiplatelet) from 9/13/24 to 9/20/24. The Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, October 2024 was reviewed on 10/9/24 at 4:16 p.m. It indicated for, .Code all high-risk drug class medications according to their pharmacological classification .Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period .Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period 3.1-31(i)

Based on record review and interview, the facility failed to implement a care plan for the use of Seroquel (an antipsychotic) medication for 1 of 3 residents reviewed for care plans (Resident 43). Findings include: On 10/4/24 at 10:52 a.m., a record review was completed for Resident 43. She had the following diagnoses which included but were not limited to dementia, anxiety, major depressive disorder, and bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels). Resident 43's medical record lacked a care plan addressing the use of Seroquel for bi-polar disorder. On 10/4/23 at 1:30 p.m., during an interview with the Director of Nursing (DON), she indicated she had nothing to add for the resident not having a care plan. A policy titled, Comprehensive Care Plans was provided by the DON on 10/3/24 at 12:55 p.m., It indicated, .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan .Physician's orders are considered part of the comprehensive plan of care . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident 102), who had diagnoses of dementia and an intellectual disability was adequately assessed for breakthrough pain and change of condition after a fall resulting in a delay of treatment for 1 of 2 residents reviewed for change of condition, and failed to ensure a resident with pain after a fall was sent to the hospital without delay after x-ray results confirmed a fracture for 1 of 2 residents reviewed for change of condition (Resident 40). Findings include: 1. On 10/1/24 at 11:47 a.m., Resident 102 was observed. He was seated in a specialty wheelchair (WC) and was positioned slouched/slid down in his seat. He had a visitor who sat with him and waited for lunch. On 10/1/24 at 11:51 a.m., an unidentified nursing staff member and the visitor repositioned Resident 102 in his WC. They pulled him to an upright seated position. As they pulled him up, Resident 102 called out nonsensical words and grimaced his face. During an interview on 10/1/24 at 11:55 a.m., Resident 102's visitor identified herself as his sister and indicated she visited him almost every day. She indicated, Resident 102 had Down's Syndrome (a genetic condition where a person is born with an extra chromosome which causes developmental and intellectual delays) and Alzheimer's dementia (a degenerative brain disease which affects cognitive function and memory). His sister indicated, they (she and the facility's Interdisciplinary team [IDT]) had a difficult time finding a good fit wheelchair for his stature, posture, and fluctuating mobility. Resident 102 had always used a rollator walker, but since his last fall, which had resulted in a femur fracture and required surgery, he needed to use a WC because he had not been able to regain his ability to walk and had experienced a stark decline in his overall condition. On 10/3/24 at 9:48 a.m., Resident 102 medical record was reviewed. He was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, Down's Syndrome, slowness and poor responsiveness, and epilepsy (a chronic brain disease that causes seizures, which are episodes of abnormal electrical activity in the brain). A care plan initiated on 6/28/23 which indicated he was at risk for pain due his diagnoses. Interventions included, but not limited to; notify MD if pain is unrelieved and/or worsening, observe for non-verbal signs of pain: changes in breathing, vocalizations, mood/behavior changes, eyes change expression, sad/worried face, crying, teeth clenched, changes in posture. A care plan initiated on 7/12/23 which indicated he exhibited cognitive impairment as example by, a BIMS score of less than 13. Resident is Severely Impaired. This care plan lacked revision of individualized risks/causes of his impairment related to his diagnosis of Down Syndrome and/or dementia. A significant change Minimum Data Set (MDS) assessment, dated 8/7/24, indicated Resident 102 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score, 7 of 15. He was interviewed for his preferences and customary daily routines and answered all but 4 of 16 questions as very important. His Functional ability assessment indicated he was independent in his ability to walk, needed minimal assistance to eat, and was able to transfer himself with stand-by assistance. A Nurse Practitioner (NP) progress note, dated 1/23/24 at 2:10 p.m., indicated Resident 102 . is able to get up out of bed and ambulate with his rollator per his baseline A nursing progress note, dated 2/20/24 at 5:58 a.m., indicated Resident 102 was found on floor after an unwitnessed fall and he sustained a laceration to his right brow. The NP and Director of Nursing (DON) were notified. A corresponding Fall Event assessment, dated 2/20/24 at 11:08 a.m., indicated Resident 102 stated he was using the bathroom and lost his balance and fell . An Event question, did nurse request an ER eval, was left blank. An Event question, Prior to the fall, when was the last time the resident was toileted or received incontinent care, was left blank. Resident 102 did not complain of pain at the time of the fall, and no new orders were received. A nursing progress note, dated 2/21/24 at 11:34 a.m., indicated Resident 102 complained of right knee pain during range of motion (ROM). He refused to get out of bed. When the NP was notified, new orders were obtained for X-Rays of his right knee, and bilateral hips. A nursing progress note, dated 2/21/24 at 5:58 p.m., indicated Resident 102 was given Tylenol which was somewhat effective and still refused to get out of bed. On 2/21/24 at 6:56 p.m., Resident 102's as needed (PRN) Tylenol orders were changed to scheduled Tylenol 1000 milligrams (mg) three times a day. A fall follow up nursing note, dated 2/21/24 at 9:22 p.m., indicated Resident 102 had a noted change with increased pain and resistance to right lower extremity. The NP was notified. New orders were received but not specified. A nursing progress note, dated 2/22/24 at 5:56 a.m., indicated Resident 102 continued to express pain with movement to right lower extremity and he refused to ambulate to the bathroom and refused hygiene care, but after several ques he did allow hygiene care. A NP progress note, dated 2/22/24 at 2:33 p.m., indicated, .[Resident 102] seen today for pain. He was found on the floor in his room on Monday with no initial complaints of pain. He is now refusing to get out of bed or ambulate. He had a R [right] knee and R [right] hip x-ray yesterday. The knee x-ray was negative. The hip x-ray showed history of AVN [Avascular necrosis (AVN), also known as osteonecrosis, is a condition where bone tissue dies due to a disruption of blood flow. It can occur in any bone, but most commonly affects the ends of long bones where they meet a joint, such as the hip)], but no acute findings. Dementia and disability makes ROS [review of symptoms] difficult. He is unable to answer questions appropriately. He has full ROM in R knee. When attempting ROM of R [right] hip he grimaces and when asked to stand/ambulate he refuses The NP's Assessment/Treatment Plan indicated, . Check femur X-ray; schedule Tylenol, Biofreeze and Lido patch. A nursing progress note, dated 2/22/24 at 10:28 p.m., indicated, Resident 102's new orders were in place, all scheduled medications had been given but he still complained of pain to his right lower extremity during movement. His family requested CT or MRI scans and the NP was notified. A new physician's order for Occupational Therapy eval and treatment was ordered on 2/22/24. An OT Evaluation and Plan of Treatment summary, dated 2/22/24, indicated, .referred to OT eval and treatment following recent falls . has fallen 3 times in the last 3 months . upon OT eval pt [patient] presents with decreased strength, endurance, unsteadiness on feet, and decreased ADL participation from baseline impacting the pt's ability to safely complete ADLs, transfers, and ambulation at maximum level of safety An OT daily summary, dated 2/23/24 at 4:47 p.m., indicated, .patient seemed to guard right lower extremity [RLE] and was not putting foot down. Patient unable to verbalize location of pain The OT note did not indicated/document that nursing staff and/or MD was notified of Resident 102 guarding RLE and not putting weight on his foot. A nursing progress note, dated 2/24/24 at 1:20 p.m., indicated Resident 102 refused in morning meal and was resistant to care. He was assisted up and brought to the dining room for lunch. Resident 102 complained of pain and limped on his right lower extremity when ambulating, so he used a WC instead. The progress note lacked documentation the NP was notified of ongoing pain, and limping. A nursing progress note, dated 2/25/24 at 2:00 p.m., indicated Resident 102 was very hostile and resisted morning care. He was aggressive towards staff and not easily redirected and was educated on kindness. The progress note lacked documentation the NP was notified of his change of behavior. An OT daily summary note dated 2/27/24 at 3:13 p.m., indicated Resident 102 refused to stand due to knee pain. Resident demonstrated full Functional Outcome Measure (FOM) of the right knee. When the therapist attempted to move Resident 102's leg similarly the resident reported pain and refused to move further. Resident 102 reported he needed to use the bathroom, but when taken to the bathroom he refused to transfer to toilet once in there. The note indicated nursing was notified. The record lacked documentation that nursing notified MD of Resident 102's continuing breakthrough pain and refusal to transfer to the toilet. A significant change MDS assessment, dated 2/28/24, indicated Resident 102's cognitive function decreased from a 7, to 3 out of 15 on his BIMS score. He was interviewed for his preferences and customary daily routines and answered only 1 of 16 questions as very important. His Functional ability assessment indicated, he required partial to moderate assistance to walk, to use the bathroom and to transfer. An OT daily summary note, dated 2/29/24 at 1:54 p.m., indicated, .patient performed therapeutic exercises using Omnicycle [the OmniCycle is a motorized therapeutic exercise system that can be used by patients with neurological, orthopedic, cardiac, or other challenges] . patient's response included 35% activity with multiple rest breaks . patient refused standing on this date The record lacked documentation the MD was notified that Resident 102 still refused to stand. An OT daily summary note, dated 3/1/24 at 2:48 p.m., indicated, .attempted to engage pt [patient] in OmniCycle for increase lower extremity strength however pt refusing on this date . pt agreeable to walk on this date and ambulated 57 feet . A nursing progress note, dated 3/4/24 at 4:53 p.m., indicated Resident 102 had an unwitnessed fall from his WC in the dining room. An IDT progress note, dated 3/5/24 at 11:49 a.m., indicated he fell from the wrong size WC in the dining room and the new intervention put in place was to have therapy eval him for the correct size WC. An OT daily summary note, dated 3/5/24 at 4:23 p.m., indicated, .recent fall noted possibly from WC being too tall for patient . writer was able to find a different WC and maintenance request to lower WC to lowest level for better WC for. Patient required max ques for sit to stand transfers A nursing progress note, dated 3/1/24 at 1:38 p.m., indicated an MRI had been scheduled for Resident 102 for 3/5/24. A nursing progress note, dated 3/6/24 at 1:42 p.m., indicated, Resident 102 had returned from his MRI appointment and the results were received and sent to the NP. The NP gave new orders to send him to the emergency room . A Hospital Record summary, dated 3/6/24 at 5:18 p.m., indicated, .He had a fall approximately 2 weeks ago with MRI obtained earlier today ordered from an outside facility. Apparently this shows after subchondral collapse consistent with AVN at the right femoral head and the nondisplaced intertrochanteric femur fracture. They were brought to ER, where x-rays were done that identified nondisplaced right intertrochanteric femur fracture and AVN of the right femoral head. Orthopedics was consulted and that patient was admitted with plans for surgical stabilization A nursing progress note, dated 3/11/24 at 8:07 p.m., indicated Resident 102 returned from hospital after femur fracture surgical repair with three surgical incisions covered with dressings. During a follow up interview on 10/4/24 at 11:49 a.m., Resident 102's sister indicated he had experienced a significant decline in his overall health since his last fall and surgery. At the time of the fall, because of his Down Syndrome and dementia, it had been very difficult to determine where he was hurt, how bad the pain was, or what caused the pain. His sister indicated when the x-rays all came back negative, but he still screamed out in pain, refused to get out of bed and couldn't use the bathroom, she requested an MRI. His sister indicated, because of Resident 102's Down Syndrome, he had a delayed pain response and high pain threshold, so if he said he was hurting, then it must have really been hurting. The sister talked to the facility NP and asked if he could be sent to the ER for an MRI, but the NP suggested they get the MRI scheduled with a guaranteed date and time, instead of sending him to the ER to sit and wait for hours. His sister indicated, she agreed at the time and scheduled the MRI through his PCP (primary care provider), but in hindsight, she would have sent him to the ER since the MRI eventually revealed the femur fracture and he needed surgery. During an interview on 10/4/24 at 1:28 p.m., the NP indicated, Resident 102's sister was very involved and well informed regarding his care and she often preferred to go through his PCP because of his Down Syndrome. The NP visited Resident 102 after the fall and ordered a series of x-rays which all came back negative. The NP had a conversation with the sister about an MRI but did not document details of the conversation. When Resident 102's progress notes were reviewed where there was no documentation of physician notification, the NP indicated she would want to be notified of ongoing and/or unrelieved pain, or new changes in behavior to address the change of condition. During an interview on 10/4/24 at 1:53 p.m., the DON indicated, if a resident experienced breakthrough pain or unrelieved symptoms and changes in behavior, she would expect nursing to notify the MD to address the change of condition and receive new orders if applicable. On 10/4/24 at 12:15 p.m., the DON provided a copy of current facility policy titled, Pain Management, revised, 7/2024. The policy indicated, .It is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management . non-Interviewable resident- pain medications will be prescribed and given based upon nursing assessment for the following: non-verbal sounds . facial expressions . protective body movements or postures . the physician will be notified of unrelieved or worsening pain On 10/4/24 at 12:15 p.m., the DON provided a copy of current facility policy titled, Resident Change of Condition Policy, revised, 11/2018. The policy indicated, .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place . acute medical change a. any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. 37981 2. On 10/3/24 at 9:39 a.m., Resident 40's record was reviewed. Her diagnoses included, but were not limited to, history of falling, non-displaced comminuted (the broken bone was more than 2 pieces) fracture of shaft of right femur (thigh bone), displaced (not in alignment) supracondylar (just above the knee joint) fracture with intercondylar (ball shaped ends of the femur) extension of lower end of right femur, right-sided hemiplegia and hemiparesis (paralysis and weakness), cognitive communication deficit, anoxic (oxygen deprivation) brain damage, cerebral infarction (stroke), intellectual disabilities (decreased acquisition of knowledge and skills), anxiety disorder, and panic disorder (unexpected and repeated episodes of intense fear accompanied by physical symptoms). A care plan, dated 4/13/24, indicated Resident 40 may yell out and become upset when her roommate was being provided care. The goal was for her not to exhibit this behavioral expression. An intervention indicated to talk with the resident and redirect her. A care plan, dated 6/20/24, indicated Resident 40 had a communication deficit related to anoxic brain damage, a history of cerebral vascular accident (stroke), and mental retardation (impairment in intellectual ability). The goal was for the resident to be able to effectively communicate her needs. An intervention indicated to use simple communication and avoid open-ended questions. A care plan, dated 6/25/24, indicated Resident 40 required assistance with toileting due to incontinence of bladder and bowel. An intervention indicated to assist with incontinence care as needed. A care plan, dated 7/23/24, indicated Resident 40 experienced the following behavior, she may yell out and cry in her room when she wanted something. Interventions included, but were not limited to, to address her immediate needs and ensure her safety. Resident 40's Fall Event, dated 9/9/24 at 2:06 p.m., indicated Resident 40 had an unwitnessed fall on 9/9/24 at 9:40 a.m. She was found on her right side on the floor next to her bed. She had removed her clothing and soiled disposable brief. After her fall, the nursing assessment indicated she was not experiencing any pain and had no injuries. She had been having behaviors and refusing care to be cleaned up. No progress note was found on the date and around the time of Resident 40's fall on 9/9/24 at 9:40 a.m. A progress note, dated 9/9/24 at 2:06 p.m., indicated Resident 40 was in bed, had removed gown and disposable brief, and played in her bowel movement (BM). She was refusing to allow care, she was yelling and fighting with the CNA. She was covered in BM. The DNS (Director of Nursing Services) was informed and she spoke to Resident 40 regarding her behaviors. Resident 40 continued to refuse care. Her bed lowered and she was covered up. The CNA pulled the curtain and was over with resident's roommate providing care. Resident 40 raised up the height of her bed and rolled off into floor in between the beds. She was lying on her right side. She was assessed with her vital signs stable, neurological assessment started and range of motion was within normal limits for her. No injury was noted. Resident 40 was assisted up into her wheelchair and a gown was put on. The CNA was able to take her to the shower and clean her up. A progress note, dated 9/9/24 at 10:29 p.m., indicated Resident 40 was observed sitting in her wheelchair with no complaints of pain while propelling herself in the hallway and dining room, but when the staff put her in bed, she started yelling and complaining of pain. PRN medications provided but did not help her pain. Her right knee was observed to be swollen, and she felt pain when it was touched. The Nurse Practitioner (NP) was notified with a new telephone order for an x-ray with 2 views. The results of her right knee x-ray, dated 9/10/24 at 1:20 a.m., indicated Resident 40 had a transverse fracture involving her right distal femur with mild callus and modest posterior angulation and displacement. The joint showed no dislocation. There was associate joint effusion swelling(define). Soft tissue swelling was seen. The conclusion was right knee fracture. Resident 40's pain medication orders included, but were not limited to, scheduled acetaminophen 500 mg (milligram) three times a day at 7:00 a.m., 3:00 p.m., and 11:00 p.m., ibuprofen 400 mg, every 6 hours PRN (as needed), and hydrocodone-acetaminophen 5-325 mg three times a day at 8:00 a.m., 12:00 p.m., and 9:00 p.m. Resident 40's medication administration record (MAR) indicated: a. Hydrocodone-acetaminophen 5-325 mg was given three times on 9/9/24. b. Acetaminophen 500 mg was given three times as scheduled on 9/9/24. c. Ibuprofen 400 mg was administered due to Resident 40's complaint of right knee pain at the level 6 on a pain scale of 0 - 10. One ibuprofen was provided on 9/9/24 at 9:43 p.m. The medication effectiveness was assessed on 9/10/24 at 6:24 a.m. as somewhat effective. A progress note, dated 9/10/24 at 8:02 a.m., indicated the facility attempted to call and notify the Resident's brother and left a message to call the facility back. The resident continued with behaviors, most of the redirections had been unsuccessful since yesterday with the resident only accepting redirection one time since yesterday during the day. A progress note, dated 9/10/24 at 8:42 a.m., indicated Resident 40 was observed playing in her BM. BM was observed all over the resident and the sheets. She had removed her gown and disposable brief and threw them on the floor. The CNA attempted to clean up the resident, but she was combative. She was observed thrashing about to, throw self out of bed. She was redirected to allow the CNA to provide care. Resident's brother notified. A progress note, dated 9/10/24 at 9:49 a.m., indicated Resident 40 was sent to the ED (emergency department) for evaluation and treatment related to the fracture. CNA (bus driver) accompanied the resident. The resident went to the hospital via the facility bus. The bus driver was also a CNA who stayed with the resident in hospital emergency room waiting room until her brother arrived. On 9/10/24 at 11:08 a.m., the interdisciplinary team (IDT) fall review note indicated Resident 40 had a fall on 9/9/24 at 9:40 a.m. The resident was in bed prior to fall waiting for the wound physician. The resident did not place call light on for assistance. She started yelling out and screaming to get out of bed. Nursing staff explained she had to be seen by the wound doctor and then she would be able to get up for breakfast. Nursing staff went back in the resident's room, and she had, played in her feces. Nursing staff explained she was going to receive a shower to clean up. She agreed. Her bed was lowered to the appropriate level and staff was assisting her roommate to get up. Resident 40 raised her bed to a higher level and rolled out of the bed. No injuries were noted at the time. Resident 40 complained of latent pain and the on-call provider paged for the facility to get an x-ray. The x-ray results indicated a transverse fracture involving right distal femur with mild callus (hardened skin) and modest posterior angulation (abnormal bend) and displacement. ER evaluation indicated she would be admitted . The determination of the root cause of the fall was the resident did not want to wait on the wound physician and wanted to get out of bed. The resident played in her feces to have staff come in and get her up. On 9/10/24 at 3:55 p.m., the bus driver/CNA called from the hospital and indicated Resident 40 was being admitted . On 9/10/24 at 3:59 p.m., the IDT behavior review note indicated Resident 40 had removed her gown in her room, while on her bed, and started playing in her bowel movement. The immediate intervention was for staff to educate her on the importance of not doing that behavior. The assessment of a potential correlation to the root cause was Resident 40 had unmet needs. The resident's soiled brief needed to be changed. The root cause of her behavioral expression was she was upset about her roommate getting up for the day before she did. She was to remain in bed so the wound physician could see her. A document titled, Hospital-ER Transfer Form, dated 9/11/24 at 12:59 p.m., indicated the time of Resident 40's transfer, due to femur fracture, was 9/10/24 at 9:30 a.m. She was transferred to the emergency room by the facility bus. A progress note was included, it indicated on 9/11/24 at 3:48 p.m., the IDT description of Resident 40's behavior was playing in her BM and attempting to throw herself out of bed. The staff had encouraged her to allow them to provide peri care. A potential correlation to the root cause was unmet needs because the resident needed to be changed. An ED (emergency department) physician's note, dated 9/10/24, indicated she saw Resident 40 at 3:31 p.m. She indicated Resident 40 told her she fell on to the floor and had pain in her right knee. An assessment of her right lower extremity (RLE) showed knee deformity, with swelling and ecchymosis (bruising), and distal femur TTP (tenderness to palpitation). She will be admitted to the hospital for an internist and orthopedic follow-ups. The hospital x-ray indicated, .impacted supracondylar fracture distal femur A care plan, dated 9/20/24, indicated Resident 40 was determined to be intellectually disabled (effects learning, problem solving, and everyday tasks) and mentally ill (conditions involving (changes in emotions, thinking and/or behavior). The goal was her to have her mental health needs met. An intervention was to have continue current mental health services. A care plan, dated 9/20/24, indicated Resident 40 exhibited cognitive impairment (problems with thinking, learning, remembering, use of judgment and making decisions) as evidence by a brief interview for mental status (BIMS) less than 13. The resident was severely impaired. An intervention was to provide the resident with prompts and cues as needed. A care plan, dated 9/24/24, indicated Resident 40 required assistance with ADLs (activities of daily living) including bed mobility, transfers, and toileting related to decreased mobility, cognitive deficits, right sided hemiplegia, and retardation. A care plan, revised on 10/1/24, indicated Resident 40 was at risk for falls due to a history of falls, cognitive deficits, communication deficit, anoxic brain damage, developmental delay, anxiety, and panic attacks. The goal was to reduce her fall risk factors to avoid significant injury. Interventions included her being placed on the morning get-up schedule per her request to be up early and she will be seen first by the wound physician so she can get up for the day. During an interview, on 10/2/24 at 2:25 p.m., the DNS indicated their mobile x-ray service would call and fax the results of an x-ray to the facility. She indicated she did not keep the faxes, so she did not know when the fax arrived at the facility. The doctor should have been notified when the x-ray results came in. During an interview, on 10/2/24 at 2:29 p.m., the Regional Director of Clinical Support (RDCS) indicated the SBAR communication (physician communication tool to provide the situation, background, assessment, and recommendation) with the physician indicated Resident 40's x-ray was abnormal on 9/10 at 9:46 am. During an interview, on 10/3/24 at 11:22 a.m., the DNS indicated the x-ray results was reported back to the facility on [DATE] at 1:20 a.m. She indicated she did not know the time because she did not keep the faxes. She indicated the staff was aware of the x-ray at 2:01 a.m. and notified the Nurse Practitioner (NP). The NP responded with, Send out. During an interview, on 10/3/24 at 11:52 a.m., Resident 40's brother indicated the facility called and indicated she fell out of bed and injured her knee. The facility had the x-ray results, and her leg was fractured. They called the morning it happened and indicated she was going to the emergency room (ER). He was annoyed that she had to wait in the ER lobby for 5 hours before being seen. He did not know why the facility sent her to the ER by the facility bus. He clearly stated he did not request that she go to the ER by the facility bus. During a phone interview, on 10/3/24 at 1:30 p.m., the local mobile x-ray company Representative 18 indicated when they received a positive result (fracture), they called the facility with the results. On 10/4/24 at 9:55 a.m., the DNS indicated the facility used progress notes and SBAR for tracking behaviors. We had no specific tracking device for behaviors. During an interview on 10/4/24 at 2:15 p.m., the DNS asked Resident 40 to stay in bed because the wound physician would be coming around. The resident was playing in her feces with her BM everywhere. CNA 17 was in Resident 40's room working with her roommate. She told Resident 40 she would give her a shower next. Resident 40's raised the level of her bed and toppled out onto the floor. The DNS indicated she was not aware of the resident raising the bed before then. The wound physician had made it to her hallway, but she did not know if he was able to see her or not. SBAR documentation, dated 9/9/24 at 10:19 p.m., between the facility and the NP, was provided by the RDCS, on 10/7/24 at 10:30 a.m. It indicated Resident 40 had a fall this morning, she was not complaining of pain while she propelled herself in the hallways and dining room, but when she was put in bed, she started yelling and complaining of pain. Her PRN medication was provided but did not relieve her pain. Her right knee was observed to be swollen, and she felt pain when it was touched. Requesting a STAT (immediate) order for a right knee x-ray. SBAR documentation, dated 9/10/24 at 2:01 a.m., between the facility and the NP, was provided by the RDCS, on 10/7/24 at 10:30 a.m. It indicated Resident 40 had a right distal femur displaced fracture. The new order was received to, Send out. SBAR documentation, dated 9/10/24 at 9:00 a.m., between the facility and the physician, was provided by the RDCS, on 10/7/24 at 10:30 a.m. It indicated Resident 40 had an abnormal x-ray of her femur. She was unstable, likely to get worse, bedside clinician requests to, send to ED for eval (evaluation) and tx (treatment) r/t (related to) distal femur rx (fracture). On 10/7/24 at 10:30 a.m., the RDCS provided an email, dated 10/3/24, from the Medical Director. It indicated, .The result of the radiograph (x-ray) was transmitted to the provider on call with response to send out the patient for assessment based on the finding of the right distal femur fracture .she was transported by facility bus to the Emergency Department for further assessment. Her care was transitioned to both internal medicine and orthopedics .she was maintaining stability without significant pain .she arrived at the ER about 9 am .(she) was formally assessed there until [sic] 3 pm. It was determined that she would need surgery, but no immediate intervention was provided other than being placed in a hinged brace During an interview, on 10/7/24 at 10:39 a.m., the Executive Director (ED) indicated regardless of whether Resident 40's roommate was getting care, the resident needed to stay in bed so the wound physician could she her on his rounds. She was seen by the wound physician consistently. During an interview with the ED, on 10/7/24 at 10:42 a.m., a request was made to interview the facility bus driver/CNA (certified nurse aide) who drove the resident to the hospital and stayed with her until her brother arrived. She indicated the bus driver no longer worked there and she would provide the phone number. No phone number was provided prior to exit. During a phone interview, on 10/7/24 at 1:53 p.m., a local mobile x-ray company medical records representative 19 indicated the facility contacted them for an x-ray on 9/9/24 at 11:16 p.m. Their x-ray technician arrived at the facility on 9/10/24 at 12:40 a.m., and completed the x-ray at 12:48 a.m. The x-ray was read, and the facility contacted by fax of a positive result (fracture) at 1:24 a.m. On 10/8/24 at 8:29 a.m., an email was received from the local mobile x-ray medical records representative. The email indicated the facility was not set up to receive phone calls, emails, or text alert when a positive result (fracture) was obtained. Therefore, the result of Resident 40's fractured femur was faxed only. A current policy, titled, Fall Management Policy, dated 08/2022, was provided by the Director of Nursing Services (DNS), on 10/3/24 at 1:00 p.m. A review of the policy, indicated, .It is the policy of American Senior Communities to ensure resident residing within the facility received adequate supervision and or assistance to prevent injury related to falls .If the resident experienced an injury from the fall, contact facility DNS/ED .Contact the physician will be contact immediately, if there are in[TRUNCATED]

Based on observation, record review, and interview, the facility failed to ensure that medications were not left unsupervised in a resident's room for 1 of 1 random observation (Resident 49) and failed to implement fall prevention interventions for a resident (Resident 37) for 1 of 3 residents reviewed for falls. Findings include: 1. On 10/2/24 at 10:32 a.m., a record review was completed for Resident 49. He had the following diagnoses which included but were not limited to type 2 diabetes mellitus (DM), hypertension (HTN), obstructive sleep apnea (OSA), hyperlipidemia (HLD), and generalized anxiety disorder (GAD). During an observation on 10/1/24 at 11:42 a.m., Resident 49 was in transmission-based precautions (TBP). Upon entering his room, it was noted he had a clear, plastic cup with approximately 8 pills inside the cup. Resident 49 indicated those were his morning medications. Resident 49's record lacked a self-medication administration assessment. During an interview with the Director of Nursing (DON) on 10/4/24 at 1:30 p.m., she indicated Resident 49 should not have had his medications left at bedside. A policy titled, General Dose Preparation and Medication Administration was provided by the DON on 10/3/24 at 1:42 p.m. It indicated, .Observe the resident's consumption of medication(s) . 2. On 10/2/24 a record review was completed for Resident 37. She had the following diagnoses which included but were not limited to osteoarthritis, HTN, HLD, and unspecified injury to the muscle. She had a history of falls with a care plan indicating she was at risk for falls due to: decreased mobility, incontinency, history of falls, cognition, age, refuses eye glasses at times and related to diagnoses of mental retardation, atrial fibrillation (a type of irregular heartbeat that causes the heart to beat faster and in an irregular pattern), seizures, intermittent explosive disorder, HTN, hypokalemia (low potassium), history of hyponatremia (when the level of sodium in your blood is lower than normal), osteoarthritis (OA), allergic rhinitis (allergies), tendon injury, hypertrophy of bone (a medical condition that causes abnormal bone growth and enlargement), fatigue, urinary tract infection (UTI), depression, constipation, history of COVID-19, fracture of left ulna, and malnutrition. Interventions included adding brake extenders to her wheel chair on 11/22/22 and bright colored tape to wheelchair brakes on 2/12/23. During an observation on 10/3/24 at 12:22 p.m., she did not have brake extenders or colored tape to her brakes on her wheelchair as care planned. She had written orders on 3/22/23 for brake extenders and on 2/8/23 for bright colored tape to wheelchair brakes. During an interview with the Director of Nursing (DON) on 10/4/24 at 1:30 p.m., she indicated Resident 37 should have had brake extenders and bright tape to her brakes of her wheelchair. A policy titled; Interdisciplinary Care Plan (IDT) Comprehensive Care Plan Policy, was provided by the DON on 10/3/24 at 12:55 p.m. It indicated, .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each minimum data set (MDS) assessment . 3.1-45(a)

Based on record review and interview, the facility failed to initiate a pharmacy recommendation for 1 of 5 residents reviewed for pharmacy requests (Resident 13). Findings include: On 10/3/24 at 11:56 a.m., a record review was completed for Resident 13. She had the following diagnoses which included dementia, insomnia, major depression, and gastroesophageal reflux disease (GERD). A pharmacy recommendation was made on 6/21/24 to reevaluate the continued need for omeprazole (a medication for GERD) discontinue and initiate famotidine (a medication for GERD) 20 mg once daily with the end goal of discontinuation. The physician accepted the recommendation and left instructions to implement the recommendation as written. The facility failed to implement the new order for famotidine 20 mg daily. On 10/4/24 at 2:10 p.m., the Director of Nursing (DON) was interviewed. She indicated she could not find where famotidine was ever initiated but did find where Tums as needed (PRN) was initiated instead. A policy titled; General Dose Preparation and Medication Administration was provided by the DON on 10/3/24 at 1:42 p.m. The policy did not discuss pharmacy recommendations and new order changes. 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(a)(6)

Based on interview and record review, the facility failed to ensure lab specimens were obtained immediately with symptoms of urinary tract infection and laboratory results were reviewed in a timely manner for a resident with an indwelling urinary catheter to prevent urinary tract infection for 1 of 3 residents reviewed for quality of care (Resident F). This deficient practice resulted in a delay of treatment and the resident developed urosepsis with acute kidney failure with a systemic inflammatory response syndrome (SIRS) and died . Findings include: During a confidential interview, it was indicated Resident F's family member received a phone call on [DATE]. The facility wanted to confirm Resident F's Do-Not-Resuscitate (DNR) orders because he had an infection and experienced a change in condition. The family member wanted Resident F to be sent out to the hospital, had been unaware that Resident F was being treated for an infection, and that his condition had worsened so severely. Resident F had a history of infections. When the family member arrived to the facility, there was an ambulance at the front door. EMS and the facility nurse said there was nothing more they could do for Resident F, and the resident took his last breaths moments after the family walked into the room. On [DATE] at 10:55 a.m., Resident F's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, history of a cerebral infarction (stroke, bleeding in the brain) which resulted in left side hemiplegia and hemiparesis, (similar conditions that cause weakness on one side of the body), Alzheimer's disease (a degenerative brain disease with affects memory and cognition) and he required the use of a suprapubic catheter (a surgically created connection between the urinary bladder and the skin through the abdominal cavity used to drain urine from the bladder in individuals with obstruction of normal urinary flow) related to neuromuscular dysfunction of the bladder. Resident F had a Physician's Scope of Treatment (POST) form dated [DATE]. The POST form gave instruction for Resident F to be a DNR if the patient had no pulse AND was not breathing, and also specified his wishes for main treatment goals were to give, full interventions including life support measures in the intensive care unit. In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation, advance airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated to meet medical needs. Resident F had a care plan, initiated [DATE], which indicated he required the use of a suprapubic catheter related to his diagnosis of neurogenic bladder. Interventions for this plan of care included, but were not limited to, report complications/UTI: acute confusion, bladder spasms, low back/flank pain, malaise, nausea, emesis, chills, fever, foul odor, concentrated urine, blood in urine .staff to record urinary output in milliliters Resident F had a care plan, initiated [DATE], which indicated he had the potential for pain related to his diagnoses which included, but was not limited to, back pain. Interventions for this plan of care included, but were not limited to, Notify MD [Medical Doctor] if pain is unrelieved and/or worsening. On [DATE] at 11:04 a.m., Resident F's Medication Administration Record (MAR) indicated he complained of back pain on a scale of 7 out of 10. An as needed (PRN) physician order for 500 milligrams (mg) of extra-strength Tylenol was administered and effective until 4:39 p.m., when he complained of increased pain at a level 9 out of 10. A second dose of his PRN Tylenol was administered. There was no documentation on the MAR, progress notes, or within the resident's electronic record that the physician was notified of resident's worsening pain. On [DATE] at 3:12 p.m., Resident F's MAR indicated he complained of pain at a level 9 out of 10 and his PRN Tylenol was administered. There was no documentation on the MAR, progress notes, or within the resident's electronic record that the physician was notified of resident's continued back pain. A Nurse Practitioner (NP) progress note, dated [DATE] at 4:09 p.m., indicated nursing staff requested the NP visit due to increased confusion. seen today for confusion. He has a history of dementia with acute worsening of confusion. He is seen today, sitting up in his wheelchair. Nursing noted increased confusion over night. He asked what time dinner was after he just finished dinner. They also noted purulent drainage around SP cath [suprapubic catheter]. On exam, he is awake but drowsy in his wheelchair. He has a low grade temp of 99.3. Other VSS [vital signs stable]. He denies SP [suprapubic] pain but does endorse CVA tenderness [Costovertebral angle- CVA tenderness often indicates kidney pathology]. His SP cath has purulent sediment noted in the tubing . The NP ordered STAT (an task that is to be completed immediately. The standard time for STAT lab results is 90 minutes, or one hour or less from specimen receipt) for a CBC (Complete metabolic panel), BMP (Basic Metabolic Panel), and urinalysis. A Lab requisition form, dated [DATE], with a timestamp that was not visible, indicated Resident F's urine sample had been collected at 4:00 p.m. The requisition did not indicate or specify STAT status. At the bottom of the requisition, Lab Use Only indicated the urine sample was not collected by the lab until [DATE] at 7:33 a.m. A nursing progress note, dated [DATE] at 4:00 p.m., indicated, collected urine specimen for STAT UA C&S [urinalysis with culture and sensitivity] stored in lab refrigerator for pick up. During an interview on [DATE] at 2:00 p.m., the Director of Nursing (DON) indicated the facility did not have a policy or procedure related to lab services/STAT lab services. On [DATE] at 1:33 p.m., the Senior [NAME] President (SVP) of Customer Service for the contracted Lab Service company provided a copy of the Lab's timeline of events for the Resident F's STAT lab order as follows: a. Order for STAT labs was received on [DATE] at 2:54 p.m. b. On [DATE] at 7:03 p.m., a Lab Associate called the facility to notify them, a Lab Technician would not be available until the next morning and made a note, nurse didn't answer page. c. On [DATE] results of the CBC were faxed at 10:41 a.m., the BMP results were faxed at 11:42 a.m., and the UA results were faxed at 10:49 a.m. On [DATE] at 9:00 a.m., the DON provided a copy of Resident F's urinalysis lab results. The results were dated [DATE] at 8:27 a.m. and were positive for signs of infection as the urine was cloudy and orange with white blood cell (WBC) clumps, many bacteria and a large amount of Leukocytes were present. The results were initialed by the NP as reviewed on ,d+[DATE]. On [DATE] at 9:00 a.m., the DON provided a copy of Resident F's C&S results. The results were reported [DATE] at 10:39 a.m. and indicated the presence of Proteus mirabilis (a gram-negative bacterium that is a common cause of catheter-associated urinary tract infections). During an interview on [DATE] at 10:24 a.m., the NP indicated she received the urinalysis results at home over the holiday weekend and decided to wait for the C&S before she ordered a treatment because he had a history of frequent infections. The NP indicated she did not remember what time she received the urinalysis or the C&S results. Resident F's electronic record including, but not limited to, vital signs, and progress notes, lacked documentation of a set of vital signs or resident assessment over the weekend on [DATE] or [DATE]. Resident F's electronic record including, but not limited to, events, documents, and progress notes, lacked documentation of assessment/monitoring of his suprapubic catheter (SP cath) insertion cite and/or tubing/drainage system after signs of an infection had been noted on [DATE]. A nursing progress note, dated [DATE] at 11:26 p.m., indicated at 4:00 p.m., Resident called for help in a very faint voice, resident panting, cyanotic [bluish-purplish discoloration] lips and legs, cold clammy all extremities, bloody urine noted in urine bag. Temperature: 101.5, unable to get BP [blood pressure] and O2 [oxygen] saturation. Placed on 2 L [liters] O2 via nasal cannula Eventually obtained BP of ,d+[DATE], pulse of 124, O2 sat of 99% at 2L O2 via nasal cannula. DON and on call NP notified. On [DATE] at 12:47 p.m., the DON provided a copy of the On-Call Provider correspondence which indicated the following: On [DATE] at 4:25 p.m., the facility nurse messaged the On-Call Provider to report Resident F's change in condition and indicated, .last week he started to have confusion and back pain. Pus and redness noted on SP cath insertion site, cloudy urine, now it's bloody, redness on SP region . The NP responded (with no timestamp noted) and indicated to administer Rocephin (antibiotic) 1 gram (gm) IM (intramuscular) now and place a peripherally inserted central catheter (PICC) to administer Vancomycin (antibiotic) 1 gm now then to have the pharmacy determine the dose time for additional Vancomycin over the next 7 days. The provider ordered STAT labs for diagnosis of sepsis. Nursing was to administer Tylenol 650 milligrams (mg) every 4 hours and as needed (PRN) ibuprofen 400 mg every 6 hours for fever. Once temps trended down vital signs were to be obtained every 4 hours for 24 hours. Additional orders included a chest x-ray after PICC placement. The facility nurse responded (with no timestamp notes), phlebotomist was not able to put PICC but she was able to put a midline [a long, flexible tube inserted into a vein in the upper arm to administer medication or fluids into the bloodstream], I will give Vancomycin IV now. At 7:49 p.m., the facility nurse responded, .we ran out [Vancomycin] in the EDK [Emergency Drug Kit], I called pharmacy to expedite vancomycin one time 1 gram IV. At 8:01 p.m., the facility nurse notified the On-Call Provider, Vancomycin came, he is now much better after Rocephin . A nursing progress note, dated [DATE] at 1:15 p.m., indicated the results of the chest x-ray concluded no abnormalities, infiltrate or effusion. An NP Progress note, dated [DATE] at 3:38 p.m., indicated Resident F was, .seen today for AKI [Acute Kidney Injury] and SIRS [Systemic Inflammatory Response Syndrome]. He was seen Friday for AMS [altered mental status] at which time, labs were ordered. Labs reviewed . Yesterday, on call provider was called after nurse noted hematuria, increased weakness, low grade temp and tachycardia. On call provider ordered Rocephin IM x 1 and Vancomycin. After discussion with pharmacy, vanc [vancomycin] had to be discontinued because of elevated creatinine and dosing being every 72 hours. He is seen today, resting in his bed. He is awake, confused and agitated. He does report that he has not been feeling well. He remains tachycardic but is afebrile on exam. His SP cath is draining dark, brown urine with purulent drainage at SP site. He is 97% [02 saturation] on room air with no reported hypoxia, cough or dyspnea. He has a RUE [right upper extremity] midline in place. He meets SIRS criteria with fever and tachycardia. Likely urinary source, however culture is <100,000. He has a history of Proteus UTI as well as EColi with ESBL. Will start rocephin and if no improvement will transition to Merrem . The NP ordered to start IV fluids and a renal ultrasound. On [DATE] at 5:20 a.m., Resident F had bloodwork drawn for a CMP and the results were reported on [DATE] at 1:46 p.m. His Creatine level rose from 4.6 to 6.7 and his BUN level was elevated at 94. A nursing progress note, dated [DATE] at 10:45 a.m., indicated Resident F, .continues on second liter of IVFs [intravenous fluids] per MD order . On [DATE] at 5:10 a.m., Resident F had bloodwork drawn for a BMP and the results were reported on [DATE] at 1:57 p.m. His BUN level rose and was now critically high at 102. A nursing progress note, dated [DATE] at 2:50 p.m., indicated, .Received call from lab regarding critical high urea nitrogen 102. On call NP notified, NP ordered additional 1L NaCl 0.9% 100ml/hr, and repeat BMP in AM. Lab request placed, resident completed 2 L NaCl 0.9%. Hooked additional 1 L NaCl 0.9% 100 ml/hr A nursing progress note, dated [DATE] at 2:07 p.m., indicated, an ultrasound technician had been unable to complete a renal ultrasound due to unable to obtain clear imaging and the NP was notified. A late nursing progress note, created, [DATE] at 3:54 p.m., and set as effective for [DATE] at 8:30 p.m. indicated, Resident's SP cath was changed per order and a 22 French catheter was inserted. Resident tolerated the change well and urine output flowing with ease. On [DATE] at 8:26 a.m., Resident F had bloodwork drawn for a CMP and the results were reported on [DATE] at 1:12 p.m. His BUN and Creatine levels remained elevated. His BUN was still critically high at 101. A nursing progress note, dated, [DATE] at 6:14 a.m., indicated during morning care the Certified Nursing Aide (CNA) called the nurse into room to show the discoloration to Resident F's left side of abdominal area. The area was hard to touch. The resident did not complain of pain when touched. Resident's name was put in the doctor's binder to be reviewed. During an interview on [DATE] at 9:00 a.m., the DON provided the Doctor's Binder for review. She indicated the binder was an internal tool used by the nurses to put notes and concerns related to resident conditions, so that when the MD or NP came in, they would look through the Doctor's Binder to review and see residents as needed. The DON looked for notes related to Resident F from May, 2024, but was unable to locate any. When the DON contacted the NP, the NP indicated she threw the old pages away after the resident's had been seen. A nursing progress note, dated [DATE] at 8:10 a.m., indicated a second nurse was notified by a CNA .that resident had a large hematoma to side of ABD [abdomen], writer assessed area and it was hard to touch, resident did not c/o pain .Vital signs were within normal limits. The NP was informed of findings. NP had seen him during the week, and would see him this morning. On [DATE] at 4:20 a.m., Resident F had bloodwork drawn for a BMP and the results were reported on [DATE] at 12:05 p.m. His BUN was even more elevated and critically high at 105. Resident F's electronic record lacked documentation, and no documentation or evidence was provided by the DON, NP, or any facility staff before exit, to indicate his increased and critically high BUN level had been reviewed. During an interview on [DATE] at 10:24 a.m., the NP could not recall if there was a note on her Doctor's Binder. The NP had seen Resident F on the morning of [DATE] and saw the discolored area. The NP described the discoloration as a large bruise that was tender to touch, but at that time he had been eating breakfast so she told him she would come back later in the day to see him again. The NP indicated the bruising could be a symptom of worsening SIRS, but the NP still felt comfortable treating Resident F in-house. The NP indicated she had been asked to come back around lunch time, to re-assess and check on Resident F as he had another change of condition. The NP indicated when she saw him, he was not well. They called Resident F's family member and reviewed his code status as a DNR, but also asked if the family would like him sent to the ER. The Family member did want him sent out. By the time EMS got to the facility, they determined due to Resident F's DNR status, he was too far gone and there was nothing more they could do except let him pass away. On [DATE] at 9:00 a.m., the DON provided a copy of the lab contract. The document was titled, American Senior Communities, L.L.C. Service Agreement, Service Agreement: Clinical Laboratory Services which was dated [DATE]. The contract indicated, .Vendor will provide Lab Services to ASC Locations in accordance with each ASC Location's policies .Vendor provides STAT (life threatening situation) services 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within four (4) hours . Vendor shall respond to an ASC Location's request for STAT Services within 30 minutes and notify ASC Location of the time that Vendor will arrive . Critical and STAT results will be phoned to the ASC Location as soon as they are available The contract did not indicate/specify a timeframe and/or a minimum number of attempts to contact the facility for Critical/STAT labs. According to the Lab Contract specifications, Resident F's urine specimen should have been picked up, processed and reported by [DATE] at 8:00 p.m. but was not picked up until more than 11 hours later. The facility did not have a policy for the Lab Service to indicate/specify a timeframe and/or a minimum number of attempts should be required to report Critical/STAT labs, and/or have facility nursing staff follow up on Critical/STAT labs. On [DATE] at 9:00 a.m., the DON provided a copy of current facility policy titled, Resident Change of Condition, revised ,d+[DATE]. The policy indicated, It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .1. Life Threatening Change: the licensed nurse will notify the family/representative party of resident change of condition and document in the medical record .2. Acute Medical Change: any acute or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken . Non-Urgent Medical Change: . the nurse in charge is responsible for notification of physician and family/representative party prior to end of assigned shift when a significant change in the resident's condition is noted. If unable to reach the physician or family/representative party, all calls to physician's or exchanges and family/representative party requesting callbacks will be documented in the medical record . the licensed nurse responsible for the resident will continue assessment and documentation in the medical record every shift until the resident's condition has stabilized This citation relates to Complaint IN00438092. 3XXX,d+[DATE](a)(2)

Based on interview and record review, the facility failed to ensure a resident, (Resident E) received treatments and services in accordance with his guardian's wishes. This deficient practice had the potential to effect 1 of 3 residents reviewed for quality of care. Findings include: During an interview on 8/1/24 at 12:11 p.m., Resident E's guardian indicated, she had received a call from Nurse Practitioner, (NP) on 6/14/24 who indicated, Resident E had not eaten or drank anything and had been sleeping more than usual. The guardian asked the NP, did she believe this change in his condition was related to the progression of his dementia, or could there be something else going on. The NP told the guardian, she did believe the decline was related to his dementia. The NP asked the family about changing his code status from a Full Code, too a Do-Not Resuscitate (DNR). Because the guardian lived out of state, she told the NP she wanted her brother to go visit Resident E first, before she made a decision about changing his code status, however, during a care plan meeting on June 27th, the guardian was informed, her brother had been asked and signed a DNR POST form which the guardian had not agreed to. The guardian indicated, no one was authorized to sign off, and/or make treatment changing decision about Resident E's care except for her. The guardian indicated, she was upset to learn that her brother had been asked to sign the DNR, and that his overall treatment plan and goals had been changed to palliative care without her knowledge or consent. During an interview on 8/1/24 at 12:58 p.m., Resident E's son indicated, his sister was Resident E's guardian, but she lived out of state, so he was often asked to visit Resident E on her behalf to check on his condition. He indicated, there was some confusion on the part of the facility and Resident E's DNR was presented to him under the assumption that his dementia had gotten worse and that he was at the end of his life, basically, he was getting ready to pass. Resident E's son indicated, the NP [NAME] him a DNR form and said it was OK for him to sign it. Resident E's son indicated he regretted signing the form, because it was presented to him as already approved by the guardian. On 7/31/24 at 10:00 a.m., Resident E's medical record was reviewed. He was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, Parkinson's disease a chronic, progressive brain disorder that affects the body's motor and non-motor systems) Alzheimer's disease (a degenerative brain disease which affects memory and cognition), Peripheral vascular disease (a progressive disorder that occurs when blood vessels outside of the heart or brain narrow, block, or spasm) and Atherosclerosis (the thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery). Resident E had a physician's order to be a full code which had been initiated 3/28/24, but was discontinued on 6/19/24. A POST form dated 6/18/24, changed his code status from a full code to a DNR with comfort measures. The POST was signed by Resident E's son and the NP. A document titled, Permanent Guardianship, dated 12/3/2020 indicated, .grated [name of Resident E's guardian] the authority to administer the permanent guardianship of the Person and Estate of [Resident E's name]. Said guardian shall have all of the authority of permanent guardianship under I.C. 29-3-7-3 A Social Service care plan meeting and documentation progress note dated 6/17/24 at 10:29 a.m., indicated, Resident E had a legal guardian who requested the resident remain a full code. A NP progress note dated 6/18/24 at NP 1:43 p.m., indicated, Resident E was .seen today in f/u [follow up] for hypernatremia. Labs reviewed and sodium remains elevated at 155 and creatinine up to 2.0. He is resting in bed with SQ button in place. He previously discontinued his Midline. Daughter called to discuss resident declining condition with poor PO [by mouth] intakes and labs. Daughter states that her father was previously a DNR with comfort care. Son in building. Reviewed POST form and signed DNR comfort measures. Discussed declining condition with poor PO intakes. He has the same wishes as his sister. Both agree on palliative care with comfort focused care. The NP gave new orders at that time to DC the SQ button and added morphine (a narcotic pain medication) and lorazepam (an anti-anxiety medication) as needed. A nursing progress note dated 6/18/24 at 9:49 p.m., indicated, Resident E's son (an not his guardian) had been notified of the new orders to DC all labs, doppler, and was placed on palliative care with morphine and lorazepam as needed. Cross reference F684. This citation relates to Complaint IN00438111. 3.1-4(l)(4)

Based on interview and record review, the facility failed to ensure the family/representative for a resident, (Resident F) was notified of a change in condition related to an acute urinary tract infection (UTI) which resulted in urosepsis-associated acute kidney injury/failure, (SA-AKI) and had a systemic inflammatory response (SIRS) for 1 of 3 residents reviewed for quality of care. Findings include: During a confidential interview, it was indicated, Resident F's family member received a phone call on the day he passed away which was 5/31/24. The facility wanted to confirm Resident F's Do-Not-Resuscitate (DNR) orders because he had an infection and experienced a change in condition. The facility asked if the family member wanted Resident F to be sent to the hospital. The family member did want Resident F to be sent out and had been unaware that Resident F was being treated for an infection and that his condition had worsened so severely. Resident F had a history of infections and they could get bad fast. When the family member arrived to the facility, there was an ambulance at the door. When the family member got to Resident F's room, EMS and the facility nurse said there was nothing more they could do, and he took his last breaths moments after the family walked into the room. The family member indicated they were shocked and in denial that this had happened so quickly and did not understand why they had not been made aware of the infection in the first place. On 7/30/24 at 10:55 a.m., Resident F's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, history of a cerebral infarction (stroke, bleeding in the brain) which resulted in left side hemiplegia and hemiparesis, (similar conditions that cause weakness on one side of the body), Alzheimer's disease (a degenerative brain disease with affects memory and cognition) and he required the use of a suprapubic catheter (a surgically created connection between the urinary bladder and the skin through the abdominal cavity used to drain urine from the bladder in individuals with obstruction of normal urinary flow) related to neuromuscular dysfunction of the bladder. Resident F had a Physician's Scope of Treatment (POST) form dated 4/16/2020. The POST form gave instruction for Resident F to be a DNR if the patient had no pulse AND was not breathing, and also specified his wishes for main treatment goals were to give, full interventions including life support measures in the intensive care unit. In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation, advance airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated to meet medical needs. Resident F had a care plan, initiated on 11/1/2012, which indicated he was in the facility for long term placement. Interventions for this plan of care included, but were not limited to, encourage family/friends to stay involved in resident care. A STAT (immediate) New Order Documentation/Temporary Care plan was initiated on 5/24/24 at 3:13 p.m. Notification to the family/representative was not noted as completed until 5/31/24 at 12:22 p.m. Resident F's condition continued to decline over the weekend of May 25th-26th with critical lab results and acute SIRS related bruising. Cross Reference F690. The record lacked documentation, and documentation and/or evidence was not provided before the time of exit, to indicated Resident F's family had been notified of his acute change of condition. On 7/31/24 at 9:00 a.m., the DON provided a copy of current facility policy titled, Resident Change of Condition, revised, 11/2018. The policy indicated, It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .1. Life Threatening Change: the licensed nurse will notify the family/representative party of resident change of condition and document in the medical record .2. Acute Medical Change: any acute or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken . Non-Urgent Medical Change: . the nurse in charge is responsible for notification of physician and family/representative party prior to end of assigned shift when a significant change in the resident's condition is noted. If unable to reach the physician or family/representative party, all calls to physician's or exchanges and family/representative party requesting callbacks will be documented in the medical record This citation relates to Complaint IN00438092. 3.1-5(a)(2)

Based on record review and interview, the facility failed to update a skin care plan for a resident with skin breakdown for 1 of 3 residents reviewed for care plans (Resident D). Findings include: On 7/31/24 at 12:13 p.m., a record review was conducted for Resident D. He had the following diagnoses which included, but were not limited to, cerebral infarction (stroke), Parkinson's disease, and diabetes mellitus. Resident D had a skin event, dated 7/17/24, indicating he had skin breakdown to his coccyx measuring 1.0 centimeters (cm) by (x) 1.0 cm x 1.0 cm. Resident D's care plan, dated 6/14/24, indicated resident was at risk for skin breakdown related to decreased mobility, incontinence, friction/shearing, and related to diagnoses of CVA (Cerebral Vascular Accident) with left sided hemiplegia (paralysis), adult failure to thrive, aphasia (loss of ability to understand or express speech, caused by brain damage), and HLD (hyperlipidemia). On 8/1/24 3:20 p.m., during an interview with the Director of Nursing Services (DNS), she indicated an event was a care plan that was good for at least seven days, after that the care plan should be updated. A policy titled, IDT (Interdisciplinary Team) Comprehensive Care Plan Policy, dated 8/2023, was provided by the MDS (Minimum Data Set) Coordinator on 8/1/24 at 3:27 p.m. It indicated, .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment This citation relates to Complaint IN00438994. 3.1-35(c)(1)

Based on record review and interview, the facility failed to ensure nursing staff accurately and thoroughly assessed and completed neurological checks after a resident fell , and when the resident fell a second time on the same day, staff failed to report or document the fall, resulting in a lack of assessment and delay of treatment for [REDACTED]. The Immediate Jeopardy began on [DATE] when Resident C had two unwitnessed falls. Staff assisted the resident up after the second fall, but failed to document the fall, or initiate the fall protocol to ensure neurological assessments were conducted. Staff failed to accurately assess Resident C's change in condition until family observed the change in the resident's condition. Resident C was sent to the hospital where a Computed Tomography (CT) scan found multiple intracranial hematomas which resulted in Resident C's death at 10:17 p.m., on [DATE]. The Executive Director (ED), Director of Nursing Services (DNS), and Regional Director of Clinical Services were notified of the Immediate Jeopardy at 4:40 p.m. on [DATE]. The Immediate Jeopardy was removed on [DATE] and the deficient practice corrected on [DATE] prior to the start of the survey and was therefore Past Noncompliance. Findings include: Resident C's record was reviewed on [DATE] at 1:08 p.m. [DIAGNOSES REDACTED]. A face sheet indicated the resident was admitted to the facility on [DATE] and expired at the hospital on [DATE]. An admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had a severe cognitive impairment, and required extensive assistance of one staff member for transfers and toilet use. A care plan, start date [DATE], indicated the resident was at risk for falls. A fall risk assessment, dated [DATE], indicated the resident was at high risk for falls. A Fall Event, dated [DATE] at 4:30 a.m., indicated the resident had an unwitnessed fall. Prior to the fall, the resident was lying in bed. The immediate intervention was to assist the resident to the toilet every two hours. The resident's physician and representative were notified of the fall. A nurse's note, dated [DATE] at 4:30 a.m., indicated the nurse was notified the resident was found on the floor naked with the brief and gown on the floor beside her. The resident was assessed, and stated she hit her head, but could not say where on her head. There was a pea sized bump on her forehead, and an ice pack was applied. Vital signs and neurological checks were initiated and within normal limits. The resident indicated she tried to take herself to the bathroom because she did not want to bother anyone. Prior to the fall, the resident was checked between 11:30 p.m., and 12:00 a.m., and was found to be naked in bed. The nurse put the resident's gown back on and changed her brief related to urinary incontinence. The Director of Nursing Services (DNS) and the Nurse Practitioner (NP) were notified. A New Skin Event, dated [DATE] at 4:30 a.m., indicated the resident had a bruise or hematoma to the forehead. The area measured approximately one centimeter (cm) by 1 cm. The physician and the resident's representative were notified. A neurological assessment, dated [DATE] at 4:30 a.m., indicated the resident's blood pressure was ,[DATE], temperature 98.0 degrees Fahrenheit (F), pulse 61, respirations 16 and normal, pupils were size 3 and reactive to light, upper extremities were strong, lower extremities were weak, consciousness was oriented, speech clear, responded to name, touch, and environment, and no abnormalities were noted. Neurological assessments were documented as completed on [DATE] at 4:45 a.m., 5:00 a.m., at 5:15 a.m., 5:45 a.m., 6:15 a.m., 6:45 a.m., 7:15 a.m., 8:15 a.m., 9:15 a.m., 10:15 a.m. and 11:15 a.m. with no abnormalities noted. A nurse's note, dated [DATE] at 6:00 a.m., indicated the resident's daughter was notified of the resident's fall. A neurological assessment, dated [DATE], sometime during the 6:00 a.m. to 2:00 p.m. shift, indicated the resident's blood pressure was ,[DATE], temperature 97.8 degrees F, pulse 90, respirations 18 and normal, pupils were size 3 and reactive to light, upper extremities were strong, lower extremities were weak, consciousness was oriented, speech clear, responded to name, touch, and environment, and no abnormalities were noted. A nurse's note, dated [DATE] at 12:30 p.m., from Licensed Practical Nurse (LPN) 3 indicated the resident was alert and oriented with clear speech. The resident was assisted to the bathroom and toileted. A small bump remained to the forehead. The note lacked documentation of any further falls. A nurse's note, dated [DATE] at 1:03 p.m., from LPN 3 indicated the resident was checked on frequently for toileting and safety related to the recent fall. Range of motion and vital signs were within normal limits. A small bump remained to the forehead, and an ice pack was applied. No change in mental status was observed. The resident was alert and oriented with mild confusion. The note lacked documentation of any further falls. A nurse's note, dated [DATE] at 4:30 p.m., from LPN 3 indicated at around 2:00 p.m., LPN 3 was notified the resident was hard to arouse. Upon assessment, the resident was mouth breathing and had an oxygen saturation of 88 percent. Oxygen was placed on the resident at two liters (L) via nasal cannula. The resident's daughter was crying outside of the facility's window and yelled, Send her to the emergency room now. 911 was called, and the resident was sent to the hospital. An order was obtained to send the resident. The DNS was notified. The note lacked documentation of any further falls. An ER Transfer Form, dated [DATE] at 5:44 p.m., indicated the resident was transferred to the ER at 3:01 p.m., related to mouth breathing and difficult to arouse. A Physician Communication Tool Event, dated [DATE] at 6:09 p.m., was completed by LPN 3. The Event indicated the resident's blood pressure was ,[DATE], temperature 97.5 degrees F, pulse 90, and respirations 22. The resident did not use oxygen. The mental status section indicated the resident was lethargic, may be unable to swallow, and unable to follow commands. The resident's problem area seemed to be undetermined, and the problem was uncertain, but the patient was deteriorating. The recommendation from LPN 3 was to send the resident to the emergency room (ER) per the family's request. An ER Preliminary Report physician progress notes [REDACTED]. The daughter called the facility to check on the resident and was told she fell recently, hit her head, but was fine. There was a bump on her head. Emergency Medical Services (EMS) reported oxygen saturation of 85 percent bagging (using a manual resuscitator to assist the resident to breathe), pulse 50, blood pressure ,[DATE], and Glasgow Coma Scale (GCS) (a clinical scale used to reliably measure a person's level of consciousness after a [MEDICAL CONDITION]) score of four (indication of severe head injury). Medical decision making included a consult with a trauma surgeon who indicated the resident had a, .non-survivable head bleed. Agreed there is nothing to do ., and a consult with the neuro reading room who indicated the resident had a, .large brain bleed The assessment and plan indicated fall, altered mental status, acute hypoxic [MEDICAL CONDITION], and [MEDICAL CONDITION] (bleeding within the brain). A CT scan of the head, dated [DATE], indicated the resident had a GCS of four, reported per the resident's daughter there had been a recent fall, resident found unresponsive, [MEDICAL CONDITION] (fast heartbeat), and hypoxic (low oxygen level in the body). The CT scan indicated a large intra-axial hematoma (bleeding within the brain itself) in the left frontal (area in the front of the brain) and parietal (area towards the middle of the brain) lobe, with note of a component extending inferiorly (back) towards the midbrain and pons (a portion of the [DIAGNOSES REDACTED]), likely with extension into the fourth ventricle (located in the back area of the pons), a note of rightward subfalcine herniation (brain displacement), uncal herniation (occurs when rising intracranial pressure causes portions of the brain to flow from one intracranial compartment to another; this is a life-threatening neurological emergency and indicates the failure of all adaptive mechanisms for intracranial compliance) as well as cerebellar tonsillar herniation (brain compression), marked dilation of the right lateral ventricle (enlargement of the brain) suggestive of obstructive [DIAGNOSES REDACTED] (occurs when the flow of cerebrospinal fluid is along one of the passage connecting the ventricles), acute subdural hematoma (a pool of blood between the brain and its outermost covering) overlying the right parietal convexity and along the right tentorium (an area at the top of the cerebellum), scalp hematoma overlying the right parietal calvarium (the top part of the skull) without definite evidence of a calvarial fracture. A final report from the ER, dated [DATE], indicated the resident expired at 10:17 p.m. The preliminary cause of death was fall and [MEDICAL CONDITION]. An Interdisciplinary Team (IDT) note, dated [DATE], indicated the IDT reviewed the unwitnessed fall from [DATE]. Prior to the fall the resident was lying in bed resting. The Certified Nursing Assistant (CNA) reported to the staff nurse the resident was sitting on her bottom on the floor in front of the bed. Upon assessment, the resident had a pea size bump on her forehead. The resident stated she tried to go to the bathroom and did not want to bother anyone. The immediate intervention was to toilet the resident every two hours. IDT also agreed to place the wheelchair close to bed for safe transfers. The IDT note lacked documentation of a second fall on [DATE]. A Fall Event, recorded [DATE], and back-dated to [DATE] at 12:30 p.m., indicated the resident had an unwitnessed fall per the resident's roommate. The resident attempted to get out of bed and was sitting on her bottom on the floor beside the bed. The resident did hit her head. The physician was notified. The event lacked documentation the resident's representative was notified of the fall. On [DATE] at 2:24 p.m., the DNS provided an investigation packet for her investigation into Resident C's falls. At the same time, she indicated she discovered the resident fell a second time on [DATE] during her investigation of the first fall. The second fall had not been documented by the staff nurse. The investigation packet included: a. An undated witness statement, from Resident L, Resident C's roommate. Resident L indicated before lunch on [DATE], Resident C stood up on her own from bed, and fell backwards. Resident L went to get help, and the CNA got her up. Resident C hit her head on the floor, between the beds. b. An undated witness statement, from LPN 3 indicated at about 2:00 p.m., she was charting at the nurse's station and was alerted the resident was hard to arouse. Upon assessment, the resident was mouth breathing, lung sounds diminished, hard to arouse, and oxygen saturation was 88 percent. Oxygen was placed on the resident at two liters via nasal cannula. The resident's daughter was yelling and crying outside the window to send the resident to the ER now. 911 was called, and the resident was transported via ambulance. c. An undated witness statement, from Registered Nurse (RN) 5 indicated she was Resident C's nurse on the 10:00 p.m. to 6:00 a.m., shift on [DATE]. Between 11:30 p.m. and 12:00 a.m., she went into the resident's room to check her vital signs and found the resident naked in bed. She changed the resident. At 4:30 a.m., during her medication pass, CNA 4 told her the resident should have been one on one observation because she was disrobing. CNA 4 then told her the resident sat on the floor, was naked, and had the brief next to her. The nurse asked CNA 4 when that happened, as it was not reported to RN 5. CNA 4 told her it was that same day, on their shift. CNA 4 picked the resident up because she had sat on the floor. RN 5 educated CNA 4 to call the nurse prior to picking a resident up off the floor. CNA 4 insisted the resident always gets up, and she just sat down on the floor. RN 5 asked CNA 4 if she saw the resident sit on the floor, and CNA 4 said, No. RN 5 immediately assessed the resident, and she was responsive with normal vital signs and neurological checks. A pea sized bump was noted to her forehead, and an ice pack was applied. CNA 4 told RN 5 she picked the resident up around 2:00 a.m. The resident was closely monitored, and there was no change in mental status noted. The DNS was notified. d. A witness statement, dated [DATE], from CNA 4 indicated, on [DATE] at 12:30 a.m., she started bed check, and observed Resident C attempt to get out of bed into the wheelchair. She assisted Resident C to the wheelchair. She did not see any falls, but the resident's brief was on the floor. She notified the charge nurse immediately. e. An interview, dated [DATE], conducted by the DNS with CNA 6 indicated on [DATE] day shift, she cared for Resident C. Resident C's roommate came out into the hall and asked for help because Resident C fell . CNA 6 went directly into the resident's room. The nurse from the front of the hall came into the resident's room and said CNA 6 could get the resident up. CNA 6 assisted the resident to the bathroom and back to bed. LPN 3, Resident C's nurse, came into the room at one point, but left again. LPN 3 did not assess the resident. At lunch, CNA 6 was in the room when the resident was served. Resident C was very hard to wake up. CNA 6 notified LPN 3 it was hard to wake the resident up. f. A documented interview, dated [DATE], was conducted by the DNS with LPN 3. LPN 3 was asked if there were any falls on her day shift on [DATE], and she stated no. LPN 3 was asked if Resident C fell on her shift on [DATE], and she stated no. LPN 3 was asked how many times she checked on Resident C on her shift on [DATE], and she stated two or three times. LPN 3 was asked how to conduct a neurological assessment, and she stated she asked the resident to follow her finger with their eyes. The DNS informed her this is not how a neurological assessment is done and demonstrated how to properly conduct a neurological assessment. LPN 3 continued to deny there were any falls on her shift. During an interview, on [DATE] at 11:29 a.m., the resident's family indicated the resident fell about 2:00 a.m. on [DATE]. The facility called to let the family know about the fall on [DATE] at 6:00 a.m. They were told the resident was fine and just had a small bump on her head. They called the facility again around 9:00 a.m. and spoke with a different nurse. The second nurse indicated the resident was fine, and ice was placed on the bump on her forehead. They arrived for the window visit in the afternoon. The resident's roommate apologized to them about the resident's fall. The roommate said the staff brought the resident's lunch into her, but the resident would not wake up, so the food was left there. They family noticed the resident was unresponsive, with her legs drawn up, so they knew the resident had a head injury of some kind. They called the facility and told them to come down to the room. The staff performed a sternal rub, and told the family the resident was just sleeping, and they should come back later or the next day. The family told them to call 911 and send her to the hospital immediately. The resident had Cheyne(NAME)(periodic breathing) respirations at the time of the transfer. The family did not think the bump on the forehead was new. The resident had always had a little bump on her forehead from a very old injury. The resident actually hit the back of her head, not the forehead. There was no obvious bruising or injury to the resident's face. During an interview, on [DATE] at 2:24 p.m., the DNS indicated when she realized there had been a second fall, she put in a Fall Event to document it. This was a couple days later. They were able to best determine the second fall occurred on [DATE] around 12:30 p.m., according to the resident's roommate. CNA 6 told the DNS she saw the resident's roommate in the hall asking for help. CNA 6 immediately entered the resident's room and called for a nurse. The front hall nurse responded, but this was not the resident's assigned nurse. The front hall nurse told CNA 6 she could get the resident up off the floor. CNA 6 assisted the resident up, to the toilet, and back to bed. She did not think the resident was injured. LPN 3 was the resident's assigned nurse. The front hall nurse reported the fall to LPN 3. The front hall nurse and LPN 3 did nothing further regarding the fall. The fall policy was not followed. Neurological checks should have been re-started at an every 15 minutes interval, and this was not done. At 2:00 p.m., the resident was found nonresponsive and was sent to the hospital. She had a brain hemorrhage and died the same day. During an interview, on [DATE] at 3:05 p.m., the DNS indicated there was no specific facility policy for neurological checks. They should have been completed as indicated on the neurological assessment form, every 15 minutes for one hour, every 30 minutes for two hours, every one hour for four hours, and every eight hours for 72 hours. The neurological assessments should have been restarted at every 15 minutes for one hour at the time of the second fall. She thought the resident's family had been notified of the second fall but was not sure if this was documented. On [DATE] at 3:03 p.m., the DNS provided a document titled, Fall Management Program, and indicated it was the policy currently being used by the facility. The policy indicated, POLICY: It is the policy .to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .PROCEDURE: .Post fall: 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. A neurological assessment will be initiated on all un-witnessed falls. A neurological assessment will be initiated on all residents with a suspected head injury based upon the fall. 2. If the resident experienced an injury from the fall, contact facility DNS/ED per facility policy. 3. The physician will be contacted immediately, if there are injuries, and orders will be obtained .4. The family will be notified immediately by the charge nurse of falls with injury .5. A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions. 6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine the root cause and other possible interventions to prevent future falls. The fall event will be reviewed by the team. IDT note will be written. The care plan will be reviewed and updated, as necessary. The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed on [DATE] and the deficient practice corrected on [DATE] when the facility implemented a systemic plan that included all nurses were reeducated on the facility fall management program, all staff were reeducated on proper steps to take when a fall occurred, all staff and alert and oriented residents were interviewed to ensure no falls had gone unreported, all cognitively impaired residents had head to toe skin assessments completed to ensure no injuries went unreported, and Certified Nursing Assistant (CNA) 4 and Licensed Practical Nurse (LPN) 3 were terminated. The correction date was prior to the start date of the survey and was therefore Past Noncompliance. This Federal tag relates to Complaints IN 573 and IN 483. 3XXX,[DATE](a)

Based on interview, and record review, the facility failed to prevent neglect when a Licensed Practical Nurse failed to assess a resident for injury prior to moving her after a fall, and failed to report the fall resulting in a delay of treatment for [REDACTED]. The immediate jeopardy began on 4/13/19 when Resident B fell forward out of wheelchair on the evening of 4/13/19 when Certified Nursing Assistant (CNA) 7 was transporting her. Licensed Practical Nurse (LPN) 5 assisted the resident up prior to assessing the resident for injury. The resident was put to bed and no notification or documentation of the fall was made. The morning of 4/14/19, LPN 5 observed bruising and a hematoma on Resident B's face, then notified the physician and management of a fall indicating it had occurred on the morning of 4/14/19. Resident B was sent to the ER approximately 18 hours after the actual fall and was diagnosed with [REDACTED]. The Executive Director (ED), Director of Nursing Services (DNS), and Regional Director of Clinical Services were notified of the immediate jeopardy at 1:13 p.m. on 4/26/19. This immediate jeopardy was removed on 4/27/19, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 4/24/19 at 2:00 p.m., the Executive Director (ED) provided a report titled, Indiana State Department of Health Survey Report System, dated 4/15/19. The report indicated, Resident (B) had an unwitnessed fall event. Resident with bruising to forehead and orbital (around the eyes) area bilaterally. MD (physician) and family notified and order to send resident to ER (emergency room ) for further evaluation and treatment received . During an interview with the Power of Attorney (POA) on 4/24/19 at 11:06 a.m., the POA indicated he was contacted on 4/14/19 around 10:54 a.m., and told Resident B was found unconscious in her room at 7:00 a.m. that morning. The POA was told the resident fell and had a bump and a bruise. The facility staff indicated they did not feel it was necessary to send the resident out for further evaluation and treatment, and advised against sending her out to the emergency room . Upon receiving photos of the resident via his spouse's cellphone, the POA felt he had been lied to regarding the extent of his mother's injuries and requested she be sent to the hospital. The resident was observed by the POA's spouse in the dining room in a wheel chair, her face horribly bruised, and had her elbows on the dining room table propping her head up on her hands as she couldn't hold her head up. The resident ended up with [DIAGNOSES REDACTED]. The POA could not believe the staff had picked her up like that as they could have severed her spinal cord and killed her. The trauma doctor in the local hospital ER told the POA the bruising on the face pooled under the skin was an indication she had laid on the floor for a long period of time. The resident had been sent to a local emergency room , where they had been told they were not equipped to handle that type of trauma, so she was sent by ambulance to a trauma hospital. A record review was completed for Resident B on 4/24/19 at 10:05 a.m. The record indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of an Admission Minimum Data Set (MDS) assessment, dated 3/22/19, indicated Resident B had the ability to make herself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 7 indicated she had severe cognitive impairment. The resident required extensive assistance of 1 for bed mobility, transfers, and locomotion on and off the unit. She required a wheelchair. She had a fall in the last month, and during the 6 month time period before admission. A review of Progress Notes for Resident B, dated 4/13/19 to 4/22/19, indicated: On 4/14/2019 at 8:00 a.m., Licensed Practical Nurse (LPN) 5 indicated, writer found resident on the right side of her bed on the floor. Resident has bruising to both eyes and to forehead. Resident stated she was trying to get up. No other injuries noted .Family, DON (DNS) and MD notified. On 4/14/2019 at 12:21 p.m., LPN 6 indicated, Nurse Practitioner (NP) ordered Resident B to be sent for evaluation and treatment secondary to unwitnessed fall with bruising to bilateral orbitals. Son (POA) aware and requested her to be seen .(Ambulance company) in building to pick resident up at this time. On 4/14/2019 at 4:51 p.m., LPN 11 indicated she had received a call requesting copies of resident information, and was informed Resident B had been transferred from the original nearby ER to a trauma hospital due to trauma and fractures. On 4/14/2019 at 8:53 p.m., LPN 11 indicated updated information on Resident B was obtained from the trauma hospital, including the resident had a fracture of C2 (referred to as the hangman's fracture, the second bone down from the skull in the cervical (neck) vertebrae). A review of a tab, titled, Events, for Resident B, indicated: On 4/14/2019 at 6:50 a.m. on a Fall Event, LPN 5 indicated, Resident B had an unwitnessed fall in her room while sleeping in bed. The resident was first observed on the right side of the bed in her pajamas and non-skid socks. There was bruising to both eyes and to the forehead. Resident representative was notified. On 4/14/2019 at 7:07 a.m., on a New Skin Event, LPN 5 indicated, Resident B had bruising to both eyes and forehead. Hematoma (a solid swelling of clotted blood within the tissue) to inner corner of both eyes. A review of document for Resident B from (name of local hospital), titled, ER Report, dated 4/14/19 at 12:40 p.m., indicated, Patient had unwitnessed fall today, hit front of head. Bilateral orbital (around the eyes) bruising noted .Complaint of neck and upper back pain. C-Collar (cervical/neck collar) in place . A review of document for Resident B from (name of local hospital), titled Final Report, dated 4/14/19 at 1:00 p.m., indicated, Found down this morning, unknown time of fall and unknown downtime, placed in c-collar .patient mumbling words and history limited .moderate right frontal scalp hematoma (localized bleeding outside of blood vessels, due to either disease or trauma including injury) and soft tissue swelling. Patient cervical spine shows acute Type II odontoid fracture (fractures occur when the cervical spine is hyper flexed or bent severely backwards, or hyperextended and bent severely forward and can be caused by trauma such as a fall or whiplash), acute posterior arch fractures bilaterally of C1 (vertebra that is the uppermost vertebra in the entire spine, located roughly on the same plane as the base of the nose) .Consult 4/14/19 3:16 p.m. (names of physician and trauma hospital) accepts and requests the patient be transferred over, will be made a Trauma 2 activation (there is evidence of significant injury or mechanism of injury that will require a team approach to their care to expedite resuscitation and treatment) .Diagnosis: [REDACTED]. Plan: Transfer to (name of trauma hospital) Review of a document for Resident B from (name of trauma hospital), dated 4/14/19 at 4:46 p.m. The report indicated, from (name of local hospital) after an unwitnessed fall suffering multiple cervical spine fractures .unclear how long down, patient concerned about bruise and pain on anterior forehead, replies nonsensically about other questions regarding pain .cervical spine fractures, though confused patient is protecting airway .CT Abdomen/Pelvis .acute burst [MEDICAL CONDITION] (located in the middle of the lumbar or the abdominal segment of the spine) vertebral body with posterior-inferior vertebral body protrusion (extension outside the normal line) of 2 mm (millimeters) into the spine canal. L3-L4 intervertebral disc space widening .superior endplate compression deformity of L5 (lowest of the lumbar spine) vertebral body .right frontal scalp contusion (bruise) and hematoma .mildly displaced bilaterally posterior C1 ring fractures (C1 burst fracture), non-displaced type II odontoid fracture .admit to PCU (Progressive Care Unit) On 4/25/19 at 2:51 p.m., the ED provided copies, untitled, and indicated, it was a time line of her investigation into Resident B's fall, reported on 4/14/19. The time line indicated, but was not limited to: On 4/14/19, no time documented, LPN 5 notified the DNS to report Resident B had a fall and was found beside her bed. The resident had bruising to her face. LPN 5 stated the resident was trying to get up out of bed. On 4/14/19, no time documented, Weekend Supervisor notified of the incident. Nurse assessed Resident B's spine, head, and neck. Neuro-checks were normal. No complaints of pain. POA reported history of wrist fracture. Range of motion was normal. MD and family notified of fall event. Order received to send resident out for evaluation at ER. On 4/15/19, no time documented, CNA 15, that worked day shift on 4/14/19 was interviewed and stated she was not aware of any fall when she was providing care to her. She said she went into the room to get her up for breakfast. She was in bed and sleeping. Resident B had bruising to forehead and around both eyes at the time she entered the room that morning. On 4/15/19, no time documented, ED interviewed CNA 7 that worked evening shift 4/13. CNA 7 reported that after dinner she had been assisting Resident B back to room out of dining room. She turned the corner and resident tipped forward out of her wheelchair and landed on the floor. CNA 7 notified the charge nurse LPN 5. LPN 5 assessed Resident B and the resident was assisted back up into wheelchair. CNA 7 assisted the resident to bed after the incident. Resident B did not have any facial bruising or visible injuries. On 4/16/19, no time documented, ED interviewed LPN 5. (LPN 5) described the fall event on 4/14/19. She verified the fall occurred on 4/14/19 and that she found (Resident B) on the floor about 6:30 a.m. (LPN 5) said the bruising was almost immediate. (Resident B's) vitals and neuros were normal, and she didn't complain of any pain. ED discussed that (CNA 15) reported getting the resident up and that the nurse had not been in the room that morning. (LPN 5) stated she thought it was before breakfast. ED asked (LPN 5) if the resident had a fall on Saturday. ED discussed that (CNA 7) had reported (Resident B) came out of wheelchair. (LPN 5) said she had been on the floor but the aide was not sure what happened. (LPN 5) was in the middle of med pass and didn't think the resident had hit that hard. (LPN 5) said the resident had no injuries at the time of the incident and denied having any pain. She felt bad the next day and then documented a fall. (LPN 5) stated the resident only had one fall on Saturday 4/13/19. The nurse had no explanation for her documentation . During an interview on 4/25/19 at 2:51 p.m., the ED and DNS indicated during follow-up of the fall incident with Resident B, it was discovered the incident in the resident medical record was not an accurate account of the event. Upon interview with multiple staff from all shifts it was discovered that Resident B had not been found on the floor beside her bed in the early morning hours of 4/14/19, but had actually fallen out of her wheelchair in the hallway on her way from the dining room after dinner on the evening of 4/13/19. During a conversation with the ED and DNS, LPN 5 initially relayed the events of the fall as she had documented in the electronic medical record. When confronted with the knowledge that CNA 7 indicated on 4/13/19 the resident had fallen in the hallway from her wheel chair and reported the fall to LPN5, LPN 5 indicated she documented her original version of the fall early Sunday morning (4/14/19) after arriving at work and seeing the bruising on Resident B's face. She had not documented the fall from the wheelchair on Saturday evening (4/13/19) because she, did not know if the resident had hit her head. LPN 5 indicated the fall documented on 4/14/19 had not occurred and was documented in place of the fall that had occurred on 4/13/19. LPN 5 indicated she had notified the POA on 4/14/19 of the inaccurate fall and he initially was hesitant to send the resident to the hospital due to it might cause her stress and he was not in town. Only after the Weekend Supervisor saw the resident and described the symptoms to the Nurse Practitioner (NP) was there an order to send the resident to the ER. During an interview on 4/25/19 at 2:56 p.m., the ED and DNS indicated the protocol for notification after a resident fall included: first assess the resident and assure they were stable. If no injury, the nurse would call family during business hours. If an apparent injury, the nurse would call family, the MD and DNS at the time of the fall. An apparent injury could include a hematoma, AMS (altered mental status), bleeding, or complaint of pain. If there was an apparent injury, staff were to leave the resident on the floor and call 911. The facility was unsure of the actual timelines as the nurse did not document or tell the truth about the incident. True assessment of the incident was not documented in the electronic medical record. LPN 5 failed to follow the Fall Policy. She failed to notify management, the physician, and the POA at the time of the fall, she did not document the fall when it occurred, then later falsified documentation and told a false account of the fall, all resulting in a delay of treatment to the resident. During a telephone interview on 4/25/19 at 4:29 p.m., LPN 5 indicated, on 4/13/19, CNA 7 was pushing Resident B from the dining room to take to bed, while she was passing medications. Around 6:45 p.m. - 7:00 p.m., LPN 5 heard CNA 7 yelling and she told the nurse Resident B had leaned forward in her wheel chair and fell forward onto the floor. Upon arrival, she observed Resident B to be lying on her right side, they picked her up from the floor, she then assessed the resident to include vital signs which were ok, and there were no injuries or bruises. CNA 7 cleaned Resident B up and put her to bed. LPN 5 then gave the Resident B her medications, she denied pain and took her medications without issue, and her vital signs were still fine. LPN 5 went home that evening after she finished her shift. LPN 5 indicated she worked the next morning (4/14/19), around 7:00 a.m. -7:30 a.m., the aide brought Resident B out for breakfast and she was observed to have bruising around her eyes. LPN 5 sent an on-line message to the on-call physician (MD) as notification of the fall. The Weekend Supervisor came back to the unit during her routine rounds and also assessed the resident. LPN 5 told the Weekend Supervisor about the physician being notified, but Weekend Supervisor did not think the resident was hurt enough to send out, and thought it was normal bruising and no pain. The POA was notified by the Weekend Supervisor after the on-call responded and said to send Resident B out for evaluation. The incident happened at the end of the shift on 4/13/19, and CNA 7 told LPN 5 the resident fell over out of the wheel chair easily, she did not document the incident during the shift as she was unsure of the extent of her injury, and she didn't think Resident B fell that hard. After she saw the bruising the next morning on 4/14/19, LPN 5 indicated, she felt she needed to document, but felt it was too late to document the incident truthfully. On 4/26/19 at 10:38 a.m., the Weekend Supervisor indicated on the morning of 4/14/19, she had been walking around before breakfast around 7:00 a.m.-7:30 a.m., doing rounds. When she entered the cottage unit, LPN 5 was at the nurse's cart, and Resident B was sitting to the right of her. LPN 5 told her Resident B had fallen, and the Weekend Supervisor could see the resident had dark purple bruising around her eyes and the bridge of her nose. The Weekend Supervisor assessed Resident B after LPN 5 did vital signs and assessed her. Resident B denied pain. The Weekend Supervisor checked Resident B's range of motion, from the base of the skull down her spine, her pupils were reactive, and no pain. As there were no complaints of pain, the Weekend Supervisor told LPN 5 to continue monitoring Resident B and follow protocol. LPN 5 did not indicate a time of the fall, and didn't indicate if she had done notifications to the family and MD yet. Around 10:40 a.m. LPN 5 came of the unit and told the Weekend Supervisor that the NP had returned a call to the facility, and wanted Resident B sent out for evaluation. When asked if the POA had been told, LPN 5 indicated she had spoken to the POA earlier but not since the call from the NP. The Weekend Supervisor then called the POA to notify him the NP wanted the resident sent out. The POA was debating to send or not, and reminded the Weekend Supervisor of Resident B's past history of a wrist fracture and stents in the brain, so could not have an MRI. The POA wanted a picture of the residents face sent to him, and when the Weekend Supervisor explained she could not do that, told her he would send someone to come see the resident and take pictures when she would not. The POA had some lady come in and take pictures right before the resident was leaving. During a telephone interview on 4/26/19 at 6:03 p.m., CNA 7 indicated after dinner on 4/13/19, sometime between 6:00 p.m. and 7:00 p.m., she was taking Resident B from the dining room down the hall to her room for evening care to go to bed. Resident B was in the wheelchair. She wasn't leaning forward or to the side and there was no warning signs that she might fall. I was walking slowly, in fact slower than normal because there were a lot of residents in the hallway. CNA indicated she looked to the side at another resident walking past her. When she looked back Resident B was on the floor. Everything happened so fast but doesn't think she heard or felt the resident fall out of the chair, but when looked back the resident was on the floor. She did not remember if Resident B was on her face or side, but remembered the resident was rubbing her head after the fall. So she must have hit her head. CNA 7 looked back down the hall for the nurse. While she was looking for and calling out for the nurse Resident B moved herself and even sat up some. LPN 5 was down the hall and responded to the CNA calling for help. LPN 5 came down and saw Resident B rubbing her head because LPN 5 moved her hair off her forehead to look at her forehead. LPN 5 asked Resident B if she was ok. LPN 5 indicated Resident B had fallen earlier that day on dayshift. I work 2nd shift so I don't know. After looking at the resident's head, legs, and arms, we got her up to her wheelchair and I took her back to her room and helped her get into bed. On 4/25/19 at 4:50 p.m., the DNS provided a document, titled, Staff In-service Nursing, dated 4/10/19. A document among the topics indicated, fall: 1. Assess resident before moving resident. 2. Open and complete (Fall Event). 3. Document a progress note including details of fall. 4. Document full set of vital signs (place under vitals). 5. A neurological assessment flow sheet will be initiated on all un-witnessed falls, witnessed falls in which resident hits head, and those with a suspected head injury. 6. Ensure tangible immediate intervention is put in place. 7. Complete a new skin event for each new injury noted if applicable. 8. Notify DNS or nurse manager on call. 9. Notify MD. 10. Notify family/responsible party . There was no documentation to indicate LPN 5 had attended the in-service training. On 4/25/19 at 2:42 p.m., the ED provided a policy, titled, Fall Management Program, revised 11/2017. The policy indicated, It is the policy of (company name) to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls. A fall refers to unintentional coming to rest on the ground, floor, or other lower level .Post fall: 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided .2. If the resident experienced an injury from the fall, contact facility DNS (Director of Nursing Services)/ED per facility policy. 3. The physician will be contacted immediately, if there are injuries, and orders will be obtained. If there are no injuries, notify the physician during normal business hours. 4. The family will be notified immediately by the charge nurse of falls with injury. If there are no injuries, notify the family during the day or evening hours .5. A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify root cause of the fall and provide immediate interventions. 6. All falls will be discussed by the IDT at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls . The immediate jeopardy that began on 4/13/19 was removed on 4/27/19 when the facility had educated nurses and CNAs on what to do if they witnessed a fall, educated nurses and nurse managers on fall management procedures, conducted resident interviews regarding falls for all cognitively intact residents, conducted full body assessments for all cognitively impaired residents, and reviewed of all falls for the previous 30 days to ensure fall procedures were followed. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 256. 3.1-27(3)

Based on observation, interview and record review, the facility failed to ensure pressure ulcer prevention and reducing interventions were evaluated and revised for a resident who entered the facility without pressure ulcers resulting in the development of a stage 3 (full thickness skin loss) pressure ulcer to the sacrum that later became unstageable and development of unstageable pressure ulcers (full thickness tissue loss in which actual depth of the ulcer is completely observed by slough and/or eschar in the wound bed) to the bilateral heels, right ankle, right foot, and the right and left medial knee for 1 of 3 residents reviewed for pressure (Resident #82). Finding includes: During an observation on 10/27/15 at 9:37 a.m., Resident #82 was sitting on a Roho cushion in a Broda chair. Pressure reducing boots were applied to the bilateral heels. During an observation on 10/28/15 at 10:31 a.m., Resident #82 was on his back on a low air loss mattress and a blanket covered his legs. During an observation on 10/29/15 at 1:52 p.m., Resident #82 was positioned on his right side with a pillow to support and maintain the position on a low air loss mattress. Pressure reducing boots were applied to the bilateral heels. During an observation on 10/29/15 at 3:46 p.m., Resident #82 was on his back on a low air loss mattress and a blanket covered his legs. During an observation on 10/30/15 at 3:33 p.m., the Assistant Director of Nursing (ADON) changed a dressing to Resident #82's sacral unstageable pressure ulcer, that had been measured as 10.5 centimeters (cm) by 9 cm by 5.5 cm during a wound assessment on 10/29/15. The wound had a small area where muscle and sloughing was visible at the base of the wound. The old dressing had scant amount of serosanguinous (containing or relating to both blood and the liquid part of blood) drainage. Pressure reducing boots were in place. During an observation on 11/2/15 at 1:40 p.m., Resident #82 was positioned on his left side with a pillow to support and maintain the position on a low air loss mattress and a blanket covered his legs. During an observation on 11/2/15 at 3:37 p.m., Resident #82 was positioned on his left side with a pillow to support and maintain the position on a low air loss mattress and a blanket covered his legs. On 11/2/15 at 3:58 p.m., Resident #82 was positioned on his left side on a low air loss mattress. His feet were pressed against the footboard of the bed. Pressure reducing boots were in place. The Assistant Director of Nursing (ADON) changed the dressing on the resident ' s bilateral heels. The left heel had an unstageable pressure ulcer the size of a half dollar with black eschar (dead tissue) in the center of the wound. The right heel wound was the size of a quarter and had black eschar in the center. During the dressing change a new dime size open area was noted on the right foot below the little toe and an open area the size of a nickel was observed on the top of the right ankle. The resident was observed to have a dressing on the left lower leg and right medial knee. During an interview on 10/28/15 at 10:45 a.m., Unit Manager #1 indicated Resident #82 had an unstageable pressure ulcer on his sacrum. During an interview on 11/2/15 at 4:07 p.m., the Assistant Director of Nursing (ADON) indicated she was unaware of the new open pressure ulcers below the little toe on bottom of the resident's right foot and the right lateral ankle. During an interview on 11/4/15 at 8:47 a.m., the Director of Nursing (DON) indicated pressure reducing interventions of turn and reposition every two hours, pressure relieving mattress on admission, incontinence care when needed, treatments according the physician orders, barrier creams and elevation of heels were implemented when a resident was identified with risk for developing skin breakdown. She indicated it was unfortunate Resident #82 developed pressure ulcers with the interventions in place. During an interview on 11/5/15 from 9:19 a.m., the DON indicated the efficacy of the interventions in place for residents with altered skin integrity or pressure ulcers was evaluated weekly in the IDT (Interdisciplinary Team) wound meetings. She indicated the Nurse Practitioner ' s wound notes were reviewed and efficacy of interventions was determined by whether the wound was healing, remained stagnant, or deteriorated. The DON indicated the intervention of pressure relieving boots was not effective since the resident developed pressure ulcers with the interventions in place and the intervention did not facilitate wound healing. She indicated the interventions should have been revised if a wound developed or deteriorated. During an interview on 11/4/15 at 2:42 p.m., the Nurse Practitioner (NP) indicated due to his comorbidities and immobility, Resident #82's pressure ulcers were unavoidable. She indicated she kept a wound treatment in place for a few weeks and evaluated if it was effective. She indicated if a wound continued to deteriorate she typically would change the treatment after two weeks. She indicated Resident #82's wound had not improved and she was not expecting his wound to heal due to organ shut down and comorbidities. On 10/30/15 at 1 p.m., Resident #82's record was reviewed. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 4/9/14 indicated Resident #82 was at risk for pressure ulcers, did not have pressure ulcers, was frequently incontinent of bladder and bowel, and required extensive assist of two for bed mobility, transfers, and toileting. The form titled, ASC Resident Assessment and Care Evaluation, dated 4/3/14 at 10:43 a.m., indicated the resident had no pressure ulcers and had the following risk factors for pressure: confined to bed or chair all or most of the time, persistently wet, fecal incontinence, immobility, and altered mental status. The form titled, ASC New Skin Event, dated 7/30/15 at 7:56 a.m., indicated Resident #82 had a new wound on his left butt cheek. The form indicated the wound measurement was pin point and a treatment order was to apply barrier cream every shift and as needed. The form titled, IDT Weekly Update Skin Events, dated 7/31/15, indicated the resident had moisture associated skin damage on the left buttock measuring 0.6 centimeters (cm) x 0.5 cm x 0 cm. A note, added to the form on 8/9/15, indicated Licensed Practical Nurse (LPN) #10 assessed the resident's wound and it measured 1 cm x 0.75 cm x less than 0.1 cm. The note indicated the increased size of the wound was discovered during peri care and barrier cream was applied. The Wound Care Specialists of Indiana (WCS) progress notes indicated the sacral wound was a stage 3 pressure ulcer, measuring 5.2 cm x 2 cm x 0.2 cm on 8/13/15. On 8/20/15, the wound measured 7.5 cm x 5.5 cm x 0.2 cm and on 8/27/15 was 9.5 cm x 6 cm x 0.2 cm. The wound was described as unstageable on 9/3/15 and measured 9 cm x 5 cm x 0.2 cm. The sacral wound increased in size to 10 cm x 5 cm x 0. The sacral wound increased in size to 10 cm x 5 cm x 0.2 cm on 9/10/15: The WCS notes indicated an unstageable pressure ulcers on the left heel, measuring 1.8 cm x 1.5 cm x 0.1 cm, a stage 3 pressure ulcer measuring 3 cm x 1 cm x 0.1 cm, and an unstageable pressure ulcer on the left medial knee were discovered on 9/10/15. The WCS notes indicated the wounds on the right and left medial knees resolved on 9/17/15. The WCS notes, dated 10/22/15, indicated an unstageable pressure ulcer measuring 4.5 cm x 4.5 cm x 0.1 cm on the right medial heel, a stage 2 pressure ulcer on the right medial knee, measuring 3.5 cm x 2.5 cm x 0.1 cm, and a stage 2 pressure ulcer on the left proximal medial lower leg, measuring 2.4 cm x 3 cm x 0.1 cm were present. The WCS notes, dated 10/29/15, indicated the pressure ulcer on the sacral area was unstageable and measured 10.5 cm x 9 cm x 5.5 cm. The left heel pressure ulcer was identified as unstageable, measuring 3.5 cm x 3.5 cm x 0.1 cm. The right medial heel had an unstageable pressure ulcer, measuring 3 cm x 3 cm x 0.1 cm. The pressure ulcer on the left proximal medial lower leg measured 4 cm x 2.5 cm x 0.1 cm and was unstageable. The right medial knee had an unstageable pressure ulcer, measuring 4.5 cm x 3 cm x 0.1 cm. The form titled, ASC Pressure Wound Skin Evaluation Report, dated 11/3/15, indicated the resident had an unstageable with a suspected deep tissue injury on bottom of his right foot and the wound was found on 11/2/15. The form indicated the wound measured 2 cm x 1 cm x 0 cm. The form titled, ASC Pressure Wound Skin Evaluation Report, dated 11/3/15, indicated the resident had an unstageable on his right lateral ankle and the wound was found on 11/2/15. The form indicated the wound measured 1 cm x 1.5 cm x 0.1 cm. A care plan for the resident's risk for skin breakdown was initiated on 4/3/14. Interventions included, but were not limited to: boots on bilateral feet, low air loss mattress, Broda chair with Roho cushion, preventative treatments and supplements as ordered, encourage resident to eat greater than 50% of meals, incontinence care, turn and reposition at least every 2 hours, and weekly skin assessments. The last new intervention added to the skin care plan was on initiated on 9/8/15, and was a, Bariatric low air loss mattress. A care plan for the resident's impaired skin integrity and pressure ulcer was initiated on 8/4/15. The skin care plans' interventions included, but were not limited to: boots on bilateral feet, observe for signs and symptoms of infection, obtain labs as ordered, assess for pain, low air loss mattress, Broda chair with Roho cushion, treatments and supplements as ordered, encourage resident to eat greater than 75%of meals, incontinence care, turn and reposition at least every 2 hours, and assess and document skin weekly and notify physician of changes. The last intervention was added on 10/12/15, and was for the Broda chair which was initiated on the skin breakdown care plan on 8/20/15. The forms titled, Treatments Flowsheet, for Resident #82 from 7/1/15 to 11/3/15 indicated the following treatments were ordered for the resident ' s sacral wound: From 6/9/15 to 8/31/15, Calazyme to buttocks/coccyx and post upper thigh every shift. From 7/30/15 to 8/4/15, Cleanse with normal saline pat dry, apply Xeroform Occlusive Gauze Patch, cover with dry gauze, then tape in place, once a day. From 8/20/15 to 8/26/15, [MEDICATION NAME] (trypsin-balsam-castor oil) ointment; 90-87-788 unit-mg-mg/gram; amount to administer: thin layer; topical, every shift. From 8/27/15 to 10/29/15, Apply soap and water to sacral wound, apply 0.25% Dakins solution to gauze and wound, Use skin prep and apply ABD pads and tape, twice a day. From 10/29/15 to 11/3/15, Cleanse sacral wound with wound cleanser, 0.25 mg Dakin ' s soaked gauze to wound and change daily BID (twice a day). Cover with abd pad and [MEDICATION NAME] sacrum wound dressing to wound on coccyx. The significant change MDS, dated [DATE], indicated the resident was occasionally incontinent of bladder, frequently incontinent of stool, had an indwelling catheter, was at risk for a pressure ulcer, had 4 unhealed pressure, and was an extensive assist of 2 for bed mobility, transfers, and toileting. On 11/4/15 at 11:03 a.m., the DON provided the current policy titled, IDT weekly review of residents with wounds, dated 2/15. The policy stated, the note should refer specifically to each site and be general whether the site has worsened, remained unchanged or improved. The policy stated, If the wound has worsened or improved the IDT note should reference these changes and credit or change the current interventions. The policy indicated care plans related to wounds should be reviewed, weekly in addition to writing an IDT note to ensure the documentation is current and reflects the interventions being utilized. 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident received appropriate monitoring, assessments, and necessary emergency intervention when a resident presented with a conscience decline, acute [MEDICAL CONDITION], below normal oxygen saturation, and a critical elevated potassium level which, if treated, could have prevented her death (Resident E). This deficient practice affected 1 of 5 residents reviewed for quality of care and nursing services. Findings include: Resident E's record was reviewed on [DATE] at 2:00 P.M. Resident E was admitted to the facility on [DATE], from an Assisted Living facility. Resident E had [DIAGNOSES REDACTED]. Resident E was a full code. An admission observation note dated [DATE]-2:55 P.M., indicated on admission, Resident E was not experiencing symptoms of acute illness or exacerbation of a chronic illness. An observation note dated [DATE]-3:11 P.M., indicated Resident E was alert, friendly, oriented to time and person, answered questions readily, had upper and lower body weakness, used oxygen at 2 liters per N/C (nasal cannula), had diminished lung sounds in the lower right lung fields, and had a regular heart rhythm. This note indicated her vitals were stable with an oxygen saturation of 96 % on 2 liters of O2 (oxygen). An observation note dated [DATE]-1:30 A.M., indicated, Resident E was alert, oriented to time place, and person, had lower body weakness, used oxygen, had breath sounds described as wheezes-upper left and right lobes, and had a regular heart rhythm. This note indicated Resident E's O2 saturation was 96% on oxygen at 2 liters. A vital flow record indicated on [DATE] at 3:42 P.M., Resident E's O2 saturation was 97% on 2 liters of oxygen. A vitals report record indicated on [DATE] at 1:51 P.M., Resident E's oxygen saturation was 100%. Documentation was lacking of Resident E's O2 saturation levels on [DATE] and [DATE]-[DATE]. A progress note dated [DATE]-7:16 A.M., indicated, "Resident started complaining of nausea around 3:00 am. Resident does not have nausea medicine so a cool cloth was provided and a basin. She did not have any further complaints other than her back hurting after interventions were implemented. Aide came to me me because when resident got up to go to the bathroom she became fatigued and said she could not stand up. Resident was in restroom sitting in her wheelchair when I arrived without O2 on. V/S (vitals) assessed and 02 level was at 67%. Resident was taken back to bed and O2 put back on. O2 saturation went back up to 91% but went back and forth between mid-80's and low-90's." Documentation of a lung assessment was lacking at this time. A progress note dated [DATE]-8:05 A.M., indicated, "Resident more tired than usual, opens eyes to name, lung fields congestion noted bilat (bilateral) with rales in left lung field. O2 on at 2 liters. Dr. notified and new orders received." A vital report sheet indicated on [DATE]-8:15 A.M., Resident E's 02 saturation was 88% on 2 liters. This note indicated the acceptable range was ,[DATE]%. Documentation was lacking the O2 was increased to maintain O2 saturation within the acceptable range. At this time Resident E's temperature was documented 99.4 F (Fahrenheit). A progress note dated [DATE]-11:00 A.M., indicated, "Chest X-ray results show acute [MEDICAL CONDITIONS]. (NP) (Nurse Practitioner) named) paged." A progress note made as a late entry on [DATE] at 2:54 P.M., indicated, "ON [DATE] around 630 P.M. critical lab K+ 6.5 (potassium) called to (NP (nurse practitioner) named), noted labs abnormal and asked if (NP named) want lab faxed to her. Lab results faxed to (NP named) and (physician named). Reported to relief nurse labs faxed and awaiting orders. Refused PM meal." Web address: http://www.webmd.com/a-to-z-guides/[MEDICAL CONDITION]-causes-symptoms-treatments, reviewed on [DATE] at 6:00 p.m. indicated the following: " ...If you have [MEDICAL CONDITION], you have too much potassium in your blood. Your body needs a delicate balance of potassium to help the heart and other muscles work properly. But too much potassium in your blood can lead to dangerous, and possibly deadly, changes in your heart rhythm. Too much potassium in your blood can affect how your heart works. Symptoms of [MEDICAL CONDITION] can include: Abnormal heart rhythm -- arrhythmia-abnormal-heart-rhythm that can be life-threatening, Slow heart rate, [MEDICAL CONDITION] is a common cause of life-threatening heart rhythm changes, or cardiac arrhythmias. It can lead to an emergency condition called ventricular fibrillation. In this condition, the lower parts of your heart flutter rapidly instead of pumping blood. Untreated, an extremely high amount of potassium in your blood can make your heart stop beating, causing death.... " Web address: http://www.webmd.com/a-to-z-guides/potassium-k-in-blood, reviewed on [DATE] at 6:00 p.m. indicated normal potassium levels for adults was 3XXX,[DATE].2 milliequivalents per liter (mEq/L). The record lacked documentation the facility followed up with the NP after critical lab orders were faxed to her. The record lacked documentation the facility monitored/assessed Resident E's, cognitive status, breath sounds, blood sugar, or vitals (including oxygen saturation) after the initial condition change with abnormal O2 saturation, elevated temperature, increased malaise, and congested lung fields were noted on [DATE] at 8:05 A.M. and 8:15 A.M. The next progress note was dated [DATE]-7:00 A.M., indicated, "Writer entered room for routine blood sugar check at which time resident was unresponsive, no heart rate, or respiration, warm to touch, resident a full code, CPR (cardio- [MEDICAL CONDITION] resuscitation), initiated (sic) at 4:55 am, sent cna (certified nursing assistant) to get another nurse, 911 called, 510 am paramedics arrived at which time took over CPR, 2 doses of [MEDICATION NAME] given per paramedics and resident intubated without success, time of death called at 524 am, family called at 528 am spoke to daughter (daughter named), MD (doctor) and DNS (Director of Nursing Services ) and Funeral home notified, post mortem care given, funeral home at facility at 700 am and remains released per order." During an interview on [DATE] at 2:22 P.M., the DON (Director of Nursing) was asked to provide documentation of Resident E's vital signs, nursing notes, physician orders, assessments, communication with the NP and/or MD from the time of her admission and documentation the family was notified of her condition change. During this interview the DON indicated, if a resident had an emergent condition change, the nurses were supposed to send the resident to the emergency room and then call the doctor. They were not to wait for the doctor to call them. They were also to call her and they did not do either for this situation. During an interview on [DATE] at 2:30 P.M., the Executive Director (ED), indicated the facility nurse's were reluctant to question (NP) named. He indicated this case was reviewed and they had found when the nurse called the (NP) with the critical values she did not think they were accurate so she requested the results be faxed to her. The nurse faxed the results to her however, when the NP did not call back with orders, the nurse did not follow up with her to see what needed to be done. During a telephone interview on [DATE]-5:25 P.M., the facility's Medical Director indicated, the facility notified his NP of the condition change and she ordered test which included labs and a chest x-ray. She was notified of the abnormal chest x-ray but was waiting on the lab results. During a telephone interview on [DATE]-5:43 P.M., the facility's Medical Director indicated, his NP indicated to him, the facility called her with Resident E's critical lab values. She was busy at the time so she asked them to fax the hard copy. She fell asleep and did not review the faxed copy. The Medical Director indicated his NP indicated to him she should have treated the high potassium level. The Medical Director also indicated he would have treated the critically high potassium level and the facility should have called the NP back or called him. The Medical Director stated, "She most likely died from a MI ([MEDICAL CONDITION])." During an interview on [DATE]-9:15, with the ED, DON, and ADON (Assistant Director of Nursing) present, the ED indicated the nurse did not follow up or attempt to call the NP back, they did not have documentation the nurse assessed Resident E from the time of the condition change until she was found non-responsive the next morning, and they did not notify the family of the condition change. This Federal tag relates to Complaint(s) IN 254 and IN 851. 3XXX,[DATE](a)