Every finding on record at East Lake Nursing & Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and physician orders were obtained for the use of oxygen for 3 of 5 residents reviewed for respiratory care. (Residents 110, 109, and 74)Findings include:1. During random observations on 4/13/26 at 3:30 p.m., and 4/14/26 at 10:39 a.m. and 3:17 p.m., Resident 110 was observed wearing oxygen via nasal cannula. The oxygen was set at seven liters per minute and connected to the concentrator in the room. The record for Resident 110 was reviewed on 4/14/26 at 3:42 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cellulitis of the left lower limb, chronic respiratory failure with hypoxia (low oxygen levels), heart disease, peripheral vascular disease, and heart failure. The admission Minimum Data Set (MDS) assessment, dated 4/7/26, indicated the resident was cognitively intact for daily decision making, had no skin issues, and received oxygen while a resident. A Care Plan, dated 4/2/26, indicated the resident was at risk for ineffective tissue perfusion related to heart failure. The approaches were to administer oxygen as ordered. A Care Plan, dated 4/2/26, indicated the resident had potential for impaired gas exchange related to chronic respiratory failure with hypoxia and heart disease. The approaches were to administer oxygen as ordered. A Physician's Order, dated 4/2/26, indicated oxygen at two liters per nasal cannula. During an interview on 4/15/26 at 3:30 p.m., the Director of Nursing had no additional information to provide. 2. During random observations on 4/13/26 at 10:50 a.m., 12:42 p.m., and 3:30 p.m., and on 4/14/26 at 10:40 a.m. and 1:36 p.m., Resident 109 was observed wearing oxygen vial nasal cannula at 2.5 liters per minute on the concentrator in her room. On 4/15/26 at 2:15 p.m. the resident was observed in bed wearing oxygen per nasal cannula at three liters per minute on the concentrator. At 3:30 p.m., Agency LPN 1 was in the resident's room and was asked to observe the oxygen rate on the concentrator. The LPN indicated the rate was set at three liters per minute. She adjusted the level back to two liters per minute. The record for Resident 109 was reviewed on 4/16/26 at 10:19 a.m., Diagnoses included, but were not limited to, compression fracture, COPD (chronic obstructive pulmonary disease), pleural effusion (fluid in the pleural space of the lungs), heart disease, chronic kidney disease, high blood pressure, and depression. The admission Minimum Data Set (MDS) assessment, dated 4/9/26, indicated the resident was moderately impaired for daily decision making and used oxygen while a resident. The resident was admitted with one Stage 2 pressure ulcer (a partial-thickness skin loss involving a shallow, open ulcer or blister, often pink/red and moist, caused by prolonged pressure or friction) at the time of admission. A Care Plan, dated 4/8/26, indicated the resident had potential for impaired gas exchange related to COPD and pleural effusion. The approaches were to administer oxygen as ordered. A Physician's Order, dated 4/3/26, indicated oxygen at two liters every shift. During an interview on 4/15/26 at 3:30 p.m., Agency LPN 1 indicated the oxygen should have been set at two liters per minute. During an interview on 4/16/26 at 10:50 a.m., the Director of Nursing had no additional information to provide. 3. On 4/13/26 at 2:56 p.m., Resident 74 was observed in bed and appeared short of breath. She was wearing oxygen vial nasal cannula at 3.5 liters. On 4/14/26 at 10:24 a.m., the resident was wearing oxygen via nasal cannula at 3.5 liters. The record for Resident 74 was reviewed on 4/14/26 at 1:13 p.m. Diagnoses included, but were not limited to, dementia, heart failure, low blood pressure, depression, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 3/5/26, indicated the resident was moderately impaired for daily decision making and required oxygen therapy. The resident required partial to moderate assistance with showering, toileting, lower body dressing and personal hygiene. A Care Plan, dated 4/25/24, indicated the resident had potential for impaired gas exchange related to congestive heart failure, pleural effusion, and emphysema. Approaches were to administer oxygen as ordered and assess vital signs and lung sounds as needed. A Physician's order, dated 4/6/26 and discontinued on 4/8/26, indicated to administer oxygen via nasal cannula continuously at 2.5 liters/minute. There was no current physician's order for oxygen therapy. During an interview on 4/15/26 at 10:34 a.m., the Director of Nursing (DON) indicated she understood the oxygen concern. No additional information was provided. 410 IAC (Indiana Administrative Code) 16.2-3.1-47(6)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to wear the correct personal protective equipment (PPE) for residents in enhanced barrier precautions and droplet isolation for 1 of 3 pressure ulcer treatments observed and 3 of 9 residents observed during medication administration. The facility also failed to ensure multi-use equipment was disinfected after each use for 3 of 3 residents who were observed having their vital signs checked. (Residents 43, 117, 74, 109, 108, 54, and 40)Findings include: 1.On 4/16/26 at 9:51 a.m., the Wound Nurse and the Assistant Director of Nursing (ADON) entered Resident 43's room to complete a treatment to the resident's sacrum. The Wound Nurse washed her hands and the ADON sanitized her hands prior to donning gloves. Neither one of the nurses donned a gown at that time. The ADON repositioned the resident to his right side and the Wound Nurse pulled down the resident's pants and removed the dressing to the sacrum. After removing the dressing, the Wound Nurse removed her gloves, washed her hands and then donned clean gloves and a gown and proceeded to do the treatment to the resident's sacrum. The ADON remained in the room with the Wound Nurse and assisted with repositioning the resident before and after the treatment. She did not wear a gown during that time. On 4/16/26 at 1:10 p.m., LPN 4 entered the resident's room to administer his nasal spray. LPN 2 accompanied LPN 4 and indicated she was in orientation and just observing. The resident was seated on the side of his bed and was asking for help getting back into bed after receiving the nasal spray. LPN 2 donned a pair of gloves and proceeded to assist the resident back into bed. She lifted the resident's legs and helped him reposition himself. A sign on the resident's door indicated the resident required Enhanced Barrier Precautions which consisted of wearing a gown and gloves during direct resident contact. During an interview on 4/20/26 at 9:10 a.m., the Infection Preventionist indicated the Wound Nurse and the ADON should have donned a gown prior to repositioning the resident and removing the dressing. She also indicated LPN 2 should have donned a gown before assisting the resident with repositioning. 2. On 4/17/26 at 11:19 a.m., LPN 3 proceeded to Resident 117's room to disconnect her intravenous (IV) antibiotic. The LPN sanitized his hands and donned a pair of gloves. He proceeded to disconnect the IV from the port and flushed the IV with normal saline. He did not donn a gown while disconnecting the antibiotic and flushing the line with normal saline. A sign on the resident's door indicated she required Enhanced Barrier Precautions which consisted of a gown and gloves during direct resident contact. During an interview on 4/20/26 at 9:10 a.m., the Infection Preventionist indicated the LPN should have worn a gown while disconnecting the IV. 3. On 4/17/26 at 11:41 a.m., LPN 4 was observed preparing medications for Resident 74. A sign on the resident's door indicated she required Droplet Precautions. During an interview at that time, the LPN indicated the resident was in isolation for pneumonia. Prior to entering the resident's room, the LPN sanitized his hands, donned a gown, N95 mask, and gloves. He entered the resident's room and administered her medication. The LPN did not wear any eye protection. The sign on the door of the resident's room indicated for droplet precautions, staff were to wear a gown, an N95 mask, gloves, and eye protection. At that time, face shields were observed in the isolation cart. During an interview on 4/20/26 at 9:35 a.m., the Infection Preventionist indicated the LPN should have put on a face shield prior to entering the resident's room. 4. During a random observation on 4/13/26 at 12:41 p.m., CNA 1 assisted Resident 109 out of bed and into the wheelchair to use the bathroom. The CNA helped the resident to stand up and pulled down her pants and brief and assisted the resident on the toilet. At that time, there was a bandage observed to the resident's sacral area. The CNA only donned clean gloves to assist the resident and did not don an isolation gown. During a random observation on 4/13/26 at 3:30 p.m., LPN 1 was asked to perform a skin assessment for the resident. She assisted the resident onto her right side and removed her pants and brief. The resident had a bandage on her sacral area. The LPN only donned a pair of gloves and no isolation gown. During an interview at that time, the LPN Indicated the resident had pressure ulcer to the sacral area. During a random observation on 4/16/26 at 7:20 a.m., there was a sign on the outside of the resident's door which indicated Enhanced Barrier Precautions. The appropriate personal protective equipment when coming in contact with the resident was to wear gloves and a gown. During an interview on 4/20/26 at 9:12 a.m., the Infection Preventionist indicated both staff persons should have worn a gown prior to having contact with the resident. The facility policy titled, Enhanced Barrier Precautions was provided by the Administrator on 4/13/26 and identified as current. The policy indicated, enhanced barrier precautions was an intervention designed to reduce the transmission of resistant organisms that employeed targeted use of gown and glove use during high contact resident care activities. Use of Personal Protective Equipment – Gown and Gloves: Don gloves and gown prior to a high-contact care activity. Examples of high-contact resident care activities include: -Dressing -Bathing/Showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube, dialysis device and access site, tracheostomy/ventilator -Wound care: any skin opening requiring a dressing -Change PPE and perform hand hygiene before caring for another resident 5. During a random observation on 4/13/26 at 10:33 a.m., LPN 1 was observed checking Resident 108's blood pressure and pulse oximetry on a multi-use/function blood pressure machine. After she finished, she pushed the machine out of the room and placed it against the wall by the medication cart. She did not immediately sanitize the machine. At 10:37 a.m., she still had not sanitized the machine and continued to pass medication to other residents. 6. During a random observation on 4/16/26 at 8:13 a.m., RN 1 was observed checking Resident 54's blood pressure and pulse oximetry with a multi-use/function blood pressure machine in the memory care dining room. After she was done checking the resident's vital signs she pushed the cart back to the medication cart, placed it against the wall, and plugged it into the outlet. She did not immediately sanitize the machine. At 8:34 a.m. RN 1 pushed the multi-use/function blood pressure machine into Resident 40's room to check his vital signs. The RN checked his blood pressure and pulse oximetry and pushed the machine back to the medication cart and plugged it into the outlet. She did not immediately sanitize the machine. During an interview on 4/16/26 at 8:45 a.m., RN 1 indicated she did not sanitize the machine after each resident. During an interview on 4/16/26 at 2:45 p.m., the Director of Nursing indicated the facility had no policy for cleaning the multi-use/function blood pressure machine. She had no additional information to provide. The current 2/2025 Standard and Transmission-Based Precautions (Isolation) policy, provided by the Administrator on 4/13/26 at 10:31 a.m., indicated shared equipment should be cleaned and disinfected in between each resident use. 410 IAC (Indiana Administrative Code)16.2 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure blood pressure parameters were followed as ordered for 2 of 3 residents reviewed for blood pressure parameters. The facility also failed to ensure areas of bruising were assessed and monitored and heel boots were applied as ordered for 2 of 4 residents reviewed for skin conditions non-pressure related. (Residents 10, 6, 62, and 110)Findings include:1. The record for Resident 10 was reviewed on 4/15/26 at 3:52 p.m. Diagnoses included, but were not limited to, hypertension and atherosclerotic heart disease. A Care Plan, dated 5/17/18 and reviewed on 4/1/26, indicated the resident was at risk for ineffective tissue perfusion related to the diagnoses of hyperlipidemia (elevated lipids), history of stroke, cardiomyopathy, coronary artery disease, and hypertension. Interventions included, but were not limited to, administer medications as ordered. The Quarterly Minimum Data Set (MDS) assessment, dated 3/31/26, indicated the resident was moderately cognitively impaired. The April 2026 Physician's Order Summary (POS) indicated the resident was to receive Clonidine HCl (a medication to treat high blood pressure) 0.3 milligrams (mg) three times a day. Hold if the resident's systolic (top number) blood pressure was less than 140 The March 2026 Medication Administration Record (MAR) indicated the resident received the Clonidine on the following dates and times even though her systolic blood pressure was less than 140: -3/1/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/3/26 at 2:00 p.m. -3/5/26 at 8:00 a.m. and 2:00 p.m. -3/6/26 at 2:00 p.m. and 8:00 p.m. -3/7/26 at 2:00 p.m. -3/8/26 at 8:00 p.m. -3/9/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/12/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/13/26 at 2:00 p.m. -3/14/26 at 8:00 a.m. and 2:00 p.m. -3/15/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/17/26 at 8:00 a.m. and 2:00 p.m. -3/19/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/20/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/23/26 at 8:00 a.m. and 2:00 p.m. -3/24/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/25/26 at 8:00 a.m. and 8:00 p.m. -3/26/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/27/26 at 2:00 p.m. -3/28/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/29/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. -3/30/26 at 2:00 p.m. and 8:00 p.m. -3/31/26 at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The April 2026 MAR indicated the resident received the Clonidine on the following dates at times even though her systolic blood pressure was less than 140: -4/2/26 at 2:00 p.m. and 8:00 p.m. -4/3/26 at 2:00 p.m. and 8:00 p.m. -4/4/26 at 2:00 p.m. -4/5/26 at 2:00 p.m. -4/6/26 at 2:00 p.m. -4/7/26 at 8:00 a.m. -4/9/26 at 2:00 p.m. and 8:00 p.m. -4/10/26 at 2:00 p.m. -4/12/26 at 2:00 p.m. -4/13/26 at 8:00 p.m. -4/14/26 at 2:00 p.m. and 8:00 p.m. During an interview on 4/20/26 at 9:00 a.m., the Director of Nursing indicated she would have to review the order and the MARs for March and April. 2. The record for Resident 6 was reviewed on 4/15/26 at 9:29 a.m. Diagnoses included, but were not limited to, dementia, type 2 diabetes, atrial fibrillation, heart disease, heart failure, major depressive disorder, adjustment disorder with anxiety and depressed mood. The 4/8/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Physician's Order, dated 8/1/24, indicated Carvedilol (a medication used to treat high blood pressure) 12.5 milligrams (mg) two times a day, hold if blood pressure was under 110/60. A Physician's Order, dated 3/20/25, indicated Hydralazine (a medication used to treat high blood pressure) 50 mg three times a day, at 8 a.m., 2 p.m., and 8 p.m., hold if blood pressure was under 110/60. The 1/2026 Medication Administration Record (MAR) indicated the Carvedilol tablet 12.5 mg was administered on the following days outside of the parameters: 7 a.m. to 11 a.m. on 1/1 and 1/21/26 7 p.m. to 11 p.m. on 1/12, 1/15, and 1/25/26 The 1/2026 MAR indicated the Hydralazine tablet 50 mg was administered on the following days outside of the parameters: 8:00 a.m. on 1/8, 1/10, and 1/21/26 2:00 p.m. on 1/8 1/18, 1/19, and 1/29/26 8:00 p.m. on 1/1, 1/12, 1/15, and 1/25/26 The 2/2026 MAR indicated the Carvedilol tablet 12.5 mg was administered on the following days outside of the parameters: 7 a.m. to 11 a.m. on 2/2, 2/4, 2/9, 2/13, 2/16, 2/18, and 2/26/26 7 p.m. to11 p.m. on 2/1, 2/11, and 2/25/26 The 2/2026 MAR indicated the Hydralazine tablet 50 mg was administered on the following days outside of the parameters: 8:00 a.m. on 2/2, 2/9, 2/13, 2/16, and 2/26/26 2:00 p.m. on 2/1, 2/12, 2/16, 2/21, and 2/26/26 8:00 p.m. on 2/1, 2/11, 2/25/26 The 3/2026 MAR indicated the Carvedilol tablet 12.5 mg was administered on the following days outside of the parameters: 7 a.m. to 11 a.m. on 3/1, 3/3, 3/5, 3/15, 3/21, 3/27, and 3/28/26 7 p.m. to 11 p.m. on 3/1, 3/4, 3/21, 3/24, 3/27, 3/29, and 3/30/26 The 3/2026 MAR indicated the Hydralazine tablet 50 mg was administered on the following days outside of the parameters: 8:00 a.m. on 3/1, 3/3, 3/5, 3/15, 3/21, 3/27, and 3/28/26 2:00 p.m. on 3/1, 3/4, 3/5, 3/7, 3/27, and 3/29/26 8:00 p.m. on 3/1, 3/4, 3/21, 3/24, 3/27, and, 3/30/26 The 4/2026 MAR indicated the Carvedilol tablet 12.5 mg was administered on the following days outside of the parameters: 7 a.m. to 11 a.m. on 4/1 and 4/8/26 7 p.m. to 11 p.m. on 4/4, 4/6, and 4/14/26 The 4/2026 MAR indicated the Hydralazine tablet 50 mg was administered on the following days outside of the parameters: 8:00 a.m. on 4/8/26 2:00 p.m. on 4/4/26 8:00 p.m. on 4/4, 4/6, and 4/14/26 During an interview on 4/16/26 at 1:15 p.m., the Director of Nursing indicated she notified the Nurse Practitioner (NP) and the Medical Doctor (MD) and the order was changed/clarified. She had no additional information to provide. 3. During random observations on 4/14/26 at 10:30 a.m. and 3:20 p.m., Resident 62 was observed with purple and red bruises to her right and left arms. The record for Resident 62 was reviewed on 4/15/26 at 4:35 p.m. Diagnoses included, but were not limited to, heart disease, heart failure and high blood pressure. The admission Minimum Data Set (MDS) assessment, dated 3/5/26, indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 3/4/26, indicated the resident was at risk for bruising related to antiplatelet use. The approaches were to observe for bruises. A Physician's Order, dated 4/2/26, indicated Aspirin 81 milligrams (mg) daily. There were no physician's orders to monitor bruising. There was no documentation in nursing progress notes from 4/2-4/14/26 regarding any bruising to the resident's upper arms. The 4/8/25 Weekly Skin Assessment indicated the resident had no bruising to her upper arms. There was no weekly skin assessment completed for 4/15/26. During an interview on 4/16/26 at 3:30 p.m., the Director of Nursing indicated she was unaware of any bruising to the resident's arms and would look into the matter. During an interview on 4/16/26 at 4:00 p.m., the Wound Nurse indicated she just went and assessed the resident and she does have some dark purple areas to the right arm and some smaller ones on the left arm. Nursing staff were to do a skin event when new bruising was observed and it would be followed in wound management typically for three days, sometimes she would keep the resident on longer. She indicated when residents were admitted or readmitted with bruising and she knew where they came from, she would not put them in wound management because she was aware of the origin. The Wound Nurse indicated geri sleeves would be the new intervention to prevent further bruising. The Wound Management Form, dated 4/16/26, indicated the following bruised areas to the resident's arms: right lower arm was 2 centimeters (cm) by 2 cm right lateral lower arm 3 cm by 2 cm left lower arm 6 cm by 3 cm 4. During an observation on 4/13/26 at 1:26 p.m., Resident 110 was observed sitting in his wheelchair with both legs in the dependent position. At that time, his legs were darkened and with some edema (swelling). During an interview at that time, the resident indicated he was supposed to have some type of compression socks on both legs, but they told him they ran out. He had no heel boots on either leg. During random observations on 4/14/26 at 10:39 a.m., 4/15/26 at 10:50 a.m., 12:10 p.m., 2:20 p.m., and 4/16/26 at 8:09 a.m., the resident was observed with no heel boots to his legs. The record for Resident 110 was reviewed on 4/14/26 at 3:42 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cellulitis of the left lower limb, heart disease, peripheral vascular disease, and heart failure. The admission Minimum Data Set (MDS) assessment, dated 4/7/26, indicated the resident was cognitively intact for daily decision making and had no skin issues. A Care Plan, dated 4/2/26, indicated the resident was at risk for skin breakdown due to rare skin moisture and limited mobility. The approaches were to provide heel boots to bilateral lower extremities, on at all times. A Physician's Order, dated 4/2/26, indicated heel checks to bilateral heels every shift and heel boots to bilateral lower extremities on at all times every shift. A Nurse's Note, dated 4/2/26 at 8:50 a.m., indicated a head to toe skin assessment was completed. The resident had dark pink skin discoloration to the left calf related to cellulitis with two plus edema to both lower extremities. The 4/2026 Medication Administration Record indicated the heel boots were signed out as being applied from 4/13-4/15/26. During an interview on 4/16/26 at 3:30 p.m., the Director of Nursing indicated the resident only needed the heel boots when he was in bed, the order had been changed to reflect that. 410 IAC (Indiana Administrative Code) 16.2 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer treatments were completed as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident 109)Finding includes:During an interview on 4/13/26 at 11:00 a.m. Resident 109 indicated her pressure ulcer bandage does not get changed every day. During a random observation on 4/13/26 at 12:41 p.m., CNA 1 assisted the resident to the bathroom. At that time, the resident had a bandage observed to her sacrum with a date of 4/11/26. The CNA observed the bandage as well and indicated the date was 4/11/26. On 4/13/26 at 3:30 p.m., LPN 1 was asked to perform a skin assessment for the resident. At that time, the resident was assisted to her right side and the LPN removed her pants and brief. The bandage on the resident's sacrum was dated 4/11/26. During an interview at that time, LPN 1 indicated she had not changed the bandage and she believed the treatment was supposed to be done every day. During a wound treatment on 4/16/26 at 7:17 a.m., the Wound Nurse removed the resident's bandage on her sacrum. The pressure ulcer had minimal drainage and was red in color. The record for Resident 109 was reviewed on 4/16/26 at 10:19 a.m., Diagnoses included, but were not limited to, compression fracture, COPD (chronic obstructive pulmonary disease), pleural effusion (fluid in the pleural space of the lungs), heart disease, chronic kidney disease, high blood pressure, and depression. The admission Minimum Data Set (MDS) assessment, dated 4/9/26, indicated the resident was moderately impaired for daily decision making. The resident was admitted with one Stage 2 pressure ulcer (a partial-thickness skin loss involving a shallow, open ulcer or blister, often pink/red and moist, caused by prolonged pressure or friction).A Care Plan, dated 4/6/26, indicated the resident had impaired skin integrity and was admitted with a pressure ulcer to the sacrum. The approaches were to provide the treatment as ordered by the physician.A Physician's Order, dated 4/6/26, indicated cleanse wound with wound cleanser, pat dry, apply triad paste and foam dressing once a day. The 4/2026 Medication Administration Record indicated the pressure ulcer treatment was signed out as being completed on 4/11 and 4/12/26. A Wound Nurse Practitioner (NP) Progress Note, dated 4/6/26, indicated the pressure ulcer measured 1 centimeter (cm) in length by 0.5 cm in width, by 0 cm in depth. The wound base had 100% of epithelial tissue. A Wound NP Progress Note, dated 4/14/26, indicated the pressure ulcer measured 0.5 cm in length, by 0.5 cm in width, by 0 cm in depth. The wound base had 100% of epithelial tissue. During an interview on 4/16/26 at 9:15 a.m., the Wound Nurse indicated she worked Monday through Friday and nursing staff were responsible to do the treatments on the weekends. She indicated the treatment should have been done as ordered by the physician. During an interview on 4/16/26 at 10:50 a.m., the Director of Nursing had no additional information to provide. 410 IAC (Indiana Administrative Code) 16.2 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure food and/or fluid intake was documented for residents with a history of weight loss for 3 of 3 residents reviewed for nutrition. (Residents 4, 6, and 74)Findings include: 1. The record for Resident 4 was reviewed on 4/16/26 at 3:07 p.m. Diagnoses included, but were not limited to Alzheimer's disease with early onset and end stage renal disease with dependence on renal dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 3/13/26, indicated the resident was cognitively impaired for daily decision making. He had sustained an unplanned weight loss and was receiving dialysis. A Nutrition At Risk (NAR) progress note, dated 4/9/26, indicated the resident had a significant weight loss of 10.9% within the last 90 days. A Care Plan, reviewed on 4/10/26, indicated the resident was at risk for altered nutritional status due to Alzheimer's disease, type 2 diabetes, dementia, end stage renal disease, hyperlipidemia, depressive disorder, and anxiety. Interventions included, but were not limited to, monitor food and fluid intake at meals. The Food Consumption Log for the dates of 3/17/26 through 4/15/26, indicated meal intakes were not documented on the following dates: -3/17/26 no breakfast or lunch intake -3/18/26 no lunch intake -3/19/26 no lunch intake -3/20/26 no intake documented for all three meals -3/21/26 no intake documented for all three meals -3/22/26 no intake for breakfast or lunch -3/23/26 no intake for dinner -3/24/26 no intake for lunch -3/26/26 no intake for breakfast or lunch -3/27/26 no intake for dinner -3/28/26 no intake for breakfast or lunch -3/29/26 no intake for breakfast or lunch -3/31/26 no intake for breakfast or lunch -4/3/26 no intake documented for all three meals -4/4/26 no intake for breakfast or lunch -4/5/26 no intake for breakfast or lunch -4/6/26 no intake for breakfast or dinner -4/7/26 no intake for dinner -4/8/26 no intake for breakfast or lunch -4/9/26 no intake for lunch -4/10/26 no intake for breakfast or dinner -4/11/26 no intake for breakfast or lunch -4/12/26 no intake for breakfast or lunch -4/13/26 no intake for breakfast -4/14/26 no intake documented for all three meals -4/15/26 no intake for lunch During an interview on 4/17/26 at 2:40 p.m., the Director of Nursing indicated the resident's food intake should have been documented and he may have been at dialysis for some of the days breakfast wasn't documented. During an interview on 4/20/26 at 11:30 a.m., the Unit Manager indicated the resident received breakfast before he went to dialysis. 2. The record for Resident 6 was reviewed on 4/15/26 at 9:29 a.m. Diagnoses included, but were not limited to, dementia, type 2 diabetes, atrial fibrillation, heart disease, heart failure, major depressive disorder, adjustment disorder with anxiety and depressed mood. The Annual Minimum Data Set (MDS) assessment, dated 3/3/26, indicated the resident had a significant weight loss and weighed 126 pounds. The 4/8/26 Quarterly MDS assessment indicated the resident was not cognitively intact for daily decision making, weighed 133 pounds, and had no weight loss. A Care Plan, updated 3/2026, indicated the resident was at risk for altered nutrition related to dementia. A Care Plan, updated 3/2026, indicated the resident required assistance and/or monitoring of nutrition. The approaches were to document the percentage of breakfast, lunch, and dinner intakes. A Physician's Order, dated 4/9/26, indicated a regular diet with super cereal with breakfast, ice cream with lunch, and yogurt with breakfast. The resident's weights were as follows: 9/1/25 144 pounds 10/5/25 140 pounds 11/3/25 139 pounds 12/3/25 137 pounds 1/5/26 136 pounds 2/2/26 133 pounds 3/3/26 126 pounds 4/1/26 133 pounds A Registered Dietitian (RD) Progress Note, dated 3/5/26, indicated the resident had a significant weight loss at 30, 90 and 180 days. The breakfast meal was not documented in the point of care charting on 1/2, 1/5, 1/6, 1/7 , 1/9, 1/11, 1/12, 1/13, 1/14, 1/15, 1/16, 1/17, 1/18, 1/19, 1/21, 1/22, 1/23, 1/27, 1/29, 1/30, 1/31, 2/1, 2/3, 2/4, 2/7-2/10, 2/11, 2/12, 2/14, 2/17, 2/18, 2/20, 2/21, 2/27, 2/28, 3/1, 3/2, 3/3, 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, 3/8, 3/9-3/16, 3/22, 3/23, 3/25, 3/26, 3/27, 3/28, 3/29, 3/30, 4/2, 4/5, 4/6, 4/7, 4/10, 4/12, and 4/14/26. The lunch meal was not documented in the point of care charting on 1/1, 1/2, 1/5, 1/6, 1/7 . 1/8, 1/11,1/14, 1/15, 1/16, 1/17, 1/18, 1/19, 1/21, 1/22, 1/23, 1/25, 1/25, 1/27, 1/28, 1/31, 2/3, 2/4, 2/5, 2/8-2/10, 2/11, 2/12, 2/14, 2/15, 2/18, 2/21, 2/22, 2/23, 2/24, 2/25, 2/26, 2/27, 2/28, 3/1, 3/2, 3/3, 3/5, 3/6, 3/8-3/14, 3/16, 3/21-3/23, 3/25, 3/29, 3/31, 4/2, 4/4, 4/5, 4/6, 4/10, 4/12, 4/13, and 4/14/26. The dinner meal was not documented in the point of care charting on 1/2, 1/3, 1/5, 1/7, 1/9, 1/10, 1/11, 1/12, 1/19, 1/24, 1/27, 2/7-2/10, 2/15, 2/18, 2/21, 2/22, 2/24, 2/27, 3/9-3/11, 3/22, 3/23, 3/24, 4/1, 4/2, and 4/7/26. During an interview on 4/16/26 at 1:15 p.m. the Director of Nursing indicated staff were to complete the meal consumptions after every meal. The facility had no policy for review. 3. The record for Resident 74 was reviewed on 4/14/26 at 1:13 p.m. Diagnoses included, but were not limited to, dementia, heart failure, low blood pressure, depression, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 3/5/26, indicated the resident was cognitively impaired for daily decision making and required supervision for eating. The resident weighed 101 pounds and had a mechanically altered diet. On 10/6/25, the resident weighed 106 pounds. On 4/7/26, the resident weighed 85 pounds The resident had a 19.8% weight loss in 6 months. A Physician's Order, dated 12/10/24, indicated to offer the resident an additional 120 milliliters (ml) of fluid every shift. A Care Plan, reviewed on 3/6/26, indicated the resident was at risk for fluid imbalance related to heart failure, dementia, dysphagia, muscle weakness, use of a diuretic medication, and nectar/mildly thick fluids. Approaches were to offer additional 120 ml of fluid every shift and record fluid intake. A Care Plan, reviewed on 3/6/26, indicated the resident had a nutritional risk related to congestive heart failure, dementia, COPD, and a mechanically altered diet with thickened liquids. Approaches were to monitor food/fluid intake at meals, monitor weight, and notify the physician and family with significant weight loss. A Care Plan dated 3/6/36, indicated the resident required assistance with care, nutrition, hydration, and elimination. Approaches were to document breakfast, lunch, and dinner percentage and fluid consumption. The Food Consumption log, dated 3/1-4/16/26, indicated the following: - No dinner was documented on 3/8, 4/6, 4/10, 4/12, and 4/14/26. - No lunch was documented on 3/1, 3/3, 3/4, 3/5, 3/8, 3/11, 3/13, 3/15, 3/18, 3/19, 3/20, 3/26, 3/28, 3/29, 3/30, 3/31, 4/2, 4/5, 4/8, 4/11, and 4/15/26. -No breakfast was documented on 3/1, 3/5, 3/7, 3/8, 3/12, 3/15, 3/16, 3/19, 3/24, 3/26, 3/28, 3/29, 3/30, 3/31, 4/2, 4/5, 4/10, 4/11, 4/12, 4/13, 4/14, and 4/15/26. - No food consumption was documented on 3/2, 3/9, 3/10, 3/14, 3/21, 3/22, 3/23, 4/4, and 4/9. A Physician's Order, dated 4/9/26, indicated to give mirtazapine (appetite stimulant) 7.5 milligrams (mg) at bedtime. During an interview on 4/20/26 at 10:50 a.m., the Director of Nursing (DON) indicated there were meals and fluids not documented. No additional information was provided. 410 IAC (Indiana Administrative Code) 16.2-3.1-46(a)(1)

Based on observation and interview, the facility failed to infection control measures were followed during medication administration observation for 1 of 8 residents observed receiving medications (Resident 17) and a linen cart was covered for 1 of 5 halls. (Hall 500) Findings include: 1. During an observation of a medication pass for Resident 17 on 1/24/2025 at 10:22 A.M., QMA 7 dropped a calcium tablet onto the medication cart. She picked up the tablet with her bare hand and placed it into a medication cup with Resident 17's other medications. During an interview with QMA 7 during the medication pass, she indicated she should not have administered the medications to the resident and should have destroyed all of the resident's medications once she had put the calcium table into the medication cup with the other medications. During an interview on 1/24/2025 at 10:26 A.M., QMA 17 indicated she was unsure of the facility policy for destruction of contaminated medications. During an interview with the Assistant Director of Nursing, who was present at the time, she indicated she was also not sure of the policy. 44111 2. During an observation on 1/24/2025 at 2:54 P.M., the linen cart in the 500 hall's cover was on top of the cart exposing the clean linens and an opened container of micro kill bleach wipes with a wipe hanging out of the top. During an interview on 1/24/2025 at 2:55 P.M. with CNAs 4 and 5, they indicated the linen should have been covered. CNA 4 indicated the container of bleach wipes should not have been left open. She then proceeded to pull the exposed wipe out of the top of the container, but then stuffed it back into the container, under the lid and closed the lid. On 1/27/2025 at 11:37 A.M., the Regional Nurse provided a policy titled, Laundry/Linen, revised 12/2021, and indicated the policy was the one currently used by the facility. The policy indicated . 2. Resident care areas: clean linen a. Clean linen must be protected from soiling or contamination. i. Carts/racks must be covered including transportation of clean and soiled linen . On 1/24/2025 at 10:54 A.M. a current policy titled, General Dose Preparation and Medication Administration,dated 11/15/2024, was provided by the Director of Nursing. The policy indicated, .Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package and .If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy 3.1-18

Based on observation, interview, and record review, the facility failed to follow the plan of care for a resident who required two staff present for care for 1 of 3 residents reviewed for care plans. (Resident 34) Finding includes: During an observation on 1/27/2025 at 9:27 A.M., CNA 8 exited Resident 35's room by herself. During an interview on 1/27/2025 at 9:29 A.M., Resident 35 indicated the CNA that had just left the room had helped him with toileting. He indicated he usually only had one caregiver in the room providing assistance because that was usually all they had working on the floor. He indicated it was rare that two staff members assisted him with care in his room, but occasionally two staff providing transfer assistance with the mechanical lift. During an observation on 1/28/2025 at 9:13 A.M., CNA 2 answered Resident 35's call light and asked the resident what he needed. The resident informed the CNA that he needed to use the urinal and CNA 2 proceeded into the resident's room and closed the room door. A record review was completed on 1/24/2025 at 10:01 A.M. Diagnoses included, but were not limited to: hypertension heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, peripheral vascular disease, type 2 diabetes mellitus and right above the knee amputation. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 35's cognition was intact and he required substantial/maximal assistance with personal hygiene and was dependent on staff assistance with bathing. A current Care Plan initiated on 8/7/2017, indicated Resident 35 needed staff assistance with activities of daily living. Interventions included, but were not limited to: care in pairs, which was typed in capital letters. A current behavior Care Plan initiated on 12/28/2020, indicated Resident 35 made false allegations and negative statements regarding staff members at time. The interventions, included but were not limited to: Care in pairs. A current Resident Profile, dated 7/9/2021, indicated care in pairs was typed in capital letters. During an interview on 1/28/2025 at 9:49 A.M., CNA 2 indicated that there were no residents in the hall that required care to be provided in pairs. During an interview on 1/28/2025 at 10:18 A.M., CNA 3 indicated that there were no residents in the hall that required care to be provided in pairs. On 1/28/2025 at 11:58 A.M., the DON indicated the facility did not have a policy regarding following the plan of care. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADLs) for a dependent resident timely related to nail care and shaving for 1 of 3 reviewed for ADLs. (Resident 35) Finding includes: During an observation and interview, on 1/23/2025 at 10:21 A.M., Resident 35 had a full beard and his nails were jagged with a brown substance under them. Resident 35 indicated he received bed baths twice a week and did not have any problems with them but preferred to have assistance with shaving and nail care. Resident 35 indicated staff had only offered to assist him with shaving once or twice a month. During an observation and interview on 1/24/2025 at 9:11 A.M., Resident 35 had a full beard and jagged nails with a brown substance under them. He indicated that no one had offered to assist him with shaving or nail care. During an observation and interview on 1/27/2025 at 9:27 A.M., Resident 35 indicated the night shift CNA had shaved him and he was happy that his goatee and mustache were now trimmed. He indicated he preferred to have the whiskers on the sides of his face, cheek and neck area shaved at least weekly. Resident 35 indicated he had not refused any offered shaving assistance. He indicated he used to shave every day at home and preferred to be shaved at least weekly. He indicated if he had access to fingernail clippers, he would attempt to trim his own nails, but no one had offered him fingernail clippers when he received his bed baths. During an observation and interview on 1/28/2025 at 9:36 A.M., Resident 35 had facial hair growth on his cheek, sides of his face and his neck but he indicated he did not need shaved yet. He indicated he would like to be shaved weekly. His fingernails remained jagged with a brown substance under them and he indicated no one had offered nail care but if they gave him clippers, he would have tried to trim his own nails. A record review was completed on 1/24/2025 at 10:01 A.M. Diagnoses included, but were not limited to: hypertension heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, peripheral vascular disease, type 2 diabetes mellitus and right above the knee amputation. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 35's cognition was intact and he required substantial/maximal assistance with personal hygiene and was dependent on staff assistance with bathing. A current Care Plan, initiated on 8/8/2017, indicated the resident required assistance/monitoring for activities of daily living for A.M. and P.M. care. During an interview on 1/28/2025 at 9:49 A.M., CNA 2 indicated when she provided A.M. care, she completed peri-care, toileted the resident, combed their hair, brushed their teeth and shaved them, if needed. When she provided a complete bed bath, she washed their hair with a shampoo cap, washed their body, applied lotion, shaved the resident, if they needed to be shaved and dressed the resident. She indicated there were no residents on the hall that refused care except for the two female residents who were combative with care. CNA 2 indicated she had not noticed that Resident 35's nails were jagged and not clean when she had provided A.M. care for the resident earlier in the morning. During an interview on 1/28/2025 at 10:18 A.M., CNA 3 indicated when he provided A.M. care, he changed the resident's brief and performed peri-care, brushed their teeth, and offered to shave them. When he provided a complete bed bath, he washed their hair with a shampoo cap, cleaned their body, dried their body and dressed them, then brushed teeth, nail care and shaved them. He indicated Resident 35 had not refused care. On 1/28/2025 at 11:33 A.M., Regional Nurse indicated the facility did not have a policy for nail care or shaving; but they followed the regulations related to resident rights. 3.1-38(3)(D)(E)

Based on observation and interview, the facility failed to date multi-dose medication containers when opened, for 2 of 3 medication carts observed. (100 hall & 600 hall) Findings include: 1. During an observation of a 100 hall medication cart with LPN 6, on 1/24/2024 at 9:58 A.M., the following multi-dose medication containers lacked a date that indicated when it was opened: 1 bottle of atropine eye drops, and 1 bottle of Mylanta. 2. During an observation of a 600 hall medication cart with LPN 5, on 1/24/2024 at 10:17 A.M., the following multi-dose medication containers lacked a date that indicated when it was opened: 3 bottles of polyethylene glycol, 1 bottle of simethicone, 1 bottle of icosapent ethyl, and 1 bottle of potassium. A policy, titled, Storage and Expiration Dating of Medications, Biologicals, and dated 7/21/2022, was provided by the Director of Nursing on 1/26/2024 at 9:15 A.M. as current. The policy indicated, .Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened 3.1-25(j)

Based on observation and interview, the facility staff failed to perform proper hand hygiene when preparing medications for administration to residents, for 2 random infection control observations during medication administration. Findings include: 1. During an observation of medication pass, on 1/23/2024 at 11:41 A.M., LPN 3 approached the medication cart and failed to perform hand hygiene before setting up medications for a resident. Alcohol based hand rub (ABHR) was available on the medication cart. During an interview on 1/23/2024 at 11:42 A.M., LPN 3 indicated she should have used the ABHR to clean her hands before setting up medications. 2. During an observation of medication pass, on 1/24/2024 at 8:45 A.M., LPN 4 made notes and documented medication for one resident, and failed to perform hand hygiene before setting up medications for another resident. ABHR was available on the medication cart. During an interview on 1/24/2024 at 8:47 A.M., LPN 4 indicated she should have washed her hands before preparing medications for the next resident. On 1/26/2024 at 9:15 A.M., the DON (Director of Nursing) indicated there is not a policy for when to use hand hygiene during medication preparation or administration. 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure Oxygen usage signage was posted outside resident rooms and failed to ensure residents had current Physician Orders for the use of oxygen for 2 of 3 residents reviewed for respiratory care. (Residents 12 and 136) Findings include: 1. During an observation, on 1/23/2024 at 2:38 P.M., Resident 12 was observed receiving oxygen. There was no oxygen signage posted in or outside of room. During an observation, on 1/24/2024 at 9:30 A.M., Resident 12 was observed receiving oxygen. There was no oxygen signage posted in or outside of room. During an observation, on 1/25/2024 at 9:13 A.M., Resident 12 was observed receiving oxygen. There was no oxygen signage posted in or outside of room. During an interview, on 1/25/2024 at 9:55 A.M., LPN 3 and LPN 12 both indicated there should have been oxygen signage posted outside of Resident 12's door indicating oxygen use. During an observation, on 1/26/2024 at 2:35 P.M., Resident 12 was observed receiving oxygen. There was no oxygen signage posted in or outside of room. A record review was completed on 1/25/2024 at 1:14 P.M. Resident 12's diagnoses included but were not limited to: acute and chronic respiratory failure with hypoxia, Atrial Fibrillation, Congestive Heart Failure, A Physician's Order, dated 12/12/2023, indicated oxygen at 4 Liters per nasal cannula. 38845 2. During an interview, on 1/22/2024 at 2:13 P.M., Resident 136 was observed to be using oxygen (O2). The resident indicated staff had not changed the O2 cannula. During an observation, on 1/23/2024 at 11:38 A.M., there was no O2 signage regarding the use of O2 on the resident's door or surrounding area. A record review was completed on 1/24/2024 at 2:28 P.M. A Discharge Summary, dated 1/5/2024, indicated continue to wean O2 as tolerated. The record lacked a current Physician's Order for the use of the O2. During an interview, on 1/25/2024 at 10:46 A.M., LPN 5 indicated normally they did not have an O2 sign posted. During an interview, on 1/25/2024 at 10:52 A.M., LPN 5 indicated there should be an O2 sign on the door. During an interview, on 1/25/2024 at 11:32 A.M., RN 9 indicated there should have been an active Physician's Order for the O2. On 1/26/2024 at 11:56 A.M., the Director of Nursing provided the policy titled, Oxygen Therapy and Devices, undated, and indicated the policy was the one currently used by the facility. The policy indicated .1). No Smoking signs need to be affixed to the FRONT and BACK of doors (OSHA regulations). Initiation of Oxygen. 1). Verify physician order . 8) Place O2 signs 3.1-47(6)

Based on record review, observation, and interview, the facility failed to ensure a person-centered care plan was developed for 1 of 26 residents whose care plans were reviewed. (Resident 12) Finding includes: A record review was completed on 1/25/2024 at 1:14 P.M. Resident 12's diagnoses included, but were not limited to: acute and chronic respiratory failure with hypoxia, Atrial Fibrillation, Congestive Heart Failure, and chronic Pleural Effusion (build up of fluid between lungs and chest). A Physicians' Order, dated 1/15/2024, indicated Resident 12 had a PleurX Drain (an indwelling suction tube used to remove excess fluid or air) to drain fluid and record output every day. A hospital Discharge Note, dated 12/12/2023, indicated the resident still required a PleurX catheter for daily drainage upon admission to the facility for chronic right pleural effusion. Resident 12's current care plans lacked a specific care plan for the use and care the PleurX drain, including potential respiratory complications and interventions. A Care Plan, dated 12/20/2023, indicated the resident was at risk for fluid imbalance due to acute kidney failure, DM II (Diabetes Mellitus), obstructive and reflux uropathy, chronic combined systolic and Congestive Heart Failure, chronic kidney disease, moderate protein calorie malnutrition, weakness, PleurX drain. Interventions included, but were not limited to: Administer medications as ordered, resident will be free from signs and symptoms of fluid volume deficit, and document and notify Medical Doctor of signs and symptoms of fluid volume deficit: dry mucous membranes, thirst, weight loss, decrease blood pressure, weak or rapid pulse, change in mental status, decreased urine output, abnormal labs, and poor skin turgor. During an interview, on 1/26/2024 at 11:28 A.M., the MDS (Minimum Data Set assessment) Nurse indicated normally, a resident would have had a care plan in place for care of a chest tube. She indicated there was acknowledgement of the PleurX tube only on his 12/20/2023 fluid imbalance care plan. When asked if Resident 22 should have had a care plan in place specific to care for PleurX, she indicated she would have to investigate further. A policy was provided on 1/26/2024 at 12:15 P.M. as current by the Director of Nursing, titled, IDT Comprehensive Care Plan Policy, and dated 1/2010, with a revision date of 8/2023. The policy indicated .The care plan must include measurable goals and resident specific interventions based on the resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychosocial well-being 3.1-35(a)

Based on interview, observation, and record review, the facility failed to ensure residents received showers or complete bed baths as scheduled for 2 of 4 residents reviewed for Activities of Daily Living. (Residents 12 and 22) Findings include: 1. During an interview, on 1/22/2024 at 1:37 P.M., Resident 12 indicated he had received only one shower since admitting to the facility on [DATE]. An Admission MDS (Minimum Data Set) Assessment, dated 12/19/2023, indicated the resident was dependent on staff for bathing and showering needs. A Significant Change MDS, dated [DATE], indicated it was very important to choose between tub bath, shower or bed baths. A review of the facility January 2024 shower binder, on 1/25/2024 at 3:00 P.M., indicated Resident 12 had the following shower sheets documented in the binder: 1/5/24 - shower 1/7/24 - shower 1/8/24 - complete bed bath 1/19/24 - shower During an interview, on 1/25/2024 at 3:54 P.M., Unit Manager 11 indicated the resident should have had more documented showers or baths located in the binder for the month of January 2024. 2. During an interview, on 1/22/2024 at 2:41 P.M., Resident 22 indicated he was not getting his showers like he should have been. A record review was completed on 1/25/2024 at 3:00 P.M. An Admission MDS (Minimum Data Set) Assessment, dated 9/22/2023, indicated it was very important for resident to choose between tub bath, shower, complete bed bath or partial bed baths. A Quarterly MDS, dated [DATE], indicated Resident 22 required maximum assist for bathing. The January 2024 binder containing bathing sheets, contained only 3 sheets, dated 1/10/2024, 1/19/2024, & 1/24/2024, which were all marked as showers. During an interview, on 1/25/2024 at 3:54 P.M., Unit Manager 11 indicated all shower and or complete bed bath documentation was completed by the staff and kept in the shower sheet binder. Sheets were to be filled out when a resident refused or requested a different day for their shower. Staff tried to accommodate requests to bathe on a different day. Unit Manager 11 indicated that she tried to ask residents if they got their shower or baths, if not documented. She indicated Resident 22 should have had more than 3 documented showers or complete bed baths, and residents should receive at least 2 showers or complete bed baths per week. A policy was requested on 1/26/2024 at 12:15 P.M., but none was provided. 3.1-38(a)(2)

Based on observation, record review and interview, the facility failed to ensure resident rooms and common areas were maintained in a clean and homelike manner on 4 of 4 nursing units, and in the main dining room and activity room. This deficient practice potentially affected all 76 residents residing in the facility. Findings include: During an environmental tour of the facility, conducted on 11/01/2022 between 9:30 A.M. - 10:38 A.M., accompanied by the Administrator and the Maintenance Supervisor the following was noted: In room [ROOM NUMBER] a chair rail molding had been removed and there were a few finishing nails, which were utilized to secure the plastic wall protective skin on the lower half of the wall, that were sticking out and were rough. During an interview with the Maintenance Supervisor, he indicated he had removed the old chair rail and had sanded the repainted the wall in the past week. He indicated he would go back and ensure the nails were smooth. In addition, there was an area on the wall, beside the soap dispenser with drywall mud visible. In room [ROOM NUMBER] there were visible cobwebs in the corner between the window wall and Resident B's room. In addition, the wall beside and behind Bed B had dried spilled liquid stains. The bathroom door and door frame were also noted to be heavily gouged with missing paint. There was also visible drywall mud noted above the toilet paper holder in the bathroom. In room [ROOM NUMBER], the window blind was noted be sagging in the middle with the bottom blind cracked in the middle. In addition, there were deep gouges in the wall beside Resident B's bed. There was also a missing chair rail above Resident B's bed. There were multiple holes noted in the drywall above Resident A's bed. In room [ROOM NUMBER] there were 4 dead flies noted on the windowsill. In addition, there were deep gouges in the wall noted beside Bed B. In room [ROOM NUMBER] there was a missing chair rail along the wall behind Bed A and B. There were gouges and old adhesive noted where the chair rail was missing. In addition, there were deep gouges noted in the wall beside Bed B. There was also marred paint and missing drywall noted on the corner of the wall beside the bathroom door. In room [ROOM NUMBER] the chair rail was missing and there were holes and old adhesive noted where the rail was missing. In addition, the air conditioning and heating unit was noted to have visible dust and debris in the vent. The Maintenance Supervisor removed the plastic covering and dust and debris were noted on the screen. In addition, the floor in the corner by the air-conditioning unit was dirty with multiple cobwebs and debris. In room [ROOM NUMBER] the windowsill was cracked from the front to the back and the whole window sill was loose and easily pulled away from the wall when lifted. In room [ROOM NUMBER], there was a large area of dry wall mud noted behind the toilet and behind Bed B. The chair well had been removed and there was old adhesive and multiple holes noted on the drywall. In addition, the corner of the wall beside the closet was noted to be heavily gouged and was missing paint and wallboard. In room [ROOM NUMBER], the corner of the wall beside the bathroom door was heavily gouged and missing drywall. The toilet tank was noted to be leaning against the wall behind it. The maintenance Supervisor indicated he had a special piece of plastic he utilized to secure the toilet tank to the base. In the main dining room, there were cobwebs noted in the corner by an exit door into the courtyard area. In the Activity room, there were cobwebs hanging from the corner of the wall beside the television. In addition, Resident 60 was observed seated in her wheelchair in the activity room. Her wheelchair was noted to be heavily soiled with a build up of dried food particles, dried splashed liquids, and grime. The soilage was noted on her wheelchair wheels, metal wheelchair sides, wheelchair brakes and brake hands and pedals. The Administrator noted the condition and indicated it was horrible. In room [ROOM NUMBER] the chair rail was missing with holes in the wall and in the bathroom by the toilet paper holder. During the Environmental tour of the facility, the Administrator disclosed the facility had been without a maintenance supervisor for approximately 6 months. The current Maintenance Supervisor had been hired about 2 months ago. The Administrator indicated the facility was aware of some of the needed repairs, had an action plan and had compiled a list. She indicated the Maintenance Director had started on the repairs. Review of the Action Plan, dated [DATE] and provided by the Administrator on 11/01/2022 at 11:42 A.M. indicated the environmental concerns included patch work, trim and paining on walls, chipped tile/flooring in rooms, broken privacy curtain hooks, broken TP Toilet paper) hooks, light fixtures. There were 52 rooms with rooms with needed repairs and/or painting indicated on the list. The goal on the action plan, after compiling the comprehensive list of repairs, was to have two resident rooms repaired per week. The facility policy and procedure, titled Daily Maintenance included the following: The listed tasks should be performed on a daily basis . The list included air conditioning and heating units, Painted/Stained surfaces, and Wheelchairs. On 11/2/2022 at 3:40 P.M., the Director of Nursing provided the policy titled, Resident Rights, dated March 15, 2017. The policy indicated . Safe Environment. you have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely . This Federal tag relates to Complaint IN00387842. 3.1-19(e)

Based on observation, record review and interview, the facility failed to provide showers timely for 2 of 3 residents reviewed for ADL's (activities of daily living). (Resident 30 & 60) Findings include: 1. During an observation, on 10/27/2022 at 9:57 A.M., Resident 30 had long, jagged and dirty fingernails. A clinical record review was completed on, 10/31/2022 at 1:56 P.M. Resident 30's diagnoses included, but were not limited to: Alzheimer's disease, dementia, hypertension and arthritis. A Quarterly MDS (Minimum Data Set) Assessment, dated 8/30/2022, indicated Resident 30 BIMS (Brief Interview for Mental Status) was unable to be completed, severe cognitive impairment. Required extensive assist of 2 staff for bed mobility, and total assist for toilet use, transfers and bathing. A care plan, dated 3/23/2022, indicated the resident required assistance with ADLs including bed mobility, transfers, eating and toileting related to: weakness, history of falls, and impaired cognition. Interventions included, but were not limited to: Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Assist with dressing/grooming/hygiene as needed. The shower schedule indicated she was to receive showers on Wednesdays and Saturdays on the evening shift. Resident 33's shower documentation, dated 9/28/2022 to 10/29/2022, indicated the resident had a shower documented on 9/28/2022; a bed bath on 10/12/2022; shower on 10/21/2022; shower on 10/22/2022; bed bath on 10/29/2022. There was no documentation to show Resident 30 had received any type of bathing on: 10/1, 10/5, 10/8, 10/15, and 10/26/2022. During an observation, on 11/1/2022 at 10:07 A.M., Resident 30's nails were observed dirty with a black substance under the nails. During an interview, on 11/01/2022 at 2:13 P.M., LPN 5 indicated there should have been more shower sheets to indicate the resident had received showers. 2. During an observation, on 10/27/2022 at 9:59 A.M., Resident 60's hair was greasy and had dirty fingernails. A clinical record review was completed on 10/31/2022 at 2:19 P.M. Resident 60's diagnoses included, but were not limited to: seizure disorder, Alzheimer's disease and dementia. An Annual MDS ( Minimum Data Set) Assessment, dated 8/2/2022, indicated the resident required extensive assist of 2 staff for bed mobility, transfers, toilet use, and was totally dependant for bathing. A care plan, dated 3/24/2022, indicated the resident required extensive assistance with ADLs (Activities of daily living). Interventions included, but were not limited to: Assist with bathing as needed per resident preference. Offer showers two times per week, and partial bath in between. The shower schedule indicated she was to receive showers on Tuesday and Fridays on the evening shift Resident 60's shower documentation, dated 9/28/2022 to 10/29/2022, indicated the resident had a bed bath on 9/13, shower on 9/27, shower on 10/24 and a bed bath on 10/27/2022. There was no documentation to show Resident 30 had received any type of bathing on: 9/30, 10/4, 10/7, 10/14, 10/18, 10/21, 10/25 and 10/28/2022. During an observation on, 11/01/2022 at 10:06 A.M., Resident 60 was observed with dirty nails. During an interview, on 11/01/2022 at 2:13 P.M., LPN 5 indicated there should have been more shower sheets to indicate the resident had received showers. On 11/2/2022 at 3:40 P.M., the Director of Nursing provided the policy titled, Resident Rights - Know Your Rights under Federal Nursing Home Regulations, dated March 15, 2017, and indicated the policy was the one currently used by the facility. The policy indicated . You have the right to be informed, and participate in, your treatment. This includes the right to: Received services and/or items included in the plan of care 3.1-38(a)(3)

Based on observation, record review and interview, the facility failed to keep medication storage carts secured/locked when visually seen in 4 of 4 medications carts observed. ( Halls 400, 500, 600 and the Cottage Unit) Findings include: 1. On 10/28/2022 at 4:40 A.M., the medication carts for the 400 and the 600 halls were observed unlocked with no licensed staff using the medication carts. 2. During a medication pass observation, on 10/28/2022 at 4:45 A.M., RN 10 retrieved medication for the resident. RN 10 indicated it might be hard to wake the resident up because she's up all night walking around. RN 10 entered room [ROOM NUMBER] B and administered the medication to her without any issues. The medication cart was left unlocked when the nurse was in the residents room. During an interview, on 10/28/2022 at 4:46 A.M., RN 10 indicated the medication cart should have been locked. 3. During a random observation, on the Cottage unit on 10/28/2022 at 5:20 P.M., the medication cart was observed unlocked. During an interview, on 10/28/2022 at 8:16 A.M., the Administrator indicated the medication carts should have been locked. On 11/2/2022 at 3:40 P.M., the Director of Nursing provided the policy titled,5.3 Storage and Expiration of Medications, Biological's, Syringes and Needles, dated 12/01/2017, and indicated the policy was the one currently used by the facility. The policy indicated .3.3 Facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 3.1-25(m)

Based on record review and interview, the facility failed to have an appropriate diagnosis for the use an Antipsychotic medication for 2 of 5 residents reviewed for unnecessary medication. (Resident 16 & 21) Findings include: 1. A clinical record review was completed on 11/01/2022 at 1:42 P.M. Resident 16's diagnoses included but were not limited to: Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, altered mental status and anxiety. Current physician orders, dated 11/1/2022, indicated Resident 16 had received Seroquel (antipsychotic) 12.5 mg (milligrams) daily for the diagnosis of unspecified dementia with behavioral disturbance since 10/12/2022. During an interview, on 11/01/2022 at 2:40 P.M., the Social Service Director indicated the current diagnosis was not appropriate for the use of Seroquel. 2. A clinical record review was completed on 10/28/2022 at 2:38 P.M. Resident 21's diagnoses included but were not limited to: Unspecified dementia with behavioral disturbance, major depressive disorder, altered mental status and anxiety. Current physician orders, dated 11/1/2022, indicated Resident 21 had received Seroquel (antipsychotic) 25 mg daily since 10/12/2022 for the diagnosis of encounter for other specified aftercare. During an interview, on 11/01/2022 at 2:40 P.M., the Social Service Director indicated the current diagnosis was not appropriate for the use of Seroquel. On 11/2/2022 at 3:41 P.M., the Director of Nursing provided the policy titled, Psychotropic Management undated, and indicated the policy was the one currently used by the facility. The policy indicated . 1. Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed , and this is documented in the medical record 3.1-48(b)(1)

Based on record review and interview, the facility failed to develop person centered care plans for hives and for a resident with depression in 2 of 22 residents whose care plans were reviewed. (Resident 30 and 7) Findings include: 1. During an observation, on 10/27/2022 at 9:57 A.M., Resident 30 was observed with round red raised areas to the right upper arm, left and right lower leg and the left inner arm. A clinical record review was completed on 10/31/2022 at 1:56 P.M. Resident 30's diagnoses included, but were not limited to: Alzheimer's disease, dementia, arthritis, and hyperthyroidism. A Quarterly MDS (Minimum Data Set) Assessment, dated 8/30/2022, indicated Resident 30 was severely impaired cognitively. Required extensive assist of 2 staff for bed mobility, total assist for toilet use and transfers, and extensive assist of 1 for eating and dressing and had no skin issues. A current care plan, dated 2/21/2022, indicated the resident had a history of hives around her mouth. During an interview, on 10/31/2022 at 1:23 P.M., the IP (Infection Preventionist) indicated Resident 30's hives just come and goes and had been treated with hydrocortisone cream. She indicated the staff had been talking about the hives last week. The IP indicated she was unsure if there was a care plan for the hives currently on her body. A Progress Note, dated 11/1/2022, indicated the IDT (Interdisciplinary Team) met to review the hives to the resident. The clinical record lacked a person centered care plan for the hives to the residents arms, legs and torso. 47419 2. During a random observation on 10/27/2022 at 11:40 A.M., Resident 72 had a flat affect. During an interview, 10/27/2022 at 11:40 A.M., Resident 72 cried when asked how she was feeling, and indicated she was not feeling good. A clinical record review was completed on 10/28/2022 at 2:47 P.M. Resident 72's diagnoses included, but were not limited to: Non-Alzheimer's dementia, depression, and diabetes mellitus. Physician orders dated, 10/6/2021, included, Zoloft (an antidepressant) 50 mg (milligrams) oral once a day, and on 2/21/2022, Mirtazepine 7.5 mg oral at bedtime. A Quarterly MDS (Minimum Data Set) Assessment, dated 10/4/2022, indicated Resident 72 had a BIMS (Brief Interview for Mental Status) score of 14, cognition intact. A care plan problem, dated 10/6/2022, indicated the resident was at risk for signs and symptoms of depression, upset with current situation, and not seeing family often. Interventions included but were not limited to: medications per order; encourage family support and involvement; emphasize and promote independence and feelings of control and choice; allow resident to express feelings; offer validation and support; and encourage activities of interest. A Progress Note, dated 7/13/2022, indicated the resident had been seen by the psychologist. The note indicated, Resident is anxious about upcoming medical procedure in 5 days and Ativan was started until the day of procedure. A Progress Note, dated 9/19/2022, indicated the resident had been seen by the psychologist. The note indicated, Resident having an anxiety about starting hemodialysis and continued difficulty with nursing home placement. Visits will be increased to every 2-4 weeks as needed. A Progress Note, dated 10/10/2022, indicated Resident 72 had been seen by the psychologist and the Resident still has difficulty adjusting to potential need for hemodialysis and appeared depressed. She was in better mood at end of session. The GDR (Gradual Dose Reduction) note for Zoloft, dated 9/26/2022, indicated, Patient with symptoms of depression. She is not getting out from her room. Decreasing Zoloft can worsen her mood. GDR note dated 9/26/2022 for Remeron indicated, Discontinuation of Remeron can worsen her sleep. During an interview on 11/01/2022 at 11:29 A.M., the Social Service staff indicated the interventions instructing staff on what made her feel better were not present and should have been. The care plan was not person centered. On 11/2/2022 at 3:41 P.M., the Director of Nursing provided the policy titled, IDT Comprehensive Care Plan Policy. The policy indicated, .Care plan problems, goals, and interventions will be updated based on changes in the resident assessment/condition, resident preferences, or family input 3.1-35(a)

Based on record review and interview, the facility failed to ensure the appropriate financial liability notification forms were provided to 2 of 3 residents who were reviewed for the ABN (Advanced Beneficiary Notice) and the NMNC (Notice of Medicare Non-Coverage). (Residents 72 & 100) Findings include: 1. A clinical record review was completed on 10/28/22 at 10:43 A.M. An Admission MDS (Minimum Data Set) Assessment, dated 6/30/2022, indicated Resident 72's BIMS (Brief Interview for Mental Status) score was 7, indicating severe cognitive impairment. Resident 72's ABN and NNMNC had not been signed by the resident, or the residents' representative. The clinical record indicated a phone call had been made to the spouse, however, there was no indication that the documents had been mailed. 2. A clinical record for Resident 100 was completed on 11/03/2022 at 11:19 A.M. An Admission MDS Assessment, dated 7/4/2022, indicated Resident had a BIMS score of 4, severe cognitive impairment. The clinical record lacked the documentation of any communication with the residents' representative, or that the ABN/ NMNA documents had been mailed. On 11/2/2022 at 3:40 P.M., the DON provided the policy titled, Checklist/Instructions for issuing a Notice of Medicare Non-Coverage (NOMNC) /Determination On Continued Stay. The policy indicated .Responsible party must come into sign the NOMNC or it needs to be sent out by mail with a return envelope During an interview, on 11/03/2022 at 11:30 A.M., Social Service staff indicated the NMNC and ABN had not been mailed to the residents' representatives and should have been mailed, along with a return envelope. 3.1-4(f)(2)

Based on observation, interview and record review, the facility failed to implement infection control procedures, including those to properly prevent and/or contain COVID-19, related to staff not wearing appropriate PPE during random observations for infection control. Finding includes: During an observation of the facility and staff conducted on 12/3/21 from 12:50 P.M. to 1:40 P.M., the following was observed: -some of the nursing staff on the 400 and 600 unit were wearing glasses/eyewear which appeared at times not to touch their foreheads. - at 1:02 P.M., the Infection Control Preventionist (ICP) was observed with eyewear that did not touch her forehead and there were gaps at both sides of the eyewear. The ICP indicated the eyewear should touch the forehead and not have any gaps. -at 1:13 P.M., the activity room was observed and all the residents were 6 feet apart from each other and had a face mask on, except Resident K and Resident M who were sitting next to the Activity Director who had a face mask on and but no face shield, as she was reading to the residents. Resident K did not have her face mask covering her nose and there was no attempt made by the Activity Director to assist resident K with the proper face mask placement. -at 1:25 P.M., CNA 4 was observed in Resident N's room providing care (closer than 6 feet of the resident) with a N95 mask donned but no face shield observed on the CNA. -at 1:31 P.M., a man was walking in the hallway near the activity room without a mask. He indicated he was an employee coming on shift. This employee had no mask on. At 1:35 P.M., the same staff (laundry aide 5) was seen in the hallway wearing his mask, which was covering his mouth but not his nose. This observation occurred in front of the Regional Director of Services. On 12/3/21 at 2:55 P.M., the Regional Director of Services provided a current policy titled, Implementing Prevention Measures for COVID-19, dated 6/2020 and revised, on 9/28/21. The policy indicated .Policy: Each facility will implement the following measures to assist in preventing the spread of COVID-19 .Mask should cover their mouth and nose when in use .HCP [Health Care Provider] must wear face mask (medical) and eye protection, face shield/or goggles that cover top, bottom, sides of eyes with no gaps) as a standard safety measure to protect LTC [Long Term Care] HCP[Health Care Providers .who provide essential direct care within 6 feet of the resident, regardless of COVID-19 status 3.1-18(a)

Based on observation, interview and record review, the facility failed to ensure a resident received adequate assistance with transfers to prevent falls, resulting in a witnessed fall and a fractured femur requiring surgical intervention for 1 of 3 residents reviewed for falls. (Resident Q) Findings include: On 9/3/19 at 11:57 [NAME]M., Resident Q's record was reviewed. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 8/6/19, indicated the resident had a BIMS (Brief Interview Mental Status) score of 7, severely impaired cognition. She required extensive assistance from 2 staff members for bed mobility, transfers, and toileting. A Care Plan, dated 10/31/17 and revised on 8/20/19, indicated Resident Q required assistance with her ADL's (Activities of Daily Living) of bed mobility, transfers, eating and toilet use. Interventions included, but were not limited to, assist with transfers as needed; extensive assist of 2 for transfers, Occupational therapy for self care, Physical therapy for mobility, and Therapy screen quarterly and prn (as needed). A Care Plan, dated 10/31/17 and revised on 8/20/19, indicated Resident Q was at risk for falls. The goal was the residents fall risk factors would be reduced in an attempt to avoid significant fall related injury. Interventions included, but were not limited to, requires extensive assist of 2 for transfers (4/11/19), non-skid strips on floor beside bed (3/11/19), call light in reach (10/31/17), and Therapy screen (10/31/17). A Resident Profile report indicated on 4/11/19, the resident required extensive assistance from 2 staff members for transfers. The report did not indicate the resident was to be transferred with the use of a mechanical lift. Resident Progress Notes, dated 7/10/19, indicated the following: At 7:45 p.m., the resident was found in her room, lying on the floor on her left side. Her brief was torn on the right side and there was a large amount of bright red blood on the floor near her buttock. Her right buttock had a large laceration and had yellow adipose (fat) tissue emerging from the area. 911 was called and the resident was transported to the ER for evaluation and treatment. At 9:05 p.m., the hospital notified the facility that Resident Q had to be taken to surgery due to the size of her wound but would probably return to the facility following surgery. The resident returned to the facility on [DATE] at 2:13 a.m. A Resident Progress Note, dated 7/11/19 at 7:43 a.m., indicated IDT (Interdisciplinary Team) met to review the resident's fall with injury. Resident Q obtained a laceration to the right side of her vagina to rectum which measured 16 cm (centimeters) by 5 cm and required approximately 30 sutures to close the wound. She had a laceration to the left side of her head that measured 1 cm by 0.1 cm that had 1 suture in it. The resident had reported she had tried to transfer herself from the wheelchair (w/c) to bed but had fallen which resulted in the lacerations. A Nursing to Therapy Referral form, dated 7/11/19 at 12:02 p.m., indicated the resident was referred to therapy due to her fall when she had attempted to transfer herself from the w/c to bed. A Physician order, dated 7/13/19, was for Resident Q to be transferred with the stand up mechanical lift. The order was discontinued on 7/15/19. Skills Validation CNA (Certified Nurse Assistants) forms, provided by the DNS (Director of Nursing Services) on 9/5/19 at 1:22 p.m., indicated the stand up mechanical lift had a sling that was applied and aligned with the resident's lower back. A mechanical lift or hoyer lift had a sling that was placed between the resident's shoulders and extended down to the back of a resident's knees. A hoyer lift sling would cover Resident Q's bottom and her wound but the stand up lift sling would not. It was unknown which mechanical lift staff had been used for Resident Q from 7/13-7/15/19. A Treatment Administration Record, dated 7/13/19 at 4:31 p.m., indicated Resident Q refused the stand up lift because Stitches to her bottom make it hard to sit and be in the lift, requested to stay in bed. The resident refused to get up and out of bed from 7/11-7/15/19 due to discomfort from sitting and use of the mechanical lift. A Physical Therapy Plan of Care, dated 7/15/19 at 1:56 p.m., indicated the resident had been referred to therapy due to a recent decline and fall which caused a laceration of the skin over her buttocks. The resident was having difficulty with transfers and bed mobility and required total assistance with a hoyer lift. Resident Q had an incision with stitches that were coming loose on the right buttock and had multiple bruises covering her body. The resident's current level of function was she required total assistance (100 % assist) with the hoyer lift with caution due to stitches on her right buttock. A PT (Physical Therapy) Daily Treatment Note, dated 7/15/19 at 4:46 p.m., stated Pt (patient) transferred on bed using stand up lift to assess safety with CNA staff. Resident Progress Notes indicated the resident had another surgery completed on 7/23/19 to reclose the wound to her right buttock laceration. Following the surgery, Resident Q was referred to the wound clinic for continued care of the laceration. The progress notes did not indicate how the resident was being transferred. There were no orders for a hoyer or stand up lift after 7/15/19. An Occupational Therapy Plan of Care, dated 7/31/19 at 7:21 a.m., indicated the resident had been referred to OT (Occupational Therapy) following a fall which resulted in a peri-rectal wound with a significant decline in her self care, balance, and mobility. The resident sustained [REDACTED]. She sustained a 15 cm by 8 cm by 4 cm open peri-rectal acute traumatic right gluteal (buttock) wound, which extended along the right labia majora to the posterior anus. Due to the complexity of the injury, she required surgery on the same day. On 7/23/19, she had to return to surgery for [REDACTED]. Precautions were falls, peri-rectal wound, decreased skin integrity, and Sera lift (stand up) for transfers. The residents current level of function showed she was able to transfer to the toilet with total assistance with the standing lift. The treatment plan was for the resident to receive OT 3 times a week for 12 weeks. An OT Daily Treatment Note, dated 8/8/19 at 9:27 a.m., indicated the resident required a standing lift for transfer from toilet to the w/c. A Fall Event, dated 8/19/19 at 7:33 p.m., indicated the resident had a fall in the shower room. The resident was found lying on her back with her right lower extremity behind her back. The resident was transported to the hospital for treatment. A Resident Progress Note, dated 8/20/19 at 10:49 a.m., indicated the IDT met to review the resident's fall that occurred on 8/19/19 at 7:33 p.m. The resident had been in the shower room receiving a shower with assistance from 2 staff members. Staff reported that the resident's legs became weak and gave out and staff lowered her to the floor. The CNA notified the nurse who entered the shower room and found the resident lying on her back with her right lower extremity behind her back. The resident was transported to the hospital for evaluation. .Resident remains in the hospital at this time and was diagnosed with [REDACTED]. A nurses note, dated 8/21/19 at 4:35 P.M., indicated the daughter stated the resident had her surgery yesterday. During a confidential interview, Employee 2 and Employee 4 indicated Resident Q was to have been transferred with the stand up lift and staff were aware of this. Employee 2 indicated the resident had slowly declined and progressed from needing assistance of 2 staff to transfer, to using a hoyer lift and then a stand up lift. Employee 2 indicated the hoyer lift sling irritated the resident's wound on her bottom and she wouldn't use it so the stand up lift had been used which didn't affect her wound. Employee 4 indicated use of the stand up lift was not put onto the resident's profile that CNA's used to tell them how to care for the resident but staff knew because therapy had instructed them on it's use. During an interview, on 9/4/19 at 10:53 [NAME]M., LPN (Licensed Practical Nurse) 5 indicated she was the nurse in charge of Resident Q when she fell on [DATE]. On 8/19/19, she was seated at the nurses station that was located across from the shower room at around 7 p.m. when she heard yelling coming from the shower room. She went to the shower room where CNA (Certified Nurse Aide) 6 was coming out of and was told the resident was on the floor. LPN 5 found the resident lying on the floor with stool and blood all around her on the floor. The resident's right leg was bent in half backwards up towards her back and under her bottom and she appeared dazed. LPN 5 indicated CNA 6 and CNA 3 explained that they had tried to transfer the resident from the toilet back into her w/c but the resident's legs gave out and she wouldn't stand. They were unable to complete the transfer and lowered her to the floor. LPN 5 indicated Resident Q was to have been transferred with the stand up lift but the 2 CNA's had not used the lift nor had they used a gait belt. On 9/4/19 at 11:43 [NAME]M., Resident Q was observed laying in her bed. She was wearing oxygen and was covered in multiple stages of bruising on her left arm, chest and both legs. Her call light was observed hanging off the bed near the floor. During an interview, on 9/4/19 at 2:27 P.M., the DON (Director of Nursing) indicated she had not been made aware the resident was to be transferred with the stand up mechanical lift. During an interview, on 9/5/19 at 10:15 [NAME]M., the COTA (Certified Occupational Therapy Assistant) indicated she had worked with Resident Q and had written the daily OT note from 8/8/19 at 9:27 a.m. She indicated it was her understanding that the resident was to be transferred with the stand up lift. On 8/8/19, she assisted a CNA to transfer the resident onto the toilet using the stand up lift. During an interview, on 9/5/19 at 11:00 [NAME]M., the Occupational Therapist indicated she had evaluated and worked with Resident Q. Resident Q had progressively declined in her abilities to transfer following several acute illnesses and had required the use of the stand up lift for safe transfers. The OT indicated she was not sure why staff would've transferred the resident without the use of the stand up lift and believed staff were all aware that she was to be transferred with the lift. On 9/5/19 at 1:45 P.M., the Administrator provided a current copy of the facility policy titled Fall Management Program which stated the following: It is the policy of (company) to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .A 'Fall' refers to unintentionally coming to rest on the ground, floor, or other lower level .Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls .The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet This Federal tag relates to Complaint IN 423. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure appropriate safety interventions were implemented for an ambulatory resident with poor safety awareness and indwelling catheter use resulting in a fall requiring surgical intervention to remove catheter tip from bladder (Resident G) and ensuring a resident was safely transferred with two staff members using a hoyer lift resulting a fall with [CONDITION(S)] and a brain bleed (Resident E) for 2 of 3 residents residents reviewed for accidents. Finding includes: 1. During an observation, on 1/14/19 at 12:00 P.M., Resident G was observed laying in low bed with an indwelling catheter hanging on the side of bed with the tubing ran down the inside of his sweat pants that he was wearing. There was approximately 1 1/2 to 2 feet of tubing from the pant leg to the bed where the bag was hanging from a plastic hook on urinary collection bag which was touching the floor. There was small areas of dryed blood noted to pants around the region where the catheter tip was inserted into the tip of the penis. During an observation, on 1/14/18 at 12:03 P.M., Resident G was observed attempting to get out bed independently with indwelling foley catheter in place. The urinary drainage bag was attached to bed frame with a plastic hook and the tubing was coming from the bottom of the resident's pants he had on. Staff had to intervene to keep resident from attempting to ambulate with indwelling catheter bag attached to bed and the tubing coming from pants presented a trip hazard for the the resident with cognitive impairment. The clinical record for Resident G was reviewed on 1/16/19 at 2:13 P.M. The diagnoses included, but were not limited to, brain cancer and [CONDITION(S)]. The admission MDS (Minimum Data Set) assessment, dated 1/4/19, indicated Resident G had a BIMS score of 5, severe cognitive impairment, and resident had an indwelling catheter in place. A care plan for risk was falls related to equipment that tethers patient, impaired cognition, impulsivity, decreased mobility and diagnoses of brain cancer, dated 12/28/18, included, but was not limited to, the following interventions: bed alarm/chair alarm and environmental checks for mobility obstacles. A care plan for indwelling catheter use, dated 12/28/18, included, but was not limited to, the following interventions: do not allow tubing or any part of the drainage system to touch the floor and manipulate tubing as much as possible. A care plan for cognitive impairment, dated 1/7/19, indicated Resident G had severe cognitive impairment. A Progress Note, dated 12/29/18 at 12:22 P.M., indicated Resident G was frequently standing and unable to tell nurse why, he ambulated with assistance and has indwelling Foley catheter. A Progress Note, dated 12/30/18 at 10:16 A.M., indicated Resident G stood up frequently and was kept at the nursing station throughout day for safety. A Progress Note, dated 1/2/19 at 1:10 P.M., indicated Resident G was noncompliant with asking for assistance and frequently stood up from wheelchair and required redirection. A Progress Note, dated 1/4/19 at 1:30 P.M., indicated Resident G was noncompliant with asking for assistance, spontaneous and repetitively stands up from wheelchair, required cueing every 5 minutes and needed to stay in sight for safety. A Progress Note, dated 1/4/19 at 1:56 P.M., indicated Resident G was observed sitting on floor next to bed and call out for help. Resident was placed by nursing station for one-on-one. A Progress Note, dated 1/5/19 at 2:44 P.M., indicated Resident G had to continuously be redirected due to restlessness and constantly standing up to walk off. A Progress Note, dated 1/6/18 at 6:30 P.M., indicated Resident G continued to get up and down and stepped on catheter and dislodged it. Resident G was sent to local hospital to assist with dislodged catheter because the balloon tip was still lodged inside. The ER (emergency room ) Report, dated 1/6/18 at 7:09 P.M., indicated that Resident G had presented to the ER with catheter issue. It was reported per nursing home records, that resident attempted to get out bed independently and accidentally ripped out his urinary catheter. The nursing home staff was unsure whether the balloon of the catheter or part of the tubing was still present in urethra. An ultrasound showed 3.8 cm (centimeters) broken catheter tip in the bladder. Resident G was to have tip of catheter removed surgically in urologist office on 1/9/18. During an interview, on 1/15/18 at 2:30 P.M., the DON (Director of Nursing) indicated the facility did not previously use a leg bag for Resident G with his getting up and down, they had been using a drainage bag system as observed. During an interview, on 1/18/19 at 3:20 P.M., the UM (Unit Manager) 8 indicated that the facility did use leg bags on residents with indwelling catheters on case by case. The decision to use leg bags was based on guidelines and one of the guidelines was to use a leg bag if the resident was mobile. On 1/18/19 at 4:31 P.M., a policy for leg bag use was requested but no policy was provided. 2. On 01/15/19 at 3:35 PM, Resident E was not interviewable. Her roommate indicated to me that Resident E had an accident several days ago where she fell from the hoyer lift. She stated that middle strap wasn't on right and she fell right out of the sling and there was just that one aide in here. You might want to talk to her daughter because she is kind of confused and can't really answer questions. A clinical record review was conducted on 01/16/19, at 9:18 AM, for Resident 11 and indicated an admitted [DATE]. Her diagnoses included, but were not limited to: hypertension, depression, anxiety, Guillian-Barre syndrome, chronic pain, spinal stenosis, and [CONDITION(S)]. The MDS (Minimum Data Set) assessment, dated 10/17/18, indicated a BIMS (Brief Interview for Mental Status) score of 4, severe cognitive impairment. The assessment indicated Resident E was an extensive assist for transfers and required 2+ people for that task. The ADL (Activities of Daily Living) care plan in place indicated all transfers were to be completed with the hoyer lift. A reportable incident, dated 01/06/19, indicated Resident E experienced a fall during bedtime care. A laceration was indicated as an injury. Staff statements were obtained, no additional resident interviews were indicated. Statements from the staff were inconsistent. The nurse indicated she found the resident sitting upright on the floor, in front of her wheelchair, during the interview. The nurse's original noted indicated she found the resident laying flat on her back on the floor. One statement indicated the sling was on top of her and the other indicated it was under her. The ED (Executive Director) indicated in the investigation the hoyer lift was 3 feet from Resident E but also indicated her leg was draped across the lift when found. The emergency room report, dated 01/07/19, indicated Resident E was evaluated for a fall from approximately 4 feet high. She presented with a [CONDITION(S)], that required 3 staples. The report indicated a 5mm hyperdensity was identified on the CT scan, indicative of a parenchymal bleed, which was not present on the previous study. During an interview, on 01/16/19 at 2:40 PM, the daughter of Resident E indicated the facility had called her the night of the incident and informed her the resident had fallen from the hoyer lift. She indicated she came right over and was told by Resident 11's roommate that the aide was transferring her mother to bed with the hoyer lift and the middle strap was undone and she slipped from the sling, landing on the floor. She also indicated the evening nurse told her she did not believe the aide's story of sliding out of the wheelchair. She asked her mother what happened and she indicated to her that she had fallen from the lift. During an interview, on 01/17/119 at 3:00 PM, the wound nurse indicated Resident E's roommate was alert with some confusion, but able to answer questions. During an interview, on 01/17/19 at 4:13 PM, a second interview was conducted with the roommate. She indicated Resident E had a fall from the hoyer last week in her room, by her bed. She indicated she was raised in the air when she fell from the sling. On 01/17/19, at 4:00 PM, the SSD (Social Services Designee) completed an updated BIMS assessment for Resident E's roommate, which indicated a score of 8, moderate cognitive impairment. Multiple progress notes for the roommate indicated she was alert and responsive with some confusion. During an interview, on 01/18/19 at 10:20 AM, the ED indicated he did not feel the roommate was reliable due to a low BIMS score of 5. He also indicated he did not interview any other residents because he felt it was an accident. When asked about a second staff in the room during transfers, he indicated there should be two people and he assumed there were. He could not provide a name or interview with a second staff member present during care. On 01/18/19, at 10:50 AM, a policy related to transfers was requested, but one was not available. This Federal tag relates to Complaint IN 871. 3.1-45(a)(2)

Based on observation, interview and record review, the facility to properly assess and provide treatment to a pressure ulcer to a residents right hip resulting in a DTI (deep tissue injury) developing (Resident C), an unstageable pressure to buttocks (Resident B) and unstageable pressure ulcers to heels and Stage 2 pressure ulcers to buttocks (Resident D) for 3 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident C was reviewed on 1/17/19 at 1:46 P.M. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change MDS (Minimum Data Set) assessment, dated 10/19/18, indicated Resident C required extensive assist with ADLs (activities of daily living), had a catheter and was at risk for pressure area development and currently did not have any pressure areas. A care plan for at risk for skin breakdown related to [CONDITION(S)] with right [CONDITION(S)], dated 4/24/12, included, but was not limited to the following interventions, dycem to wheelchair (12/12/18), resident up for lunch daily but prefers to stay up and participate in activities (9/20/17), low air loss mattress (9/12/15) and roho cushion to wheelchair (2/18/13). There was no care plan available for review for actual skin breakdown. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders present to monitor area to right hip for worsening or signs/symptoms of infection. A Progress Note, dated 12/6/18 at 2:32 P.M., indicated Resident C was observed by Physical Therapy to have open areas noted to right posterior thigh and right posterior hip. Areas were pink with a small amount of serous (clear) drainage noted. A Non-ulcer Pressure Skin Event, dated 12/6/18 at 12:00 P.M., indicated Resident C had a partial thickness wound to right posterior thigh that measured 3 cm (centimeters) x 5 cm with a small amount of serous drainage noted. A Progress Note, dated 12/11/18, indicated the Wound NP (Nurse Practitioner) was in to see moisture associated areas to right side. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan was for limiting head of bed elevation, consider use of [MEDICATION(S)], no pads under resident and consider topical antifungal. There were no changes in treatment to areas noted and no updates noted to at risk for skin break down and no care plan for new area was completed. A Progress Note, dated 12/25/18 at 10:23 P.M., indicated Resident C was sent to the local hospital for evaluation and treatment. The ER (emergency room ) Report, dated 12/25/18, indicated Resident C presented to the ER with dry, diffuse breakdown to skin to the buttocks and coccyx area and open areas to right posterior buttock and upper thigh. A Consultation Note, dated 12/26/18, indicated Resident C had multiple decubitis ulcers that were pink with granulation tissue. A Discharge Summary, dated 12/31/18, indicated Resident C was readmitted to facility with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Extended Care Facility Patient/Resident Transfer Form- Physician orders,dated 12/31/18, indicated orders for wound care. There were no orders present for the stage 2 to coccyx upon readmission and no care plans for areas were noted. A Progress Note, dated 1/2/19 at 3:20 P.M., indicated Resident C areas to right hip were present before resident was transferred to hospital on 12/25/18. A Non-Ulcer Skin Event, dated 1/2/19 at 2:24 P.M., indicated Resident C had a partial thickness wound noted to right thigh measuring 4.5 cm x 1.2 cm with a small amount of blood noted, classified as moisture associated skin damage. A Non-Ulcer Skin Event, dated 1/2/19 at 2:26 P.M., indicated Resident C had a partial thickness wound noted to right thigh measuring 1.8 cm x 1.8 cm with a small amount of blood noted, classified as moisture associated skin damage. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The current order was for [MEDICATION(S)] Blue Baterisotatic Wound dressing considering resident's skin is 80% tensile strength related to history of skin grafts. Resident C had returned from hospital stay on 12/31/18. No new skin concerns were reported. Wound nurse would follow up in two weeks. There was no documentation present that the Wound NP was aware of the documented observation and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no wound documentation available to review from 1/2/19 to 1/17/19. During an observation, on 1/17/19 at 2:26 P.M., the wound to Resident C's right posterior thigh presented as a DTI with Stage 2 pressure ulcers noted within the DTI area. The DTI was noted on the posterior thigh, below the scar from the skin graft. During an interview, on 1/17/19 at 2:26 P.M., the Wound NP indicated the area to the right thigh was caused by moisture and pressure. She indicated the area did not have good tensile strength due to history of skin graft to area and was fragile. She indicated the open areas to right thigh were stage 2 pressure ulcers and DTI to surrounding tissue, she was not aware how long pressure had been applied to the area. A Wound Note, dated 1/17/19 at 2:49 P.M., indicated Resident C had a Unstageable/Deep Tissue that measured 13 cm x 7 cm and wound was declining. The tissue was dark purple and boggy upon palpation. During an observation, on 1/17/19 at 2:30 P.M., Resident C's wheelchair was noted to be a geri chair with roho cushion in place that was did not have sufficient amount of air in it (when pressure as applied the wheelchair could be felt through the roho cushion, air was not being distributed through out cushion). During an observation, on 1/17/19 at 3:05 P.M., Resident C was observed in wheelchair with roho cushion low air, right leg was turned out with flaccid right arm resting on leg. The area to the right posterior thigh aligned were pressure area. A Wound Note, dated 1/17/19 at 3:26 P.M., indicated a Stage 2 pressure ulcer to right hip measuring 1 cm x 1 cm x 0.1 cm with granulation tissue present and surround tissue was dark purple. A Wound Note, dated 1/17/19 at 3:33 P.M., indicated a Stage 2 pressure ulcer to right medial thigh measuring 0.3 cm x 0.3 cm x 0.1 cm with granulation tissue present and surround tissue was dark purple. A Wound Note, dated 1/17/19 at 5:59 P.M., indicated a Stage 2 pressure ulcer to right lateral thigh measuring 1 cm x 0.8 cm x 0.2 cm with granulation tissue present and surround tissue was dark purple. A Wound Note, dated 1/17/19 at 6:01 P.M., indicated a Stage 2 pressure ulcer to right distal posterior thigh measuring 6 cm x 1 cm x 0.25 cm with granulation tissue present and surround tissue was dark purple. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound measurements to right hip were 13 cm x 7 cm and classification was SDTI (suspected deep tissue injury), the right upper hip had 2 areas measuring 0.3 cm x 0.3 cm x 0.1 cm and 2.1 cm x 1 cm x 0.1 cm, posterior right hip wound measured 1 cm x 0.8 cm x 0.2 cm and left upper hip wound measured 1 cm x 1 cm x 0.1 cm. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan was to trial wedge cushion to wheelchair, offloading right hip, wound required daily monitoring and therapy to fit resident for larger wheelchair. During an interview, on 1/17/19 at 3:40 P.M., the DON (Director of Nursing) wounds should be monitored weekly by the wound nurse and a care plan for impaired skin integrity should have been started. She indicated that it was the responsibility of the MDS (Minimum Data Set) Nurse to start and update wound care plans. During an interview, on 01/18/19 at 2:40 PM, the wound nurse indicated she was not aware the areas classified as moisture associated skin damage with skin loss were to be documented as Stage 2 pressure ulcers. She indicated she classified moisture damaged skin as redness, drainage, and maceration. During an interview, on 1/18/19 at 2:40 P.M., the DON indicated roho cushion air level was not checked routinely and that there were no wound certified nurses in the facility. She indicated the facility employed a Wound NP that was to oversee the resident with wounds weekly but Resident C had not been seen since 1/2/18 by the Wound NP. 2. The clinical record for Resident B was reviewed on 1/27/19 at 12:51 P.M. The diagnosed included, but were not limited to, dementia and [CONDITION(S)]. The admission MDS (Minimum Data Set) assessment, dated 10/21/18, indicated Resident B required extensive assist with ADLs (activities of daily living) and did not have any pressure ulcers noted on admission. A Nurses' Transfer/Discharge Condition Assessment Form, dated 10/21/18, indicated Resident B was readmitted back into facility with a Stage 2 pressure area noted left buttocks and a Stage 1 Pressure ulcer to right buttocks. An Admission Observation, dated 10/21/18 at 2:32 P.M., indicated Resident B had a 2 cm (centimeter) x 1 cm wound to left buttocks, 1 cm x 1 cm wound to right buttocks, shearing noted to buttocks and 3 cm x 2. 4 cm redness to left heel. A Progress Note, dated 10/21/18 at 9:20 P.M., indicated Resident B had a reddened area to left heel measuring 3 cm x 2.4 cm. He had shearing noted to buttocks and an abrasion to left buttocks measuring 2 cm x 1 cm and an abrasion to right buttocks measuring 1 cm x 1 cm. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no care plans available for areas noted upon admission. There were no wound notes available for areas noted upon admission. A Progress Note, dated 10/24/18 at 12:26 P.M., indicated Resident B had open areas noted to coccyx. A Progress Note, dated 10/26/18 at 11:13 A.M., indicated Resident B had open areas noted to coccyx. A Progress Note, dated 10/29/18 at 3:05 P.M., indicated the dietician reported no pressure ulcers. A Progress Note, dated 10/29/18 at 4:23 P.M., indicated Resident B was a extensive transfer of two people, required extensive assist of 2 people with bed mobility and preferred to sleep in his recliner. He had open areas noted to buttocks. A Progress Note, dated 11/7/18 at 1:16 P.M., indicated wound care was provided to area on buttocks. The Home Discharge Instructions and Information, dated 11/8/18 at 1:17 P.M., indicated no skin issues where present. A Progress Note, dated 11/8/18 at 1:45 P.M., indicate Resident B was discharged to Assisted Living. During an interview, on 1/17/18 at 1:45 P.M., the DON from the assisted living center indicated that Resident B was admitted on [DATE] with 2 small open areas and dark red, yellow slough noted to surrounding tissue. Resident was started on antibiotics for 11 days and [MEDICATION(S)]. The physician had been doctor and wound center consult was ordered. She indicated Resident B was sent the local hospital on 11/24/18 from assisted living. The Discharge Summary, dated 11/28/18, indicated Resident B was admitted to local hospital with sacral decubitus infection. The History & Physical, dated 11/25/18, indicated Resident B's family member was convinced the deterioration started after his recent discharge on 10/21 to an inpatient rehabilitation facility due to poor care and his sacral decub was a Stage 3 located in gluteal fold and was 7 cm x 5 cm with green pustulant drainage and surrounding tissue had [CONDITION(S)]. During an interview, on 1/17/19 at 2:01 P.M., the DON (Director of Nursing) indicated she was aware wound documentation had been missed and wound assessment from admission was not reviewed by the wound nurse nor was the wound nurse aware of wounds. She indicated the wound should have been looked at the following day by wound nurse and the wounds were never assessed by wound nurse. There was no physician notification documented. She indicated the discharge summary did not include information regarding wound for the receiving facility. 3. A clinical record review was conducted on 01/16/19, at 10:22 AM, for Resident D and indicated an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) assessment, dated 12/30/18, indicated a BIMS (Brief Interview for Mental Status) score of 13, cognitively intact. One stage 2 and one unstageable pressure area were indicated. Neither were present upon admission. MASD (Moisture Associated Skin Damage) was not indicated as present. A care plan was in related to pressure areas to right and left heels, right buttock, and sacrum. The problem start date was 10/19/18. An intervention was in place to assess the wounds weekly and to document the measurements and description. No additional care plans in were place related to impaired skin integrity. The onset of a wound area to the right buttock and sacrum began 01/04/19 and were originally classified as pressure, but changed to MASD on 01/08/19. The measurements at the time of onset were as follows: 0.4cm x 0.4cm x 0cm and was identified as a stage 2. No indicated of an area to the left buttock. The sacrum wound measured as follows on 01/04/19: 1.5cm x 1.0cm x 0cm and a stage 2. The onset of the right heel wound was 10/19/18. The area measured as follows: 3cm x 2cm x 0.5cm and a stage 3. The onset of the left heel was 12/24/18. The area measured as follows: 2cm x 3cm x 0cm and a stage 2. On 01/18/19, at 10:30 AM, wound care was observed with the wound nurse. Wound care provided per order, with appropriate hand hygiene. The area to the sacral area measured 1.4cm x 0.6cm x 0.1 cm. The left buttock area measured 0.3cm x 0.3cm x 0.1cm. The wound nurse indicated the areas were now classified as MASD and no longer considered pressure. On 01/18/19, at 2:20 PM, wound care was observed with the wound nurse for bilateral heels. Measurements were as follows: Left heel - 4.0cm x 4.3cm x 0cm; draining serosanginous drainage, unstageable. Right heel - closed: no measurements, unstageable. Wound care proved per order, with appropriate hand hygiene. During an interview, on 01/18/19 at 2:40 PM, the wound nurse and the DON (Director of Nursing) indicated when residents have identified areas of concern related to pressure the wound nurse must assess them within 1 business day. If it occurs on a Friday, the floor nursing staff would assess, but were not allowed to stage. The DON indicated she was the back up wound nurse when the original nurse was out. They indicated the areas to the bottom were considered moisture based on the appearance of maceration, despite his catheter. The wound nurse indicated the moisture was coming from the way his buttocks came together when sitting in his chair. During an interview, on 01/18/19 at 4:16 PM, the DON indicated no care plan was in place for the MASD. A policy was provided by the DON (Director of Nursing) on 01/18/19 at 3:00 PM, titled Skin Management Program, dated 04/2018, and indicated this was the policy currently used by the facility. The policy indicated .The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported. 7. Facility skin sweeps (head-to-toe-assessment) are conducted monthly to assess all residents' current skin conditions .A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented This Federal tag is related to Complaint IN 460. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed implement continuous assessments to 1 of 4 residents reviewed for falls with an injury. This fall resulted in the resident being hospitalized with a large right frontal subdural hematoma requiring surgical intervention. (Resident F) Finding includes: On 10/17/18 at 11:45 A.M., a review of the clinical record for Resident F was conducted. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) Assessment, dated 8/7/18, revealed a Brief Interview for Mental Status (BIMS) score of 5, severely impaired cognition. He was a,limited assist of 1 person with bed mobility, transfers and toileting. The assessment indicated he walked in the room/corridor with supervision and used an assistive device, a walker. A care plan, dated 11/6/17, indicated the resident was at risk for a fall due to his impaired cognition. Interventions included but were not limited to: personal items within reach, non-skid foot wear, call light within reach and bed in lowest position-added on 9/20/18. A Fall Event, dated 9/14/18 at 11:15 P.M., indicated the resident had a witnessed fall. The event said the resident was in the common area, when he bent down to pick something off the floor and fell forward hitting his head on the floor. The event indicated the resident had reported to the nurse he had a headache and had received a 5 centimeter hematoma to his right forehead. The intervention placed to prevent another fall was to kept the resident in the common are for direct supervision. Vital signs were taken and recorded on 9/14/18 and on 9/16/18. There was no mention of the resident's use of a walker during the fall or after the fall. A Progress Note, written by LPN (Licensed Practical Nurse) 4, dated 9/14/18 at 10:19 P.M., indicated .Resident alert with some confusion. Resident is HOH (hard of hearing) which interferes with clear communication. 5 cm (centimeter) knot to right side of forehead ice applied. Dr (doctor notified) There were no progress notes documented for 9/15/18. A Progress Note, written by RN 8, dated 9/16/18 at 8:58 P.M., indicated .Patient is a f/u (follow up) fall with neuros (neruological assessment). Patient is alert with confusion. Patient c/o (complains of) a headache. Patient is on routine pain medication and received a PRN (as needed) dose at about 9 pm. Patient has a bump on his right forehead with some bruising noted. Patient right eye is also bruised. Patient is a little un-steady on his feet. Patient has a walker. Patient is currently sitting down. Will continue to monitor A Progress Note, written by RN 8, dated 9/16/18 at 10:24 P.M., indicated .Patient is having increased confusion and is un-steady on his feet. Patient last fall was documented on 9/14/18. Patient had and eye coordination is off. Patient is c/o headache. PRN given. Patient is currently sitting down due to un-steady gait. Patient has a bruise under right eye. Notified MD (Medical Doctor) with a new order received and noted to sent patient to the ER (emergency room ) for eval (evaluation) The Neurological Assessment indicated assessments were be taken every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every hour for 4 hours, then every 8 hours for 72 hours. There was no assessment on 9/15/18 at midnight, 12:30 A.M., 2:00 A.M., 4:00 A.M. and 5 A.M. due to resident was sleeping. On 9/15/18 the night shift assessment was left blank and day shift on 9/16/18 was blank. A part of the assessment concerning consciousness was not completed (left blank or a dash) for 9/15/18 and 9/16/18. Incident #301, dated 9/17/18 at 9:40 A.M., Resident F was noted to have change in condition. Resident F was independently ambulatory with his walker on the dementia unit. On 9/17/18 approximately 8:30 P.M., the staff noted the resident had increased confusion and difficulty with hand/eye coordination. The nurse contacted the physician and the resident was taken, immediately, to a local emergency room , for an evaluation. The incident indicated a CT of the resident's head revealed an acute subdural hematoma. The preventative measures indicated the plan of care would be reviewed by Interdisciplinary Team (IDT), upon his return, to the facility. The emergency room (ER) report, dated 9/16/18, indicated the patient presented to the ER for an evaluation of altered mental status. The patient fell two day prior to his arrival. He suffered a right forehead contusion. Staff from the nursing home noted he developed periorbital ecchymosis. The patient was evaluated by CT scan of the head, which demonstrates a large right frontal subdural hematoma with midline shift. A neurosurgeon on call advised the patient would require an operative decompression of his subdural hematoma. On 10/18/18 at 9:44 A.M., the Administrator provided a policy titled, Fall Management Program, dated 7/2001 and revised on 11/2017, and indicated the policy was the one currently used by the facility. The policy indicated .Post fall 1. Any residents 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 al residents with a suspected head injury based upon the fall This Federal tag relates to complaint IN 081. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident was free from significant medication errors related to an acute change in condition in which a resident was unresponsive and transported to the hospital and found to have a narcotic medication she had not been prescribed in her system. This deficient practice affected 1 of 3 residents reviewed for narcotic medications. (Resident B) Finding includes: The clinical record for Resident B was reviewed on 11/16/16 at 2:00 P.M. Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 50 mg (milligram); Oral Four Times A Day; 03:00AM, 08:00AM, 04:00PM, 09:00PM A Medication Administration Record [REDACTED].M. On 11/17/16 at 11:15 A.M., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 indicated she was the nurse providing care to Resident B on 10/29/16. She indicated Resident B had received her morning medications between 07:20 A.M. and 07:25 A.M LPN #1 indicated Resident B opened her eyes and her blood pressure was within her normal parameters. She went on to explain that she checked on Resident B at approximately 08:10 A.M. and again around 10:00 A.M. and found that Resident B was not responding appropriately when she was spoken to and subsequently tapped on the shoulder. LPN #1 indicated Resident B was usually alert and oriented and she noted the change in condition, conducted an assessment, and notified the physician who then indicated Resident B should be sent to the emergency room for evaluation of symptoms. A ER (emergency room ) Physicians Report dated 10/29/16 indicated the following: .The patient presented with altered mental status and unresponsiveness. The patient has had decreased respiratory drive pinpoint pupils and has reportedly been on [MEDICATION NAME] she was given [MEDICATION NAME] (a medication that is used to reverse the effects of narcotic pain medication) here without any significant response or change in the department an extensive workup was undertaken finding her somewhat anemic (low iron in the blood) but also having a urinary tract infection, no other significant abnormalities. Patient was switched to [MEDICAL CONDITION] (bilevel positive airway pressure, a therapy used for patients suffering from sleep apnea) which improved her overall respiratory effort but her respiratory rate from about 8-12. The patient has not responded to any other significant interventions A hospital History and Physical dated 10/30/16 indicated . Chief Complaint: Altered Mental Status . History of Present Illness: This is a [AGE] year-old resident of (nursing home) who was brought to the emergency department with above complaint. Source of information is the patient's records. I also had a teleconference with the nursing staff yesterday. Apparantly, this patient was in her usual state of health until yesterday when she was found to have slurred speech. The patient did not eat yesterday morning. Nursing reported that patient had pinpoint pupils. The patient was therefore sent to the emergeny department for further evaluation . Assessment: 1. Altered mental status/metabolic [MEDICAL CONDITION] (a catagory of [DIAGNOSES REDACTED]. I suspect that change in mentation (mental status) was due to the fact that patient received [MEDICATION NAME] (an opioid narcotic pain medication) probably accidentally at the nursing home. Medicine is not listed on her MAR A hospital Discharge Summary dated 10/31/2016 indicated .discharge date : 10/31/2016 .Final Diagnosis: [REDACTED]. Hospital Course: The patient was initially evaluated in the emergency department. The drug screen tested positive for [MEDICATION NAME]. The patient was subsequently admitted to the hospital for further evaluation and treatment On 11/17/16 at 9:51 A.M. an interview was conducted with Resident B. Resident B indicated she was recently hospitalized because she received [MEDICATION NAME], a medication that was not prescribed to her. She then indicated she was to receive [MEDICATION NAME] and believed she was allergic to [MEDICATION NAME]. Resident B indicated she did not know how or when she received the [MEDICATION NAME] as she only remembers receiving her medication Friday night (10/28/16) and then waking up in the hospital Saturday (10/29/16) around 4:00 P.M Resident B indicated she was very upset by this because she depends on the staff to give her medication to her and it now makes her afraid she will get the wrong medicine again. Resident B indicated she did not give herself any medications and the facility staff had found a unlabeled pill bottle in the bottom of her dresser drawer that she kept bobbie pins and safety pins in and talked with her about it. On 11/17/16 at 1:00 P.M., an interview was conducted with the Staff Development Nurse and the Corporate Clinical Nurse. The Corporate Clinical Nurse indicated the facility had conducted an investigation into what could have happened and were unable to substantiate a medication error had occurred at the facility. The Corporate Clinical Nurse indicated a empty unlabeled pill bottle had been found in the residents dresser drawer and facility staff had not indicated a medication error had occurred during interview process of the investigation. A Med Options Behavioral Health Services progress report dated 11/2/16 was reviewed on 11/17/16 at 1:15 P.M The progress note indicated . Psychology was asked by staff to see pt (patient) as she was recently sent to hospital for AMS (altered mental status). Review of hospital records in chart suggests that pt may have received wrong pain medication. She tested positive at hospital for [MEDICATION NAME], despite no opiods prescribed. Room search negative for medication per staff. No history of self- medicating with substances This Federal tag is related to Complaint IN 286. 3.1-25(b)(9)