Every finding on record at Fairway Village

Based on observation, interview, and record review the facility failed to ensure paper towels were available for facility staff and residents for 11 of 24 rooms observed. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 7/20/23 at 10:35 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 2. On 7/20/23 at 10:36 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 3. On 7/20/23 at 10:37 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 4. On 7/20/23 at 10:38 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 5. On 7/20/23 at 10:39 a.m., room [ROOM NUMBER] and room [ROOM NUMBER]'s shared bathroom was observed. The paper towel dispenser was not able to dispense paper towels. 6. On 7/20/23 at 10:45 a.m., room [ROOM NUMBER]'s bathroom was observed. The paper towel dispenser was not able to dispense paper towels. During an interview on 7/20/23 at 10:30 a.m., Licensed Practical Nurse (LPN) 1, indicated the paper towel dispenser in room [ROOM NUMBER] was out of paper towels. During an interview on 7/20/23 at 10:45 a.m., Housekeeper 3 indicated the available paper towels were too small for the automatic paper towel dispenser, and indicated most of the paper towel holders in the facility did not work. They have not worked for awhile, and indicated she reported the issue to her supervisor. During an interview on 7/20/23 at 11:00 a.m., Certified Nursing Assistant (CNA) 2 indicated the only working paper towel dispenser was located behind the nursing station. During an interview on 7/20/23 at 10:35 a.m., the Director of Nursing indicated all the resident bathrooms should have paper towels available for proper hand hygiene. During an interview on 7/20/23 at 12:55 p.m., the Administrator was unaware the paper towel dispensers were not dispensing paper towels properly. The batteries were dead in some of the dispensers, but the dispensers all had paper towels in them. During an interview on 7/21/23 at 9:00 a.m., Regional Corporate Support Director indicated the facility should always have paper towels available in all the residents rooms. On 7/20/23 at 12:55 p.m., the Administrator provided a policy titled Hand Hygiene, dated February, 2010, and indicated it was the current policy being used by the facility. A review of the policy indicated, 1. check that sink areas are supplied with soap and paper towels.8. Use clean paper towel; dry hands and wrists.10. Use paper towel to turn off faucet. 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure a resident's code status preference was documented accurately in the clinical record for 1 of 16 residents reviewed for advanced directives (code status). (Resident 18) Finding includes: On 7/19/23 at 1:51 p.m., the clinical record for Resident 18 was reviewed. The diagnoses included, but were not limited to, dementia, acquired absence of left leg above the knee, and adult failure to thrive. Resident 18's face sheet indicated the resident was a full code (meaning a desire for all life sustaining measures to be implemented) and had an Emergency Contact person responsible for making health care decisions on behalf of the resident. The Quarterly MDS (Minimum Data Set) assessment, dated 6/20/23, indicated Resident 18 was severely cognitively impaired. Resident 18's care plan, initiated on 7/25/19 and current through 9/29/23, indicated Resident/legal representative prefers a full code status .code status will be honored .review advanced directives [code status] with resident/legal representative during care conferences and as needed . Physician Orders, dated 5/4/22, indicated Resident 18 was a full code, effective 5/4/22, with no end date noted. On 7/21/23 at 8:15 a.m., the Director of Nursing Services (DNS) provided a copy of Resident 18's State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order, dated 6/5/20. A review of the document indicated Resident 18's code status was Do not attempt resuscitation [DNR]. Resident 18's Emergency Contact person provided verbal consent via phone on 6/5/20. The document was signed by two witnesses and the physician on 6/5/20. No other advanced directive code status documents were provided. On 7/24/23 at 10:40 a.m., the DNS provided copies of the following progress notes and corresponding care plan meeting results as it related to Resident 18's code status: - Progress notes, dated 9/14/20 at 5:00 p.m., indicated .[Resident] continues with full code status . - Progress notes, dated 9/16/20 at 11:10 a.m., indicated .Resident .moderate cognitively impaired .[Emergency Contact] remains the same .wishes to remain a full code . - Progress notes, dated 1/11/22 at 12:20 p.m., indicated .Resident is full code status and prefers to remain so at this time .[Resident is] moderate cognitively impaired .resident and family invited to care plan [meeting]. The Care Plan Summary, dated 1/20/22, indicated neither the resident or Emergency Contact person attended the meeting. - Progress notes, dated 5/11/22 at 12:21 p.m., indicated .resident on this day able to participate in MDS assessment .[moderately cognitively impaired] .resident is a full code status . The clinical record lacked a response from the Emergency Contact person regarding the planned care plan meeting. - Progress notes, dated 11/14/22 at 1:53 p.m., indicated .attempted to contact [Emergency Contact] to schedule quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 4/3/23 at 2:30 p.m., indicated .attempted to contact [Emergency Contact] to invite to quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 7/13/23 at 10:44 a.m., indicated .attempted to call [Emergency Contact] to set quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 7/20/23 at 9:58 a.m., indicated .attempted to contact [Emergency Contact] to schedule quarterly care plan [meeting] . The clinical record lacked a response from the Emergency Contact person. - Progress notes, dated 7/24/23 at 9:58 a.m., indicated .attempted to call [Emergency Contact] to discuss resident's code status. No reply or answer . The clinical record lacked a response from the Emergency Contact person. On 7/24/23 at 10:40 a.m., the DNS provided copies of the following Observation - Care Plan Summaries related to Resident 18's code status. A review of the documents indicated: - Summary dated: 6/25/20 at 9:57 a.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 12/15/20 at 12:15 p.m., indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 2/3/21 at 12:54 p.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 7/27/21 at 11:28 a.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 10/28/21 at 2:38 p.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. - Summary dated: 6/30/23 at 2:41 p.m. indicated neither Resident 18 nor the Emergency Contact person participated in the meeting and had not provided feedback regarding the code status. During an interview on 7/20/23 at 11:00 a.m., the DNS indicated Resident 18's code status was considered a full code. During an interview on 7/20/23 at 2:38 p.m., Resident 18's Emergency Contact person indicated, the Out of Hospital DNR document was completed on 6/5/20. The document indicated Resident 18 was a DNR and that decision had not changed. During an interview on 7/24/23 at 11:29 a.m., the DNS indicated the only advanced directive document for Resident 18 was the 6/5/20 Out of Hospital DNR document. On 7/21/23 at 8:15 a.m., the DNS provided a copy of Resident Rights policy, dated November 2016, and indicated it was the current policy in use by the facility. A review of the policy indicated, .this document informs each resident/responsible party of his/her rights and responsibilities regarding medical care while a resident at the facility .all staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care . On 7/21/23 at 8:15 a.m., the DNS provided a copy of Advanced Directives policy, dated February 2023, and indicated it was the current policy in use by the facility. A review of the policy indicated, .the facility's care will reflect the resident's wishes as expressed in the Directive . 3.1-4(f)(4)(A)(ii)

Based on observation, interview, and record review, the facility failed to prevent accident and hazards for 2 of 2 residents reviewed for accidents. A thin liquid treatment was left at a resident's bedside. (Resident 12, Resident 39) Finding includes: During an observation on 7/20/23 at 10:30 a.m., Licensed Practical Nurse (LPN) 4 was observed at the treatment cart, located next to the nurse's station. LPN 4 retrieved Resident 12's physician's prescribed betadine solution from the treatment cart. LPN 4 poured the betadine solution into a small medication (med) cup and then carried the un-covered med cup to Resident 12's room, located at the far end of the hall. The following was observed on 7/20/23 from 10:32 a.m. to 10:40 a.m.: - Resident 12 was resting on his bed in the supine position upon entry into the room. Resident 12 was then observed to independently reposition self into a sitting position on the side of the bed. Resident 12's bed and chair were observed to be within 8 inches from each other and were approximately 8 feet from the small table where the betadine med cup was placed. - Resident 12's roommate, Resident 39, was observed sitting in his chair, next to his bed. Resident 39 was approximately 10 feet from the small table where the betadine med cup was placed. - LPN 4 placed the betadine med cup on the small table next to the restroom door. - LPN 4 entered the adjoining restroom for approximately 10 seconds before exiting. - LPN 4 exited Resident 12's room, entered a resident's room across the hall, and then was observed walking down the hall toward the nurse's station. During that time, the med cup containing the betadine was observed on the small table. - LPN 4 returned to Resident 12's room. LPN 4 moved the betadine med cup from the small table and placed it on Resident 12's chair, located next to the bed on where Resident 12 was sitting. LPN 4 spilled a small amount of the betadine solution onto the chair. At that time, LPN 4 indicated she needed to get something to clean up the spill. The betadine med cup was left on the chair and LPN exited the room. - LPN 4 returned to Resident 12's room, cleaned up the spill, and then applied the remaining betadine to Resident 12's scabbed areas on the left hand. No facility staff were observed in the resident's room or in the immediate area during the time periods that LPN 4 had left the betadine med cup unattended in the resident occupied room. 1. On 7/19/23 at 1:48 p.m., the clinical record for Resident 12 was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and dementia. Physician orders, included, but were not limited to, .apply betadine [a thin liquefied antiseptic non-sterile topical solution that works on a broad range of germs and used on minor wounds] to scabbed skin tears on left hand each shift .start date 7/19/23 with no end date noted . The Annual Minimum Data Set (MDS) assessment, dated 5/10/23, indicated Resident 12 was severely cognitively impaired and required set up assistance with ambulation. 2. On 7/21/23 at 9:57 a.m., the clinical record for Resident 39 was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, and dysphagia (difficulty swallowing foods or liquids). Physician orders included, but were not limited to, regular diet with nectar thick/mildly thick liquids .start date 3/28/23 with no end date noted . The Significant Change Minimum Data Set (MDS) assessment, dated 6/9/23, indicated Resident 39 was severely cognitively impaired and required set up assistance with ambulation. On 7/21/23 at 11:00 a.m., a review of a betadine solution label indicated .keep out of reach . During an interview on 7/20/23 at 3:08 p.m., the Director of Nursing Services (DNS) indicated the betadine solution medication should not have been left unattended in the resident's room. The DNS indicated Resident 12 and Resident 39 were severely cognitively impaired and were able to ambulate independently. During an interview on 7/21/23 at 2:23 p.m., the Infection Preventionist (IP) indicated she was near the nurse's station on 7/20/23 around 10:35 a.m. LPN 4 was in the hall at that time and had requested the IP staff member to monitor Resident 12's hall to ensure no residents entered Resident 12's room. The IP staff member indicated she remained at the nurse's station area during that time and indicated LPN 4 should not have left the betadine solution unattended in Resident 12's room. During an interview on 7/24/23 at 9:25 a.m., LPN 4 indicated medications were not to be left unattended in a resident's room. On 7/21/23 at 9:10 a.m., the DNS provided a copy of the Medication Pass Procedure Section: Skills Validation policy, dated December 2016, and indicated it was the current policy in use by the facility. A review of the policy indicated, .7. Medications-not left at bedside . 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure the daily posted nurse staffing documents reflected the actual hours worked by staff from 6/14/23 through 7/17/23. Finding includes: On 7/18/23 at 2:00 p.m., the Director of Nursing Services (DNS) provided a copy of the daily Posted Nursing Staffing Data documents for 6/14/23 through 7/17/23. A review of the documents indicated, but were not limited to, the following: - a column titled Specific Shift had dedicated space available for the actual work start times and end times per shift for each licensed staff. - the documents lacked the actual hours worked by staff. During an interview on 7/21/23 at 1:56 p.m., the DNS indicated the daily posted nurse staffing documents lacked the actual work start and end times for each shift. On 7/21/23 at 8:15 a.m., the DNS provided a copy of the Posted Staffing Data and Retention Requirements policy, dated July 2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .To allow public access to posted nursing staffing data per federal regulations .the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses .licensed practical nurses .certified nurse aides .the total hours column should be all hours worked during each specific shift. Total hours should include the total actual hours worked on each shift including partial shifts. For example, a licensed nurse works .and your shifts are 2-10 p.m .

Based on observation, interview, and record review, the facility failed to ensure the facility's dumpster container lids were kept closed when not in use for 2 of 2 observations. Findings include: During an observation with the Dietary Manager (DM), on 9/12/22 from 10:05 a.m. to 10:10 a.m., the dumpster container area, located adjacent to the kitchen's rear exit door was observed. The dumpster container had 2 separate top lids. Both lids were observed to not be closed. Inside the dumpster container, multiple filled trash bags were visible. The dumpster container was 2/3 full of trash bags. Multiple large black flies were observed flying around and inside the trash bags. No staff were observed near the dumpster area. During an observation with the DM, on 9/14/22 from 11:23 a.m. to 11:27 a.m., the dumpster container area, located adjacent to the kitchen's rear exit door was observed. The dumpster container had 2 separate top lids. The lid on the left side of the container was observed to not be closed. Inside the dumpster container, multiple filled trash bags, a used mattress, and a mattress cover were visible. Half of the mattress cover was observed hanging outside of the dumpster container. Multiple large black flies were observed flying around and inside the trash bags. No staff were observed near the dumpster area. During an interview on 9/12/22 at 10:15 a.m., the DM indicated the dumpster lids were to be kept closed when not in use. On 9/14/22 at 1:09 p.m., the Director of Nursing Services provided a copy of the Trash Removal policy, dated April 2018, and indicated it was the current policy in use by the facility. A review of the policy indicated, .always dispense trash in container outside .if trash area is getting unsightly, clean it up or alert your supervisor . On 9/14/22 at 3:30 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside . 3.1-21(i)(2) 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to prevent abuse when a male resident struck 2 male residents with his cane. This resulted in one resident having a small laceration to the head and another resident a skin tear to the left hand. (Resident B, Resident C, Resident D) Finding includes: 1. During an interview on 7/28/22 at 9:10 a.m., LPN 1 (Licensed Practical Nurse) indicated she was the nurse when Resident B hit Resident C with his cane. Resident B and Resident C were roommates at that time. She was sitting at the nurse's station and she heard someone say stop it. She went to Resident B and C's room. Resident C was standing up holding his head and indicated Resident B hit him. Then Resident B indicated he hit Resident C because Resident C was coming at him. Resident C had a small laceration to the top of his head. The clinical record for Resident B was reviewed on 7/28/22 at 8:54 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 6/28/22, indicated Resident B was not cognitively intact. A Progress Note, dated 6/12/22 at 1:12 p.m., indicated Resident B had an altercation with his roommate. Resident B assisted by staff to leave the room and was taken into another room. Resident B's was redirected and was easily calmed down. A Social Service Progress Note, dated 6/13/22 at 7:50 p.m., indicated Resident B used his cane to hit Resident C. On 7/28/22 at 8:50 a.m., Resident B was observed sitting up in bed. At that time, Resident B indicated he had no recollection of any incident with another resident nor staff. The clinical record for Resident C was reviewed on 7/28/22 at 9:01 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change MDS assessment, dated 7/14/22, indicated Resident C was not cognitively intact. A Progress Note, dated 6/12/22 at 12:59 p.m., indicated Resident C's roommate made contact with the left side of Resident C's head resulting in small abrasion approximately 2 cm (centimeters) by 2 cm. On 7/28/22 at 9:05 a.m., observed Resident C sitting up in wheelchair. Resident C denied any incident with another resident in the past few months. Resident C denied any pain in the head area and there was no bruising nor laceration noted at the time of observation. 2. During an interview on 7/28/22 at 9:10 a.m., LPN 1 indicated there was an incident yesterday, when she was working, when Resident B accidentally hit Resident D's hand with his cane. She got to Resident B's room, and she saw a resident trying to walk into Resident B's and Resident D's room. Resident B was sitting up in bed and swinging his cane to stop the other resident from walking in the room. As she was attempting to re-direct the resident from walking in the room, Resident D stood up and tried to help stop the resident from entering the room and Resident B's cane hit Resident D's left hand. Resident D had a skin tear on his left hand. The clinical record for Resident B was reviewed, on 7/28/22 at 8:54 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment, dated 6/28/22, indicated Resident B was not cognitively intact. A Progress Note, dated 7/26/22 at 6:20 p.m., indicated writer was in hallway when loud voices were heard from resident room. Upon arrival at Resident B's room, writer noted resident from other unit standing in threshold and Resident B was sitting up in bed waving cane near the doorway in an effort to shoo resident from doorway. Cane made contact with Resident D's hand A Progress Note, dated 7/27/22 at 11:19 a.m., indicated Resident B attempted to shoo resident out of his room and in the process his cane made contact with roommate Resident D, resulting in a skin tear on left hand. The clinical record for Resident D was reviewed on 7/28/22 at 9:55 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS assessment, dated 6/10/22, indicated Resident D was not cognitively intact. A Progress Note, dated 7/26/22 at 6:20 p.m., indicated writer was in hallway when loud voices were heard from resident room. Upon arrival at Resident B's room writer noted resident from other unit standing in threshold and Resident B was sitting up in bed waving cane near the doorway in an effort to shoo resident from doorway. Cane made contact with Resident D's hand A Progress Note, dated 7/27/22 at 10:36 a.m., indicated IDT (Interdisciplinary Team): The Director of Nursing Services and MDS Coordinator spoke to Resident D this morning about the events resulting in his skin tear. Resident D stated he has known his roommate for 1 year and does not remember why the incident happened. IDT is aware that Resident D was involved in an altercation on 7/26/22 involving Resident B (roommate). Resident S wandered into this resident's room . at this time, Resident D does not believe that the contact made was accidental but states he will not retaliate. On 7/28/22 at 10:04 a.m., Resident D was resting in his recliner. Observed a skin tear to the left hand. At the time of the observation, Resident D was not able to recall how he got the skin tear. On 7/28/22 at 9:19 a.m., the Director of Nursing provided a copy of a facility policy, titled Abuse Prohibition, Reporting and Investigation, dated 2/2020, and indicated this was the current policy used by the facility. A review of the policy indicated It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse . This Federal tag relates to Complaint IN 702. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse when a resident spit on another resident's face after a verbal argument for 1 of 3 residents reviewed for abuse. (Resident D, Resident C) Finding includes: The clinical record for Resident C was reviewed on 3/7/22 at 10:33 a.m. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C was not cognitively intact. A Nurse's progress note, dated 1/18/22 at 11:54 a.m., indicated Resident C was arguing with Resident D in the hallway. After the residents were separated twice, Resident C walked back down the hallway and within close range spit on Resident D's face. On 3/7/22 at 10:40 a.m., Resident C was observed walking in the hallway with a pleasant mood. Resident C was unable to remember any incident with another resident. The clinical record for Resident D was reviewed on 3/7/22 at 10:48 a.m. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D was not cognitively intact. On 3/7/22 at 10:43 a.m., Resident D was observed sitting in the main dining room. Resident D was unable to remember any incident with another resident. During an interview on 3/7/22 at 11:06 a.m., LPN (Licensed Practical Nurse) 1 indicated on 1/18/22 Resident C and Resident D had an argument in the hallway because Resident D thought Resident C was in his way. The staff separated the residents and then Resident C walked back down the hall to Resident D and spit on Resident D's face. Resident C then walked away. On 3/7/22 at 9:26 a.m., The Administrator provided a copy of a facility policy, titled Abuse Prohibition, Reporting, and Investigation, dated 2/2010, and indicated this was the current policy used by the facility. A review of the policy indicated It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse . This Federal tag relates to Complaint IN 276. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure staff supervision was provided to prevent falls for a resident who was assessed at high risk for falls for 1 of 8 residents reviewed for falls (Resident B) and the facility failed to ensure a resident's wander guard (a security bracelet worn by a resident to help prevent an elopement) was monitored for placement and proper functioning for 1 of 2 residents reviewed for elopement risk (Resident 22). Findings include: 1. Resident B's clinical record was reviewed on 8/18/21 at 9:35 a.m. Diagnosis included, but were not limited to, dementia with behavioral disturbance, delusional disorder, generalized anxiety disorder, restlessness, and agitation. The significant change MDS (Minimum Data Set) assessment, dated 6/18/21, indicated Resident B was severely cognitively impaired; required assistance of 2 staff for bed mobility and transfers; required assistance with walking in his room and in the corridor; and had 2 or more falls with no injury and 1 fall with a minor injury since admission. Resident B's care plan, dated 3/4/21 through 9/24/21, indicated .problem: Resident is at risk for falls due to: history of falls .requires assistance/supervision for mobility, transfer and ambulation, unsteady gait .approach: staff to offer assist and walk with resident when seen walking . The care plan lacked documentation of staff supervision to prevent the reoccurrence of falls. The fall risk assessment, dated 6/18/21, indicated Resident B was at high risk for falls. The Observation note, dated 6/24/21 at 5:48 p.m., indicated Resident B required assistance with transfers/walking, risk of falls. On 8/19/21 at 1:40 p.m., the Director of Nursing provided copies of Resident B's Safety Events - ASC Fall Event documents for eleven unwitnessed falls. A review of the documents indicated the following: Resident B had eleven unwitnessed falls from 3/13/21 to 6/21/21. a. Event date: 3/13/21 at 11:44 a.m. Unwitnessed fall while ambulating in the hall. No injury noted. Intervention: changed resident [Resident B] put boots on and took him to a common area. [Resident B] ambulates as he pleases. Root cause: unsteady gait, history of falls, requires assistance/supervision for mobility transfer and ambulation, altered awareness of immediate physical environment. b. Event date: 3/19/21 at 4:15 a.m. Unwitnessed fall while walking down the hall towards North unit, then attempted to run behind CNA [Certified Nursing Assistant] . No injury noted. Intervention: Res [Resident B] on hourly checks. Root cause: unsteady gait, history of falls, requires assistance/supervision for mobility transfer and ambulation, altered awareness of immediate physical environment. c. Event date: 4/5/21 at 11:15 a.m. Unwitnessed fall while sitting in w/c [wheelchair] during activities. No injury noted. Intervention: observe. Root cause: Resident slid out of chair. d. Event date: 5/21/21 at 10:00 p.m. Unwitnessed fall while wandering around the room/ No injury noted. Intervention: increased monitoring, door left open for observation. Root cause: unsteady gait, history of falls, requires assistance/supervision for mobility transfer and ambulation, altered awareness of immediate physical environment. e. Event date: 5/27/21 at 11:00 a.m. Unwitnessed fall while in Resident's room. No injury noted. Intervention: observe. Root cause: Resident attempted to walk independently r/t [due to] restlessness and agitation. f. Event date: 6/2/21 at 10:15 a.m. Unwitnessed fall while in Resident's room. No injury noted. Intervention: hipsters [hip protectors used for those who may be prone to hip injury] to be worn. Root cause: Resident attempted to walk independently and tripped on the fall mat on floor. g. Event date: 6/5/21 at 4:30 p.m. Unwitnessed fall while ambulating in the hall. Type of injury: Small raised red area noted on outer right elbow, measured 3 cm x 2 cm x 0.4 cm (raised). Intervention: observe. Root cause: Resident attempted to walk independently and while agitated. h. Event date: 6/9/21 at 9:49 p.m. Unwitnessed fall while in Resident's room. No injury noted. Intervention: knee pads. Root cause: Resident tripped. i. Event date: 6/10/21 at 5:09 a.m. Unwitnessed fall while Resident was walking out of his room. No injury noted. Intervention: extra mat removed. Yellow stop guard removed off door. Root cause: unsteady and shuffling gait. j. Date of event: 6/19/21 at 2:28 a.m. Unwitnessed fall while in Resident's room. Type of injury: skin tear on mid back. Intervention: leave room door open at night, placed night light in Resident's room. Root cause: Resident ambulating in low light conditions. k. Date of event: 6/21/21 at 12:15 p.m. Unwitnessed fall while Resident was walking near room 8. No injury noted. Intervention: observe. Root cause: unsteady, impulsive gait. The clinical record lacked documentation that Resident B was supervised or assisted during transfers and ambulation when unwitnessed fall events occurred. The unwitnessed fall event documents lacked a detailed root cause analysis description of the underlining causes of the unwitnessed falls and methods to prevent the reoccurrence of unwitnessed falls. The care plan lacked updated documentation of staff supervision to prevent the reoccurrence of unwitnessed falls. During an interview, on 8/18/21 at 11:30 a.m., Licensed Practical Nurse (LPN) 2 indicated Resident B was a high risk resident as he has had multiple falls with no significant injuries as a result of any falls. He required assistance and supervision with transfers and ambulation. During an interview, on 8/19/21 at 12:05 p.m., the Director of Nursing indicated Resident B had multiple unwitnessed falls, refused personal care, and required supervision while ambulating. Staff implemented various fall interventions; however, close supervision or one on one supervision was not always implemented or documented. On 8/19/21 at 1:40 p.m., the Director of Nursing provided a copy of the Fall Management Program policy, dated November 2017, and indicated it was the current policy in use by the facility. A review of the policy indicated, .to ensure residents residing within the facility receive adequate supervision and/or assistance to prevent injury related to falls . 2. The clinical record for Resident 22 was reviewed on 8/17/21 at 9:40 a.m. Diagnoses included, but were not limited to, alcohol dependence with alcohol-induced dementia, dementia in other diseases classified elsewhere without behavioral disturbances and altered mental status. An admission elopement risk assessment, dated 6/23/21 at 3:43 p.m., indicated, Resident 22 was at risk for elopement, and was not assigned a wander guard. An updated elopement risk assessment, dated 6/25/21 at 8:24 a.m., indicated, Resident 22 had a history of eloping from home or a facility. Resident 22 was assigned a wander guard. The clinical record lacked a Physician's order for a wander guard. The clinical record lacked documentation of monitoring for placement and proper functioning of the wander guard. On 8/18/21 at 9:40 a.m., Resident 22 was resting in his bed. A wander guard was observed on Resident 22's left lower leg. During an interview on 8/19/21 at 12:10 p.m., the Director of Nursing (DON) indicated, the wander guard should have been monitored for proper placement and proper functioning daily. On 8/18/21 at 11:30 a.m., the Director of Nursing provided a copy of a facility policy, titled Elopement and Response Program, dated 10/2017, and indicated this was the current policy used by the facility. A review of the policy indicated, residents at risk for elopement may utilize a security bracelet per Physician's order that will be checked for placement and function no less than daily. This Federal tag is related to Complaint IN 305. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a multi use vial of [MEDICATION(S)] (a skin test tool used to test for tuberculosis) was dated at the time the vial had been opened, as indicated by facility policy and manufacturer recommendation, for 1 of 1 vials observed during medication storage review. Findings include: During review of medication storage , on 8/17/21 at 8:35 a.m., in the locked medication storage room, located on the south hall, observed an opened and used multi use vial of [MEDICATION(S)] in the refrigerator. The vial was not labeled indicating when the vial was opened. During an interview, on 8/17/21 at 9:00 a.m., Licensed Practical Nurse (LPN) 1 indicated the opened vial of [MEDICATION(S)] should have been dated at the time it was opened. LPN 1 also indicated she was not sure when the vial had been opened. [MEDICATION(S)] at www.fda.gov, (November 2013) was retrieved on 8/20/2021. The guidance included: Storage: Vials in use more than 30 days should be discarded due to the possible oxidation and degeneration which may affect potency. On 8/19/21 at 9:09 a.m., the Director of Nursing (DON) provided a policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated 4/5/19, the DON also indicated it was the current policy being used by the facility. A review of the policy indicated, .5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 3.1-25(j)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections as evidenced by: One randomly observed staff member failed to sanitize their hands prior to donning PPE (Personal Protective Equipment) when entering a resident's room who was quarantined for droplet isolation in, one of two resident rooms in 14 day quarantine (Resident B). Three randomly observed staff members failed to sanitize or wash their hands after repositioning their face masks and one staff member failed to leave the mask in place, securely covering their mouth and nose. These deficient practices had the potential to spread infections, including COVID-19, to all thirty-five residents in the skilled nursing facility. Findings include: 1. During observation of the north unit, on 10/21/20 at 10:30 a.m., CNA 4 (Certified Nursing Assistant) was observed to don PPE prior to entering the room of Resident B, who was in 14 day quarantine droplet precautions (yellow zone) following admission to the facility. CNA 4 was not observed to sanitize her hands with ABHR (Alcohol Based Hand Rub) or wash her hands with soap and water, prior to donning the gloves. CNA 4 was observed to doff (remove) the PPE and sanitize their hands after leaving Resident B's room, however when interviewing CNA 4 in the hallway immediately following this observation, CNA 4 was observed to reposition the face mask covering her nose and mouth multiple times with her bare hands while speaking. CNA 4 was not observed to wash or sanitize her hands after touching the mask. During observation of the south unit, on 10/21/20 at 10:45 a.m., Qualified Medication Aide (QMA) 5 was wearing a KN95 (medical grade) face mask. During interview with the QMA 5 at that time, QMA 5 was observed to reposition the KN95 mask covering his nose and mouth multiple times with their bare hands. During and following the interview, QMA 5 was not observed to sanitize their hands with ABHR (Alcohol Based Hand Rub) or wash their hands with soap and water after touching and repositioning the KN95 face mask. During an observation on the north unit, on 10/21/20 at 11:25 a.m., CNA 4 was standing in the hallway at the entrance to an unknown resident's door. CNA 4 repositioned her face mask 3 separate times while speaking with the resident in his room. After concluding the conversation, CNA 4 was observed to walk to the Yellow zone of the facility and sat in a chair, directly across from two residents in 14 day quarantine. CNA was not observed to sanitize her hands with ABHR or wash her hands with soap and water after touching her face mask. During an interview with the DON (Director of Nursing), on 10/21/20 at approximately 11:30 a.m., the DON indicated it was her expectation that all staff would sanitize their hands prior to donning PPE and immediately sanitize their hands after repositioning and/or touching their face mask. Resident B's medical record was reviewed on 10/21/20 at approximately 12:35 p.m. Resident B was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The facility's current policy and procedure titled, Hand Hygiene Policy, with an origination date of 3/2018, provided by the DON and reviewed on 10/21/20 at 11:45 a.m., indicated the purpose of the policy was to .provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees. The policy further indicated Moments of hand hygiene . included .Before Clean/Aseptic procedure . The facility's current policy and procedure titled, Personal Protective Equipment (PPE) Donning and Doffing for Droplet Plus Isolation with an original date of 10/2020, provided by the DON and reviewed on 10/21/20 at 11:45 a.m., indicated *PPE must be donned correctly before entering the patient area (e.g. isolation room .). The first procedural step listed was 1. Perform hand hygiene. The Indiana State Department of Health Epidemiology Resource Center guidance: COVID-19 Information for Long-Term Care Facilities, last updated on 08/17/20 (https://www.coronavirus.in.gov/files/IN_COVID-19_LTC_08.17.20.pdf accessed on 09/24/20), indicated: Direct care providers should wear a surgical mask for the duration of their shifts. 2. During observation of the main dining area, on 10/21/2020 at approximately 10:50 a.m., an Activity Assistant (AA) 6 was conducting an activity. An estimated twelve residents were observed in the dining room during the activity, with some residents wandering in and out of the dining room and down the halls of the facility. Approximately 70% of the residents in and out of the dining room during the activity were not wearing face masks. E6 was observed wearing a KN95 face mask on her face and standing in the middle portion of the dining room amid the residents. AA6 was read from a papering she held in front of her. As she read, AA 6 was observed to grasp the front of the KN95 mask with her bare hand and pull the mask approximately 2 -3 inches away from her mouth, thus exposing her mouth and mucus membranes to the residents in the room. AA 6 was not observed at any time to sanitize her hands with ABHR or wash her hands after touching the KN95 mask. The facility activity schedule for the day, reviewed on 10/21/20 at approximately 12:20 p.m., indicated an activity of Today in History was scheduled at 10:30 a.m. and Daily Tidbits were scheduled at 11:00 a.m. 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to obtain a Physician's order for residents wearing a one piece zip up outfit (restraint) (Resident 13 and 42), the facility failed to complete a physical restraint assessment for residents wearing a one piece zip up outfit (Resident 13, 31, and 42) and the facility failed to document family notification and obtained a signed consent for residents wearing a one piece zip up outfit (Residents 13, 31, and 42) for 3 of 3 residents reviewed for restraints. Findings include: 1a. On 09/04/19 at 9:13 a.m., Resident 13 was observed wearing a long sleeved one piece outfit that consisted of a shirt and pants. The shirt portion of the outfit contained a long zipper, sewn into the back, that extended from the resident's waist to the resident's neck. Interview, on 9/5/19 at 11:32 a.m., Certified Nursing Assistant (CNA) 1, indicated the one piece outfit prevented the resident from undressing, exposing himself, and it also prevented the resident from urinating and defecating in public places. The CNA was unsure if the resident could take the outfit off without assistance. On 9/5/19 at 1:22 p.m., the clinical record for Resident 13 was reviewed, [DIAGNOSES REDACTED]. A change in condition Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident 13's cognitive status was severely impaired and he required extensive assistance with dressing and toileting. A care plan, dated 11/26/18 and current through 10/11/19, indicated Problem: Resident will relieve himself of bowel and/or bladder in inappropriate places such as hallway and other resident's rooms. Goal: Resident will not relieve himself in inappropriate places. Interventions included, but were not limited to, (MONTH) utilize one piece dressing with zipper in rear. The clinical record lacked a Physician's order including the type, duration, frequency, and medical condition or symptom(s) warranting the resident to wear a one piece outfit. Interview, on 9/6/19 at 1:33 p.m., the Director of Nursing (DON) indicated a physician's order had not been obtained for the one piece outfit. 1b. On 9/5/19 at 12:00 p.m., Resident 42 was observed wearing a one piece outfit. The outfit consisted of a shirt and pants. The shirt portion of the outfit contained a long zipper, sewn into in the back, that started at the resident's waist and ended at the resident's neck. On 9/5/19 at 1:55 p.m., the clinical record of Resident 42 was reviewed, [DIAGNOSES REDACTED]. An annual MDS Assessment, dated 5/22/19, indicated Resident 42's cognitive status was severely impaired and required extensive assistance with dressing and toileting. A care plan, dated 8/16/18 and current through 11/29/19, indicated Problem: Resident has a history of undressing and voiding in inappropriate places. Goal: Resident will be appropriately clothed in public areas of the facility. Resident will receive appropriate toileting care. Interventions included, but were not limited to, Resident to utilize single piece clothing item that zips in the back. The clinical record lacked a Physician's order including the type, duration, frequency, and medical condition or symptom(s) warranting the resident to wear a one piece outfit. Interview, on 9/6/19 at 1:33 p.m., the Director of Nursing (DON) indicated a Physician's order had not been obtained for the one piece outfit. 2a. On 09/04/19 at 9:13 a.m., Resident 13 was observed wearing a long sleeved one piece outfit that consisted of a shirt and pants. The shirt portion of the outfit contained a long zipper, sewn into the back, that extended from the resident's waist to the resident's neck. Interview, on 9/5/19 at 11:32 a.m., Certified Nursing Assistant (CNA) 1, indicated the one piece outfit prevented the resident from undressing, exposing himself, and it also prevented the resident from urinating and defecating in public places. The CNA was unsure if the resident could take the outfit off without assistance. On 9/5/19 at 1:22 p.m., the clinical record for Resident 13 was reviewed, [DIAGNOSES REDACTED]. A change in condition MDS Assessment, dated 7/2/19, indicated Resident 13 was severely cognitively impaired and required extensive assistance with dressing and toileting. A Care plan, dated 11/26/18 and current through 10/11/19, indicated Problem: Resident will relieve himself of bowel and/or bladder in inappropriate places such as hallway and other resident's rooms. Goal: Resident will not relieve himself in inappropriate places. Interventions included, but were not limited to, (MONTH) utilize one piece dressing with zipper in rear. The clinical record lacked physical restraint assessment(s). Interview, on 9/6/19 at 1:33 p.m., the DON indicated physical restraint assessment(s), for the one piece outfit, had not been completed. 2b. On 9/5/19 at 12:00 p.m., Resident 42 was observed wearing a one piece outfit. The outfit consisted of a shirt and pants. The shirt portion of the outfit contained a long zipper, sewn into in the back, that started at the resident's waist and ended at the resident's neck. On 9/5/19 at 1:55 p.m., the clinical record for Resident 42 was reviewed, [DIAGNOSES REDACTED]. An annual MDS Assessment, dated 5/22/19, indicated Resident 42's cognitive status was severely impaired and required extensive assistance with dressing and toileting. A care plan, dated 8/16/18 and current through 11/29/19, indicated Problem: Resident has history of undressing and voiding in inappropriate places. Goal: Resident will be appropriately clothed in public areas of the facility. Interventions included, but were not limited to, Resident to utilize single piece clothing item that zips in the back. Interview, on 9/6/19 at 1:33 p.m., the DON indicated physical restraint assessment(s), for the one piece outfit, had not been completed. 2c. On 9/5/19 at 12:10 p.m., Resident 31 was observed wearing a one piece outfit. The outfit consisted of a shirt and pants. The shirt portion contained a long zipper, sewn into in the back, that started at the resident's waist and ended at the resident's neck. On 9/5/19 at 2:15 p.m., the clinical record for Resident 31 was reviewed, [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 8/6/19, indicated Resident 31's cognitive status was severely impaired and required extensive assist with dressing and toileting. A care plan, dated 11/2/16 and current through 11/15/19, indicated Problem: Resident is incontinent due to dementia. History of voiding in inappropriate places. Utilizes one piece outfit. Goal: Resident will be free from adverse effects of incontinence. Interventions included, but were not limited to, Utilizes one piece outfit that zips in the back as needed. The clinical record lacked physical restraint assessments. Interview, on 9/6/19 at 1:33 p.m., the DON indicated physical restraint assessment(s) for the one piece outfit had not been completed. 3a. On 09/04/19 at 9:13 a.m., Resident 13 was observed wearing a long sleeved one piece outfit that consisted of a shirt and pants. The shirt portion of the outfit contained a long zipper, sewn into in the back, that extended from the resident's waist to the resident's neck. Interview, on 9/5/19 at 11:32 a.m., Certified Nursing Assistant (CNA) 1, indicated the one piece outfit prevented the resident from undressing, exposing himself, and it also prevented the resident from urinating and defecating in public places. The CNA was unsure if the resident could take the outfit off without assistance. On 9/5/19 at 1:22 p.m., the clinical record for Resident 13 was reviewed. [DIAGNOSES REDACTED]. A change in condition, Minimum Data Set Assessment, dated 7/2/19, indicated Resident 13's cognitive status was severely impaired and required extensive assistance with dressing and toileting. A Care plan, dated 11/26/18 and current through 10/11/19, indicated Problem: Resident will relieve himself of bowel and/or bladder in inappropriate places such as hallway and other resident's rooms. Goal: Resident will not relieve himself in inappropriate places. Interventions included, but were not limited to, (MONTH) utilize one piece dressing with zipper in rear. The clinical record lacked a signed restraint notification and consent form for the one piece outfit. Interview, on 9/6/19 at 1:33 p.m., the DON indicated the restraint notification and consent form was not available. 3b. On 9/5/19 at 12:00 p.m., Resident 42 was observed wearing a one piece outfit. The outfit consisted of a shirt and pants. The shirt portion of the outfit contained a long zipper sewn into in the back that started at the resident's waist and ended at the resident's neck. On 9/5/19 at 1:55 p.m., the clinical record for Resident 42 was reviewed. [DIAGNOSES REDACTED]. An annual MDS Assessment, dated 5/22/19, indicated Resident 42's cognitive status was severely impaired and required extensive assistance with dressing and toileting. A care plan, dated 8/16/18 and current through 11/29/19, indicated Problem: Resident has history of undressing and voiding in inappropriate places. Goal: Resident will be appropriately clothed in public areas of the facility. The resident will receive appropriate toileting care. Interventions included, but were not limited to, Resident to utilize single piece clothing item that zips in the back. The clinical record lacked a signed restraint notification and consent form. Interview, on 9/6/19 at 1:33 p.m., the DON indicated the restraint notification and consent form was not available. 3c. On 9/5/19 at 12:10 p.m., Resident 31 was observed wearing a one piece outfit. The outfit consisted of a shirt and pants. The shirt portion contained a long zipper, sewn into the back, that started at the resident's waist and ended at the resident's neck. On 9/5/19 at 2:15 p.m., the clinical record for Resident 31 was reviewed, [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 8/6/19, indicated Resident 31's cognitive status was severely impaired and required extensive assist with dressing and toileting. A care plan, dated 11/2/16 and current through 11/15/19, indicated Problem: Resident is incontinent due to dementia. History of voiding in inappropriate places. Utilizes one piece outfit. Goal: Resident will be free from adverse effects of incontinence. Interventions included, but were not limited to, Utilizes one piece outfit that zips in the back as needed. The clinical record lacked documentation of a signed restraint notification and consent form. Interview, on 9/6/19 at 1:33 p.m., the DON indicated the restraint notification and consent form was not available. Interview, on 9/5/19 at 3:00 p.m., the Director of Nursing (DON) indicated the one piece outfits were used to prevent the residents from exposing themselves in front of the other residents. Interview, on 9/6/19 at 1:33 p.m., the Physical Therapist indicated, residents would need to be assessed to determine if the resident could independently remove the one piece outfit without staff assistance. It would depend on the residents range of motion and cognitive status. On 9/5/19 at 3:32 p.m., the DON provided a policy titled Physical restraints, dated (MONTH) 2010, and indicated it was the current policy being used by the facility. A review of the policy indicated .Definition: A physical restraint is defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.Procedure: 1. A physical restraint assessment will be completed prior to the initiation or a restraint.5. A Physician's order will be obtained and will include the type, duration, frequency, and the medical condition or symptom (s) warranting the restraint use.7. The resident and or family member will sign the restraint notification form at the next visit or it will be mailed out for signature, which includes the risks and benefits of restraint use 3.1-3(w) 3.1-26(b) 3.1-26(q)

Based on interview and record review, the facility failed to ensure a discharged resident's medications were accounted for and disposed of properly for 1 of 1 resident reviewed for medication disposition. (Resident 44) Findings include: On 9/9/19 at 9:51 a.m., Resident 44's closed clinical record was reviewed. Resident 44 was admitted to the facility on [DATE] and discharged to another long term care nursing facility on 6/13/19. At the time of discharge, Resident 44's Physician order [REDACTED].>[MEDICATION NAME] ([MEDICATION NAME]) tablet 500 mg (milligrams) [MEDICATION NAME] sprinkles ([MEDICATION NAME]) capsule 250 mg [MEDICATION NAME] nanocrystallized tablet 145 mg [MEDICATION NAME] tablet 160 mg [MEDICATION NAME] tablet 5 mg [MEDICATION NAME] tablet 25 mcg (microgram) omega-3 fish oil 300-1,000 mg pantoprazole tablet 40 mg potassium chloride tablet 20 mEq (miliequivalent) [MEDICATION NAME] ([MEDICATION NAME]) tablet 3 mg rivastigmine patch 9.5 mg senna tablet 8.6 mg tamsulosin capsule .4 mg [MEDICATION NAME] tablet 75 mg [MEDICATION NAME] tablet 5 mg An observation detail list report, dated 6/13/19, indicated Resident 44 was transferred to another skilled nursing facility on 6/13/19. The clinical record lacked documentation that indicated the disposition of Resident 44's medications. Interview, on 9/9/19 at 11:35 a.m., the DON (Director of Nursing) indicated Resident's 44's current medications were given to the new nursing facility. The facility had not recorded the type of medication, dosage, or the amount of medication released to the new nursing facility. Interview, on 9/9/19 at 11:45 a.m., the DON indicated the facility did not have a medication disposition policy. 3.1-25(s)

Based on observation, interview, and record review, the facility failed to ensure the facility's dumpster sliding doors were kept closed when not in use. This had the potential to affect 43 of 43 residents residing in the facility. Findings include: On 9/3/19 from 10:55 a.m. to 10:59 a.m., observed the facility's trash dumpster area, which was located adjacent to the kitchen's rear door. The dumpster had a sliding panel door on two sides of the dumpster. Observed both sliding panel doors on the dumpster to not be closed. No staff were observed near the trash dumpster area. On 9/6/19 from 10:45 a.m. to 10:50 a.m., observed the facility's trash dumpster area, which was located adjacent to the kitchen's rear door. The dumpster had a sliding panel door on two sides of the dumpster. Observed one sliding panel door on the dumpster to not be closed. No staff were observed near the trash dumpster area. Interview, on 9/3/19 at 11:10 a.m., the DM (Dietary Manager) indicated all residents residing in the facility received food from the kitchen. The current facility census was 43 residents. Interview, on 9/6/19 at 10:50 a.m., the DM indicated the dumpster sliding doors were to be kept closed when not in use. On 9/6/19 at 4:25 p.m., the Director of Nursing provided a copy of the facility's Dietary/Food Services policy, dated (MONTH) 2012, and indicated it was the current policy in use by the facility. A review of the policy indicated, .dietary waste management included .outside holding areas .dumpster lids are closed . On 9/9/19 at 2:15 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective (MONTH) 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside . 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident assessed to exhibit intrusive wandering behavior was provided supervision to prevent the resident from wandering into another resident's room and having pushed the other resident down, which resulted in a [MEDICAL CONDITION], for 1 of 3 residents reviewed for accidents. (Resident B and C) Finding include: On 2/27/19 at 9:40 a.m., observed Resident B in the therapy room. Two therapy staff were with Resident B, who was about to start using a stationary pedal machine. Resident B did not respond when spoken to. On 2/27/19 at 3:00 p.m., observed Resident B wandering the front hall. Resident B was spoken to, however did not communicate with anyone. On 2/28/19 at 12:30 p.m., observed Resident B walking the hall, hand in hand with a CNA (Certified Nursing Assistant), with no verbal exchange when spoken to by the CNA. On 2/27/19 at 11:00 a.m. Resident B's clinical record was reviewed. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment, dated 1/23/19, indicated Resident B was severely cognitively impaired. Required supervision for walking in the hall. Wandering behavior was not exhibited during this time. Other behaviors such as entering other residents' rooms, without permission, was exhibited 1 to 3 days during the assessment period. A care plan, initiated on 1/23/19 and current through 4/30/19, indicated, Intrusive wandering into other residents' room (sic), at times will get into their beds. Goal indicated, the resident would be safe from harm to self or others as a result of his wandering, through the next review. Interventions included, but were not limited to, staff will redirect resident away from other residents' rooms. When the resident was wandering, staff were to redirect the resident with conversation about his family. Incident documentation, dated 2/12/19, indicated on 2/12/2019 at 6:31 p.m., Resident B entered the room of Resident's C and D, thinking it was his room. Resident C attempted to assist Resident B out of the room. Resident B pushed Resident C, causing Resident C to fall backwards. Staff immediately separated the residents. Nurse's notes, dated 2/13/19 at 10:26 p.m., indicated Resident C complained of pain to their left knee, and shoulder. Pain medication documented as somewhat effective. X-ray of left shoulder and hip was ordered. Nurse's notes dated 2/14/19 at 2:15 p.m., Mobile-X called and reported Resident C's left hip was positive for a fracture. Resident C was transported via ambulance to the hospital for evaluation/treatment. Interview of the Charge Nurse, on 2/27/2019 at 2:15 p.m., indicated the fall on 2/12/2019; was unwitnessed. She came into Resident C and D's room after a CNA called her to come to the room. She observed Resident C to be lying on the floor next to his bed. Resident B was standing over Resident C and Resident D (Resident C's roommate) indicated Resident B pushed his roommate and hurt him. Two CNA's were noted to be in the room. One CNA was standing between Resident B and Resident C, as Resident B was getting angry. Interview of CNA 1, on 2/28/19 at 11:23 a.m., indicated she was rolling a resident back to his room after lunch. She looked to the right she saw a pair of legs on the floor. She indicated she entered Resident C and D's room to check on what might have happen. Resident D (roommate) was upset, indicating Resident B pushed his roommate (Resident C) down and hurt him. As she was calling to the nurse and CNA 2 came in to assist and put herself in between Resident B and Resident C. Interview of CNA 2, on 2/28/2019 at 11:30 a.m., indicated she heard yelling in the hall near Resident C and D's room. She went to check on the residents and noticed Resident C on the floor. Resident B was standing over Resident C. Resident D (roommate) was upset stating Resident B pushed his roommate (Resident C) down and hurt him. CNA 2 indicated she stepped in between Resident B and Resident C, to re-direct Resident B out of the room. On 2/28/19 at 11:50 a.m., LPN 1 provided the facility's Fall Management Program Policy, revised date (MONTH) (YEAR), and indicated the policy was the one being currently used by the facility. A review of the policy indicated, it was the policy of American Senior Communities to ensure residents residing within a facility receive adequate supervision and or assistance to prevent injuries related to falls. This Federal tag relates to Complaint IN 008. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a freezer unit contained a thermometer and the facility failed to ensure the freezer temperature was at zero or below as indicated by facility policy for 1 of 1 resident snack nourishment refrigerator/freezer unit. This had the potential to affect 43 of 43 residents who had access to utilize the snack refrigerator unit. Findings Include: 1. On 8/14/18 at 11:50 a.m., the resident snack nourishment refrigerator/freezer unit was observed. The freezer unit section contained 5 frozen Bob(NAME)sandwiches. The freezer section of the refrigerator/freezer unit lacked a thermometer. During an interview, on 8/14/18 at 11:50 a.m., Dietary Cook 2 indicated the freezer unit section was to contain a thermometer. On 8/15/18 at 2:25 p.m., the DNS (Director of Nursing Services) provided the American Senior Communities Food Storage policy, dated (MONTH) (YEAR), and indicated it was the current policy in use by the facility. Review of the policy indicated, .thermometers should be checked utilizing an internal thermometer . 2. On 8/14/18 at 2:15 p.m., the resident snack nourishment refrigerator/freezer unit was observed. The freezer unit section was observed to be at 18*F. The freezer contained 5 frozen Bob(NAME)sandwiches. On 8/14/18 at 4:15 p.m., the resident snack nourishment refrigerator/freezer unit was observed. The freezer unit section was observed to be at 20*F. The freezer contained 5 frozen Bob(NAME)sandwiches. During an interview, on 8/14/18 at 2:15 p.m., Dietary Staff 2 indicated the freezer section temperature was to be at zero or below. During an interview, on 8/17/18 at 4:20 p.m., the ED (Executive Director) indicated there were 43 residents who had access to the resident snack nourishment refrigerator/freezer unit. On 8/15/18 at 2:25 p.m., the DNS (Director of Nursing Services) provided the American Senior Communities Food Storage policy, dated (MONTH) (YEAR), and indicated it was the current policy in use by the facility. Review of the policy indicated, .temperatures for the freezer should be 0*F or below . On 8/17/18 at 3:15 p.m., a review of the Title 410 IAC 7-24-197 (a), of the Retail Food Establishment Sanitation Requirements, indicated stored frozen foods shall be maintained frozen and should be stored at zero (0) degrees Fahrenheit. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure call lights were in the reach of a resident for 2 of 8 residents observed for call light accessibility. (Residents 45 and 9) Findings include: 1. On 8/16/18 at 11:10 a.m., observed Resident 45 in his room. The resident was laying in bed quietly, with both eyes closed. The call light was draped over the top of the resident's dresser, hooked to the dresser drawer knob, and out of the reach of the resident. On 8/16/18 at 11:10 a.m., observed Licensed Practical Nurse 1 adjust Resident 45's call light so it would be in the reach of the resident. During an interview, at that time, Licensed Practical Nurse 1, indicated all residents should have their call light in reach. On 08/16/18 at 11:43 a.m., the clinical record for Resident 45 was reviewed. [DIAGNOSES REDACTED]. A significant change in status Minimum Data Set (MDS) assessment, dated 7/31/18, indicated Resident 45's cognition was severely impaired. 2. On 8/16/18 at 11:00 a.m., observed Resident 9 laying on a low mattress with both eyes open, the resident waved, but was nonverbal. Resident 9's call light was laying behind his head, hooked to the side of the bed, and out of the reach of the resident. On 8/16/18 at 11:10 a.m., observed Licensed Practical Nurse 1 adjust Resident 9's call light so that it would be in the reach of the resident. During an interview, at that time, Licensed Practical Nurse 1, indicated all residents should have their call light in reach. On 8/16/18 at 12:13 p.m., the clinical record for Resident 9 was reviewed. [DIAGNOSES REDACTED]. A quarterly review MDS assessment, dated 5/22/18, indicated Resident 9's cognition was moderately impaired. During an interview, on 8/16/18 at 12:00 p.m., the Director of Nursing indicated the facility did not have a call light policy. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse for 1 of 1 resident reviewed for abuse. (Resident 197) Findings include: On 8/15/18 at 8:40 a.m., observed Certified Nursing Assistant (CNA) 3 exit Resident 197's room. As she exited the room CNA 3 stated, I'm f***ing done with this. When CNA 3 became aware of the observation she stated, Oh great. On 8/15/18 at 9:45 a.m., the Executive Director (ED), provided a copy of CNA 3's statement, dated 8/15/18, that indicated, I apparently said a curse word coming out of his (Resident 197) room and the state worker heard it. Resident 197's clinical record was reviewed on 8/15/18 at 9:45 a.m. Resident was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Pre-admission BIMS (Brief Interview for Mental Status) was assessed as moderate cognitive impairment. Care plan, dated 6/2/2017, indicated Resident had no hearing impairment. On 8/14/18 at 9:00 a.m., the ED provided the abuse policy. With an original date 2/2010, revised 10/2017, and titled, Abuse Prohibition, Reporting, and Investigation, and indicated it was the current policy being used by the facility. A review of the policy indicated, It is the policy of American Senior Communities to protect residents from abuse. 3.1-27(b)

Based on observation, record review, and interview, the facility failed to ensure care plans were developed for a resident with a hand contracture (Resident 31) for 1 of 2 residents reviewed for position and mobility/range of motion and a resident with a behavior causing skin irritation (Resident 39) for 1 of 7 residents reviewed for behaviors. Findings include: 1. During an observation and interview, on 8/15/18 at 2:00 p.m., Resident 31's right hand and fingers were observed to be contracted. The resident indicated and demonstrated he was unable to open his right hand nor straighten out his fingers all the way. The clinical record of Resident 31 was reviewed on 8/16/18 at 2:02 p.m. [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment, dated 10/10/17, indicated Resident 31 had a functional range of motion impairment on one side, both upper and lower extremities. A care plan indicating services to be provided to prevent worsening of Resident 31's right hand contracture was not found in the resident's clinical record. Observation, on 8/17/18 at 10:00 a.m. with the Rehab Services Manager (RSM), the resident was unable to open his right hand all the way. The RSM attempted to get his fingers on the right hand to fully extend, but was unable to do so without hurting the resident. The RSM indicated Resident 31's right hand and fingers were contracted and services were not being provided to prevent the right hand and fingers from contracting further. Interview 8/17/18 at 10:45 a.m., the Director of Nursing Services indicated a care plan which addressed services to be provided to prevent worsening of Resident 31's right hand contracture should have been developed. 2. On 8/15/18 at 9:15 a.m., Resident 39 was observed in his room. Resident 39's bilateral hands were bright red in color and a small slit like open area noted on his left pinky knuckle and a small slit like open area noted on his left ring finger knuckle. Surrounding skin appeared to be moist and wrinkled. On 08/17/18 at 02:04 p.m., Resident 39's clinical record was reviewed. A quarterly Minimum Data Set (MDS) assessment, dated 7/17/18, indicated Resident 39 was cognitively intact. During an interview, on 8/15/18 at 9:17 a.m., Resident 39 indicated the rash was [MEDICAL CONDITION], the staff does not always put his medicated creams on his hands. Recapitulated physician's orders [REDACTED]. A care plan, dated 12/22/17 and revised on 7/26/18, indicated resident is at risk for skin breakdown due to impaired mobility and occasionally moist skin. During an interview, on 8/17/18 at 11:22 a.m., the Director of Nursing (DON) indicated, Resident 39 would constantly wash his hands and left the soap on his hands, which caused his hands to dry out. Resident 39's clinical record lacked a care plan for constant skin washing behavior. On 8/17/18 at 2:20 p.m., the DON provided a policy, titled: Interdisciplinary Team (IDT) Comprehensive Care Plan Review, dated 1/2010, and indicated it was the current policy being used by the facility. A review of the policy, indicated, Policy: It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the residents highest level of functioning including medical, nursing, mental and psychosocial needs. 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure a resident with limited range of motion received services to prevent further decrease in range of motion for 1 of 2 residents reviewed for decrease in range of motion. (Resident 31) Findings include: During an observation and interview, on 8/15/18 at 2:00 p.m., Resident 31's right hand and fingers were observed to be contracted. A contracture is a permanent shortening of a muscle or tenon resulting in decreased movement and range of motion. The resident indicated and demonstrated he was unable to open his right hand nor straighten out his fingers all the way. The clinical record of Resident 31 was reviewed on 8/16/18 at 2:02 p.m. [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment, dated 10/10/17, indicated Resident 31 had a functional range of motion impairment on one side, both upper and lower extremities. No documentation was found in the resident's record which indicated services were being provided to prevent worsening contracture of the right hand and fingers. Observation, on 8/17/18 at 10:00 a.m. with the Rehab Services Manager (RSM), the resident was unable to open his right hand all the way. The RSM attempted to get his fingers on the right hand fully extended, but was unable to do so without hurting the resident. The RSM indicated Resident 31's right hand and fingers were contracted and services were not being provided to prevent the right hand and fingers from contracting further. The RSM indicated, I will have physical therapy work with his right hand. 3.1-42(a)(2)

Based on record review, interview, and observation, the facility failed to ensure adequate supervision to prevent resident (Resident 197) to push down other residents (Resident 196 and 18) for 3 of 5 residents reviewed for accidents. Findings include: Review, on 8/14/18 at 2:45 p.m., of Facility Reported Incidents indicated the following: Facility Reported Incident, dated 6/1/18, indicated Resident 197 had a resident to resident altercation when another resident (Resident 196) attempted to enter Resident 197's room. Reportedly, Resident 197 made direct physical contact with Resident 196 and both, experienced an unexpected change of plane. The Incident Report indicated a stop sign was to be placed at Resident 197's door. Facility Reported Incident, dated 7/14/18, indicated Resident 197 and Resident 18 were involved in a resident to resident altercation. Resident 18 had wandered into Resident 197's room. Resident 197 became upset and made physical contact with Resident 18, causing Resident 18 to fall. No injuries reported as a result of the altercation. Incident report indicated staff will observe for Resident 197's stop sign outside of room during rounding to ensure the sign is in place. Resident's 197's clinical record was reviewed on 8/15/18 at 9:15 a.m. Resident 197 was readmitted on [DATE]. [DIAGNOSES REDACTED]. A Pre-admission assessment, dated 8/14/18, indicated a BIMS indicated the resident had moderate cognitive impairment and was ambulatory. On admission he was care planned for behaviors of intrusive wandering, demanding requests, inappropriate sexual comments and refusal of treatments, medication, and assistance. Resident 197's care plan, updated 7/13/18, indicated to include a stop sign at his door to ensure privacy. The care plan lacked documentation of additional interventions to ensure his privacy and prevent resident to resident altercations. Interview with the ED, on 8/17/18 a 2:50 p.m., indicated Resident 197 did not willfully push him with the intention of making him fall, he just wanted Resident 18 out of his personal space. On 8/14/18 at 9:00 a.m., the ED provided the abuse policy which included procedure for resident to resident altercations. The abuse policy, original date 2/2010, revised 10/2017, and titled, Abuse Prohibition, Reporting, and Investigation, indicated it was the current policy being used by the facility. A review of the policy indicated American Senior Communities will not permit residents to be subjected to abuse by anyone, including employees, other residents 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident was not slapped, knocked to the ground and free from having sustained a left eye laceration and left knee abrasion as indicated by the Abuse Prohibition policy for 1 of 3 residents reviewed for abuse in a sample of 3 (Resident B and CNA 1). Findings include: A facility reported incident dated 8/16/17 at 5:40 p.m., indicated Resident B had been asked to leave the dining area while it was being cleaned after a meal. Resident B became upset and as he was leaving the area, called CNA 1 a n------ b----- and slapped her with the back of his hand. CNA (Certified Nursing Assistant) 1 retaliated by striking Resident B to the face. Resident B fell to the floor and sustained a laceration to the left eye measuring 1.3 centimeters (cm) x 0.6 cm x 0.2 cm and an abrasion to the left knee measuring 1.6 cm x 1.4 cm x <0.1 cm. A statement written by CNA 1 on 8/16/17 at 5:53 p.m., indicated Resident B was asked to leave the dining room while it was being cleaned. As he was walked by, Resident B slapped the CNA in the face with the back of his hand. CNA 1 also included in her statement, she hit him back. A statement written by Laundry Aide 2 on 8/16/17 at 5:45 p.m., indicated Resident B came into the dining room and was asked to leave. Resident B started cursing and called CNA 1 a stupid n-----. Laundry Aide 2 also indicated, CNA 1 told Resident B that word didn't bother her. Resident B then responded with, I will knock you the h--- out and backhanded CNA 1. CNA 1 hit Resident B back and he fell to the ground. A statement written by Activity Assistant/Bus Driver 3 on 8/16/17 at 5:45 p.m., indicated Resident B came into the dining room while it was being cleaned and he was asked to leave. Resident B got upset and called Activity Assistant a b----. When he got to the hallway he called CNA 1 a n-----. CNA 1 told him that word didn't hurt her. Resident B then indicated he would knock CNA 1 the f--- out and backhanded her in the face. CNA 1 then hit him back and he fell to the floor. The record for Resident B was reviewed on 8/28/17. [DIAGNOSES REDACTED]. During an interview with the Administrator on 8/28/17 at 1:30 p.m., he indicated CNA #1 had been terminated and Resident B had been discharged to the hospital for a psychiatric evaluation and had not returned to the facility at this time. On 8/29/17 at 8:45 a.m., the Administrator provided the Abuse Prohibition, Reporting, and Investigation policy, dated February 2010 and revised on November 2016, and indicated the policy was the one currently being used by the facility. It is the policy of ( name of company) to protect residents from abuse including physical abuse . Physical Abuse - a willful act against a resident by another resident, staff or other individuals. This Federal tag relates to Complaint IN 213. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure the physician was notified of a resident's decreased appetite and failure to eat which resulted in an 8.7% significant weight loss for 1 of 3 residents reviewed for physician notification in a sample of 3 (Resident #B). Findings include: The clinical record for Resident #B was reviewed on 7/15/15 at 10:00 a.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. On 5/18/15, Resident #B was assessed to have swallowing difficulties, needing assistance with food and fluids, and on nectar thick liquids (a diet designed to prevent aspiration of fluids into the lungs). A care plan dated 5/27/15, indicated the resident was at risk for nutritional deficits related to varied intakes and the need for thickened liquids. A care plan intervention indicated the resident was to be offered substitutes or alternates for intakes (meal consumption) less than 50%. Review of Resident #B's meal intake record for June 2015, indicated the resident consumed the following amounts of food: 26-50% of meal intake--6/3 breakfast, 6/5 dinner, 6/6 breakfast, 6/7 lunch, 6/9 dinner, 6/12 lunch, 6/13 dinner, 6/15 dinner, 6/16 breakfast, 6/17 breakfast, 6/18 lunch, 6/20 breakfast and dinner, 6/22 breakfast, 6/23 breakfast. 1-25% of meal intake--6/2 lunch and dinner, 6/3 lunch and dinner, 6/4 lunch and dinner, 6/5 breakfast and lunch, 6/8 breakfast and dinner, 6/9 lunch, 6/10 dinner, 6/11 dinner, 6/12 dinner, 6/14 breakfast, 6/15 breakfast, 6/18 dinner, 6/19 breakfast and lunch, 6/20 lunch, 6/21 breakfast and lunch, 6/22 lunch, 6/25 lunch. No meal intake--6/13 lunch, 6/14 lunch, 6/16 dinner, 6/17 lunch and dinner, 6/19 dinner, 6/21 dinner, 6/22 dinner, 6/23 lunch and dinner, 6/24 breakfast, lunch and dinner, 6/25 breakfast. Weights for the resident were as follows and shows the resident lost 15 pounds (lbs.) is 30 days, which is an 8.7% significant decrease in weight. 5/19/15 (on admission) 172 (lbs.) 5/26/15--172 lbs. 6/8/15-- 168 lbs. 6/16/15--166 lbs. 6/23/15--157 lbs The clinical record lacked documentation the physician had been notified of the weight loss and meal percentages consumed until 6/24/15. During an interview with the the Administrator and Director of Nursing on 7/15/15 at 4:05 p.m., documentation was requested for interventions in place for the resident's decreased meal consumption During an interview with the Administrator on 7/16/15 at 9:30 a.m., she indicated there were no interventions put into place for the resident's decreased meal consumption. The Nutrition-at-Risk team should have been monitoring this resident and notifying the physician. This Federal tag relates to Complaint IN 450. 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview the facility failed to ensure a resident with a decreased appetite, received adequate nutrition monitoring and interventions to prevent a significant weight loss of 8.7% for 1 of 3 residents reviewed for weight loss in a sample of 3 (Resident #B). Findings include: The clinical record for Resident #B was reviewed on 7/15/15 at 10:00 a.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. On 5/18/15, Resident #B was assessed to have swallowing difficulties, needing assistance with food and fluids and on nectar thick liquids to prevent aspiration of fluids into the lungs. The resident's admission Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired (BIMS-brief interview of mental status score was 4). The resident's weight on admission was 172 pounds (lbs) and on discharge to the hospital on [DATE], 157 lbs., which is an 8.7% significant weight loss in 30 days. A care plan dated 5/27/15, indicated the resident was at risk for nutritional deficits related to varied intakes and the need for thickened liquids. A care plan intervention indicated the resident was to be offered substitutes or alternates for intakes (meal consumption) less than 50%. Review of Resident #B's meal intake record for June 2015, indicated the resident consumed the following amounts of food: 26-50% of meal intake--6/3 breakfast, 6/5 dinner, 6/6 breakfast, 6/7 lunch, 6/9 dinner, 6/12 lunch, 6/13 dinner, 6/15 dinner, 6/16 breakfast, 6/17 breakfast, 6/18 lunch, 6/20 breakfast and dinner, 6/22 breakfast, 6/23 breakfast. 1-25% of meal intake --6/2 lunch and dinner, 6/3 lunch and dinner, 6/4 lunch and dinner, 6/5 breakfast and lunch, 6/8 breakfast and dinner, 6/9 lunch, 6/10 dinner, 6/11 dinner, 6/12 dinner, 6/14 breakfast, 6/15 breakfast, 6/18 dinner, 6/19 breakfast and lunch, 6/20 lunch, 6/21 breakfast and lunch, 6/22 lunch, 6/25 lunch. No meal intake--6/13 lunch, 6/14 lunch, 6/16 dinner, 6/17 lunch and dinner, 6/19 dinner, 6/21 dinner, 6/22 dinner, 6/23 lunch and dinner, 6/24 breakfast, lunch and dinner, 6/25 breakfast. The record lacked documentation Resident #B was offered substitutes, alternate meals as indicated in the plan of care or provided any supplements. The clinical record lacked documentation the physician had been notified of the weight loss and meal percentages consumed until 6/24/15. During an interview with the the Administrator and Director of Nursing on 7/15/15 at 4:05 p.m., documentation was requested for interventions in place for the resident's decreased meal consumption. During an interview with the Administrator on 7/16/15 at 9:30 a.m., she indicated there were no interventions put into place for the resident's decreased meal consumption. The Nutrition-at-Risk team should have been monitoring this resident and notifying the physician. This Federal tag relates to Complaint IN 450. 3.1-46(a)(1)

A. Based on observation, interview and record review, the facility failed to ensure resident safety from access to chemicals stored in a "Soiled Utility" room for 2 of 2 residents randomly observed and reviewed for safety of 20 mobile residents on the north unit. (Resident #24, Resident #42) Findings include: A. During the initial tour of the north unit of the facility on 1/27/14 at 11:15 a.m., an observation indicated a door marked, "Soiled Utility." A key was observed hanging from a string on the hand rail next to door. The door was locked. The key on the string was within reach of the doorknob and keyhole and accessed the soiled utility room. In the soiled utility room under an unlocked sink, were two bottles of bleach. Three specimen containers were observed on the counter top with unidentifiable, green-brown colored specimens inside the containers. Sealed biohazard containers were located in the "Soiled Utility" room. No residents were observed in the area at the time of the observation. During an interview on 1/27/14 at 11:25 a.m., the DON was queried regarding any ambulatory or mobile residents on the north unit and the mobile/ambulatory residents' cognition status. On 1/27/14 at 1:30 p.m., the DoN provided a type-written prepared list of residents titled, "Ambulatory or W/C (wheelchair) North Unit." The DoN denoted Resident #42 as "confused." During an interview on 1/27/14 at 1:50 p.m., the DoN was requested to provide a copy of the Material Safety Data Sheet (MSDS) for the bleach that was stored under the sink in the "Soiled Utility" room. A. 1. The record for Resident #24 was reviewed on 1/30/14 at 1:50 p.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment for Resident #24, dated 12/2/13, indicated Resident #24 was unable to complete the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #24 was moderately impaired, decisions poor, and required cues and supervision. The MDS indicated Resident #24 was independent with locomotion on the unit using a wheelchair. A care plan for Resident #24, dated 6/11/13, with an updated goal date of 3/5/14, indicated, "Risk of increasing confusion and disordered thoughts secondary to schizophrenia...Keep environment free of hazards...." A. 2. The record for Resident #42 was reviewed on 1/31/14 at 12:45 p.m. [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment for Resident #42, dated 12/30/13, indicated a BIMS of 10 out of a possible 15, which indicated he could not report the correct year or day of the week. The MDS indicated Resident #42 required supervision and oversight for mobility on the unit and did not utilize assistive devices for mobility. A care plan for Resident #42, dated 10/8/13, with an updated goal date of 4/2/14, indicated, "Potential for increasing confusion secondary to dementia...Verbal reminders which assist resident in orientation...." The MSDS for bleach was provided by the DoN on 1/27/14 at 2:25 p.m. The MSDS for bleach indicated, "...Health Hazard Information...Respiratory tract irritant...IF SWALLOWED: Call poison control center or doctor immediately for treatment advice...SKIN CONTACT: Contact with liquid can cause chemical burns...EYE CONTACT: Hold eye open and rinse slowly and gently with water for 15-20 minutes...Call a poison control center or doctor for treatment advice...." 3.1-45(a)(1)

Based on observation, record review, and interview, the facility failed to ensure a newly admitted resident was safely transferred from one surface to another, which required emergency hospital treatment of [REDACTED]. (Resident #77) Findings include: The clinical record of Resident #77 was reviewed on 3/14/14 at 12:00 p.m. [DIAGNOSES REDACTED]. Resident #77 was admitted to the facility on [DATE]. A nursing admission assessment, completed by Licensed Practical Nurse (LPN) #1 indicated she was alert to person only, appeared angry and anxious, needed total assist to transfer, and was a fall risk due to being intermittently confused, non-ambulatory, and chairfast. A nurse's note, dated 3/10/14, written by LPN #1, indicated Resident #77 needed the assistance of 2 people to transfer. A nurses's note, dated 3/11/14 at 7:00 p.m., written by LPN #1, indicated Certified Nursing Assistant (CNA) #2 reported to her she noted blood coming from Resident #77's leg after transferring her (the resident) from her wheelchair to her bed. LPN #1 indicated she assessed the resident and observed a "large laceration (a jagged or torn wound of the skin" on her left lower leg which measured 15 centimeters (cm) by 3 cm., with a moderate amount of blood coming from the wound. The nurse's note indicated the resident was transferred, via ambulance, to a local emergency room . A nurse's note, dated 3/12/14 at 12:00 a.m., indicated Resident #77 returned to the facility from the hospital, "31 staples to LLE (left lower extremity), dsg. c/d/i (Dressing clean, dry, intact)." A physical therapy evaluation, dated 3/12/14, indicated Resident #77 was non-ambulatory, debilitated, had poor balance. The evaluation recommended using a hoyer lift for the resident for transfers. A hoyer lift is a mechanical apparatus with a sling and straps, which can transfer residents between surfaces, i.e. from their bed to a chair. During an interview with CNA #2 on 3/17/14 at 1:55 p.m., she indicated Resident #77 was "heavy" and "couldn't bear weight." She indicated she used a gait belt and transferred the resident by herself. She indicated she wouldn't try it again by herself because Resident #77 needed a hoyer lift. She indicated, "I shouldn't have done it by myself. Normally, they let us know how to transfer new residents after physical therapy does their evaluation." She indicated she wasn't sure how they were supposed to know how to transfer someone prior to their physical therapy evaluation. During an interview with the Nurse Consultant on 3/17/14 at 2:00 p.m., she indicated she was not sure what the facility policy was regarding transfers of new residents, prior to their physical therapy evaluation. She indicated, "If someone came to me and asked, I would read their admission information and tell them to take 2 people to transfer the resident." During an interview with the Maintenance Director on 3/17/14 at 2:10 p.m., he indicated he removed a "retrofit bedrail attachment" from Resident #77's bed after the resident received her leg laceration. He indicated he did not observe any sharp areas on the attachment. During an interview with LPN #1 on 3/17/14 at 2:15 p.m., she indicated she didn't know what the transfer policy was for new residents, but she usually makes them a 2 person transfer "if any doubt." She indicated she thought CNA #2, who was working with her that evening, knew Resident #77 was a 2 person transfer. On 3/17/14 at 2:20 p.m., an interview was attempted with Resident #77. She would not answer any questions. The facility filed an Incident Report with the Indiana State Department of Health on 3/12/14, regarding Resident #77's leg injury. A follow-up investigation, dated 3/14/14, indicated preventive measures taken were the resident received a different bed, a siderail bracket was removed from the old bed, CNA #2 received 1:1 instruction, and an inservice for nursing staff was scheduled on 3/14/14 to review transfer safety. Review of the resident's record and the facility Incident Report and Investigation did not determine the definite origin of Resident #77's injury. This deficiency was cited on 1/31/14. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide services according to the resident's plan of care, to maintain personal hygiene and skin integrity. This affected 2 of 2 residents reviewed for residents requiring assistance with personal hygiene needs. (Residents #E and #66.) Findings Include: 1) The clinical record for Resident #E was reviewed on 3/26/13 at 3:00 p.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #E had a BIMS (Brief Interview for Mental Status) score of 15/15, indicating he was cognitively intact with no memory impairment. The MDS also indicated Resident #E required extensive assistance from staff to take care of personal hygiene needs and is always incontinent of urine (has no control of bladder). A facility care plan dated 8/10/12 was as printed, "Risk for skin break down due to incontinence of bowel and bladder" and a Goal that was as printed, " No pressure ulcer formation" and "Resident will be clean, dry and odor free." Interventions to meet the goal were as printed, "clean after each episode of incontinence" and "monitor skin for redness." A facility care plan dated 8/10/12 was as printed, "Resident requires assistance from staff for activities of daily living due to [MEDICAL CONDITION]." and a Goal that was as printed, " Resident will be clean, dry and odor free." Interventions to meet the goal were as printed, "Assist with bathing twice weekly," "Assist Resident with incontinent care and clean clothing as needed," and "Offer resident choices, such as white clothing to wear and time for resident's shower." A facility document titled "Pressure Ulcer Assessment, Braden Scale for Predicting Pressure Ulcer Risk" and dated 9/1/12 indicated Resident #E was not at high risk for pressure ulcers. During an interview on 4/1/13 at 10:30 a.m., via Electronic Mail (email), a staff person from a local area hospital, indicated some of the staff that worked with Resident #E were concerned for Resident #E's well being. The staff person indicated they were concerned with Resident #E's cleanliness, and current status of skin condition. The staff personal also indicated that when transport personnel picked up Resident #E from the facility, they noted Resident #E was lying in a puddle of urine. During an observation of incontinence care on 4/1/13 at 3:25 p.m., and in presence of CNA #1 (Certified Nurses Assistant), Resident #E was noted to have urine soaked bed sheet and top sheet he was covered with, a urine soaked hospital type gown on his body, and urine soaked hand towels that were covering his genitalia. CNA #1 stated, "I always find him like this" and indicated "I had him a urinal in here and he was staying dry, but I don't know where the urinal has gone, I haven't been here for a few days." Resident #E was noted to have bright red area in his groin region, the right side of the groin area was very bright red and noted to be bleeding slightly when CNA#1 wiped facility barrier cream (thick cream to protect the skin) away from the area. The front side, inner thigh area was noted to be slightly red and appeared to be chapped. Resident #E was turned over by CNA#1 and the bottom of the buttocks area and back of the thighs were noted to be bright red with scant amounts of barrier cream on the areas. When CNA #1 cleaned the anus of Resident #E, a medium amount of feces, from a previous bowel movement, was noted on the wash cloth. Resident #E yelled out and moaned in pain during the time of the cleaning of the groin and anus. Resident #E's mattress was noted to have a large wet, urine soaked spot on it, dead skin, and spotted with old, dried skin cream. During an interview with Resident #E on 4/1/13 at 4:00 p.m., Resident #E indicated they rarely get a bath or shower and stated "its such an ordeal to get cleaned up, let alone get an entire bath or shower", they also indicated they frequently ask to get out of bed, however staff do not accommodate the request. Shower records for Resident #E were requested on 4/1/13 at 4:15 p.m. Showers for Resident # E are as follows... Showers on February 1 (facility indicated resident refused shower this date, but was offered), 12, 15, and March 19 (bed bath given), 22 (bed bath given), and 26 (bed bath given), indicating Resident #E had 2 showers and 3 bed baths over the course of 59 days. "Licensed Nurse Weekly Skin Assessment" sheets were reviewed on 4/1/13 at 4:20 p.m. Skin Assessments were done and indicated as follows... Skin Assessment 2/26/13 indicated "buttocks excoriated (raw/red skin)" Skin Assessment 3/5/13 indicated "groin excoriated" Skin Assessment 3/19/13 indicated "red area under Right armpit" Skin Assessment 3/26/13 indicated there was bruising and swelling of the abdomen and lower limbs Skin Assessment 3/28/13 indicated "rectum has hemorrhoids that are swollen and lower extremities slightly swollen" Further information was requested from the facility Administrator on 4/1/13 at 4:30 p.m., in regards to showering for Resident #E. During an interview with the Administrator on 4/1/13 at 4:45 p.m., she indicated no further information was available. 2) During an observation and following interview with Resident #66 on 4/2/13 at 10:30 a.m., she indicated she was upset while waiting for assistance to get into the shower. Resident #66 stated, "you get a shower maybe once every 2 weeks, let alone 2 showers each week!" The clinical record for Resident #66 was reviewed on 4/2/14 at 10:45 a.m. [DIAGNOSES REDACTED]. A facility care plan dated 2/13/13, was as printed "Resident requires assistance from staff for activities of daily living due to [MEDICAL CONDITION] related to [MEDICAL CONDITION]", with a goal as printed "Resident will be clean, dry, odor free, and appropriately dressed", with interventions to the goal as printed "Assist with bathing twice weekly, and personal hygiene daily as needed" and "offer resident choices, such as what clothing to wear and time for resident's shower." A review of Resident #66's shower records on 4/2/13 at 11:00 a.m., indicated Resident #66 was offered a shower on 3/8/13 but refused to take it due to being in too much pain, then would have had a shower on 3/12/13 but was at the hospital, then had a shower on 3/15/13, the next shower was on 3/22/13, then on 3/26/13, then on 4/2/13. During the month of March, 2013, Resident #66 was offered 5 showers instead of 8, and went seven days between showers from 3/15/13 to 3/22/13 and went seven days between showers from 3/26/13 to 4/2/13. Further information was requested from the facility ADON (Assistant Director of Nursing) on 4/2/13 at 11:45 a.m., in regards to showers being done for Resident #66. No further information was available. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain personal hygiene and skin integrity. This affected 2 of 2 residents reviewed for residents requiring assistance with personal hygiene needs. (Residents #E and #66.) Findings Include: 1) The clinical record for Resident #E was reviewed on 3/26/13 at 3:00 p.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #E had a BIMS (Brief Interview for Mental Status) score of 15/15, indicating he was cognitively intact with no memory impairment. The MDS also indicated Resident #E required extensive assistance from staff to take care of personal hygiene needs and is always incontinent of urine (has no control of bladder). A facility care plan dated 8/10/12 was as printed, "Risk for skin break down due to incontinence of bowel and bladder" and a Goal that was as printed, " No pressure ulcer formation" and "Resident will be clean, dry and odor free." Interventions to meet the goal were as printed, "clean after each episode of incontinence" and "monitor skin for redness." A facility care plan dated 8/10/12 was as printed, "Resident requires assistance from staff for activities of daily living due to [MEDICAL CONDITION]." and a Goal that was as printed, " Resident will be clean, dry and odor free." Interventions to meet the goal were as printed, "Assist with bathing twice weekly", "Assist Resident with incontinent care and clean clothing as needed", and "Offer resident choices, such as white clothing to wear and time for resident's shower." A facility document titled "Pressure Ulcer Assessment, Braden Scale for Predicting Pressure Ulcer Risk" and dated 9/1/12 indicated Resident #E was not at high risk for pressure ulcers. During an interview on 4/1/13 at 10:30 a.m., via Electronic Mail (email), a staff person from a local area hospital, indicated some of the staff that worked with Resident #E were concerned for Resident #E's well being. The staff person indicated they were concerned with Resident #E's cleanliness, and current status of skin condition. The staff personal also indicated that when transport personnel picked up Resident #E from the facility, they noted Resident #E was lying in a puddle of urine. During an observation of incontinence care on 4/1/13 at 3:25 p.m., and in presence of CNA #1 (Certified Nurses Assistant), Resident #E was noted to have urine soaked bed sheet and top sheet he was covered with, a urine soaked hospital type gown on his body, and urine soaked hand towels that were covering his genitalia. CNA #1 stated "I always find him like this" and indicated "I had him a urinal in here and he was staying dry, but I don't know where the urinal has gone, I haven't been here for a few days." Resident #E was noted to have bright red area in his groin region, the right side of the groin area was very bright red and noted to be bleeding slightly when CNA#1 wiped facility barrier cream (thick cream to protect the skin) away from the area. The front side, inner thigh area was noted to be slightly red and appeared to be chapped. Resident #E was turned over by CNA#1 and the bottom of the buttocks area and back of the thighs were noted to be bright red with scant amounts of barrier cream on the areas. When CNA #1 cleaned the anus of Resident #E, a medium amount of feces, from a previous bowel movement, was noted on the wash cloth. Resident #E yelled out and moaned in pain during the time of the cleaning of the groin and anus. Resident #E's mattress was noted to have a large wet, urine soaked spot on it, dead skin, and spotted with old, dried skin cream. During an interview with Resident #E on 4/1/13 at 4:00 p.m., Resident #E indicated they rarely get a bath or shower and stated, "its such an ordeal to get cleaned up, let alone get an entire bath or shower," they also indicated they frequently ask to get out of bed, however staff do not accommodate the request. Shower records for Resident #E were requested on 4/1/13 at 4:15 p.m. Showers for Resident # E are as follows... Showers on February 1 (facility indicated resident refused shower this date, but was offered), 12, 15, and March 19 (bed bath given), 22 (bed bath given), and 26 (bed bath given), indicating Resident #E had 2 showers and 3 bed baths over the course of 59 days. "Licensed Nurse Weekly Skin Assessment" sheets were reviewed on 4/1/13 at 4:20 p.m. Skin Assessments were done and indicated as follows... Skin Assessment 2/26/13 indicated "buttocks excoriated (raw/red skin)" Skin Assessment 3/5/13 indicated "groin excoriated" Skin Assessment 3/19/13 indicated "red area under Right armpit" Skin Assessment 3/26/13 indicated there was bruising and swelling of the abdomen and lower limbs Skin Assessment 3/28/13 indicated "rectum has hemorrhoids that are swollen and lower extremities slightly swollen" Further information was requested from the facility Administrator on 4/1/13 at 4:30 p.m., in regards to showering for Resident #E. During an interview with the Administrator on 4/1/13 at 4:45 p.m., she indicated no further information was available. 2) During an observation and following interview with Resident #66 on 4/2/13 at 10:30 a.m., she indicated she was upset while waiting for assistance to get into the shower. Resident #66 stated, "you get a shower maybe once every 2 weeks, let alone 2 showers each week!" The clinical record for Resident #66 was reviewed on 4/2/14 at 10:45 a.m. [DIAGNOSES REDACTED]. A facility care plan dated 2/13/13, was as printed "Resident requires assistance from staff for activities of daily living due to [MEDICAL CONDITION] related to [MEDICAL CONDITION]", with a goal as printed "Resident will be clean, dry, odor free and appropriately dressed," with interventions to the goal as printed "Assist with bathing twice weekly, and personal hygiene daily as needed" and "offer resident choices, such as what clothing to wear and time for resident's shower." A review of Resident #66's shower records on 4/2/13 at 11:00 a.m., indicated Resident #66 was offered a shower on 3/8/13 but refused to take it due to being in too much pain, then would have had a shower on 3/12/13 but was at the hospital, then had a shower on 3/15/13, the next shower was on 3/22/13, then on 3/26/13, then on 4/2/13. During the month of March, 2013, Resident #66 was offered 5 showers instead of 8, and went seven days between showers from 3/15/13 to 3/22/13 and went seven days between showers from 3/26/13 to 4/2/13. Further information was requested from the facility ADON (Assistant Director of Nursing) on 4/2/13 at 11:45 a.m., in regards to showers being done for Resident #66. No further information was available. 3.1-38(a)(3)

Based on record review and interview the facility failed to provide Restorative Range of Motion Services as care planned for 2 of 6 residents in a sample of 6 residents that met the criteria for range of motion. The facility also failed to follow a physicians order for blood sugar monitoring for 1 of 10 residents reviewed for Unnecessary Medications in a sample of 10 residents. This involved Resident #'s 9, 10, and 29. Findings Include: 1) Clinical Records for Resident #9 were reviewed on [DATE] at 10:00 a.m. [DIAGNOSES REDACTED]. A facility Plan of Care dated [DATE] indicated Resident #9 is, "Unable to independently move bilateral (both) legs due to [MEDICAL CONDITION] related to MS" ([MEDICAL CONDITION]), "Resident will tolerate three sets of 20 repetitions of Passive Range of Motion to bilateral legs". "Perform Passive Range (where staff assists the resident move their joints) of Motion on hips, knees, and ankles doing 3 sets of 20 repetitions." A facility Rehabilitation/Restorative Service Delivery Record dated for [DATE], indicated Resident #9 started on the facility's "Restorative" program [DATE]. The form indicated, "Perform Passive Range of Motion to bilateral legs (hips, knees and ankles) 3 sets of 20 repetitions to each joint, six to seven days per week." The form indicated resident received Range of Motion Services (ROM) on [DATE], 22, 23, 24, 29, 30, and [DATE], 8, 9,12,13,19, and offered but Resident #9 refused services on the 20th, indicating Resident #9 received Restorative Range of Motion Services 7 times in 2 weeks in [DATE], and 8 times in 3 weeks in [DATE], missing more than half of the required times for receiving required range of motion services. During an interview with the facility Minimal Data Set (MDS) Coordinator on [DATE] at 3:00 p.m., he indicated they have had to, "pull" the person used to provide Restorative Services to work as a CNA (Certified Nurses Assistant) to provide care for residents because the facility had been short staffed. During an interview with CNA #9 on [DATE] at 9:30 a.m., she indicated she had been pulled away from the Restorative Services program to help with resident care needs because the facility was short staffed. During an interview with the facility Minimal Data Set (MDS) Coordinator on [DATE] at 2:00 p.m., he indicated there was no policy and procedure in regards to Restorative or Range of Motion Services. 2) Clinical Records for Resident #10 were reviewed on [DATE] at 1:00 p.m. [DIAGNOSES REDACTED]. Resident #10's clinical record indicated a physicians order started [DATE] to, "Check blood sugar two times daily, call MD (medical doctor) if below 70 or above 400." The record indicated a high blood sugar level of 416 on [DATE]. The record also indicated that the blood sugar reading to be done daily at 4:00 p.m., was not done on [DATE], [DATE], nor [DATE]. A request for further information in regards to the blood sugar monitoring was requested of the Assistant Director of Nursing (ADON) on [DATE] at 2:30 p.m. During an interview with the ADON on [DATE] at 9:00 a.m., she indicated no further information was available for the blood sugar monitoring. During an interview with the facility Minimal Data Set (MDS) Coordinator on [DATE] at 2:00 p.m., a facility policy for Diabetic Monitoring was requested. A facility policy dated 2005, and titled, "Blood Sugar Monitoring" indicated, "If blood glucose level is above or below normal range, document the time the physician was notified" and to, "Check physicians order for blood sugar testing frequency." 3) On [DATE] at 11:40 a.m., during an interview with Resident # 29 they indicated the facility staff had not offered to do the Range of Motion, put their splint on their hand at night, nor walk them as the therapist's plan indicated. On [DATE] at 2:00 p.m., a review of the Rehabilitation/Restorative Service Delivery Record for Resident # 29 indicated they were to receive: 1) Assist resident to transfer from wheelchair to bed and from bed to wheelchair using gait belt and hemi walker. Two sets of 5 repetitions six to seven days per week. Maintain standing position for three minutes each rep. 2) walk resident 50 feet using gait belt and hemiwalker twice, six to seven days per week. 3) Perform Passive Range of Motion to all joints of Right arm (shoulder, elbow, wrist) two sets of 10 repetitions to improve ADL independence. The documentation indicated that resident #29 received Restorative Service on [DATE] as indicated. On [DATE] Restorative Service were refuse by the resident. On [DATE] Restorative Service were not offered. On [DATE] Restorative Service were not offered. On [DATE] Restorative Service were not offered. On [DATE] Restorative Service were revived after interview with resident. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 2:30 p.m., she indicated due to 6 CNA's being removed from the schedule, the Restorative Aide was reassigned to direct resident care. Restorative service were not provided on [DATE], [DATE], nor [DATE]. 3XXX,[DATE](g)(2)

A) Based on observation, interview, and record review, the facility failed to provide services according to the resident's plan of care, to maintain personal hygiene and skin integrity. This affected 2 of 2 residents reviewed for residents requiring assistance with personal hygiene needs. (Residents #E and #66.) B) Based on observation, record review, and interview, the facility failed to ensure services were provided according to residents' plans of care, for passive range of motion exercises, splint application, and blood sugar monitoring, for 4 of 17 residents reviewed for services being provided according to their plans of care in a total sample of 17. (Residents #29, #35, #A, and #9) Findings include: A1)The clinical record for Resident #E was reviewed on 3/26/13 at 3:00 p.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated Resident #E had a BIMS (Brief Interview for Mental Status) score of 15/15, indicating he was cognitively intact with no memory impairment. The MDS also indicated Resident #E required extensive assistance from staff for bed mobility, transfers, to take care of personal hygiene needs and is always incontinent of urine and bowel (has no control of bladder or bowel movements). A facility care plan dated 8/10/12 indicated, "Risk for skin break down due to incontinence of bowel and bladder" and a Goal that indicated, " No pressure ulcer formation" and "Resident will be clean, dry and odor free." Interventions to meet the goal indicated, "clean after each episode of incontinence" and "monitor skin for redness" A facility care plan dated 8/10/12 indicated, "Resident requires assistance from staff for activities of daily living due to [MEDICAL CONDITION]." and a Goal that indicated, " Resident will be clean, dry and odor free." Interventions to meet the goal indicated, "Assist with bathing twice weekly", "Assist Resident with incontinent care and clean clothing as needed", and "Offer resident choices, such as white clothing to wear and time for resident's shower." A facility document titled "Pressure Ulcer Assessment, Braden Scale for Predicting Pressure Ulcer Risk" and dated 9/1/12 indicated Resident #E was not at high risk for pressure ulcers. During an interview on 4/1/13 at 10:30 a.m., via Electronic Mail (email), a staff person from a local area hospital, indicated some of the staff that worked with Resident #E were concerned for Resident #E's well being. The staff person indicated they were concerned with Resident #E's cleanliness, and current status of skin condition. The staff personal also indicated that when transport personnel picked up Resident #E from the facility on 3/15/13, they noted Resident #E was lying in a puddle of urine. During an observation of incontinence care on 4/1/13 at 3:25 p.m., and in presence of CNA #1 (Certified Nurses Assistant), Resident #E was noted to have a urine soaked bed sheet and a top sheet he was covered with, a urine soaked hospital type gown on his body, and two urine soaked hand towels that were covering his genitalia. CNA #1 stated, "I always find him like this" and indicated, "I had him a urinal in here and he was staying dry, but I don't know where the urinal has gone, I haven't been here for a few days." Resident #E was noted to have bright red areas of excoriation in his groin region, the right side of the groin area was very bright red and noted to be bleeding slightly when CNA #1 wiped facility barrier cream (thick cream to protect the skin) away from the area. Resident #E moaned in pain and had facial grimacing while CNA #1 provided this care. The front side, inner thigh area was noted to be slightly red and appeared to be chapped. Resident #E was turned over by CNA#1 and a large area of the bottom of the buttocks area and down the back of the thighs were noted to be bright red with scant amounts of barrier cream on the areas. When CNA #1 cleaned the anus of Resident #E, a medium amount of feces, from a previous bowel movement, was noted on the wash cloth. Resident #E yelled out and moaned in pain during the entire time of the cleaning of the groin, anus, and legs. Resident #E's mattress was noted to have a large wet, urine soaked spot on it, dead skin, and spotted with old, dried skin cream. During an interview with Resident #E on 4/1/13 at 4:00 p.m., Resident #E indicated they rarely get a bath or shower and stated, "Its such an ordeal to get cleaned up, let alone get an entire bath or shower," they also indicated they frequently ask to get out of bed, however staff do not accommodate the request. Shower records for Resident #E were requested on 4/1/13 at 4:15 p.m. Showers for Resident # E were as follows... Showers on February 1 (facility indicates resident refused shower this date, but was offered), 12, 15, and March 19 (bed bath given), 22 (bed bath given), and 26 (bed bath given), indicating Resident #E had 2 showers and 3 bed baths over the course of 59 days. "Licensed Nurse Weekly Skin Assessment" sheets were reviewed on 4/1/13 at 4:20 p.m. Skin Assessments were done and indicated as follows... Skin Assessment 2/26/13 indicated "buttocks excoriated (raw/red skin)" Skin Assessment 3/5/13 indicated "groin excoriated" Skin Assessment 3/19/13 indicated "red area under Right armpit" Skin Assessment 3/26/13 indicated there was bruising and swelling of the abdomen and lower limbs Skin Assessment 3/28/13 indicated "rectum has hemorrhoids that are swollen and lower extremities slightly swollen" Further information was requested from the facility Administrator on 4/1/13 at 4:30 p.m., in regards to showering for Resident #E. During an interview with the Administrator on 4/1/13 at 4:45 p.m., she indicated no further information was available. A2) During an observation and following interview with Resident #66 on 4/2/13 at 10:30 a.m., she indicated she was upset while waiting for assistance to get into the shower. Resident #66 stated, "You get a shower maybe once every 2 weeks, let alone 2 showers each week!" The clinical record for Resident #66 was reviewed on 4/2/14 at 10:45 a.m. [DIAGNOSES REDACTED]. A facility care plan dated 2/13/13, indicated "Resident requires assistance from staff for activities of daily living due to [MEDICAL CONDITION] related to [MEDICAL CONDITION]", goals to the care plan indicated "Resident will be clean, dry, odor free and appropriately dressed", interventions to the goal indicated "Assist with bathing twice weekly, and personal hygiene daily as needed" and "offer resident choices, such as what clothing to wear and time for resident's shower." A review of Resident #66's shower records on 4/2/13 at 11:00 a.m., indicated Resident #66 was offered a shower on 3/8/13 but refused to take it due to being in too much pain, then would have had a shower on 3/12/13 but was at the hospital, then had a shower on 3/15/13, the next shower was on 3/22/13, then on 3/26/13, then on 4/2/13. During the month of March, 2013, Resident #66 was offered 5 showers instead of 8, and went seven days between showers from 3/15/13 to 3/22/13 and went seven days between showers from 3/26/13 to 4/2/13. Further information was requested from the facility ADON (Assistant Director of Nursing) on 4/2/13 at 11:45 a.m., in regards to showers being done for Resident #66. No further information was available. B1) The record of Resident #29 was reviewed on 4/1/13 at 10:55 a.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessments dated 12/12/12 and 3/11/13, indicated Resident #29 was independent with her decision making. A Monthly Summary, dated 3/5/13, indicated Resident #29 had contractures (an abnormal shortening of muscles) in her right arm. An Occupational Therapy Evaluation, dated 1/4/13, indicated, "Discharge to restorative for daily passive range of motion (moving of a joint through its range of motion without exertion by the resident) & splinting." During an observation on 4/1/31 at 11:00 a.m., Resident #29's right hand was observed to be tightly fisted. She was not wearing a hand splint. Recapitulated physician's orders [REDACTED].#29 was to have a right hand splint applied at bedtime and to wear the splint 5-6 hours, as tolerated. A care plan for Resident #29, dated 1/19/13, updated through 4/19/13, indicated a problem of, "Resident is unable to independently move Right arm due to [MEDICAL CONDITION] (paralysis) related [MEDICAL CONDITION](stroke)." The goal was, "Resident will tolerate two sets of 15 repetitions of Passive Range of Motion (PROM) to Right arm (shoulder, elbow and wrist) daily through next review." Interventions included, "Perform two sets of 15 repetitions of Passive Range of Motion to Right arm (shoulder, elbow and wrist) daily, six to seven days per week." A "Restorative Program" for Resident #29, dated 1/19/13, indicated, "...Problem: 1) Resident requires assist with Right PROM...Specific Instructions: 1) Resident will receive PROM 2 set x 15 reps (repetitions) of right Upper extremity to all joints to maintain ability to splint and assist with ADL (Activities of Daily Living) performance..." A Treatment Record for March, 2013, indicated Resident #29 did not have the hand splint applied on March 2, 6, 28, and 30. A Rehabilitation/Restorative Service Delivery Record for March, 2013, for Resident #29, indicated, "Perform Passive Range of Motion to all joints of Right arm (shoulder, elbow, wrist) two sets of 10 repetitions to improve ADL independence. This Service Delivery record indicated the resident did not receive PROM to all joints of her right arm on March 9, 10, 16, 17, 18, 23, 24, 27, 30, and 31. During an interview with Resident #29 on 4/1/31 at 11:00 a.m., she indicated "They rarely put my splint on or do my hand exercises. Maybe once a month. I can't remember the last time." B2) The record of Resident #35 was reviewed on 4/1/13 at 1:10 p.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment, ((MDS) dated [DATE], indicated Resident #35 was severely impaired in his decision making. A care plan for Resident #35, dated 1/24/13 and current through 5/1/13, indicated a problem of, "Resident is unable to independently move legs and arms due to muscle contractures. (abnormal shortening of muscles)" The goal was, "Resident will tolerate three sets of 20 repetitions of Passive Range of Motion (moving of a joint through its range of motion without exertion by the resident) to bilateral legs." Interventions included, "Perform Passive Range of Motion on bilateral legs and arms doing three sets of 20 repetitions..." A care plan for Resident #35, dated 1/24/13 and current through 4/24/13, indicated a problem of, "Resident is unable to put left hand splint on and off. Splint is needed to address contracture in left hand." The goal was, "Resident will tolerate left hand splint two times per day for two hours each with assistance from staff six to seven days per week through next review." Interventions included, "Assist to don left hand splint twice daily..." Resident #35 was not wearing a splint on his left hand during on observation on 4/1/13 at 1:10 p.m. A Rehabilitation/Restorative Service Delivery Record for Resident #35, for March 2013, indicated, "Perform Passive Range of Motion to bilateral arms and legs, three sets of 20 reps, including all joints six to seven days per week. The record indicated PROM was not provided for the resident on March, 9, 10, 16, 17, 18, 23, 24, 27, 30, and 31, 2013. The same delivery record indicated, "Assist resident to don Left hand splint, on for two hours at a time, twice per day, six to seven days per week." The record indicated the left hand splint was not applied on March 9, 10, 16, 17, 18, 23, 24, 27, 30, and 31, 2013. During an interview with the Assistant Director of Nursing on 2/26/13 at 3:15 p.m., she indicated she was not able to find any further information regarding passive range of motion services not provided or splint applications for Residents #29 and #35. She indicated the facility now has a Certified Nursing Assistant (CNA) who is assigned Monday through Friday to provide all the restorative services. She indicated all of the CNA's have been trained to provide these services if the Restorative Aide is not available. B3-a) Clinical Records for Resident #9 were reviewed on 4/1/13 at 1:45 p.m. [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident # 9 was independent with her decision making, total dependence-two person physical assist for Activities of Daily Living (ADL) assistance, Restorative Nursing Programs: Range of motion (passive), Splint or brace assistance. A facility Plan of Care dated 12/17/12 indicated Resident # 9 is, "Unable to independently move bilateral (both) legs due to [MEDICAL CONDITION] related to MS ([MEDICAL CONDITION])." "Resident will tolerate three sets of 20 repetitions of Passive Range of Motion to bilateral legs." "Perform Passive Range (where staff assists the resident move their joints) of Motion on hips, knees, and ankles doing 3 sets of 20 repetitions." A facility Rehabilitation /Restorative Service Delivery Record dated for March 2013, indicated Resident # 9 was on the facility's "Restorative" program. The form indicated, "Perform Passive Range of Motion to bilateral legs (hips, knees, and ankles) doing 3 sets of 20 repetitions to each joint, six to seven days per week." The form indicated resident was not offered Range of Motion Services (ROM) on March 10, 16, 17, 18, 23, and 24, 2013. During an interview with the facility Assistant Director of Nursing (ADN) on 4/1/13 at 2:45 p.m., she indicated the days on the facility Rehabilitation /Restorative Service Delivery Record that were blank indicated the service was not done. B3-b) The Clinical Record for Resident #9 was reviewed on 4/1/13 at 10:00 a.m. [DIAGNOSES REDACTED]. Resident #9's clinical record indicated a physicians order started 11/1/12 to "Check blood sugar daily, call MD (medical doctor) if below 70 or above 405." The clinical record indicated blood sugar levels were not checked on the following dates... March 3, 8, 10, 11, 12, 18, and 21, 2013. Further information was requested from the ADON (Assistant Director of Nursing) on 4/1/13 at 11:30 a.m. During an interview with the ADON on 4/1/13 at 3:00 p.m., she indicated no further information was available and was unsure of why the blood sugar levels had not been checked on the dates mentioned. B4) The Clinical Records for Resident #A were reviewed on 4/1/13 at 9:00 a.m. [DIAGNOSES REDACTED]. Resident #10's clinical record indicated a physicians order started 3/28/11 to "Check blood sugar two times daily, call MD (medical doctor) if below 70 or above 400." The clinical record indicated blood sugar levels were not checked on the following dates... March 13, 14, 15, 17, 19, 20, 23, and 24, 2013 for the scheduled 6:00 a.m. check and on 3/21/13 for the scheduled 4:00 p.m. check. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to provide wound care as ordered to a resident with a stage IV pressure ulcer on the left heel and failed to ensure inflation of an air mattress for a second resident at risk for pressure sores resulting in a stage II pressure sore to the buttocks for 2 of 3 residents reviewed who met the criteria for pressure ulcers. (Resident #15 and #4) Findings include: 1. The clinical record for Resident #15 was reviewed on 7/10/12 at 1:42 p.m. The [DIAGNOSES REDACTED]. The 7/6/12 MD order indicated, "1. (symbol for "no") shower or bath, don't (symbol for change) until pt (patient) F/U (follow up) (symbol for "with") MD (name of doctor) 7/12 at 2:30 p.m. 2. Wound Vac to (symbol for left) heel (symbol for change) M, W, F (Monday, Wednesday, Friday) apply over skin graft & [MEDICATION NAME]". The 7/12/12 wound care clinic notes indicated, "This patient presents to the (name of wound care clinic) today one-week status [REDACTED]. Orders were written for the patient to have a wound VAC placed to the surgical site. This was to be completed by the extended care facility however this was failed to be done. Despite this the wound appears to be making progress...Orders were written for a wound VAC to be placed to the left heel wound to be changed on a Monday, Wednesday, Friday rotation and is to be done at her extended care facility. They were contacted by the nursing from the wound care clinic and directed to obtain a VAC and to do so. This patient will be seen in one week." Review of the weekly skin assessments for the pressure ulcer to Resident #15's left heel began on 4/24/12 and indicated the ulcer was at a stage IV on this date. During interview with the DON (Director of Nursing) on 7/18/12 at 10:55 a.m. about any skin assessments done prior to 4/24/12, she indicated the previous wound nurse must have taken the wound care binder with her when she terminated employment so no skin assessment information was available prior to 4/24/12. An observation of Resident #15's left heel wound was made with LPN #5 on 7/18/12 at 11:16 a.m. The entire left foot, including all 5 toes were swollen. Ten stitches were in a circular pattern around the wound. The wound itself was pinkish yellow and bone appeared missing. 2. The clinical record for Resident #4 was reviewed on 7/10/12 at 2:40 p.m. The [DIAGNOSES REDACTED]. The 7/13/12 wound care clinic notes for Resident #4 indicated, "The patient has not been seen in the wound care clinic since April. Between these appointments he was hospitalized for [REDACTED]." "...the right buttock is 6.0 x 3.0 x 0.1." "...arrangements are being made to get him a new air mattress." The 7/13/12 skin condition report indicated a new area on the right buttock measuring 6.0 cm x 3.0 cm by 0.1 cm. The 7/13/12 receipt for a low air loss mattress for Resident #4 was provided by LPN #7 on 7/19/12 at 1:15 p.m. The 4/19/12 skin care plan indicated the problem was "Risk for skin breakdown due to total dependence on staff for bed mobility." The goal was "No new skin breakdown." An intervention was, "Pressure reducing mattress". During an interview with LPN #5 on 7/17/12 at 11:35 a.m., he indicated he noticed Resident #4's air mattress was deflated on 7/9/12. During an interview with Resident #4 on 7/18/12 at 12:15 p.m., he indicated, "It hurt my butt so bad." When queried about how long his mattress was deflated, he indicated, "I'm not sure how long it was like that, maybe a month." He indicated he knew there was something wrong with his mattress and that he told the aide with the golden brown hair so she turned him over. On 7/18/12 at 2:50 p.m. Resident #4 was heard yelling from his room, "My butt hurts!" The 6/5/12 admission MDS (minimum data set) assessment indicated Resident #4's BIMS (Brief Interview for Mental Status) score was 15 (highest possible score indicating resident is cognitively intact). Pressure ulcer prevention policy/procedure provided by the Administrator on 7/17/2012 at 3:30 p.m. indicated, "Procedure: 1. A pressure wound risk assessment will be completed on each resident upon admission, quarterly, and when a significant change of condition occurs. 2. Residents who are identified to be at risk for skin breakdown will be care planned to prevent breakdown. 3. Residents who are incontinent will be assessed and interventions put into place to address their incontinence. Examples of interventions include toileting program or routine incontinence care. 4. Residents who are able to reposition themselves will be repositioned by staff. During routine care, CNAs will look at resident's skin and notify the charge nurse of any early signs of breakdown, such as persistent red areas on the skin. 6. A skin assessment will be performed on each resident by a licensed nurse once weekly. This normally occurs on the resident's shower day." 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to have an order for [REDACTED].#5 Findings include: 1. Resident #26's clinical record was reviewed on 7/16/2012 at 9:10 a.m. [DIAGNOSES REDACTED]. A nurses noted dated 6/19/2012 at 10 a.m. indicated, "New order received to anchor foley catheter for 21 days for wound healing. A wound care center note dated 6/29/2012 indicated, "...He presently has a foley (urinary catheter) in and it was felt that urinary incontinence may have contributed to his ulcerations in the buttock." A nurses noted dated 7/7/2012 at 2 p.m. indicated, "New order received and noted for [MEDICATION NAME] DS one by mouth every 12 hours for 7 days for urinary tract infection. Resident and pharmacy notified. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview with LPN #11 on 7/12/2012 at 12:05 p.m. indicated she was present when Resident #26 left for the emergency roiagnom on [DATE]th, and he did have the foley catheter in when he left. Interview on 7/16/2012 at 11:00 a.m. with the MDS Coordinator indicated Resident #26 never had a catheter care plan, he thinks the resident had a catheter put in so his wounds could heal. Interview with CNA #12 on 7/16/2012 at 2:00 p.m. indicated she would clean the catheter at least every shift, she would do it more often as necessary depending on the client. Some residents get dirty when going to the bathroom so she would need to clean the catheter each time they used the bathroom. A treatment record for the month of July indicated, "Anchor 16 FR 5 cc foley cath times 21 days for wound healing. Foley cath care every shift as per facility protocol. Remove catheter on 7/10/2012." Nothing is marked off, the month is entirely blank for catheter care and removal. A hospital admission note dated 7/12/2012 indicated, "Physical exam: Abdomen:...Foley-dirty appearing. Plan: Primary Diagnoses: [REDACTED]." Interview with LPN #2 on 7/17/2012 at 9 a.m. indicated, he had a stage 2 pressure ulcer on the right buttocks and a stage 2 pressure ulcer on his left buttock. The MD at (name of wound care center) recommended and his attending MD ordered the foley for urinary incontinence. He was wet all the time, he is paraplegic due to a previous stroke, so he is unable to move himself to and from the bed or wheelchair. He is on a check and change every 2 hours program. He is a quiet guy, and doesn't speak up when he's wet. Interview with the Director of Nurses on 7/17/2012 at 12:00 p.m. indicated she thinks there might be a problem with having residents with catheters ordered by the facility's MD because they are missing the [DIAGNOSES REDACTED]. Interview with CNA #1 on 7/19/2012 at 1:23 p.m. indicated LPN #5 had already performed cath care today and didn't come get me because the resident refused to have surveyor observe the care. 2. The clinical record for Resident #5 was reviewed on 7/12/12 at 11:00 a.m. The [DIAGNOSES REDACTED]. A review of the readmission Physician Orders, dated 4/17/12, did not indicate an order for [REDACTED]. A clarification of admission orders [REDACTED]. No order for catheter care was located within the clinical record, including physician's orders [REDACTED]. A care plan for risk of UTI (urinary tract infection) due to indwelling catheter, dated 4/25/12, had a goal of no signs of UTI. The following were interventions for the care plan: monitor indwelling catheter and change catheter or bag when needed, monitor urine for sediment, cloudy, odor, and blood, report problems with urine or fever promptly to MD (medical doctor), encourage fluids, monitor lab as ordered, and turn every two hours/monitor skin for redness, and good peri care. The care plan also indicated that catheter placement was for wound healing. Catheter care was not part of the care plan. An UA and C and S (urinalysis with culture and sensitivity-test for an urinary tract infection) was ordered on [DATE] at 9 a.m. An Physician order [REDACTED]. On 6/11/12 at 8:45 p.m., a Nurse's Note indicated that Resident #5 complained of bladder spasms and the MD (Medical Doctor) was notified. The Nurse's Note indicated that an UA and C and S was ordered. A NP (Nurse Practitioner) visit note, dated 6/13/12, indicated that "patient c/o (complaint of) bladder spasms bothering her quit (sic) a bit, (with) frequent UTIs." The visit note indicated that [MEDICATION NAME] was ordered. On 6/18/12, at 5 p.m., a physician's orders [REDACTED]. At 2:30 p.m., on 7/12/12, the DoN (Director of Nursing) indicated Resident #5 initially had a Foley catheter placed to promote wound healing, but the wounds are healed, so she was not sure why the Resident still had the catheter in place. She also indicated that she previously told Resident #5, that the best prevention for UTIs was to remove the urinary catheter. On 7/16/12 at 10:30 a.m., a copy of written order for catheter care was requested, along with a current [DIAGNOSES REDACTED]. A review of a NP (Nurse Practitioner) visit note, dated 6/26/12, received by the DoN on 7/16/12 at 10:30 a.m.,indicated that Resident #5 had [MEDICAL CONDITION]. On 7/16/12 at 11:00 a.m., the Assistant Administrator/MDS coordinator indicated that the above care plan needs to be updated, since the facility located a [DIAGNOSES REDACTED]. A copy of a care plan, dated 7/16/12, for risk of UT due to indwelling catheter was provided on 7/16/12 at 12:05 p.m. An intervention was to provide Foley catheter care each shift. The care plan also indicated that the indwelling catheter was placed for [MEDICAL CONDITION]. The DoN indicated on 7/16/12 at 12:20 p.m., that she just called Resident #5's urologist and was told that Resident #5 was diagnosed with [REDACTED]. The DoN was unable to provide a copy of the consultation. She indicated that the consultation was 8/25/11. In an interview with CNA #2, on 7/16/12 at 2:00 p.m., she indicated that catheter care should be done the same time that perineal care was provided each shift. When the care is provided, it is marked in the ADL (assistance of daily living) book on the TAR (treatment administration record). The care is marked in the section marked Foley Cath. CNA #2 also indicated that she is unsure if peri care or cath (catheter) care was provided if the space was blank, in the Foley Cath section on the TAR, for the shift. She indicated that she wasn't sure if there was an order for [REDACTED]. There were blank spaces on the May and June TAR for the section titled, Foley Cath: day shift on 5/2/12, 5/4/12, 5/28/12, 5/29/12, 5/30/12, 6/4/12 through 6/19/12, 6/21/12, 6/22/12, 6/25/12, 6/27/12, 6/28/12, 6/29/12, 6/30/12. At 3:10 p.m., on 7/16/12, the DoN (Director of Nursing) indicated that its certainly a possibility that a lack of catheter care could have been a cause for the above UTIs. LPN #5 indicated, on 7/17/12 at 12:30 p.m., that Resident #5 has not had any open wounds since 6/18/12. On 7/17/12 at 3:05 p.m., the DoN (Director of Nursing), indicated that was she unable to determine if catheter care was completed on the above dates or if it was completed when peri care was completed. A policy provided by the Administrator on 7/17/2012 at 10:30 a.m. indicated, "Foley catheter care policy/procedure: Supra pubic and foley catheter care will be done daily and as needed. Procedure: 13. Document care given, and report anything unusual to charge nurse." 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident did not receive another resident's medication resulting in a 4 day hospitalization for altered mental status and [MEDICAL CONDITION], reduced oxygen supply, for 1 of 3 residents reviewed who met the criteria for hospitalization . (Resident #60) Findings include: The clinical record for Resident #60 was reviewed on 7/18/12 at 9:30 a.m. The [DIAGNOSES REDACTED]. The 6/20/12 hospital discharge papers indicated Resident #60 was admitted to the hospital on [DATE] and presented to the emergency department from ECF (extended care facility) due to AMS (altered mental status). "Pt (patient) was altered and non-responsive to any stimuli other than noxious so hx (history) of gained from son at bedside and nurse at ECF over the phone. Per nurse (name of nurse) (she is the night nurse) and of day before admission pt was fine. He was walking around and alert, though his baseline is somewhat demented. She was told that this morning at 9:00 a.m. the (sic) day of admission the day nurse gave the patient 200 mg [MEDICATION NAME] and 20 mg [MEDICATION NAME] that were meant for another patient. Since that point the patient was very hard to arouse. He was sleeping and snoring the whole time, but would not react to sternal rub. Blood pressure and temperature where (sic) stable the entire day, but night nurse came on at 2:00 p.m. today and pt was still very hard to arouse so they decided that pt should be sent to the ED (emergency department). She denied pt having loss of motor function or witnessed [MEDICAL CONDITION]. Unknown (sic) if pt lost bowel or urine incontinence as he is incontinent at baseline...In (name of hospital unit) patient he was still hard to arouse, but would momentarily wake to sternal rub and noxious stimuli and followed command to squeeze my hand. He also could move all extremities. BP (blood pressure) wa (sic) stble (sic) and pt was afebrile. Son states that he was much better than he was preivously (sic) in the day." "Hospital course: 1. AMS: pt was altered when he arrived to hospital - hard to arouse and would localize painful stimuli...Pt has a likely explanation for AMS with medical error of giving other patient's medication. (200 mg [MEDICATION NAME] and 20 mg [MEDICATION NAME]) 2. [MEDICAL CONDITION]: ...due to atelectasis (collapse of lung tissue affecting part or all of one lung; prevents normal oxygen absorption to healthy tissues) from being altered and poor inspiratory (inspiration of air into the lungs) effort..." During an interview with the MDS Coordinator/Assistant Administrator on 7/18/12 at 10:57 a.m., he indicated, "The pills were for another resident and when she went to give (name of Resident #60) his pills, she realized she had just given him the wrong ones." 3.1-25(b)(9) 3.1-48(c)(2)

Based on observation, record review and interview, the facility failed to ensure a resident who entered the facility without pressure areas, received the treatment and services to prevent pressure areas from developing, and a resident who had a history of [REDACTED]. This resulted in residents acquiring multiple pressure ulcers, for 2 of 4 residents reviewed for pressure ulcers in a sample of 11. (Residents "B" and "G"). Findings include: 1. The record for Resident "B" was reviewed on 09-29-11 at 10:05 a.m. [DIAGNOSES REDACTED]. The record indicated the resident had a [MEDICAL CONDITION]. These [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set assessment, dated 08-12-11, indicated the resident required total assistance from the staff for bed mobility, transfer, dressing, hygiene and bathing. The assessment indicated the resident was at risk for the development of pressure ulcers but did not have any open areas at the time of the assessment. Review of the Care Area Assessment Documentation Notes, also dated 08-12-11, indicated "Resident is at risk for pressure ulcers due to total dependence on staff for bed mobility and total incontinence of bowel. No pressure ulcers are noted at this time." Review of the resident's Minimum Data Set assessment, dated 09-16-11, indicated the resident did not have any pressure ulcers. The resident's plan of care dated 08-12-11, indicated the resident was at "risk for skin breakdown due to total incontinence of bowel and total dependence on staff for bed mobility." A handwritten notation (undated) indicated "resident presents with extremely bony prominences and is on a turn schedule." Interventions to this plan of care included "use turn schedule and wedge cushion when on rt. (right) / lft. (left) side. Ensure catheter tubing not against leg or hip. Observe skin for redness." The record indicated the resident had a hospital stay from 09-02-11 thru 09-06-11 and return to the facility with no open areas, but was assessed upon re-admission for pressure wounds and was determined to be at "high risk" as noted on the Nursing Readmission assessment dated [DATE]. Review of the "Shower Report" dated 09-18-11 (Sunday) indicated "washed resident up 09-17-11, did not give full bed bath, in hospital 09-18-11." The record lacked identification of skin issues or concerns. Review of the nurses notes, dated 09-18-11 at 10:30 a.m., indicated the "resident noted to have increased tremors. diaphoretic, axillary (temperature) 101.0, blood pressure 141/114, pulse 112, sat (oxygen saturation level) at 89%. MD (Medical Doctor) notified." "New order to send resident to (name of local area hospital) for treatment and evaluation." Review of the emergency room nursing notes, dated 09-18-11, indicated the following:"Pt. with multiple Stage 1 dime size decubs. (decubitus) along spine and to bilateral pelvic bones." The hospital history and physical, dated 09-18-11, noted the resident had "pressure areas of concern on the cervical, [MEDICATION NAME], lumbar prcosess <sic>, sacral. Left buttocks, with abrasion (s) to the right ear, and a concern with the right hand between the thumb and index finger. Physical Exam: Integumentary - warm, diaphoretic, back has multiple DTI's (deep tissue injuries) over spine and pelvis, right hand between thumb and index finger has a malodorous wound with whitish discharge, no surrounding warmth, [DIAGNOSES REDACTED]tous." Review of the Hospital Critical Care notation - final report dated 09-18-11 thru 09-23-11, indicated "skin breakdown - this does not appear to be cellulitus but does have significant breakdown." Review of the Hospital Wound Care notation, dated 09-19-11, indicated "Upon assessment, patient noted to have multiple dime sized (illegible word) to spinal colum <sic> along with coxxcy <sic> adn <sic> sacral and iliac crest area." Review of the Wound Care "Final Report" notation, dated 09-18-11 thru 09-23-11, indicated the following: "right ear - multiple dried scabbed areas - all intact, no drainage noted," "right hand - between thumb and first finger - intact linear brown scab, without [DIAGNOSES REDACTED], without drainage," "left hand between thumb and first finger approx. (approximately) 1 cm (centimeter) by 0.2 cm by 0.1 linear wound with 100 % pink base." "Spinous process with multiple small round darkened red and/or purple circular areas over bony prominences: all intact," "right hip with approx. 2 cm circular blanchable [DIAGNOSES REDACTED] - intact," "Assessment and Plan: right ear resolving, left hand present on admission - from braces at facility per family member, spinous process - deep tissue injury present on admission." During an observation on 10-04-11 at 9:15 a.m., the resident was observed in contact isolation [MEDICAL CONDITIONS]. The hospital nursing staff turned the resident to the right side, and six areas, dark brown in color, were observed along the resident's spine. In addition, the resident had dressings over two areas noted on the coccyx, left buttocks and a circular area adjacent to the area noted on the left buttocks. In addition "scarred" areas were observed between the thumb and index finger of both the right and left hand, as well as the resident's right ear. During an interview on 09-29-11 at 12:15 p.m., an interested family member indicated that upon arriving at the hospital (reference date 09-18-11) they could smell an odor but "couldn't figure out where it was coming from." "(Resident) wore braces - and they (in reference to the staff at the facility) were supposed to leave them on for 4 hours and then off for 4 hours. The braces were left on (resident) both hands. There was the brace and under the brace was like an ace bandage. We, my (family member) and I, kept smelling a horrible smell. It seemed like it was coming from (resident's) hands. We took off the brace and then the bandage, the odor was horrible and there was a wound between the thumb and forefinger on both hands. It looked like someone cut it open." 2. The record for Resident "G" was reviewed on 10-05-11 at 11:20 a.m. [DIAGNOSES REDACTED]. The resident's record indicated an allergy to tape. Review of the Minimum Data Set assessment, dated 10-04-11, indicated the resident required extensive assistance with bed mobility, and total care for transfer, dressing and personal hygiene. In addition, the assessment indicated the resident was assessed at risk for developing pressure ulcers and currently had 3 stage two ulcers. Review of the current plan of care dated 07-22-11, indicated the resident was a "risk for skin breakdown due to total dependence on staff for bed mobility, total incontinence of bowel due to [MEDICAL CONDITIONS] and long term history of pressure ulcers." Interventions to this plan of care included pressure reducing mattress, and reposition at least every two hours. A review of the CNA (certified nurse aide) assignment sheet instructed the staff to "turn side to side. Limit time in chair to meals only. Keep heels off bed. Blue multi-podus boots at night and up in chair." During the initial tour of the facility on 09-29-11 at 8:30 a.m., employee licensed practical nurse employee #3 indicated the resident had wounds with an area on the buttocks and right heel. During observation on 09-30-11 at 9:15 a.m., the resident was observed lying on back in bed. The CNA turned the resident to the left side for observation of the resident. During this observation a dressing was observed on the resident's buttocks/coccyx area and dated 09-29-11. The skin adjacent to the dressing was bright red in color along the right side and bottom edge of the dressing. The resident's upper back, scapula area, had a small dime size reddened area observed. During this observation, licensed practical nurse employee #3 was in attendance. The nurse indicated she was unaware why the resident's skin was bright red in color and further stated "I think it's from the tape. (Resident) is going to the Wound Clinic today. The area up here (pointing to the dime size reddened area) won't blanch. I don't know what it's from." The record indicated the resident was seen by a local Wound Care Clinic for treatment, with a recent visit dated 09-30-11. The notation indicated the resident had "ulcers of the sacrum, and the buttocks and also of right heel and the ischium. The ulcer of the coccyx is...1.7 cm (centimeters) by 0.8 cm by 1.2 cm. with 1.2 cm of undermining. The right heel is 0.8 cm. by 0.4 cm. by 0.1 cm, and the buttocks measured at 1.2 cm. by 1.0 cm. by 0.2 cm." During an observation on 10-05-11 at 9:40 a.m., the resident was positioned to the left side. At 12:00 p.m., the resident was positioned on back with a pillow beneath the posterior of the ankles. The resident's heels were on the bed. During interview on 10-05-11 at 12:30 p.m., the Director of Nurses indicated the staff "cannot use a pillow to position the heels off the bed because the pillow will just sink down." This federal deficiency relates to complaints IN 319 and IN 468. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure the nutrition needs and hydration needs were met, in that when a resident was dependent for nutrition via a feeding tube, the facility failed to ensure the resident's nutrition and hydration needs were met which resulted in the need for hospitalization for the treatment of [REDACTED]. (Resident "B"). Findings include: 1. The record for Resident "B" was reviewed on 09-29-11 at 10:05 a.m. [DIAGNOSES REDACTED]. The record indicated the resident had a [MEDICAL CONDITION] and a gastrostomy feeding tube. These [DIAGNOSES REDACTED]. Review of the Resident's Minimum Data Set assessment, dated 08-12-11, indicated the resident required total assistance from the staff for bed mobility, transfer, dressing, hygiene, bathing and feeding. Review of the Care Area Assessment Documentation Notes, also dated 08-12-11, indicated "Resident is unable to swallow due to persistent vegetative state. (Resident) relies on [DEVICE] (gastrostomy) for all nutrition and hydration." The resident's plan of care, dated 08-12-11, indicated the resident's "nutrition and hydration needs will be met through next review AEB (as evidenced by) no significant weight changes." Interventions to this plan of care instructed the nursing staff to "monitor for tolerance of feeding and report diarrhea or vomiting, monitor lab and weights as ordered. Report loss or abnormals, feeding as ordered, monitor fluid intake and skin turgor." Review of the September 2011 physician rewrite indicated the resident was to receive Fibersource 320 c.c. per [DEVICE] 5 times a day with 100 c.c. of free water with each feeding. Review of the "Monthly Weight Report," on 10-05-11 at 12:00 p.m., indicated the resident weighed 102.5 lbs. (pounds) in July 2011, 120.4 lbs in August 2011, and 96.4 lbs in September 2011. However, review of the weekly weights, dated 09-14-11, indicated the resident weighed 88.6 lbs., and the next available recorded weight was 88.3 lbs. on 09-28-11. Further review of the facility Nutrition Assessment notations, dated 08-15-11, indicated the resident was "dependent on [DEVICE] feedings due to persistent vegetative state and inability to chew and swallow." The dietician nutrition assessment indicated the resident's BUN (blood urea nitrogen - lab test) was 14, and dehydration concerns were not noted, and the use of Fibersource at 320 c.c., 5 times a day would provide 1920 kcalories and 84.8 grams of protein. The 09-12-11 notation indicated "Post hosp. (hospitalization ) for UTI (urinary tract infection. Hosp. d/c (discharge) noted feeding of [MEDICATION NAME]. Suggest continue TF (tube feeding) as prior to hosp. Fibersource HN 320 mg 5 times a day, followed by 100 ml of water. Sept (September) wt. recorded at 96.4 lbs, (arrow down) of 24 lbs. / 19.9% in one month ?? questionable. July (2011) weight recorded at 102.5 lbs. Request weekly wt. (weight) until stable wt. noted." Documentation provided by the Director of Nurses on 09-30-11 at 1:05 p.m., indicated the resident was transported to the local area hospital and then returned to the facility on the following occasions: To the hospital on 07-25-11 and returned to the facility on [DATE], to the hospital on 09-03-11 and returned to the facility on [DATE], to the hospital on 09-06-11 and returned to the facility on [DATE], and on 09-23-11, and then once again transported to the local area hospital on 09-28-11 and remained there at the time of this visit. Review of hospital records on 10-04-11 at 9:15 a.m., indicated the resident had been admitted to the local area hospital on the following dates and Diagnoses: [REDACTED]. 09-03-11 with [DIAGNOSES REDACTED]. 09-18-11 with [DIAGNOSES REDACTED].<sic> fluid administration, right lower lung collapse, severe [MEDICAL CONDITION], acute kidney injury - likely secondary to dehydration," 09-28-11 with [DIAGNOSES REDACTED]." Review of the Tube Feeding Record for September 2011 prompted the nursing staff to document the formula total, water total, water tube flush, residual checked, intake, and output. The nursing staff failed to document as follows: 09-01-11 6:00 a.m. to 2:00 p.m. shift - no documentation for output, 2:00 p.m. to 10:00 p.m. shift no documentation noted for formula total, water total, water tube flush, resident check intake or output. 09-02-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for formula total, water total, water tube flush or output. 09-07-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for output. 09-08-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for output. 09-09-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for output. 09-10-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for output. 09-11-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for output. 09-12-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for formula total, water total, water tube flush, residual or output. 09-13-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for formula total, water total, water tube flush residual checked, intake or output. 09-14-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for formula total, water total, water tube flush residual checked, intake or output. 09-15-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for formula total, water total, water tube flush residual checked, intake or output. 09-16-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for formula total, water total, water tube flush residual checked, intake or output. 09-17-11 6:00 a.m. to 2:00 p.m. shift - no documentation noted for formula total, water total, water tube flush residual checked, intake or output. Although the tube feeding record lacked documentation on the above dates, the documentation that was provided indicated the resident did not receive 1600 c.c. of Fibersource feeding as directed, but rather 1280 c.c. of the Fibersource with 320 c.c. on the evening shift 320 c.c. on the night shift, and 640 c.c. was documented on the day shift. The record lacked documentation from September 1, 2011 thru September 2, 2011, at which time the resident was hospitalized and returned to the facility on [DATE], and then September 6, 2011 thru September 18, 2011, in regard to if the nutrition and hydration needs of the resident were being met. 2. Review of the facility "Hydration Program" on 10-05-11 at 12:00 p.m., and dated 08-98, indicated the following:"POLICY (bold type) In that residents requiring thickened liquids are at risk for dehydration due to inaccessibility of fluids staff shall offer fluids on a regular schedule per a documented hydration program to those residents noted to be at increased risk due to poor fluid intake, abnormal creatinine level etc." The policy failed to address the hydration needs of a resident dependent upon tube feedings for nutrition and hydration needs. 3. Review of the facility policy titled "Intake and Output Recording, on 09-30-11 at 11:40 a.m., and dated 12-96, indicated the following: "PURPOSE (bold type and underscored) To provide an accurate record of the residents intake and output." "POLICY (bold type and underscored) An intake and output record is maintained when needed to monitor the resident's fluid balance. Intake and output will be recorded on residents with the following: tube feedings, anchored catheter, a physician's order for I & O (intake and output)." 4. Facility policy titled "Gastrostomy Tube Feeding," reviewed on 09-30-11 at 11:40 a.m., indicated the following: "PURPOSE To provide the resident with essential nutrition and hydration through a tube inserted through a surgical opening into the stomach." "Document in Nurse's Notes the type of feeding, amount of feeding, amount of water, resident tolerance and other pertinent information." This Federal deficiency relates to complaints IN 319 and IN 468. 3.1-44(a)(2)

A. Based on record review and interview, the facility failed to ensure the safety and supervision of the residents in that a resident who required supervision with ADLs (activities of daily living) was allowed to shave independently, which resulted in bleeding and multiple cuts to the head. This deficient practice affected 1 of 3 residents who required supervision for activities of daily living in a sample of 11. (Resident "C"). B. Based on observation, record review and interview, the facility failed to ensure the safety of residents and provide the assistive devices needed to alert the staff of unassisted transfer/ambulation for 1 of 3 residents reviewed for falls in the sample of 11, resulting in injuries to the face which were deep purple in color with multiple bruises and abrasions around both eyes, cheeks, chin and forehead, and a large knot/hematoma on the left cheek bone adjacent to the left eye. (Resident "B"). C. Based on observation, record review and interview, the facility failed to ensure the whereabouts of residents in that the facility allowed residents the code to the locked front door, which resulted in a resident missing from the facility for a period of time without staff being aware the resident had left the premises, for 3 of 3 residents reviewed who were allowed information related to the locked front door in which they were able to come and go from the facility premises without the staff knowing the residents' whereabouts, in a sample of 11. (Residents "J", "H", "K"). Findings include: A.) The record for resident "C" was reviewed on 09-29-11 at 2:40 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 06-27-11, indicated the resident required supervision with hygiene and assistance with bathing. The resident's current plan of care, dated 07-01-11, indicated, "needs supervision for dressing and bathing due to left hemiparesis, with interventions which included "assist resident with ADLs (activities of daily living) as needed, assist resident to shower twice weekly." During an interview on 09-30-11 at 12:30 p.m., a visitor indicated a need to "check" on this resident as resident had a "safety razor in possession and cut (resident) head numerous times." When interviewed how this visitor obtained this information, the visitor indicated "a resident told me about it. (Resident) said there was blood everywhere." Review of the nurses notes, dated 09-15-11 (no time documented) indicated, "Resident in room and shaving (resident) scalp without supervision. Has cut self in 5 places and bleeding." The nurses notes dated 09-26-11 at 3:00 p.m. indicated "has shaved head and cut self in numerous places with razor. Has 3 razors in trash along with bloody tissue and washcloth." During a discussion with the Administrator and Director of Nurses at the daily exit conference on 09-29-11 at 4:00 p.m., the administrative staff verified the resident "gave self a shower and the other day and (resident) head was cut to high heaven. (Resident) does own shaving." During further discussion, the Administrator and Director of Nurses indicated they were unaware the resident had two episodes of cutting self. During an interview on 09-30-11 at 9:15 a.m. CNA (certified nurses aide) employee #9 indicated the residents "aren't supposed to have razors at all." During interview on 09-30-11 at 9:20 a.m. CNA #7 indicated "I think if they are independent then they can have razors." During interview on 09-30-11 at 9:45 a.m., licensed practical nurse employee #1 indicated "No resident if supposed to have a razor in their possession." During interview on 10-04-11 at 12:00 p.m., the Director of Nurses indicated "when we did a sweep of (resident) room we found 12 razors." B.) The record for Resident "E" was reviewed on 09-29-11 at 12:10 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the hospital patient information/discharge orders, dated 09-09-11, indicated the resident required "bed rest - may sit on side of bed with assistance. The patient is currently A & O (alert and oriented) times 1 (self)." Review of the Nursing Admission Skin condition report, dated 09-09-11 indicated that at the time of admission to the facility the resident had "multiple bruises and scapping <sic> to bilateral upper extremities, scapping <sic> to right knee cap." "Initial care plan: problem fall risk. Approach: bed alarm, call light in reach. Goal: no falls." During the initial tour of the facility on 09-29-11 at 8:30 a.m., licensed practical nurse employee #3 indicated the resident was a "fall risk" and had recently fallen out of bed and sustained extensive bruising to face, arms and hands. The name plate outside of the resident's room had a "star" adjacent to the resident's name. The licensed practical nurse indicated the "star" was placed there to alert the staff the resident was a fall risk. Review of the Minimum Data Set assessment, dated 09-16-11, indicated the resident required extensive assistance with bed mobility and was assessed as "total" care/assistance from the staff with transfer. Review of the current plan of care, dated 09-27-11, indicated the resident "gets bruises and skin tears easily due to anticoagulant use." The "goal" indicated "resident will be free of serious injuries through next review." Interventions to this plan of care included "Pad side rails on bed with pillows, pillow cases, bed pad alarm in bed, PSA (personal safety alarm) in wheelchair to alert staff if resident tries to transfer without assistance. A subsequent current plan of care dated 09-22-11, indicated the resident had the "Potential for injuries from falls due to recent history of falls." Interventions included "Monitor resident for steadiness and balance, personal safety alarm (PSA) when up in wheelchair, pressure pad alarm in bed." The certified nurses aide assignment sheet with resident specific information indicated the resident required a bed pad alarm and a PSA when up in the wheelchair. Review of the nurses notes indicated the following:"09-09-11 4:00 p.m. Alert to self, inappropriate\ speech noted. Resident on bedrest. Attempted to climb OOB (out of bed) times 3 times this shift bed alarm placed." "09-10-11 10:30 a.m. - Pt. (patient) has tried to climb out of bed times 2 this shift." "09-10-11 10:00 p.m. - Bed alarm in place alarms when res. (resident) moving about in bed." "09-14-11 6:00 a.m. - Sitting up on side of bed multiple times during this noc (night)." "09-18-11 8:00 p.m. - Alert to person inappropriate speech at times. Resident attempt to get OOB times 2. Likes to sit on edge of bed." "09-21-11 11:20 a.m. - Pt. found in room lying on floor on left side, alarm sounding, fall matt at bed side. pt alert verbal abrasion/laceration 5 in length area blue/purple with bright red drng (drainage), s/t skin tear noted to left elbow measures .6 by .5 cm (centimeters) flap intact." During the initial tour of the facility on 09-29-11 at 8:30 a.m., the resident was observed seated in a wheelchair. The resident's face was deep purple in color with multiple bruises and abrasions around both eyes, cheeks, chin and forehead. The resident had a large knot on the left cheek bone adjacent to the left eye. During an observation on 10-05-11 at 9:40 a.m., the resident was seated in a wheelchair in room. The resident, in a continuing motion, placed the palms of both hands on the armrests of the wheelchair and attempted a standing position. During a subsequent observation on 10-05-11 at 9:50 a.m., the resident continued attempts at standing. Upon entering the resident's room, the resident lacked a PSA alarm while seated in the wheelchair. During this observation an alarm was observed on the resident's nightstand. CNA (Certified Nurses Aide) employee #7 entered the resident's room. When interviewed the CNA indicated she was unaware the resident required a PSA. When requested the CNA reviewed her assignment sheet which instructed staff of the need for the personal alarm. The CNA turned toward the nightstand and stated, "that probably needs to be on the wheelchair and attached to (resident)." The Director of Nurses was in attendance during this observation. The resident was observed with white kerlix/gauze type dressings to bilateral arms from the wrists to the elbows. The siderails of the resident's bed were not padded to protect the resident from additional injury. C 1.) The record for resident "J" was reviewed on 09-30-11 at 9:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE], indicated the resident had no cognitive impairment; however, the resident' plan of care indicated the resident was at risk for confusion and disorganized thought due to the [DIAGNOSES REDACTED]. Review of an incident reported to ISDH, dated 09-17-11 at approximately 5:00 a.m., indicated the following:"(Resident) states that (resident) left the facility at about 5:00 a.m. and wheeled self to (name of local area restaurant) approximately seven blocks from the facility. After arriving at (name of local area restaurant), (resident) telephoned a friend to meet (resident) and (other family member) as well. (Family member) telephoned the facility at about 8:30 a.m. indicated (resident) was at (name of local area restaurant). CNA (name documented of employee #9) went to the restaurant to bring (resident) back but (resident) refused to come back with her at that time. (Name of CNA) then left (resident) at (name of local area restaurant) with (family member) and friend. (Resident) had his friend bring (resident) back to the facility later that morning." Further review of the report indicated the Assistant Administrator spoke with the resident and reminded the resident of the need to "sign in and out of the facility." The resident indicated (resident) "made a mistake today and in the future will sign out prior to leaving the facility." Statements, handwritten, by facility staff member indicated she "thought" she saw the resident around 6:00 a.m., however, the facility staff was unaware of the resident's whereabouts for approximately 2 - 2 1/2 hours. During observation on 10-04-11 at 11:25 a.m., the local area restaurant was approximately 1/2 mile from the facility. Getting to the restaurant necessitated crossing four lanes of moving traffic from north to the south lanes, and two lanes of traffic for the east west lanes of traffic. Review of the Social Service Review and Resident Interview, dated 08-08-11 indicated "Outside Supervision Needs - "understands the facility LOA policy (Signing in/out), and may sit out on front porch unsupervised." Although the incident occurred on 09-17-11, the facility failed to do a post elopement assessment until 10-05-11. C 2.) The record for Resident "H" was reviewed on 10-05-11 at 11:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set, dated dated [DATE], indicated the resident had no cognitive impairment but did display short term memory loss. During observation on 10-04-11 at 1:10 p.m., the resident was observed with a stumbling gait. During an observation on 10-04-11 at 1:10 p.m., this resident was observed walking toward the front door of the facility with another resident's family member. The resident accessed the key pad, entered the code and exited the building with this visitor. During interview, on 10-04-11 at 1:45 p.m., the resident indicated (resident) did not get the code from a staff member. The resident was reminded the code had been changed the previous Friday, 09-30-11, and again asked to think about where (resident) obtained the code. The resident stated "I have short term memory problems I don't remember." The resident became confrontational and asked "Do you mean I have to ask someone to let me out to go to church ?" The Director of Nurses who was in attendance stated, "Yes." The resident then stated (resident) let self out of the facility on Sunday to attend church without anyone letting her out. The elopement risk assessment was not conducted until 10-05-11. C 3.) The record for Resident "K" was reviewed on 10-04-11 at 2:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set assessment, dated 08-31-11, indicated the resident had no cognitive impairment or memory loss. The resident used a motorized wheelchair for mobility. A physician order [REDACTED]. During an observation on 10-04-11 at 11:30 a.m., the resident was observed in a motorized wheelchair approximately 6 blocks from the facility on Keystone Avenue, a four lane divided street that runs north and south. Review of the "Sign In/Out" sheet, dated 10-04-11, indicated the staff member "signed" the resident as returned to the facility at 11:00 a.m. Further review of the "Sign In/Out sheet, indicated the resident left the faciity on [DATE] at 12:30 p.m., but lacked a staff member's signature of the resident's return to the facility. There was no indication the staff were aware of the resident's whereabouts. During an interview on 10-04-11 at 1:00 p.m. the Director of Nurses indicated the resident liked to cross the street and watch the golfers (at the local area golf course). During interview on 10-04-11 at 2:30 p.m., the Assistant Administrator indicated he telephoned the staff member who verified she had not actually looked at the exact time the resident returned, but rather knew it was around the time she "ate" and then "took her smoke break." C 4.) During observation on 10-05-11 at 10:30 a.m., a group of nursing students were observed in the facility. One nursing student approached the front door and verbally stated the code to exit the facility. During interview on 10-05-11 at 10:40 a.m., the Director of Nurses was alerted who then indicated the students were given the code but must not be aware of the importance not to verbally state the code in the event there are residents in the area. Review of Friendship Healthcare Center "Rules for Residents, on 09-30-11 at 11:00 a.m., and dated as "revised" January 2009 indicated the following:"It is the policy of Friendship Healthcare to expect resident to behave in such a manner that the safety, well being and right of others are respected." "4. Residents are not to cause injury to themselves or others." "6. Residents are not to leave the facility without signing out. They must sign back in upon return. LOA (leave of absence) resident need to be accompanied by a staff member, family member, or responsible party. Residents should remain within fenced areas when outside, unless accompanied by a suitable attendant." "12. Upon admission, no resident will be allowed outside unsupervised until having been assessed for elopement potential." Review of Inservice education on 09-30-11 at 1:30 p.m., instructed the nursing staff as follows: "For our residents' safety, please be sure to not (underscored) give out the door code to our resident's. The door code may be given to family members. however, please politely ask them to respect the rules of out facility and not give the code out to their loved one or any other resident. Please be advised, any employee caught giving the code out to a resident will be immediately terminated." This federal deficiency relates to complaint IN 468. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure care for the special needs of a resident was provided, in that when a resident was admitted to the facility with a [MEDICAL CONDITION] and experienced respiratory distress, the nursing staff failed to provide immediate care in regard to suctioning to clear the resident's airway and aid the resident with breathing difficulties, while waiting for the emergency medical technicians to arrive and transport the resident to the local area hospital. This deficient practice affected 1 of 1 resident with a [MEDICAL CONDITION] in a sample of 6. (Resident "B"). The Immediate Jeopardy began on 07-22-11 when the resident displayed signs and symptoms of respiratory distress and the licensed nursing staff failed to provide immediate/emergent interventions to clear the resident's airway. The Administrator, Owner and Director of Nurses were notified of the Immediate Jeopardy at 2:45 p.m. on 08-18-11. The Immediate Jeopardy was removed on 08-19-11, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The record for resident "B" was reviewed on 08-16-11 at 1:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The clinical record indicated the resident had a [MEDICAL CONDITION] and a percutaneous endoscopic gastrostomy feeding tube at the time of admission to the facility on [DATE]. Review of the "Nursing Admission Assessment," dated 07-22-11 at 6:45 p.m., included an initial care plan. However, this care plan lacked specifics for the resident or nursing interventions related to needs associated with respiratory care and lacked an assessment of the "chest/lungs" related to breath sounds to include rales, rhonci, wheezes or cough. The assessment indicated the resident had a size #6 Shiley [MEDICAL CONDITION]. The nurses notes, documented at the time of admission indicated the resident's oxygen saturation level was measured at 94 %. The clinical record lacked the original physician orders [REDACTED]. However, review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"suction trach. ([MEDICAL CONDITION]) prn (as needed) to clear secretions." Review of the nurses notes, dated 07-25-11, indicated the following: "6:00 a.m. Resting quietly during the noc (night) O2 (oxygen) per trach. ([MEDICAL CONDITION]). Collar at 28 % on all shift. Neb. (nebulizer) tx. (treatment) given at 1:00 a.m. and 5:00 a.m. Breath sounds prior to (illegible word) congest (congestion), after sl. (slight) congest. No respiratory distress. Resp. rate 28 (illegible word), v/s (vital signs) (temperature) 98.8 - (pulse) 124 - (respirations) 28. O2 sat. (saturation) during the noc. (night) 88 % - 90 %." This notation was documented by Licensed Practical Nurse employee #10. "9:00 a.m. The QMA (qualified medication aide) paged for this nurse to come and assess resident. (Res.) was in obvious respiratory distress. (Res.) oxygen saturation was at 75 % (Normal is greater than 90%) and HR (heart rate) was at 170 bpm (beats per minute) (normal is 60 -100). Due to (Res.) recent admission and my unfamiuliararity <sic> with the patient 911 was called and (Res.) was sent to (Name of local area hospital) emergency room ." This notation was documented by the former Director of Nurses employee #6. The resident was transported to the local hospital emergency roiagnom on [DATE]. A review of the "Final Report," from the hospital, dated 08-01-11 indicated the following: "(age and sex of patient documented) s/p (status [REDACTED]. They noted desaturations. Did not resolve with [MEDICAL CONDITION] toilet and so was brought to the ED (emergency department). Exam HR - 150's, ST (sinus [MEDICAL CONDITION] (viewed EKG), RR (respiratory rate) 30's, SpO2 (oxygen saturation level) in high 80's. A/P (assessment/plan) 1. [MEDICAL CONDITIONS], 2. Sinus [MEDICAL CONDITION] to dehydration, 3. [MEDICAL CONDITION] aspiration." Further documentation indicated the resident had "possible mucus plug." During interview on 08-17-11 at 11:00 a.m., the former Director of Nurses employee #6 indicated prior to the resident's admission to the facility, she had given the nursing staff an inservice regarding tracheostomies. The former Director of Nurses indicated the following in regard to the events which involved Resident "B" on the morning of 07-25-11. "(Name of licensed practical nurse employee #2) had chest pain the day before and had to go to the hospital to get checked out. She had a doctor's appointment scheduled for that day but she came in to work (07-25-11) and said she would work until her doctor's appointment. I agreed I would cover for her from 9:00 a.m. to 10:00 a.m. I was late in coming in to relieve her, but I did cover from 9:00 to 10:00 a.m. I really don't know what time she left. (Name of Qualified Medication Aide employee #8) called me to the room. (Res.) heart rate was elevated, I didn't suction (res.) it made me a nervous wreck. I just panicked. I resigned the day my vacation started I think it was on 07-26-11 or 07-27-11." During interview on 08-17-11 at 11:20 a.m., licensed practical nurse employee #2 indicated, "I had a doctor's appointment - a cardiologist because I had chest pain the previous week, not the day before. That day it was myself and (name of QMA employee #8) scheduled to work. I worked the North station and (name of QMA employee #8) was on South. I went down and looked at (res.) at 6:30 a.m. (res.) was fine - I didn't do anything else. (Name of former Director of Nurses employee #6) said she would take over when I left and then another nurse was coming in at 10:00 a.m." When further interviewed if she had checked on the resident or provided any care including medications to the resident before she left for her doctor appointment, the licensed practical nurse replied, "no." Review of Licensed Practical Nurse Employee time card for 07-25-11 indicated she left the facility at 8:20 a.m. During interview on 08-17-11 at 2:00 p.m., QMA employee #8 indicated "I never laid eyes on the (res.) before that morning. I went into the room and (res.) just didn't look right to me. I came out of the room and (name of licensed practical nurse employee #1) was at the desk. I told him he needed to go in the room and check (res.) out. I never went back in the room." Licensed practical nurse employee #1 was interviewed on 08-17-11 at 2:20 p.m., and questioned what was the condition of the resident that concerned QMA #8. The licensed nurse indicated that before he went to the resident's room, he instructed QMA employee #8 to notify the former Director of Nurses employee #6 to come to the room. "(name of resident) was in respiratory distress. I know 911 was called." When questioned what was done for the resident to alleviate any respiratory distress while waiting for the Emergency Medical Technicians to arrive at the facility, the licensed practical nurse indicated "nothing - I didn't suction (res.) and neither did (name of the former Director of Nurses)." Record Review on 08-17-11 at 2:00 p.m. indicated "Inservice Meeting - 06-30-11, 2:00 - 2:30 p.m.," and prior to the admission of the resident, indicated the following: "Subject [MEDICAL CONDITION] ... " The documentation provided by the facility on 08-17-11 at 2:00 p.m. lacked the content of the Inservice education. Review of the names of the nurses who attended the Inservice included LPN's (Licensed Practical Nurses) #2, #10, #11 (no longer employed at the facility) and #12 (no longer employed at the facility). On 08-18-11 at 8:40 a.m., the Administrator/licensed practical nurse employee #1 provided subsequent inservice education, dated 07-08-11, prior to the resident's admission to the facility, and arranged with a local Respiratory company, from 9:30 a.m. to 12:30 p.m., and again from 1:45 p.m. to 4:15 p.m. Nurse attendees included LPN's #2, #7, #10 and #13. The "sign in" sheet lacked the signatures of the former Director of Nurses employee #6 and Licensed Practical Nurse employee #1 to indicate attendance at the Inservice education. The content of the Inservice education included patient assessments, caring for [MEDICAL CONDITION] patient, trach. tube changes, problem solving, and facility focused topics." A review of the current listing of nurses at the facility to include Registered Nurses and Licensed Practical Nurses were a total of 11 nurses employed during the time of the two inservices. However, of the 11 nurses, only 4 nurses attended the Inservice Education with Licensed Practical Nurses employees #2 and #10 attending both meetings. Review of the Nurses notes, dated 08-01-11 through 08-18-11 indicated the following Licensed Nurses provided care for Resident "B" and had not attended either Inservice Meeting: Registered Nurses employees #3 and #14, Licensed Practical Nurses employees #1, #15, #16. During an interview on 08-18-11 at 10:00 a.m., the current Director of Nurses employee #5 indicated the resident had a #6 Shiley [MEDICAL CONDITION]. During interview on 08-18-11 at 10:15 a.m. Licensed Practical nurse employee #2 indicated she was unsure of the size of the [MEDICAL CONDITION]. When further interviewed if she was aware if the [MEDICAL CONDITION] was "cuffed or not cuffed," the LPN responded "I'm not sure but my guess would be [MEDICATION NAME] because (resident) would be inappropriate for a cuffed [MEDICAL CONDITION]." At 10:20 a.m. the Licensed Practical Nurse approached this surveyor and indicated "I checked and the trach. is a #6 and I was surprised to find out that the [MEDICAL CONDITION] is cuffed." During interview on 08-18-11 at 10:30 a.m. the Administrator and Director of Nurses, the resident's room was observed. During this observation, the water from the humidification was leaking onto the floor. The Director of Nurses indicated the "set-up" was incorrect. The Administrator was requested to check the sizes for the replacement Shiley tracheostomies. The Administrator confirmed there were three sizes, 4.0, 5.0 and 6.0 available, but only one "the 5.0 was cuffed." When a policy was requested from the Administrator on 08-18-11 at 9:00 a.m., in regard to the care for a resident in respiratory distress (with or without at [MEDICAL CONDITION]), the Administrator indicated he was unable to find a policy. When further interviewed if any additional inservice education had been provided to the nursing staff while the resident was in the hospital or after return, the Administrator indicated, "no." The Immediate Jeopardy that began on 07-22-11 was removed on 08-19-11 when the facility took steps to remove the immediacy of the situation and employed the services of a local respiratory company to inservice the licensed nursing staff. Through interview, the nurses were inserviced on the correct procedure with suctioning, and the steps to take when a resident was observed with respiratory distress. Through observation, the nursing staff followed sterile technique in suctioning a resident with a [MEDICAL CONDITION]. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because of the need for ongoing monitoring. This Federal tag relates to complaint number IN 742. 3.1-47(a)(5) 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure the necessary care and services were provided for a resident with wounds, and that the resident attained the highest practical physical care for the wounds, which did not diminish or deteriorate, in that when the condition of a resident's lower legs worsened, and a new open area had developed, the nursing staff failed to ensure appropriate care, for 1 of 3 residents reviewed for open areas in a sample of 6. (Resident "E") Findings include: The record for resident "E" was reviewed on 08-17-11 at 12:45 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the resident's plan of care, dated 08-08-11, indicated "Risk for infection of surgical site. Location, bilateral feet. Resident has a stasis ulcer on right leg. (Has bilateral stumps - no toes." Interventions included "Treatment as ordered, report any drainage to MD (Medical Doctor), Wound clinic." During an observation on 08-17-11 at 9:25 a.m. Resident "E" was seated in a wheelchair. Licensed nurse employee #2 removed the dressing to the right lower leg. The dressing was dated 08-16-11. The dressing was observed to contain bloody and yellow drainage. The resident's lower leg was bright red from the stump to the knee. The Nurse indicated the open area on the underneath side of the stump measured 5.2 cm (centimeters) in length, 3.6 cm width and 0.4 depth. The licensed nurse explained she cleansed and then wiped the area with Santyl and [MEDICATION NAME] and then applied calcium alginate in wound bed. The licensed nurse then applied [MEDICATION NAME] lotion to the lower extremity and stump, wrapped the lower leg with kerlix, and then applied an ACE wrap over the kerlix. The licensed nurse then removed the Kerlix from the resident's left lower leg/stump, the resident's skin was bright red from the calf to the knee and grayish/brown from the calf to the stump area. The skin appeared peeling. The licensed nurse indicated "It looks like dried skin - it has to be washed and there's an area right here that looks suspicious. I need to get a basin of water and wash that up real good before I lotion it up." After the nurse cleansed the left lower leg/stump, the nurse measured the "suspicious area." The licensed nurse indicated the area measured 1.2 cm by 1.0 cm by < (less than) 0.1 cm. Review of the nurses notes prior to 08-17-11, lacked documentation of the condition/color of the resident's legs or the new open area. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure the safety and supervision of residents, in that when residents were identified as fall risks, the facility failed to ensure the proper use of devices to alert the staff of unassisted transfer or ambulation which resulted in injury for 2 residents. This affected 4 of 6 sampled and 10 of 10 supplemental sampled residents reviewed for falls. (Residents "A", "B", "C", "D", "E", "G", "H", "I", "J", "K", "L", "M", "O" and "P") Findings include: 1. The record for resident "A" was reviewed on 08-16-11 at 11:15 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. During the initial tour of the facility on 08-16-11 at 9:15 a.m., with Licensed practical nurse employee #2 in attendance, the resident was observed in bed. The resident had significant bruising beneath both eyes and a large knot on the forehead. The licensed nurse indicated "(name of resident) just got out of the hospital." The resident indicated "I fell out of my wheelchair and I don't know how." Review of the Minimum Data Set assessment dated [DATE] indicated the resident was "total care for transfer and at risk for falls due to dependent on staff for ADL's (activities of daily living) and not being ambulatory." The "Physical Restraint Order" log for July 2011 indicated "Restraint Order - wheelchair seat belt due to dementia. Release q (every) 2 h (hours)." Review of the nurses notes, dated 07-30-11 at 5:30 p.m., indicated "Pt. (patient) found lying on floor on right side beside w/c (wheelchair). Supper tray on bed table. Pt. alert verbal. Lg (large) hematoma on res. (resident) forehead. BP (blood pressure) 160/112, T (temperature) 98 degrees, P (pulse) 100, R (respirations) 20, O2 sat. (oxygen saturation level ) 76 %." The licensed nurse notified the resident's physician who gave instructions to send the resident to the local area hospital emergency room ." The resident returned from the hospital emergency roiagnom on [DATE] at 11:15 p.m. A review of the occurrence report, dated 07-30-11 indicated the resident had injury to the center of face, lip, and mouth. The "root cause" was noted as "due to resident action or internal risk factors," position when found - lying in fetal position on right, alarm - not sounding." Review of the "Neurological Assessment, dated 07-30-11 included the assessment on 07-30-11 at 5:30 p.m., and 11:00 p.m., 07-31-11 at 8:00 a.m. and 8:00 p.m. and 08-01-11 at 2:00 a.m. 2. The record for resident "C" was reviewed on 08-16-11 at 2:10 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the nurses notes, dated 06-17-00 at 9:00 p.m. indicated "Res. found sitting on coccyx in front of bed. no alarm sounding. Reddened area to right side of back." Review of the CNA (certified nurses aide) assignment sheet indicated the resident required a "PSA (personal safety alarm in bed and wheelchair. alarming w/c seat belt, DO NOT leave resident in room or bathroom unattended." A review of the "Fall Risk Assessment, dated 06-01-11 indicated the resident scored an "11." The assessment indicated the resident was at HIGH RISK for falls. The Administrator indicated he was unaware the resident had fallen or sustained an injury. During an observation on 08-17-11 at 11:00 a.m., with the Administrator in attendance resident "C" was observed seated in wheelchair, in room. The resident had a bruise on the left forehead, yellow in color. During this observation, the resident had been left in the room unattended. and there was no identification related to a "leaf or waterfall" on the residents door to the room or wheelchair which would identify the resident as a fall risk. 3.) The record for resident "J" was reviewed on 08-17-11 at 2:30 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's plan of care dated 06-15-11 indicated the "resident wears wheelchair seat belt for positioning." Review of the nurses notes, dated 04-29-11 at 6:20 a.m., indicated the following:"Resident found on dinning <sic> room floor. face down with wheelchair close by. No seizure activity noted but resident has still extremities <sic>. Unable to get BP (blood pressure) due to rigidity." The nurses notes lacked documentation related to the use of the PSA seat belt to alert the staff of unassisted transfer/ambulation. Resident "J" was identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 06-13-11 indicated the resident scored a "7." The assessment indicated the resident was not at HIGH RISK for falls. During observation on 8/17/11 at 11:00 a.m., although the resident had an alarming seat belt present, when tested , the seat belt did not sound. 4.) During observation on 08-17-11 at 11:00 a.m., with the Administrator in attendance the following observations were made for residents identified as "fall risk." The record for resident "L" was reviewed on 08-19-11 at 12:45 p.m., and was identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 10-22-10 indicated the resident scored an "12." A review of the "Fall Risk Assessment, dated 04-18-11 indicated the resident scored a "4." The assessment did not indicate the resident was at HIGH RISK for falls. The assessment indicated the resident was at HIGH RISK for falls. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for resident "M" was reviewed on 08-19-11 at 12:50 p.m., and was identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 04-25-11 indicated the resident scored a "4." The assessment did not indicate the resident was at HIGH RISK for falls. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for resident "B" was reviewed on 08-19-11 at 1:00 p.m., and was identified as a fall risk on the CNA assignment sheet. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for resident "D" was reviewed on 08-19-11 at 1:10 p.m., and was not identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 05-31-11 indicated the resident scored an "11." The assessment indicated the resident was at HIGH RISK for falls. However during an observation on 08-18-11 at 11:00 a.m., the resident was in bed. During this observation, a sensor control box was observed situated on the side of the bed. When the resident rolled from side to side the alarm did not function with an audible sound. In addition a mat had been placed at the side of the bed in the event the resident fell from the bed. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for resident "E" was reviewed on 08-17-11 at 12:45 p.m., and was identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 06-20-11 indicated the resident scored an "8." The assessment indicated the resident was not at HIGH RISK for falls. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for resident "G" was reviewed on 08-19-11 at 1:40 p.m., and was identified as a fall risk on the CNA assignment sheet. The CNA assignment sheet indicated the resident required a PSA while in wheelchair. The resident did not have the alarm device while observed seated in the wheelchair. The record for Resident "H" was reviewed on 08-19-11 at 1:50 p.m., and was identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 06-27-11 indicated the resident scored an "8." The assessment indicated the resident was not at HIGH RISK for falls. The CNA assignment sheet indicated the resident required a PSA while in wheelchair. During this observation the device was not on the wheelchair. A seatbelt was observed hanging on the side of the wheelchair. The record for Resident "O" was reviewed on 08-19-11 at 1:55 p.m., and was identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 06-12-11 indicated the resident scored a "12." The assessment indicated the resident was at HIGH RISK for falls. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for Resident "P" was reviewed on 08-19-11 at 1:55 p.m., and was identified as a fall risk on the CNA assignment sheet. A review of the "Fall Risk Assessment, dated 04-25-11 indicated the resident scored an "15." The assessment indicated the resident was at HIGH RISK for falls. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for Resident "A" was reviewed on 08-19-11 at 2:00 p.m., and was identified as a fall risk on the CNA assignment sheet. The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for resident "I" was reviewed on 08-19-11 at 2:10 p.m., and was identified with a PSA in the wheelchair. During this observation, the resident did not have the required device. A review of the "Fall Risk Assessment, dated 04-18-11 indicated the resident scored a "10." The assessment indicated the resident was at HIGH RISK for falls. In addition, The door to the resident's room lacked a "leaf or waterfall" which would have identified the resident as a fall risk. The record for Resident "K" was reviewed on 08-19-11 at 2:15 p.m., and was identified as a HIGH FALL RISK on the 06-13-11 Fall Risk Assessment. The resident was assessed with [REDACTED]." During family interview on 08-18-11 at 3:00 a.m., the family member indicated the resident fell while at home prior to admission, and had fallen once since being admitted to the facility. The family member indicated the resident had fallen prior to admission and had extensive facial bruising. During further interview the family member indicated the resident had bruising on lower back after mis-judging where the toilet was situated. This fall occurred after being admitted to the facility. The nurses notes lacked documentation of the resident's fall with injury. In addition the door to the resident's room lacked any means of identification to alert the facility staff of the resident's history of falls or fall risk. 5.) Review of facility policy on 08-18-11 at 1:55 p.m. titled "Fall Prevention," and dated as "revised 06-12-2002 indicated the following:"Policy (bold type and underscored) The purpose of this policy is to minimize or prevent falls from occurring to our resident staff and visitors." "Procedure (bold type and underscored): "1.) All written policies regarding emergency care, incident reporting, etc. will apply." "2.) Residents will be assessed through the MDS (minimum data set) and fall risk assessments upon admission, two weeks after admission, and quarterly to identify those at risk for falls." "4.) Appropriate interventions will be implemented on an individual basis. The following devices may be used for fall prevention: walkers, canes, positioning devices, wheelchairs, bed alarms, chair alarms, floor pads, etc. " "7.) Fall risks will be identified to the staff by an image of a leaf posted on the back of resident's wheelchair, on resident's door,, and/or other areas as appropriate depending on he location of falls or risk for falls." "8.) Charge nurses will check all resident at the change of shift, and C.N.A.'s will check residents every two hours throughout the shift to monitor for hazards or unsafe behaviors, and intervene when appropriate to prevent falls." "9.) All departments will assist in monitoring those residents identified as having an increased risk for falls by noting the presence of the leaf image and identifying hazards or unsafe behaviors during the course of their duties." 6.) Review of the "Fallen Resident," Policy/Procedure, on 08-19-11 at 2:30 p.m., and dated 06-09-2008 indicated the following:"Policy (bold type and underscored) Upon observing a fall or findings a resident who has fallen, the resident will be assessed for injuries and emergency care provided." "Procedure (bold type and underscored) 6. Perform neuro checks as per policy." 7.) Review of a current Addendum, dated 03-17-2010 titled "Addendum to Falls Policy/Procedure indicated the following:"Policy - A waterfall sticker will be used to identity residents at an increased risk for falls." "Procedure - To identify those residents at a risk for falling." "Procedure - A waterfall sticker will be placed on the bedroom door of all residents at an increased risk for falls." 8.) Review of the policy "Personal Safety Alarm Policy/Procedure," on 08-19-11 at 2:30 p.m., and dated 04-14-2010 indicated the following: "Policy (bold type and underscored) Friendship Healthcare will will <sic> implement interventions to prevent falls and maintain the safety and well-being of residents." "Purpose (bold type an underscored) To provide a means to alert staff of unsafe movement by high fall risk residents." "Procedure (bold type and underscored) 4. Nursing Staff will check for placement and proper functioning each shift, and document this on the Treatment Administration Record." This Federal tag relates to complaint number IN 742. 3.1-45(a)(2)

A. Based on record review and interview, the facility failed to ensure the safety and supervision of the residents in that a resident who required supervision with ADLs (activities of daily living) was allowed to shave independently, which resulted in bleeding and multiple cuts to the head. This deficient practice affected 1 of 3 residents who required supervision for activities of daily living in a sample of 11. (Resident "C"). B. Based on observation, record review and interview, the facility failed to ensure the safety of residents and provide the assistive devices needed to alert the staff of unassisted transfer/ambulation for 1 of 3 residents reviewed for falls in the sample of 11, resulting in injuries to the face which were deep purple in color with multiple bruises and abrasions around both eyes, cheeks, chin and forehead, and a large knot/hematoma on the left cheek bone adjacent to the left eye. (Resident "B"). C. Based on observation, record review and interview, the facility failed to ensure the whereabouts of residents in that the facility allowed residents the code to the locked front door, which resulted in a resident missing from the facility for a period of time without staff being aware the resident had left the premises, for 3 of 3 residents reviewed who were allowed information related to the locked front door in which they were able to come and go from the facility premises without the staff knowing the residents' whereabouts, in a sample of 11. (Residents "J", "H", "K"). Findings include: A.) The record for resident "C" was reviewed on 09-29-11 at 2:40 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 06-27-11, indicated the resident required supervision with hygiene and assistance with bathing. The resident's current plan of care, dated 07-01-11, indicated, "needs supervision for dressing and bathing due to left hemiparesis, with interventions which included "assist resident with ADLs (activities of daily living) as needed, assist resident to shower twice weekly." During an interview on 09-30-11 at 12:30 p.m., a visitor indicated a need to "check" on this resident as resident had a "safety razor in possession and cut (resident) head numerous times." When interviewed how this visitor obtained this information, the visitor indicated "a resident told me about it. (Resident) said there was blood everywhere." Review of the nurses notes, dated 09-15-11 (no time documented) indicated, "Resident in room and shaving (resident) scalp without supervision. Has cut self in 5 places and bleeding." The nurses notes dated 09-26-11 at 3:00 p.m. indicated "has shaved head and cut self in numerous places with razor. Has 3 razors in trash along with bloody tissue and washcloth." During a discussion with the Administrator and Director of Nurses at the daily exit conference on 09-29-11 at 4:00 p.m., the administrative staff verified the resident "gave self a shower and the other day and (resident) head was cut to high heaven. (Resident) does own shaving." During further discussion, the Administrator and Director of Nurses indicated they were unaware the resident had two episodes of cutting self. During an interview on 09-30-11 at 9:15 a.m. CNA (certified nurses aide) employee #9 indicated the residents "aren't supposed to have razors at all." During interview on 09-30-11 at 9:20 a.m. CNA #7 indicated "I think if they are independent then they can have razors." During interview on 09-30-11 at 9:45 a.m., licensed practical nurse employee #1 indicated "No resident if supposed to have a razor in their possession." During interview on 10-04-11 at 12:00 p.m., the Director of Nurses indicated "when we did a sweep of (resident) room we found 12 razors." B.) The record for Resident "E" was reviewed on 09-29-11 at 12:10 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the hospital patient information/discharge orders, dated 09-09-11, indicated the resident required "bed rest - may sit on side of bed with assistance. The patient is currently A & O (alert and oriented) times 1 (self)." Review of the Nursing Admission Skin condition report, dated 09-09-11 indicated that at the time of admission to the facility the resident had "multiple bruises and scapping <sic> to bilateral upper extremities, scapping <sic> to right knee cap." "Initial care plan: problem fall risk. Approach: bed alarm, call light in reach. Goal: no falls." During the initial tour of the facility on 09-29-11 at 8:30 a.m., licensed practical nurse employee #3 indicated the resident was a "fall risk" and had recently fallen out of bed and sustained extensive bruising to face, arms and hands. The name plate outside of the resident's room had a "star" adjacent to the resident's name. The licensed practical nurse indicated the "star" was placed there to alert the staff the resident was a fall risk. Review of the Minimum Data Set assessment, dated 09-16-11, indicated the resident required extensive assistance with bed mobility and was assessed as "total" care/assistance from the staff with transfer. Review of the current plan of care, dated 09-27-11, indicated the resident "gets bruises and skin tears easily due to anticoagulant use." The "goal" indicated "resident will be free of serious injuries through next review." Interventions to this plan of care included "Pad side rails on bed with pillows, pillow cases, bed pad alarm in bed, PSA (personal safety alarm) in wheelchair to alert staff if resident tries to transfer without assistance. A subsequent current plan of care dated 09-22-11, indicated the resident had the "Potential for injuries from falls due to recent history of falls." Interventions included "Monitor resident for steadiness and balance, personal safety alarm (PSA) when up in wheelchair, pressure pad alarm in bed." The certified nurses aide assignment sheet with resident specific information indicated the resident required a bed pad alarm and a PSA when up in the wheelchair. Review of the nurses notes indicated the following:"09-09-11 4:00 p.m. Alert to self, inappropriate\ speech noted. Resident on bedrest. Attempted to climb OOB (out of bed) times 3 times this shift bed alarm placed." "09-10-11 10:30 a.m. - Pt. (patient) has tried to climb out of bed times 2 this shift." "09-10-11 10:00 p.m. - Bed alarm in place alarms when res. (resident) moving about in bed." "09-14-11 6:00 a.m. - Sitting up on side of bed multiple times during this noc (night)." "09-18-11 8:00 p.m. - Alert to person inappropriate speech at times. Resident attempt to get OOB times 2. Likes to sit on edge of bed." "09-21-11 11:20 a.m. - Pt. found in room lying on floor on left side, alarm sounding, fall matt at bed side. pt alert verbal abrasion/laceration 5 in length area blue/purple with bright red drng (drainage), s/t skin tear noted to left elbow measures .6 by .5 cm (centimeters) flap intact." During the initial tour of the facility on 09-29-11 at 8:30 a.m., the resident was observed seated in a wheelchair. The resident's face was deep purple in color with multiple bruises and abrasions around both eyes, cheeks, chin and forehead. The resident had a large knot on the left cheek bone adjacent to the left eye. During an observation on 10-05-11 at 9:40 a.m., the resident was seated in a wheelchair in room. The resident, in a continuing motion, placed the palms of both hands on the armrests of the wheelchair and attempted a standing position. During a subsequent observation on 10-05-11 at 9:50 a.m., the resident continued attempts at standing. Upon entering the resident's room, the resident lacked a PSA alarm while seated in the wheelchair. During this observation an alarm was observed on the resident's nightstand. CNA (Certified Nurses Aide) employee #7 entered the resident's room. When interviewed the CNA indicated she was unaware the resident required a PSA. When requested the CNA reviewed her assignment sheet which instructed staff of the need for the personal alarm. The CNA turned toward the nightstand and stated, "that probably needs to be on the wheelchair and attached to (resident)." The Director of Nurses was in attendance during this observation. The resident was observed with white kerlix/gauze type dressings to bilateral arms from the wrists to the elbows. The siderails of the resident's bed were not padded to protect the resident from additional injury. C 1.) The record for resident "J" was reviewed on 09-30-11 at 9:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE], indicated the resident had no cognitive impairment; however, the resident' plan of care indicated the resident was at risk for confusion and disorganized thought due to the [DIAGNOSES REDACTED]. Review of an incident reported to ISDH, dated 09-17-11 at approximately 5:00 a.m., indicated the following:"(Resident) states that (resident) left the facility at about 5:00 a.m. and wheeled self to (name of local area restaurant) approximately seven blocks from the facility. After arriving at (name of local area restaurant), (resident) telephoned a friend to meet (resident) and (other family member) as well. (Family member) telephoned the facility at about 8:30 a.m. indicated (resident) was at (name of local area restaurant). CNA (name documented of employee #9) went to the restaurant to bring (resident) back but (resident) refused to come back with her at that time. (Name of CNA) then left (resident) at (name of local area restaurant) with (family member) and friend. (Resident) had his friend bring (resident) back to the facility later that morning." Further review of the report indicated the Assistant Administrator spoke with the resident and reminded the resident of the need to "sign in and out of the facility." The resident indicated (resident) "made a mistake today and in the future will sign out prior to leaving the facility." Statements, handwritten, by facility staff member indicated she "thought" she saw the resident around 6:00 a.m., however, the facility staff was unaware of the resident's whereabouts for approximately 2 - 2 1/2 hours. During observation on 10-04-11 at 11:25 a.m., the local area restaurant was approximately 1/2 mile from the facility. Getting to the restaurant necessitated crossing four lanes of moving traffic from north to the south lanes, and two lanes of traffic for the east west lanes of traffic. Review of the Social Service Review and Resident Interview, dated 08-08-11 indicated "Outside Supervision Needs - "understands the facility LOA policy (Signing in/out), and may sit out on front porch unsupervised." Although the incident occurred on 09-17-11, the facility failed to do a post elopement assessment until 10-05-11. C 2.) The record for Resident "H" was reviewed on 10-05-11 at 11:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set, dated dated [DATE], indicated the resident had no cognitive impairment but did display short term memory loss. During observation on 10-04-11 at 1:10 p.m., the resident was observed with a stumbling gait. During an observation on 10-04-11 at 1:10 p.m., this resident was observed walking toward the front door of the facility with another resident's family member. The resident accessed the key pad, entered the code and exited the building with this visitor. During interview, on 10-04-11 at 1:45 p.m., the resident indicated (resident) did not get the code from a staff member. The resident was reminded the code had been changed the previous Friday, 09-30-11, and again asked to think about where (resident) obtained the code. The resident stated "I have short term memory problems I don't remember." The resident became confrontational and asked "Do you mean I have to ask someone to let me out to go to church ?" The Director of Nurses who was in attendance stated, "Yes." The resident then stated (resident) let self out of the facility on Sunday to attend church without anyone letting her out. The elopement risk assessment was not conducted until 10-05-11. C 3.) The record for Resident "K" was reviewed on 10-04-11 at 2:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set assessment, dated 08-31-11, indicated the resident had no cognitive impairment or memory loss. The resident used a motorized wheelchair for mobility. A physician order [REDACTED]. During an observation on 10-04-11 at 11:30 a.m., the resident was observed in a motorized wheelchair approximately 6 blocks from the facility on Keystone Avenue, a four lane divided street that runs north and south. Review of the "Sign In/Out" sheet, dated 10-04-11, indicated the staff member "signed" the resident as returned to the facility at 11:00 a.m. Further review of the "Sign In/Out sheet, indicated the resident left the faciity on [DATE] at 12:30 p.m., but lacked a staff member's signature of the resident's return to the facility. There was no indication the staff were aware of the resident's whereabouts. During an interview on 10-04-11 at 1:00 p.m. the Director of Nurses indicated the resident liked to cross the street and watch the golfers (at the local area golf course). During interview on 10-04-11 at 2:30 p.m., the Assistant Administrator indicated he telephoned the staff member who verified she had not actually looked at the exact time the resident returned, but rather knew it was around the time she "ate" and then "took her smoke break." C 4.) During observation on 10-05-11 at 10:30 a.m., a group of nursing students were observed in the facility. One nursing student approached the front door and verbally stated the code to exit the facility. During interview on 10-05-11 at 10:40 a.m., the Director of Nurses was alerted who then indicated the students were given the code but must not be aware of the importance not to verbally state the code in the event there are residents in the area. Review of Friendship Healthcare Center "Rules for Residents, on 09-30-11 at 11:00 a.m., and dated as "revised" January 2009 indicated the following:"It is the policy of Friendship Healthcare to expect resident to behave in such a manner that the safety, well being and right of others are respected." "4. Residents are not to cause injury to themselves or others." "6. Residents are not to leave the facility without signing out. They must sign back in upon return. LOA (leave of absence) resident need to be accompanied by a staff member, family member, or responsible party. Residents should remain within fenced areas when outside, unless accompanied by a suitable attendant." "12. Upon admission, no resident will be allowed outside unsupervised until having been assessed for elopement potential." Review of Inservice education on 09-30-11 at 1:30 p.m., instructed the nursing staff as follows: "For our residents' safety, please be sure to not (underscored) give out the door code to our resident's. The door code may be given to family members. however, please politely ask them to respect the rules of out facility and not give the code out to their loved one or any other resident. Please be advised, any employee caught giving the code out to a resident will be immediately terminated." This federal deficiency was cited on 08-19-11. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-45(a)(2)

Based on interview, observation, and record review, the facility failed to change a resident's dressing and assess for further breakdown of a stage II pressure ulcer for 4 days until such time as the stage II pressure ulcer had become a stage IV area. This deficient practice affected 1 of 3 residents reviewed for pressure ulcers in a sample of 4 (Resident #B). Findings include: Review on 07/05/11 at 1:35 p.m., of Resident #B's clinical record indicated: Resident #B had the [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) assessment dated [DATE], indicated the resident had the [DIAGNOSES REDACTED]. with falls or weight loss; had 3 stage II pressure ulcers and one unstageable pressure ulcer; received a daily antipsychotic medication and no insulin injections. The June 2011 physician's orders [REDACTED]. [MEDICATION NAME] packet-cherry 1 packet twice daily (05/16/11) [MEDICATION NAME] 1250 mg (milligrams) po (by mouth) daily (07/14/10) Ensure 120 cc (cubic centimeters) po tid (three times daily) (03/07/11) [MEDICATION NAME] 5/325 mg 2 tablets po 1 hour prior to dressing change (04/22/11) [MEDICATION NAME] 5/325 mg 1 tablet po daily at 9 p.m. (04/22/11) [MEDICATION NAME] 7.5 mg po at bedtime (05/18/11) Multivitamin 1 po daily for supplement (05/18/11) Vitamin C 500 mg po daily for supplement (07/14/11) Silver [MEDICATION NAME] cream apply topically to buttocks and cover with ABD pad (large thick absorbent pad), change daily 6 a-2 p shift (04/29/11) Resident to be up in chair at degrees as much as possible (no initiation date) Keep heels floating off bed (no initiation date) A TAR record (treatment administration record) for June 2011 indicated staff had changed the dressings to the resident's "buttocks" (silvadiazine and ABD pad) daily as ordered on 06/23 through 06/29/11. A fax communication dated 07/05/11, indicated the resident's physician had given the order "santyl to heel and coccyx slough areas change daily. On back only for meals. Wound gel to wound beds on buttocks and heel . [MEDICATION NAME] to excoriated areas on buttocks..." Review of the weekly "Pressure Ulcer Reports" indicated: "Coccyx: date identified: 04/14/11--stage II: 1.9 cm long x (by) 1.1 cm wide x 0.1 cm deep no drainage 06/02/11--stage II: 1.6 cm long x 1.0 cm wide x 0.1 cm deep 06/09/11--stage II: 5.0 cm long x 4.0 cm wide x (blank) with 80% slough During interview on 07/06/11 at 1 p.m., the Director of Nursing was unable to provide weekly pressure ulcer assessment reports regarding this resident's coccyx pressure ulcer past 06/09/11 and up to 07/01/11, as these reports as "they had not been done" . Dietary progress notes dated 04/18/11 (which was the most recent entry), indicated no documentation regarding the resident's pressure ulcers. A care plan problem dated 08/16/10, for "Open areas to left buttock & (and) coccyx, chronic red [MEDICAL CONDITION] bilateral buttocks/thighs". This care plan for skin breakdown had not been updated to reflect the resident's different pressure ulcers and their changes in progress/regression, nor did the care plan reflect treatments or dietary recommendations of any kind. A hepatic profile lab report dated 05/02/11, indicated a total protein of 5.8 (low) and an [MEDICATION NAME] of 2.8 (low). During interview on 07/06/11 at 9:15 a.m., the Director of Nursing indicated Resident #B's coccyx area had been a stage II, but had been found to be a stage IV on 07/01/11, when RN #1 had gone to change the resident's dressings with RN #1 having found the dressing to have a date of 06/26/11. The Director of Nursing indicated skin had come off with the resident's dressings when the dressings had been removed in several places causing several open areas. The Director of Nursing further added the resident had a long history of fragile skin with [MEDICAL CONDITION] to the buttock area as well as had a history of [REDACTED]. During interview on 07/06/11 at 1 p.m., the Director of Nursing indicated LPN #1 had been responsible not only for daily dressing changes/assessments, but had also been responsible for weekly measurements of the resident's wounds, but had not done the resident's coccyx measurement/assessment since 06/09/11, as none were found. During observation on 07/07/11 at 10:10 a.m., LPN #2 removed the resident's dressing to the coccyx area. The coccyx wound was approximately the size of a quarter with 100 % yellow slough. The wound margins were smooth and there was no drainage coming from the wound. There were 5 irregularly shaped shallow areas around the lower perimeter of the coccyx wound which were bright red in color with little bleeding. LPN #1 indicated these 5 irregular areas had not been present until 07/01/11, when the 4 day old dressing had been removed (ABD and Coverroll). During observation on 07/07/11 at 12:45 p.m., the NP (Nurse Practitioner) examined the resident's coccyx wound and indicated the wound measured 2 cm x 2 cm and had a depth of less than 0.1 cm with no tunneling. The NP gave orders for a wound culture to be done and to give [MEDICATION NAME] DS (an antibiotic) until the culture was back. During interview on 07/07/11 at 1 p.m., the NP indicated the resident had chronic [MEDICAL CONDITION] to his bottom which made the skin to that area very friable and prone to breakdown. The NP further indicated the resident had a long history of skin problems and had required multiple skin flap procedures due to non-healing pressure ulcers in the past. This Federal tag relates to Complaint IN 695. 3.1-40(a)(2)